Why no routine annual conference gynaecological checks in UK?

[stoppedlurking56]

Am I missing something?

When I lived in Germany/Belgium all of my female colleagues would have annual appointments with a gynaecologist - like we do here with the dentist. This was years ago when we were all mid to late-twenties, and I forgot about it til after I came back here and had a pregnancy and hospital birth... I've always wondered if women's gynaecological health is worse here in the UK because of it.
How could I see a gynaecologist here for a full checkup - would I have to go private? I'm British and living in Scotland now, late thirties. I've never had such a routine annual check either abroad or here. I'd like to understand the differences in the systems.
I posted in FWR because it strikes me that women's health is pretty far down the NHS list of priorities - but interested in others' views. Am I right to notice this?

You don't need a smear more often than every three years, every 5 years if you are older. There is no benefit from having one more frequently - more frequent smears aren't associated with better cancer survival rates.

As far as I am aware there is absolutely no benefit to the bimanual pelvic exam that is done in the US - I have never heard of a doc actually picking up a case of ovarian cancer through this alone where there weren't other symptoms. And actually the American College of Physicians has just issued new guidance saying that yearly pelvic exams are not necessary. A 3 yearly smear, as per the NHS, is what they are recommending. However the cultural habit of having an annual gynae exam is going to be hard to break - after all women have been told for decades that it's the responsible thing for good little girls to do, so they have bought into it just as much as the medical profession has.

IMO telling women they need a yearly "womanly bits" exam is both unethical and anti-feminist. Unethical because it's a totally unnecessary intrusive examination, and anti-feminist because it's only women who get told that our reproductive systems are inherently likely to go manky.

OP there is nothing stopping you seeing an NHS nurse for a blood pressure check and maybe a breast exam, and you should be able to get smear tests, but you are going to get a funny look if you want an ultrasound when you are asymptomatic.

Would they scan your pancreas while they're at it just in case? What about lung and bowel cancers (much more common than ovarian cancer?) How's about a quick chest Xray with an upgrade to CT if there's anything dodgy looking?

How is preventive care for women anti-feminist?

It is really more of an annual physical -- you don't get a smear every year, you can tell them you don't want the manual pelvic exam. Nobody is forced to do anything. Like it or not our reproductive systems and our bodies in general do go manky and there are loads of things where early detection is key. I even knew someone who had a melanoma caught because her gyno noticed it and persuaded her to go to a dermatologist to get checked out.

Personally I preferred a system heavy on preventive care and where I could go see a gyno directly. In the US you used to need a referral to see a gyno but women's groups lobbied heavily to make it law that women could go directly to a gyno, seeing this as an important feminist issue.

Anti-feminist? But equality shouldn't be blind to actual physical differences, I thought. I'm not saying that our bits cause hysteria. I need to think about that argument some more before commenting fully.

I could see the anti-feminist argument if women were being frogmarched to the gyno and forced to submit to unnecessary exams every year -- but I don't think that's how it works in reality. Some women go every year (usually if they've had previous issues), some go every few years, some never go unless they have a problem. You don't necessarily get all the tests every time.

My personal feeling is that women's health is rather neglected generally and so anything that gives women more options to access is a good thing.

I had a friend who did a dissertation (nursing degree) on a comparison of cervical vs. prostate screening.The reason there isn't a mass prostate screening programme in younger men (under about 60, I think) is that it's detrimental - the idiopathic (doctor induced) damage done by unnecessary screening for false positives (Sevenzark's experience) outweighs the dangers of "misses" i.e. cases which aren't picked up until late on. The statistical analysis my friend did during his dissertation showed that if you applied the same evidence-based approach to cervical screening, certainly among young women (under 25) screening was counter productive, and at frequent intervals in older women the same held true.

So my feeling is that given that you have two testing programmes with similar issues regarding false positives/missed cases, but with rather different decisions being made by NICE etc. (IIRC the conclusion of his dissertation was that women were unnecessarily screened too frequently), then it's possible (not guaranteed) that there may be a feminist issue in here. Especially when the reasons for worrying about the effects of overtreatment are quality-of-life issues - typically a woman's ability to carry a baby to term (cervical incompetence due to shortening of the cervix is one possible issue from unnecessary treatment) or a man's sexual performance (I think something like one in three men is left with serious erectile disfunction after prostate treatment). Because healthcare professionals do have a long history of taking things that impinge on men's quality of life seriously while being dismissive of things that impact on women's quality of life.

However, the "may" in my last paragraph is important - it could also be that the cervical programme was already in place before people started carrying out this sort of detailed statistical analysis. (And the problem with statistical analysis is that all though it gives you the best outcome at a population level, it's an absolutely shit deal if you have the misfortune to get a rapidly developing case of cervical cancer two and a half years before your next screen is due).

Sorry - that should be "Sevenzark's experience with the cervical cancer screening programme" - I didn't mean to suggest you had a prostate, Seven!

It doesn't have to be overtly violent to be sexist/anti-feminist/oppressive. The overall message, megaphoned by media, that women's bodies are ticking time bombs and need more consistent observation (but only on certain parts that are cared most about within patriarchy) and the fact women are pushed not only to check more but are more blamed if our health goes wrong. Sexism can easily be seen to be part of it.

Prostate cancer is the most common cancer in cis men in the UK with over 41k in 2011 and is one of the big 4 (along with Bowel, Lung, and Breast), Cervical cancer 12th most common in cis women with just over 3000. Awareness of both is good and needed but the treatment both by the media and in medicine has an obvious bias. It does make quite a bit of difference. One is treated as just one of those things while the other leads to those suffering getting both questions on their smear schedule and sex life and more blame.

We could have preventative healthcare without the bias and a more comprehensive one as you described if there is evidence for it, it would take a lot of restructuring and searching within current medical practice, media, general education and so on. But right now, there are obvious bias within all of them on gender (even when men are the more likely sufferer).

It's worth also mentioning, though, that prostate cancer is, on the whole, a disease of old age and tends (though not always) to be slowly developing, and as one healthcare professional I know put it, "old men tend to die with it rather than from it." Cervical cancer is, I think, much more evenly spread across age groups and a much more aggressive disease.

I could see the anti-feminist argument if women were being frogmarched to the gyno and forced to submit to unnecessary exams every year -- but I don't think that's how it works in reality.

I decline cervical smears for reasons that are personal to me. I come under pressure to have one every single time I visit the doctor, even if it is not gynae related, because the computer system is set up so that the doctor is alerted to the fact you haven't had a smear recently and has to ask you. I have to explain myself every single fucking time and relive the reasons that I don't want one every single time just to get any care at all through the NHS. It is getting to be really, really intrusive, upsetting and coercive. The last time I was asked, a few weeks ago, I almost burst into tears in front of the practice nurse because I am so tired of having to retell my story over and over when I know it is in my notes. I've also just had to send a request off to the screening program to stop contacting me via post.

You are not allowed to just say no and have your choice respected - the system is not set up for that.

When I was prescribed the pill in the US, I was again pressured to have a pelvic exam every single time I went to have it renewed. When I declined exams I was treated with enormous surprise and obvious disapproval. The very last time I had the pill prescribed there, they wouldn't let me have it without giving me a breast exam. Which I didn't want and am perfectly capable of doing myself.

I'm thrilled for you if people respect your informed choices about your care and don't try to coerce you into exams you don't want, but that doesn't seem to happen to me unfortunately.

I'm sorry you've had that experience. I was referring more to the US system, as we were talking about places where you do have annual exams. It's true that if you're on the pill they will be a bit more insistent because the pill raises the risk of certain cancers and problems (and doctors get sued all the time in the US). But if you've had these problems in both countries it sounds like the problem is more with the guidelines in the first place than whether a system has annual exams or not.

I do completely agree that women should not be coerced into unwanted exams, I guess I don't see the annual exams as automatically doing so. I'm sure there are a lot of insensitive doctors out there though.

I think you don't really see how coercive the medical profession (on both sides of the pond) is wrt women's bodies until you try to opt out of something that is normalised in the way smears or pelvic exams are. I'm not knocking smears by the way. They are a fantastic screening tool (pelvic exams are of dubious value though). But for me the cost/benefit doesn't make it worth it.

It is the shaming and the boundary pushing and the total lack of respect for my capacity to make an informed choice about what interventions I do and do not want, and the fact that in the US it isn't even based on good science that makes me pissed off. It is what happens when poor guidelines meets patriarchal medical culture.

Some American health insurance is set up so you can't get it to pay for contraception if you don't have the annual smear and pelvic exam, which means the totally unnecessary and often painful pelvic exam is very much a feminist issue as access to contraception is being held to ransom.

Crap admin systems and staff training are also problems in most places, eg women in the UK being told they are too young for a smear, when if they have family history of gynae cancers or symptoms, they should be referred for one.

It is poorly evidenced and scientifically indefensible. The American college of gynaecologists acknowledge that "no current scientific evidence supports or refutes an annual pelvic exam for an asymptomatic, low-risk patient". They then come up with the nonsense that. "the College continues to firmly believe in the clinical value of pelvic examinations, While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients. Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician".

I don't feel an intimate examination is required to allow me to talk to my doctor or to tell me I am normal (unless I am specifically concerned). Frankly, I prefer my screening to be scientifically based because of the issues alluded to above. Screening is not a neutral thing - it can cause significant harm. What really makes me cross is that friends coming from a more commercial based system think we are offering crap care in the uk when actually it is a complete waste of resources that they have been conditioned to expect. I am not against bp screening etc and there is currently a large uk trial due to report in 2015 on the value of tv ultrasound screening for ovarian cancer but currently it is not recommended. I will base my healthcare needs on proven science rather than a "gut feeling" that sticking hands up a vagina every year is beneficial.

I had a quick look at ovarian cancer screening on google and cancer research said this about trans-vaginal scans:

"Transvaginal ultrasound
This is an ultrasound examination done by putting the ultrasound probe into the vagina. It gives a better picture of the ovaries than an ultrasound over the abdomen. Even so, it can still be difficult to tell whether there is a cancer on the ovary or just a harmless cyst.

There is no clear evidence so far that these tests can pick up cancers early and save lives. Doctors are waiting for the final results of 2 large UK trials to be published in 2015. These trials looked at ovarian cancer screening in the general population and those at high risk of developing it. There is information about research into screening for ovarian cancer in this section."

I don't think that the lack of screening using this on the NHS can be taken as letting women down can it?

• of course trans-vaginal scans are quite intrusive so for someone like FairPhyllis it would be yet another thing.

I'm not saying don't get then if you are offered them and don't want them, I'm more saying that given it's an intrusive procedure and doesn't seem to be very effective, not having them on the NHS is a neutral or good thing depending on your take on the whole better safe than sorry / spend money where it's needed approach.

"Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician"

OMFG am genuinely taken aback by that. That's appalling.

I know - patronising paternalism much?! There was a big stink in America when the ACOG changed its guidance last year to suggest you don't have to do a pelvic exam on under 21s - lots of people saying they would be doing it anyway. It's nonsense and I really feel it is fee related. Anyone asking for annual penis exams to reassure of normalcy on a population basis?

GPs are given an incentive to get every eligible woman up on the couch for a smear test. That is why women are harassed every time they pay the good doctor a visit.

Smear tests are different - the incentivisation may be questionable but the science is not completely absent. External genitalia examination and Bi-manual internal exams which are the standard annual test in the us (and other healthcare systems) is nonsense. This is a commercial and a feminist issue.

I have a note on my records at my GP practice from the senior partner that I should not be provided with the pill unless I agree to a smear. Happy to prescribe without bp check, weight check or general history but absolutely essential that my cervix is swabbed for some reason.

Oh and I need counselling about whatever trauma I've experienced. No, I just don't want one. I've done my research, I've seen the damage caused to two of my sisters from unnecessary treatment. I'm happy with my position. I simply don't wish to have one. And when I do feel that it would be appropriate, I'll happily make an appointment with the Practice Nurse.

Needless to say the family planning clinic are much less backwards and were very supportive of me being an active participant in my healthcare.

Off topic I know, but I have never understood the relationship between the Pill and optional cancer screening. IMO, any GP that holds contraception hostage until you agree to a smear test should go back to school to learn about informed consent.

Can I throw in a cultural note here though, as an American?

I am not actually appalled by that statement because I know that sex education and general knowledge of reproductive health in the US is extremely dire in many places. There are huge parts of the country where students learn little more than abstinence and nothing about contraception. Abortion is barely still legal in many states, you can bet many young women don't know anything about it. There is essentially a culture that aims to keep women ignorant about their bodies, about sex, so that they will be good little submissive wives. Even in liberal parts of the country, Americans can be pretty prudish about sex.

I cannot tell you how many women I knew in my 20s who did not know what a clitoris was, who didn't understand basic biology, who thought if you jumped up and down after sex you couldn't get pregnant. THAT is appalling.

So yes, I can see why that statement sounds paternalistic, but there is no doubt that gynos do a huge amount of education in their work. It's not because 'women are dumb' it's because American women are purposefully kept ignorant and shameful of their own bodies.

I'm not saying all gynos are great or that there aren't problems in the system but to see them as part of the patriarchy just does not make sense to me. There are so many ways in which they are a corrective to the patriarchy as it exists in the US.

Well I didn't expect such debate and information, thank you everyone. I will definitely follow up those links and await the result of the trials mentioned. Sorry to hear that so many of you have had bad experiences. Mine were more in the other direction - absence of interest/care from the medical profession. Very helpful discussion.

That is all appalling dreamingbohemian (and the lack of knowledge is def not ltd to the us - it is still seen with depressing regularity in the uk) and I am sure the education received via a well woman check is great but I still struggle to believe that public health education rather than a genital and vaginal exam YEARLY is the way forward which is what the ACOG recommend. There just isn't any evidence that it is a useful procedure to prevent cancer or other pathology in low risk individuals and the OB GYNs should be highlighting this. They aren't. People just might need to be shown where a clitoris once (and I have my doubts). They don't need to be reminded every year. I do think intimate examinations in females are tolerated without question where they would not be in males. As a pp alluded to, people feel comfortable with the healthcare they are raised with. This doesn't mean it should not be questioned.

dreamingbohemian the ignorance you talk about is appalling and the idea of gynaes educating women is fine but do they really need to stick their hands up their vaginas unnecessarily in order to do that?

ACOG say yes which is ridiculous. They actually state that there is no scientific basis for doing so, but carry on because it's a good conversation starter. I mean, really?!