For most women, the physician they are most likely to see on a regular basis is their gynecologist. Women visit their gynecologist's office for birth control, STD testing and any number of other health matters, from vaginal infections to menstrual cramps.
The American College of Obstetricians and Gynecologists (ACOG) recommends annual check-ups, starting with a visit between ages 13 and 15. Most women will continue to see a gynecologist or other reproductive healthcare provider, such as a midwife, throughout their lives. So how can you maximize your yearly visit with the gynecologist? Suzanne Merrill-Nach, MD, a gynecologist in private practice in San Diego, Calif. and ACOG spokesperson, offers some expert advice about maintaining your reproductive health.
What tests are done in the routine visit?
The Pap smear is done annually in women over 21 or younger women who are sexually active. The Pap can be deferred to once every three years in women over 30 if you are at low risk and you've had three normal Pap smears. If you had genital warts, have multiple sexual partners, or have had multiple partners in the past, or are a smoker that puts you at higher risk of developing cancer of the cervix, that means you should continue to do yearly Pap smears. But we still do the yearly checkup whether or not you're getting a Pap smear to make sure everything looks OK, because we're checking other things such as the breasts, ovaries and menstrual cycles.
On a breast exam, we're looking for any changes in the skin, any nipple discharge, and any lumps or bumps that seem different. For the pelvic exam, we check the vagina for signs of infection, which is discharge or redness. On the cervix, we look for any changes on the outer part of the cervix, any white areas, any bumps. We try to assess the size and the overall shape of the uterus and we make sure that the ovaries aren't enlarged.
Many gynecologists also do basic preventative care for women. We do blood pressure screening, diabetes screening, cholesterol screening, and even check vaccinations such as tetanus shots.
How do you know if a STD screening should be performed?
It's important to tell the person doing your exam if there's been a change in your sexual relationship. Typically, a STD screening should be done yearly in women up to 26. After that, we should do them ideally before you have a new partner, and the new partner should also be tested. If you've changed partners or you have other high-risk behaviors, then an AIDS test should be offered.
If you know your partner has multiple partners or suspect it, you're still at risk, even if you haven't had other partners, so you should be tested for STDs. It's also good to let your gynecologist know if your partner has genital warts or herpes, even if you don't have any evidence of these illnesses.
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What about your health history is important to share?
At each visit it is important to go over your family history, your personal history, how your health has been over the past year, your family history in regard to cancers, diabetes and heart disease. If you have a family history of premenopausal breast cancer or breast cancer in multiple family members, you should tell your provider. We recommend mammograms beginning at age 40 if you have no family history of early cancer.
If you have a family history of ovarian cancer, women might be able to decrease their risks by being on birth control pills even if they don't need them for birth control. Unfortunately, we don't have any good tests for ovarian cancer at this time.
What other kinds of information does your reproductive healthcare provider want to know?
We would want to know about your menstrual cycle. Period flow varies tremendously from woman to woman. A normal menstrual cycle is between 21 to 35 days intervals, and they should last less than seven days. If you're having such heavy periods that you're soaking through pads or tampons in two or three hours, that would probably need to be evaluated.
You should tell your provider about any discharge that seems different than what you're used to, especially with itching or irritation or burning or odor. Many women who have had recurrent or prior yeast infections who are having similar recurrent type symptoms can use the over-the-counter medicines. But if you're not sure, or if you haven't had them before, it's better to be examined.
If your menstrual cramps are not easily treated with over-the-counter medicines, or if you're all of a sudden having problems or cramps that are getting worse, that should be evaluated. You should also mention if mood symptoms are bothersome or if they interfere with your relationships and your ability to function at work or with family and friends.
Most women experience bladder infections, which is the fairly sudden onset of having to pee all the time, pain or pressure with urination or at the end of urination, blood in your urine, backache and fever. We would want to talk about urinary tract symptoms during the visit.
Is it appropriate to discuss depression with your reproductive healthcare provider?
Some gynecologists will do more primary care than others. But, it's always OK to discuss it, and if the doctor or provider isn't comfortable with treating things outside the GYN field, they can always refer. But it's good to bring it up, and doctors need to know other issues that are going on in your health. If we're taking care of certain body systems, we don't want to ignore all the rest. Sometimes there's an overlap between PMS and anxiety and depression, and it's hard to tell. So it's OK to bring it up and help tease out whether it seems to be PMS or an ongoing kind of problem.
How can the patient and reproductive healthcare provider choose the best possible birth control method?
It's really a combination of individual preference and the individual's history and other health issues. It's important that a woman evaluate all the different methods that are available to her. If you have trouble remembering pills, or if you have a history of blood clots or high blood pressure, then it's not going to work real well for you. For people who have trouble remembering pills, there are patches or vaginal rings, which give them the option of the same hormones without having to take a pill. Some people are very happy with condoms, and if used correctly and consistently, they are a good option. For people who are pretty sure they don't want a pregnancy in the next five to 10 years, but want to keep their options open, there are good long-term methods, such as IUDs. And there are permanent methods for people that are really sure they never want to get pregnant. So you have to look at the individual, and how they like to space pregnancies or to prevent them.
A woman should also be aware of the option for emergency contraception to be used if you have unprotected sex or a condom breaks or falls off, so you should preplan for that during the visit.
Do women ever bring up issues pertaining to libido?
I'd say after vaginal infections, it's the most common thing that is discussed. The birth control pills, or estrogen hormones in older women, can decrease libido. When you add that to a very hectic lifestyle, it can be a real problem. So it's important to bring it up.
When should you discuss menopause?
Perimenopause is the time of irregular periods before your periods stop. So if you're having irregular periods, hot flashes or night sweats that are bothersome, it's time to bring that up. If symptoms are interfering with your sleep or your function at work, and if it's a problem for you that you might want to do something about, then it's time to talk to the gynecologist.
What does your reproductive healthcare provider need to know about plans for pregnancy?
Before you plan on getting pregnant, it's good to discuss that with your gynecologist. We'd like to know before you're pregnant that you are immune to German measles. It's also important that you take a multivitamin at least a month prior to conception. Folic acid can decrease the risk of certain spinal cord and brain abnormalities. We also will usually go over a genetics questionnaire about your family and your partner's family history, looking for things that might be passed along to your child. There are different tests that can be done prior to pregnancy to see if you're at risk of certain gene mutations such as cystic fibrosis and sickle-cell anemia, for example.
Do you have any overall advice for a woman who is preparing for her GYN visit?
Try to schedule routine exams for about the middle of a cycle, usually two weeks after a period starts. If you're having some vaginal discharge or irritation, we need to know that before we do the speculum exam. If you are having any bleeding, or if you've had recent intercourse or put vaginal medicines in the vagina, it may affect the quality of the Pap smear, which is a test to detect cancer or pre-cancerous changes, sexually transmitted diseases or other infections. So basically, it's best to have nothing in the vagina for several days prior to your routine visit. And don't douche, because that washes out cells and other things that we need to see.
I think it's a good idea for every woman to write down when she has periods, so she knows what her cycle length is: how long from the first day of one period to the first day of the next. I think it's important to be sure you write down symptoms and bring them up at the beginning of the appointment rather than after the exam. If you're preparing for your yearly checkup, it's good to write down if you're having any questions. It's very common to get into the doctor's office and kind of forget the little things that you were also needing to bring up. It's not uncommon for somebody to have their exam, be dressed and say, "Oh, I forgot to ask you about…."
The other is to find out how you're going to get the results. What's the practice of the office that you're visiting? Do they always call you with the results? Do they mail you results? Should you call them? If you should call for the results, you should know what time frame to make sure you get the results. Every office is a little bit different, but you want to make sure you understand what to expect.
It's also important to be realistic about what you can take care of at your yearly checkup. You may want to have a separate visit to deal with bigger issues and not try to squeeze it into your yearly checkup.
