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Dr. Gaudet: Life-Saving Tests for Women

Body+Soul, 2007

When she was about to turn 60, Cay came to see me for a checkup. Several years had passed since our last visit, so I reviewed her entire history and discovered that she hadn't had a mammogram in three years. Since Cay had both an aunt and a sister with breast cancer, I was alarmed. But when I told her she should schedule a mammogram, Cay asked quietly, "Do I really have to?"

Even though the women who come to see me are generally quite health-conscious, most haven't had all of the routine screenings recommended for optimal self-care and disease prevention. Some even argue that since they know their bodies well, they have an intuitive sense of anything that might be wrong. While I'm the first to agree that listening to our bodies can provide important information, I also believe that we can't rely solely on intuition to protect our health.

Health screenings, by definition, can detect the possibility of illness before symptoms occur -- and can therefore lengthen the number of years you're around to laugh, love, work, and otherwise live your life. If you're behind on screenings, stop to reflect on why you might be letting them slip. The underlying reasons are very often unconscious. Here are the top three that I come across in my practice, along with my advice for working with them, consciously.

"I'm scared."
At first I was taken aback by Cay's avoidance, but then I realized how afraid she must be. Women who fear a certain disease are often likely to dodge the screening test. On one level, this is understandable: We avoid what we fear. So if you're particularly scared of getting breast cancer, your instinct may be to shun mammograms. Of course, most of us see the flaw in this logic pretty quickly: If you have risk factors, or if you have a high level of fear or anxiety about a particular condition, then you should be even more vigilant about screening. But many intelligent, informed women don't ever get to this step.

If you have a family history of an illness, think about whether you're up to date on screenings. If you're not, then why not? Might fear be an issue? Don't judge yourself. Instead focus on uncovering any feelings that you've been keeping unconscious. Bringing your fear to light can help you honor it, rather than letting it dictate your behavior. Instead of putting off your mammogram, for instance, you might decide to ask a friend to accompany you to your screening and let the technician know that you're afraid.

After four follow-up phone calls, I was finally able to get Cay to come in for a mammogram. When it was over and the results came back normal, her relief was enormous -- as enormous, I suspect, as her fear had been.

"I'm too busy!"
I can relate to this one. When I last did a check of my overall wellness, I realized that even though I was eating right, working out, and taking good care of my mental and spiritual health, I was behind on several of my own screenings. As a doctor, I knew how important they were, and yet -- as a single mom with a toddler and a full-time career -- I kept letting them slide to the bottom of my to-do list. After all, I had no symptoms prompting me to go. Once I realized I was overdue on so many tests, I made getting screened a priority. But for three months, I still couldn't fit the tests into my jam-packed schedule.

I finally decided to take an entire week off from work, just for my health. While my adventure-seeking side was annoyed that I would "waste" a week of vacation time, my deeper self knew I had made the best choice. Not only did I get caught up on my screenings, but my son and dogs did, too. I rewarded myself each day with a small indulgence: a fabulous massage, a pedicure, a walk, or a leisurely glass of wine with a friend. By the end of the week, I had decided to use my vacation time in this way every year. It was by far the best thing I could do for my health -- both physical and emotional.

Once you choose a strategy that works best for your schedule, it'll be nearly impossible to let those screenings slip. Even if they don't seem critical to you, treat the tests like you would an important meeting. Our need for screenings grows as we age, so we have to work on establishing new patterns that let us fit these cornerstones of self-care into our lives.

"Recommendations change constantly, and I've heard some tests cause harm."
Some patients complain that health professionals can't agree on the timetable of screenings. But while recommendations on when to get tested may vary, there's little controversy among health professionals over whether women should seek screenings in the first place. (For example, while some groups say that women should start screening for breast cancer at age 50 and others recommend age 40, they all agree that mammograms should be done annually from age 50 onward.)

The fact that there are differing suggestions means simply that, yes, controversy does exist. (I adapt my screenings timetable from that of the U.S. Preventive Services Task Force, which reviews data on screenings and comes up with science-based guidelines.) But if you're using the timing controversy as an excuse not to get screened, I'd encourage you to look deeper. More often than not, this belies a more personal reason (quite possibly the fear we explored above).

Meanwhile, some people snub tests, believing they cause harm or should not be trusted. Regarding the former, science shows (and I believe) that the worries surrounding most tests are unfounded -- and moreover, that tests save lives. Concerning the latter, it's true that because screenings only look for the possibility of a problem, there is a percentage of "false positives" (in which the results come back abnormal, but it turns out you don't have the associated disease). In these situations, you may have further tests, including invasive procedures like breast or cervical biopsies. This can be stressful, and it's important to seek out support. But despite the worry and hassle, false positives are infinitely less stressful -- and potentially less tragic -- than an untested negative.

Controversy and Confusion
When it comes to some basic screenings, experts don't always agree on the who-what-when. Here's my take on a few such tests.

Mammograms
Professional health groups disagree on whether to start mammograms at age 50 or 40. I recommend that, if you decide to begin at 40, you do so annually. At this age, breast cancers are more likely to progress quickly, so if you only screen every two years, you lose a lot of the benefit that can come from screening. While some patients worry about the radiation involved with mammography, it isn't used at a level shown to cause harm. As for new technologies like thermagrams, promoted as safe and comfortable alternatives, there's no evidence they're effective, and they shouldn't be used in place of mammograms.

Pap Tests, Pelvic Exams, and CA-125
If you have no history of abnormal Pap smears and are in a monogamous relationship, it's now recommended that you have a Pap test every three years. Many physicians, however, feel that, since women still need to get a pelvic exam every year, it's a good idea to have a Pap while they're at it. Part of the reason pelvic exams are recommended yearly is that there's no good screening test for ovarian cancer; a pelvic exam can reveal masses that may indicate cancer. Some nonmedical groups encourage women to ask for a blood test called CA-125, named after a protein found at high levels in some types of ovarian cancer. But CA-125 can be elevated for many reasons, so it's not a reliable screening test. If you're found to have a mass, however, CA-125 will be checked and monitored.

Fasting Glucose Test
Women who had diabetes during pregnancy (gestational diabetes) may have up to a 50 percent increased risk of developing the disease later in life. If you were diabetic while pregnant, you should get screened for diabetes after you give birth and frequently thereafter. There's no real controversy around this test, but it's often overlooked.

Bone Density
This test screens for osteoporosis, a silent and serious disease. Most recommendations state that bone density testing should not start until age 65. But many clinicians, myself included, find that getting a baseline bone density exam (DEXA scan) around menopause can provide useful information, when discussing such issues as the pros and cons of hormone therapy.

Screening Schedule
The following chart gives my baseline timetable for women's general health screenings, which are adapted from the U.S. Preventive Services Task Force recommendations. A number of factors, including family history and lifestyle habits, may alter this schedule, and additional tests are often recommended based on risk factors. Talk to your physician about the best schedule for you.

Ages 20-44
Blood Pressure (for heart disease): every 1-2 years
Pelvic Exam (for masses, including ovarian cancer): every year
Pap Test (for cervical cancer): every 1-3 years
Clinical Breast Exam (for breast cancer): every year
Mammogram (for breast cancer): every year (age 40+)

Ages 45-65
Blood Pressure: every 1-2 years
Cholesterol: every 1-5 years
Colonoscopy: every 10 years (age 55+)
Pelvic Exam: every year
Pap Test: every 1-3 years
Clinical Breast Exam: every year
Mammogram: every year
Bone Density: consider at menopause

Ages 65+
Blood Pressure: every 1-2 years
Cholesterol: every 1-2 years
Colonoscopy: every 10 years
Pelvic Exam: every year
Pap Test: every 1-3 years
Clinical Breast Exam: every year
Mammogram: every year
Bone Density: every 2 years

Text by Dr. Tracy Gaudet