Transcript Tara Gignac, BSc., ND - Ontario Association of Naturopathic Doctors

Women’s Health Exams in
Naturopathic Practice
Tara Gignac BSc, ND
OAND Convention 2014
Niagara Falls, ON
Why?
The clinical trends
There is a strong trend in conventional
medicine away from physical exam.
 It is time consuming, uncomfortable for
both patient and doctor and the evidence
does not seem to support it.

Breast cancer
There were approximately 22,700 new
cases of breast cancer and 5,400 deaths
from breast cancer in Canada during
2009. Incidence and case-fatality rates
increase with age.
Canadian Task Force on Preventive
Health - Recommendations
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Does not recommend clinical breast exam in healthy women
without risk or breast changes.
Nor do they recommend the teaching of self breast exam in these
women.
Who are “healthy women”?
Women aged 40–74 without personal or family history of breast
cancer, known BRCA1 or 2 mutation, or prior chest wall radiation.
Both of these recommendations are weak b/c there simply isn’t
enough quality evidence to support it – either way.
http://canadiantaskforce.ca/ctfphc-guidelines/2011-breastcancer/clinician-bse-recommendation/
Ovarian Cancer
2,600 women newly Dx this year.
5th most common cancer for women and is
the most fatal women’s cancer.
Why?
Symptoms are commonly suffered by
women – pelvic pain, frequent or urgent
urination, feeling full quickly or bloating.
And the symptoms occur often in late
stage.
Canadian Task Force on Preventive
Health - Recommendations
does not recommend routine screening for
ovarian cancer – no data to support PE,
transvaginal US or CA-125.
http://canadiantaskforce.ca/appraisedguidelines/2013-ovarian-cancer/
US Review of the literature

Dr. Humphrey of the American College of Physicians
undertook a review of the research on pelvic exams
when the new cervical screening guidelines in 2012
did not address the issue.
What they found:
-"positive predictive value" of pelvic exams for
ovarian cancer was less than 4 percent
- 11 percent to 60 percent of women complained
of pain or discomfort from the procedure.
- One study showed, 174 abnormal screenings
occurred among 2,000 healthy, average-risk women.
Follow-up tests resulted in 31 surgeries, which found
ovarian cancer in just two of the women
CA-125
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The cancer antigen 125 (CA 125) blood test isn't recommended for women with an average risk of ovarian
cancer.
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While women with ovarian cancer often have an elevated level of CA 125, an elevated CA 125 level doesn't
always mean you have ovarian cancer. Some women with ovarian cancer never have an elevated CA 125 level.
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Many other conditions also can cause an elevated CA 125 level, including:
Diverticulitis
Endometriosis
Liver cirrhosis
Normal menstruation
Pelvic inflammatory disease
Pregnancy
Uterine fibroids
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Women with a high risk of ovarian cancer, such as those with mutations in the BRCA1 and BRCA2 genes, which
increase the risk of breast and ovarian cancers, may consider periodic CA 125 testing. But even in these highrisk situations, there's some disagreement about the usefulness of the CA 125 test.
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A study of 78,216 women ages 55 to 74 randomly selected to receive either an annual CA 125 test and pelvic
ultrasound screening or the usual medical care showed that CA 125 test and ultrasound screening did not
reduce ovarian cancer deaths. The study also found that false-positive tests led to additional testing and
procedures that sometimes resulted in serious complications.
Why continue to do them?

Because we are naturopathic doctors
NOT conventional doctors.
Function vs. Pathology
Prevention of disease – early intervention.
Case CA-125
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C.S. – 41 yo female. 40lbs over-weight.
Using hormonal birth control for greater
then 10 years. Diet and lifestyle – SAD.
Found out aunt had ovarian cancer – wanted
to do blood test.
CA-125 = 36 (normal range = <36).
Retested in 1 month still 36.
Benefit of test? Connecting her to the real
things she can be doing to prevent ovarian
cancer – maintaining a healthy body weight.
Cervical Cancer
In 2011, an estimated 1300 new cases of cervical cancer were diagnosed in
Canada, with about 350 deaths.
 The number of cases of diagnosed cervical cancer increases among women
aged 25 years and older, peaking during the fifth decade of life.
 The incidence of and mortality due to cervical cancer in Canada have
decreased substantially in the past 50 years and long-term survival rates
after treatment are high.
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Since the dawn of the PAP smear:
Lifetime incidence was 1.5% in 1972, and is now 0.7%.
Risk of death from cervical cancer is now 0.2%. Most advanced cervical
cancer (and associated mortality) occurs among women who have never
undergone screening or who have had a long interval between Pap tests.
Between 1981 and 2009, incidence rates for cervical cancer in Ontario
declined by 38 percent and mortality rates declined by 59 percent.
The new guidelines - 2013
Cervical cancer screening is recommended every three years
for all women starting at age 21 who are or ever have been
sexually active.
 Sexual activity includes intercourse, as well as digital or oral
sexual activity involving the genital area with a partner of
either gender.
 Women who are not sexually active by 21 years of age
should delay cervical cancer screening until sexually active.
 Regardless of sexual history, there is no evidence to support
screening women under 21 years of age.
 Based on the latest clinical evidence, cervical cancer
screening every three years is effective.
CMAJ January 8, 2013 vol. 185 no. 1 First published
January 7, 2013, doi: 10.1503/cmaj.121505
http://www.cmaj.ca/content/185/1/35.full
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What has stayed the same
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The recommendations for follow-up of abnormal cytology have not changed (we will
discuss later)
https://www.cancercare.on.ca/pcs/screening/cervscreening/abnormal_followup/
Women who are immunocompromised should receive annual cervical cytology screening
(e.g., women who are currently taking long-term immunosuppressants or those who are
HIV-positive).
Screening may be discontinued at the age of 70 if there is adequate negative screening
history in the previous 10 years (i.e., three or more negative tests). Incidence of cervical
cancer is low in older women who have been adequately screened.There is no evidence
to suggest continued screening in women with new partners.
Screening can be discontinued in women who have undergone a total hysterectomy for
benign causes and who have no history of cervical dysplasia or HPV infection.
Women who have undergone a subtotal hysterectomy and retained their cervix should
continue screening according to the guidelines.
Women who have sex with women should follow the same screening regimen as women
who have sex with men.
Pregnant women should be screened according to the guidelines; however, care should be
taken not to over-screen. Only conduct Pap tests during pre-natal and post-natal visits if
the woman is otherwise due for screening.
Keeping our patients calm

Cervical cancer is rare in women less
than age 21. From 2003 to 2007, there
were on average fewer than 10 cases in a
five-year period in women aged 15 to 19
across the entire province. No deaths
from cervical cancer occurred in this age
group for the same time period.

Cancer Care Ontario. (Ontario Cancer Registry 2010). Prepared by Surveillance, Prevention and
Cancer Control, Cancer Care Ontario.

Sasieni P, Castanon A, Cuzick J, Snow J. Effectiveness of cervical screening with age: population
based case-control study of prospectively recorded data. BMJ 2009;339:b2968.
Keeping our patients calm
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Young women have high rates of low-grade cytological abnormalities that are,
in most cases, transient human papillomavirus (HPV) infections, many of which
are non-oncogenic.
Approximately 90 percent of young women will clear an HPV infection within
24 months without consequence to their cervical health.
Treating young women with cervical dysplasia is linked to a small but significant
risk of adverse future pregnancy outcomes (e.g., preterm delivery or low birth
weight).
Research demonstrates that very few low-grade cervical intraepithelial
neoplasia in women in their early 20s would progress to cancer within five
years if left untreated.
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Moscicki AB. Cervical cytology testing in teens. Curr Opin Obstet Gynecol. 2005 Oct;17(5):471–5.
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Bartholomew DA. Human papillomavirus infection in adolescents: a rational approach. Adolesc Med Clin. 2004 Oct;15(3):569–95.
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Moscicki AB, Shiboski S, Hills N et al. Regression of low-grade squamous intra-epithelial lesions in young women. Lancet. 2004, 364(9446): 1678–83.
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Sasieni P, Castanon A, and Cuzick J. The Impact of Cervical Screening on Young Women: A Critical Review of the Literature 2002–2009. NHS Cancer Screening
Programmes Publication No 31. Sheffield; February 2010.
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Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of
cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008;337:a1284. doi: 10.1136/bmj.a1284.
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Bruinsma F, Lumley J, Tan J, and Quinn M. Precancerous changes in the cervix and risk of subsequent preterm birth. BJOG. 2007;114:70–80.
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Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early
invasive cervical lesions: systematic review and meta-analysis. Lancet. 2006;367:489–98.
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Sasieni P, Castanon A, Parkin DM. How many cervical cancers are prevented by treatment of screen-detected disease in young women? Int J Cancer. 2009; 124: 461–4.
The Risk
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A cohort study published in 2005 did not
find a benefit with annual screening.1 This
corroborates evidence that showed that
the excess cervical cancer risk when
screening every three years compared to
annually was approximately three in
100,000.2
1. Coldman A, Phillips N, Kan L, Matisic J, Benedet L, Towers L. Risk of invasive cervical cancer
after Pap smears: the protective effect of multiple negatives. J Med Screen. 2005;12(1):7–11.
2. Sawaya GF, McConnell KJ, Kulasingam SL, Lawson HW, Kerlikowske K, Melnikow J, et al. Risk of
cervical cancer associated with extending the interval between cervical-cancer screenings. N
Engl J Med. 2003;349(16):1501–9.
Ontario Cervical Screening program
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In 2012, the OCSP released updated cervical
screening cytology guidelines. In the future,
the OCSP will use a population-based
registry to send test result letters to women
in Ontario, who have had a screening test or
are due for their next screening, and will
send invitation letters to women who have
not been screened for cervical cancer in the
prior three years. These letters will serve as
reminders and encourage these women to
talk to their healthcare providers about
cervical cancer screening.
Sample letter
Invitation to screening
 https://www.cancercare.on.ca/common/pa
ges/UserFile.aspx?fileId=292805
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Sample letter
Results
 https://www.cancercare.on.ca/common/pa
ges/UserFile.aspx?fileId=287681
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Sample letter
Reminder to get test done
 https://www.cancercare.on.ca/common/pa
ges/UserFile.aspx?fileId=292805
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HPV testing
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Cancer Care Ontario’s screening guidelines recommend that
Ontario transition to primary HPV screening. Cancer Care Ontario
is actively working with the MOHLTC to implement the HPV test
as a primary tool for cervical cancer screening.
In the meantime, HPV testing should only be considered as a triage
following an atypical squamous cells of undetermined significance
(ASCUS) cytology result for women who are age 30 years and
older. Be- cause HPV testing is not currently publicly funded and is
not part of the organized screening program, many women do not
opt to have the HPV test. An appropriate alternative following an
ASCUS cytology result is to repeat the Pap test in six months
(refer to 2012 Ontario Cervical Screening Cytology Guidelines
Summary: www.cancercare.on.ca/screenforlife).
If you and your patient decide to proceed with HPV testing based
on the above cytology management guidelines, please contact your
local laboratory to determine how to order the test and the cost
to the patient.
$139 our cost - LifeLabs
StoneTree Naturopathic Clinic
WELL WOMEN VISIT
The WWV day
The numbers
 2003-2008 (pre-WWV days)
avg 5/yr
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2009-2014 (post-WWV days)
avg 25/yr
Room set-up
Supplies Check list
Using lube
http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2669006/
 http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3601690/

Forms and Handouts
Forms and Handouts
Forms and Handouts
Reviewing the P/E
http://www.youtube.com/watch?v=T5N8mt
9CXS4
 http://www.youtube.com/watch?v=b0VjvB
vSf6A
 http://www.youtube.com/watch?v=_hl7isL
pN8w
What you should see
What you might see
What you might see
Who we have seen
The numbers
 Age
 <20
 20-29
 30-49
 50-69
 >70

number
1
10
44
47
4
What we have seen - Breast
Most WNL
 occasional FC breasts and bumps we
check yearly.
 Case of inverted nimple (K.M. 49yo) –
referral back to MD
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What we hope to see for everyone
1.
2.
3.
Satisfactory for evaluation
Transformation zone component
identified.
Negative for intraepithelial lesion or
malignancy.
Transformation zone NOT
identified.
This commonly occurs during pregnancy and
in postmenopausal women. However, women
who have no endocervical cells on Pap
smears are not at increased risk of having
dysplasia. The Pap smear should be repeated
only if the patient has not had a normal Pap
smear in the previous 1 to 2 years or if poor
future compliance is suspected.
Mitchell H, Medley G: Longitudinal study of women with negative cervical smears according to
endocervical status. Lancet 337:265-267, 1991.
What we have seen - PAP
<20 20-29 30-49 50-69
70+
Atrophy
NSRC
InfE0
Candida
0
0
1
0
0
1
0
1
7
1
2
0
16
3
0
1
1
0
0
Other things we’ve seen
Partially obstructed by bacteria –
transformation zone
 Atrophy, inflammatory effects
 Reactive endometrial cells and
inflammatory effects
 Endometrial cells present in a
women after age 40 (consistent with
menstrual data) and non-specific
reactive changes.

Non-specific reactive changes
Changes in the skin cells of the cervix which suggest
that a healing process is underway or that the cervix
is reacting to the presence of a virus or bacteria.
 Need to R/O infectious disease

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This is not considered dangerous or increased risk of
cancer. However the PAP is suggested to be redone
sooner then normal – from 6-12 months because:
Reactive or Reparative changes
make the Pap more difficult to interpret and a
dysplasia could be missed.
Specific reactive changes
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Equals specific evidence of STD
Trichomonad, bacterial vaginosis (Clue Cells)
Pap not great for this – culture better.
HPV can be diagnosed
Actinomyces – in IUD users
Fungal organisms morphologically consistent
with Candida species
Predominance of coccobacilli consistent with
shift in vaginal flora
Inflammatory effects
A very common finding – often not significant.
 Inflammation merely means the cervix is irritated for some reason. In the
absence of any symptoms or any other significant abnormality on the Pap,
it can be safely ignored.

If it is severe or obscuring then it is likely more significant
 R/O STD. If not there – conventionally they just wait and retest
 If inflammation is severe enough, it may interfere with the ability of the
cytologist to accurately read the Pap. In such cases, it is wise to repeat the
Pap at more frequent intervals (6-12 months)

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One study has shown cervical neoplasia in 12 of 96 women (13%) who had
inflammatory changes on Pap smear.[14] Increasing the frequency of Pap
smears after finding inflammation and colposcopic examination of patients
who have persistent inflammation might be warranted
Wilson JD, Robinson AJ, Kinghorn SA, et al: Implications of inflammatory changes on cervical
cytology. Br Med J 300:638-640, 1990.
Atrophy

This is an expected finding in menopausal women not
taking estrogen replacement therapy.
If this is the only abnormal finding and the patient has
no symptoms, it can be safely ignored.
 If the patient complains of vaginal dryness, irritation,
painful intercourse, vaginal discharge, odor, or other
symptoms, then the Pap finding of atrophic vaginitis is
helpful in determining the cause.
 If the Pap smear has other abnormalities, treating the
patient for 2-3 weeks with Premarin 0.625 mg PO
daily and then repeating the Pap will often result in
the other abnormality disappearing.

Endometrial cells present

This indicates that endometrial cells, normally located inside
the uterus, have been shed and are appearing at the mouth of
the cervix.

This is a normal finding in women of childbearing age,
particularly if they are close to starting or just finishing their
menstrual period. Menopausal women taking estrogen
replacement therapy may also normally show a few
endometrial cells on their Pap smears from time to time.

In menopausal women not taking estrogen replacement
therapy, the presence of endometrial cells is an abnormal
finding and should be followed up with an endometrial
biopsy to try to determine the reason for the presence of
these cells.
Reactive, reparative atypia
Presence of immature cells formed
in the process of healing or regrowth
of the squamous epithelium
 is a common finding that follows
treatment of dysplasia and other
conditions such as cervical or
vaginal infections.
 It is a benign finding that does not
warrant increased surveillance.

Unsatisfactory smear
WHY?
1. The doctor or nurse practitioner did not
take an adequate sample.
2. If you are pregnant or take oral
contraceptives hormonal changes may
influence the smear quality.
Repeat test in three months. This is the
minimum time needed to replace new cells
on the cervix.
Abnormal Paps
An abnormal Pap test does not mean you
have cervical cancer.
 Approximately four million Pap tests are
done every year in Canada.
 About 8% (over 325,000) have abnormal
results. The number of women diagnosed
with cancer is around 1400.

When it’s bad news
Of all the abnormal Pap test results in
2012, 89.9% were low-grade (51.6% were
atypical squamous cells of undetermined
significance or ASCUS, and 38.3% were
low-grade squamous intraepithelial lesions
or LSIL).
 Only 5.9% were high-grade squamous
intraepithelial lesions (HSIL).
 3.4% were atypical squamous cells, cannot
exclude HSIL (ASC-H).
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What to do with…
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Atypical Squamous Cells of Undetermined Significance (ASCUS)
Atypical Squamous Cells, Cannot Exclude HSIL (ASC-H)
Atypical Glandular Cells (AGC), Atypical Endocervical Cells,
Atypical Endometrial Cells
Low-Grade Squamous Intraepithelial Lesion (LSIL)
High-Grade Squamous Intraepithelial Lesion (HSIL)
Squamous Carcinoma, Adenocarcinoma, Other Malignant
Neoplasms
Unsatisfactory for Evaluation
Satisfactory for Evaluation, No Transformation Zone Present
Benign Endometrial Cells on Pap Tests
https://www.cancercare.on.ca/pcs/screening/cervscreening/abnormal_f
ollowup/
When to refer

Taken from Standards of Practice – BDDT-N
2.3 Actively consult and/or refer as appropriate to other health professionals
when the patient’s condition so warrants in providing optimal care.
Referral is so warranted when:
a) a life-threatening situation occurs or is suspected
b) the diagnosis or the treatment of a patient or of a specific
condition is not within the scope of naturopathic practice
c) the diagnosis or treatment of a patient or specific treatment
requires expertise or technology that is not available to the naturopathic
doctor
d) a diagnosis is required but cannot be confirmed with the training
and technology that is available to the naturopathic doctor
e) response to treatment is not adequate or the patient’s condition
deteriorates
f) a second opinion is desired
Q&A
THANKS