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Who Needs a Gynecologist -- and When?

By Ishani Ganguli
Special to The Washington Post
Tuesday, October 2, 2007

Along with glass ceilings and high heels, a visit to the gynecologist falls somewhere on the dark side of being the fairer sex. It's something to which many women grimly resign themselves. That's because, from a woman's first signs of puberty to menopause and beyond, her gynecologic exams and relationship with the doctor who performs them can play a critical role in her health.

But the question that many face, and that experts still debate, is who should provide the care -- and when.

Some experts say women are often more comfortable being examined by their family doctor, whom they've known for years and can speak to frankly about intimate matters. General practitioners handle almost 20 percent of routine gynecologic exams, according to a study published last week in the Archives of Internal Medicine.

As long as a woman gets the care she needs, "it doesn't matter who renders it -- whether they see their pediatrician or go to the clinic or the nurse practitioner or the gynecologist," said Kenneth Blank, a gynecologist affiliated with the Georgetown and George Washington University medical schools.

Others say that although many family practice doctors are knowledgeable about the field, they may be too time-pressed to focus on gynecologic care. "I think our first choice should be for the OB-GYN to handle these kinds of problems, because that's what their training and experience allows them to do best," said Steven Sondheimer, co-chair of the gynecologic practice committee of the American College of Obstetricians and Gynecologists (ACOG) and a professor of OB-GYN at the University of Pennsylvania.

In fact, for many women, a gynecologist serves as primary care physician, the only doctor they visit routinely.

Annual gynecologic exams are still recommended by many physicians even though their value has long been contested. But the question of when to start and end gynecologic care is far from clear-cut.

About 19 million American women, or 18 percent of adult women, receive annual pelvic exams, at a cost of $2.6 billion a year, according to the Archives study.

"It's important for women to have a doctor who's comfortable dealing with reproductive and, if you will, genital issues, because, throughout a large part of our lives, that is where our health concerns are focused," said Marcie Richardson, a Boston-based obstetrician-gynecologist.

But starting that relationship often involves apprehension.

Primed by images of hard metal stirrups and a frigid speculum, "a lot of young women who have never been to the gynecologist are somewhat intimidated," Blank said.

In part to alleviate these fears, ACOG recommends that girls begin seeing a gynecologist between ages 13 and 15 -- not necessarily for a pelvic exam (unless they're sexually active) but to build a relationship with the doctor and to start tackling difficult issues such as first intimate relationships, birth control and sexually transmitted infections.

But Blank says girls may be readier, medically and emotionally, to transition to a gynecologist once they've graduated from high school. That's especially true when this doctor is already seeing other members of their family, as some of Richardson's patients can attest.

Judy Gelfand, a school principal who lives in Newton, Mass., followed that approach with her younger daughter. "She was about to start college, and I thought it was time for her to start seeing [Richardson]" -- the same doctor who delivered her, Gelfand said.

Anne Gerberg, a 52-year-old nurse who also sees Richardson, took a middle course with her family.

"I think it depends on the kid; it doesn't always make sense to go early," she said. Her daughter Laura was 17 when irregular periods prompted a first visit to Richardson.

"I wasn't really sure what it would be like," Laura said. I didn't know of any of my friends who have had to go to the gynecologist. [But] I wasn't really nervous or anything."

A Trusted Counselor

ACOG recommends annual pelvic exams starting once women are sexually active, or else at age 18, though the cost-effectiveness of such frequency has been debated in recent years. ACOG also advises that women start getting annual Pap smears -- in which the doctor takes a swab of the cervix to check for signs of cancer -- within three years of becoming sexually active, or by the time they turn 21.

(For certain women 30 and older, the organization recently loosened the recommended Pap test intervals to every two or three years. The move has caught some women by surprise. "Trying to talk [these] women out of getting Pap smears is challenging," Richardson said.)

A drop in the average age of puberty -- a century ago, most girls had their first period at 14, compared with between 12 and 13 today -- has coincided with rising concern about teen sex.

"I'm certainly seeing younger people than I used to," said Richardson, who has been practicing for 30 years. "My mother never would have done that with me. I think this has to do with mothers coming to grips with the fact that their daughters are sexually active earlier."

In the past few years, sexual activity among teens has dipped by some estimates: In a Kaiser Family Foundation survey, 53 percent of high-school-age boys and girls reported in 1995 that they had had intercourse, compared with 47 percent in 2005. But teens remain a vulnerable demographic when it comes to sexual health, and good early care, whether it is from a specialist or a pediatrician, can make a big difference.

"From my perspective, it partly depends on how comfortable your primary care doctor is with handling reproductive/gynecologic issues," Richardson said. "Because some are really good at it, and some don't have a clue."

A girl may have questions, for example, about vaginal discharge or uneven breast size, and may be embarrassed to ask her mother.

For Paula Hillard, a professor of OB-GYN at Stanford University, "the telling issue is whether or not the girl has the opportunity to talk privately with her primary care physician. All adolescents deserve that confidentiality or privacy," she said, "whether or not they have issues that demand confidentiality or privacy."

A larger issue than which practitioner to see may be whether many get any care at all, polls suggest.

Only six in 10 sexually active boys and girls ages 15 to 17 have seen any health-care provider about their sexual health, a 2002 survey by the Kaiser Family Foundation found. And less than a third reported that they had talked with a health-care provider about HIV/AIDS, other sexually transmitted diseases or birth control.

A Slip in Habits

As discussions about first times shift to conversations about firstborns, women are more likely to exercise the OB-GYN option.

Richardson recommends that women see an OB-GYN if they are even thinking about getting pregnant, because many aspects of prenatal care -- such as eating foods that contain enough folate -- are critical within weeks of conception. Prenatal care is by far the most common reason for OB-GYN visits, according to the National Center for Health Statistics.

The farther they get from their childbearing years, the more likely women are to forgo routine gynecologic exams, the Archives study shows. Although about 20 percent of those between ages 25 and 54 got an annual exam, the figure dropped to about 10 percent in women 55 to 64 and 5 percent in women 65 and older.

This may not be wise. The onset of menopause does not diminish the medical relevance of pelvic exams, and ACOG and other major clinical organizations recommend annual ones through much of the post-menopause period. In fact, researchers now find that the pelvic exam can also reveal early signs of ovarian cancer, for which the risk increases with age.

Because menopause hits most American women around age 51, many will spend up to 40 percent of their lives post-menopause. Once they experience the constellation of menopause symptoms, including hot flashes and sleeplessness, some women look for sympathetic ears.

"I do sometimes see people who say, 'When I go to my old gynecologist, her waiting room is totally full of pregnant women. She doesn't know much about menopause,' " Richardson said. "I've learned way more about menopause as I've entered that stage of life myself."

For those who continue to receive gynecologic care, many, like Gerberg and Gelfand, prefer sticking with the OB-GYN who delivered their children -- often their only regular connection to health care.

"For me, it's not just my personal relationship with [Richardson]," Gelfand said. "I have an incredible amount of trust in her because she knows what she's doing. That, to me, trumps everything." ¿

Ishani Ganguli is a second-year student at Harvard Medical School. Comments:health@washpost.com.

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