AIBU to think I don’t need to go to the gynaecologist every year?!

[Watchagotcha]

I live in France but am from the UK. I was out with some friends last night - some French, mostly Brits who’ve been here a lot longer than me. We got talking about various medical issues, and it transpires that pretty much all my friends go to see their gynaecologist every year! I’m not sure what for: smear tests, when they are due; breast exams; and just “making sure everything is okay”.

Is this really necessary? What kinds of conditions might they be picking up on that I wouldn’t notice and go to the dr with myself?

Do I need to see a gynaecologist yearly?
YABU = yes you do, the gynaecologist might find something that needs treated
YANBU = no, don’t be daft, go to the dr if you need to and get regular smears when they are due

My best friend went to her GP to ask for a mammogram because her mother had just been diagnosed with BRCA breast cancer (the hereditary type). The GP refused because she was only in her 40s. Two years later she was dead from breast cancer. There are also disadvantages to underdiagnosing, not seeing specialists and being part of a system that tries to cost cut everywhere.

For those who think “ it does no harm “ I would question that. You will get more false positive tests and treatments that will harm some people will be done - eg biopsies Of lesions that will never be one significant - or even the psychological harm of the anxiety whilst waiting for results that can be significant in some people.

Yes, a surprising number of posters don't even seem aware that this issue exists. I'm not saying an annual gynae exam is better or worse than not having one, because I don't know. No idea of the evidence. But everyone should be aware that with preventative care and screening for the asymptomatic, the goal has to be striking the optimum balance between the risk of missing problems that would be detected with more regular checks and the risk of causing problems from over-treatment. That's the answer to this question.

It's not at all straightforward. You do X number of colps, you prevent Y women from developing further problems by performing these colps, you cause Z preterm births because of the damage to the cervix. Now fill in the blanks with the numbers that will cause least harm and achieve the greatest benefit!

@nespressowoo so the system worked for your friend. Those changes would have taken many years more to become cancer.

@Booboostwo your friend's GP was wrong, she should have been referred to a genetics clinic. Her situation with a mother with brca is totally different to population screening.

waterbottle12 if you don't do population screening you rely on individual doctors to identify high risk individuals across all kinds of conditions. If you use GPs the width of knowledge required is further increased than if patients have direct access to specialists. Hence more mistakes like the one the one I mentioned. So this is an argument in favor of screening.

@Booboostwo your friend would never have been old enough for population screening. Those with a higher than average risk due to FH are a special case. Her family would have a case for a complaint/lawsuit against the GP if they wanted to go down that route. Population screening starting below 40 will never happen as the rates of breast cancer at that age are so low the risks will definitely outweigh the benefits.

For those who are interested in overdiagnosis:

www.preventingoverdiagnosis.net/?page_id=1176

www.cancerresearchuk.org/health-professional/screening/overdiagnosis

www.nhs.uk/news/medical-practice/are-we-overdiagnosing-harmless-problems/

@Booboostwo also this is pretty basic knowledge for a GP that someone with a first degree relative who is BRCA positive needs to see a geneticist. In any system you can't account for doctors, nurses, dentists etc who make mistakes. massive population screening which can cause harm isn't the answer to that. There will always be human error.

waterbottle21 my friend was 42 when she went to her GP, six months later she found the lump, less than two years after that she was dead. As I mentioned before France, for example, offers mammograms to all women over 40 as standard. So here is an example of a different cost/benefit/risk analysis than the one NICE have made in this case.

In terms of the breast cancer screening between 40 - 50, I am not sure which country has it right, I think there is insufficient evidence either way. Nor do I think screening would have necessarily meant that my friend would have survived as her cancer was very aggressive. However, my original example was an example of an example of the risks of underdiagnosing. Overdiagnosing risks include unnecessary stress and anxiety, unnecessary diagnostic procedures and unnecessary treatment procedures with all their related risks. But that doesn't mean that underdiagnosing is unproblematic, as the risks there include death.

In a system like the UK where patients have delayed access to non-specialists who then gatekeep access to equally underfunded specialists, underdiagnosing becomes even more prevalent.

waterbottle21 human error exists in every part of the medical process but you can stack the odds in the patient's favor. Deciding against a screening programme for under 50s, AND having a non-specialist doctor gatekeeper system, AND underfunding the entire system, vastly increases the chances of suffering from human error.

@Booboostwo but have France been honest and published figures on how many women are harmed? We know in the UK, 3 women are harmed for every 1 who is helped, the figures will be worse for a system that starts younger. France is a prime example of overdiagnosis, go to your doctor with a cold and you'll come out with about 4 prescriptions. their health service is crumbling financially under the demand and likely to change in the next years/decades.

How would you feel if you were the woman screened at 40, who had unnecessary surgery and maybe significant complications for something that would never have caused you harm?

Completely agree with your point on underfunding.

waterbottle12 I have no evidence either way on whether French authorities are somehow manipulating medical date to hide adverse results - do you? Unless you do, it's a pretty paranoid claim to make. Most stats on screening, diagnoses, outcomes, etc. come from EU health databases and I have no reason to assume France submits fraudulent reports.

It is irrelevant how I would feel if it happened to me. Screening doesn't work this way, it's a numbers game. This is equivalent to saying how would you feel if your breast cancer had gone undetected to prevent the harms of overdiagnosing in other women, and you had terminal cancer as a result? Someone will always loose, there is no version with no harms. Public policy decisions (of which screening is one type) are made on consequentialist grounds: the lowest harms for the smallest number of people.

Quantifying harms is the nightmare NICE and other similar bodies face and is a fascinating area of research in itself, but focusing exclusively on overdiagnosing harms while ignoring underdiagnosing harms is clearly wrong.

And yes, France's health service is about to go the way of the NHS in terms of underfunding as they can't afford it either, but what is the relevance of that?

I have no evidence either way on whether French authorities are somehow manipulating medical date to hide adverse results - do you

@Booboostwo no I have none, I don't know if they publish such data. But I would expect an honest system to publish data similar to that linked above, and if France did that, for a system that started at 40 it would undoubtedly show that more than 3 women were harmed for every woman helped.

And yes, France's health service is about to go the way of the NHS in terms of underfunding as they can't afford it either, but what is the relevance of that?

the relevance is that for a national system we have to help the most number of people for a given pot of money. breast screening from the age of 40 doesn't do that - it helps a tiny number of women and harms a lot more, and much better things could be done with that money. that's obviously different from someone choosing to pay privately - you can do what you want with your own money.

Annual check is standard in my home country too, first World with socialised health care.

waterbottle12 google scholar and resarchgate are your friend as well as the European Health for all Database (HFA-DB). Until you familiarize yourself with the evidence I suggest you refrain from rhetoric questions suggesting the France is hiding adverse effects. This is not the Daily Fail.

As I have said before NICE takes a number of factors into consideration when making decisions on the availability of screening, diagnostics, treatments, etc. Specifically in the case of breast cancer screening for the 40-50 group, I don't necessarily think they are wrong to withhold screening.

I live in France where my taxes pay for breast cancer for the 40-50 age bracket screening, but thanks for the advice on what I can do with my own money. Personally I decided to decline the screening exactly because of overdiagnosis concerns, but I also think how one reasons is as important as the conclusion one arrives at.

@Booboostwo I never said France were hiding the data. I just said that I don't know if they publish it. you said that:

1)your friend would have benefited from universal screening, though she died below the age of 50
2)NICE isn't wrong to start screening at 50.

Those positions are inconsistent (though for the sake of accuracy, some pilot areas are now starting at 47 in the UK, so the first invitation would be received between 47 and 50, not 50 and 53)

No such thing like that in the ik5. The only person you can see about anything is a GP who most of the time dismisses your concerns and sends you home. It often takes multiple visits to even get referred. Then there is a huge wait.
Smear every three years, in there for about 30 seconds. That's it.
Im 35, I've never seen a gynaecologist, a dermatologist, never had anyone check me over for anything. I've had 2 children with c sections for both as they were breech so never even had any pelvic examinations during pregnancy or birth either.

In the UK

I'm from the UK and don't have a gynaecologist.. no one I know does, it's just not a standard thing here. Obviously I go to get a smear test when summoned but other than that would just go and see my GP if I was having problems or concerned about something.

If you have the option to though I don't see the harm in it, it can only be a good thing but i'm sure you must be paying for the privilege?

waterbottle12 you said But have France been honest and published figures on how many women have been harmed? this is not request for information. If you want information you say "Where can I find statistical information on outcomes in France?". As I said this is not the Daily Fail.

Of course the two statements are compatible. Statistically a screening program may not be warranted even if a particular individual might have benefited from it. Public policy is not made because no one will be harmed, it is made in an attempt to harm as few people as possible.

Also you seem to missunderstand some very simple points:

I introduced the example of my friend not in relation to screening but in relation to the choice between gatekeeper vs direct specialist access systems. A specialist would have been less likely to make the mistake her GP did.

You then replied with relation to screening, so I have been engaging with what you said. I am NOT advocating for screening in the 40-50 bracket NEITHER because my fiend died, NOR because of some other reason. On the whole I think that breast cancer screening for the 40-50 age is not a good idea because of overdiagnosis AND I also think that gatekeeper medical systems suffer from underdiagnosis problems.

I think we're talking at cross purposes here and TBH I don't have the time for this. If we're saying the same things then no need to debate further. My query about France was quite clearly a question about whether they had published the data, not an accusation.

over and out!

I am UK based and have private health insurance through work with an annual medical and have a full breast/gyne exam as part of this. They don’t do annual smears though, that’s still every 3 years but i am only 30 and I understand they go annual when you turn 50 or so.

When I was pregnant I briefly used a pregnancy board used mainly by Americans. I was shocked by how many times they see an obstetrician during pregnancy, how many scans they have, early hcg blood tests, early scans, even a smear test during pregnancy which is completely and utterly pointless. All babies see a paediatrician regularly.

For the vast majority none of this is necessary and is no doubt a symptom of a privatised healthcare system which needs patients through its doors regularly. Of course there are also those women and children who have conditions picked up and treated where otherwise they might have been missed.

Annual gynae visits does seem excessive but we are at the other end of the spectrum - women who need to see a gynaecologist often dismissed for years before finally getting a referral, and in some cases being seen, getting an ultrasound and then being discharged without a diagnosis.

I saw two gynaes and had countless scans, internals etc through my teens - my endo wasn’t diagnosed until my second laparoscopy because even when they did the first one they didn’t look properly. Took ten years total.

There really needs to be a balance between these two systems. One in ten women have endometriosis, then there’s fibroids (more common), PCOS, other types of cysts, PID, cervical cell changes, cervical erosions, prolapses, menopause and related issues, and various other gynae conditions - gynae issues affect a significant proportion of women, it’s not just a tiny minority. If we aren’t all going to see a gynae routinely then GPs need to be more willing to refer (or rather the system has to support GPs to refer patients who need it rather than being set up to reduce referrals). There’s no point having universal healthcare if you can’t access the care you need. The stories I’ve heard over the years in endo groups are heart breaking.

waterbottle12 sorry to have taken up your precious time, but you engaged with my post. I'm not really up on walkie-talkie speak, am I supposed to say over and out now?