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Womens Health Exams in Naturopathic Practice Tara Gignac BSc, ND OAND Convention 2014 Niagara Falls, ON

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Why?

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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.

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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.

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Canadian Task Force on Preventive Health - Recommendations 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 4074 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 isnt enough quality evidence to support it either way. http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast- cancer/clinician-bse-recommendation/http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast- cancer/clinician-bse-recommendation/

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Ovarian Cancer 2,600 women newly Dx this year. 5th most common cancer for women and is the most fatal womens 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.

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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/appraised- guidelines/2013-ovarian-cancer/

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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

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CA-125 The cancer antigen 125 (CA 125) blood test isn't recommended for women with an average risk of ovarian cancer. 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. Many other conditions also can cause an elevated CA 125 level, including: Diverticulitis Endometriosis Liver cirrhosis Normal menstruation Pelvic inflammatory disease Pregnancy Uterine fibroids 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 high- risk situations, there's some disagreement about the usefulness of the CA 125 test. 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.

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Why continue to do them? Because we are naturopathic doctors NOT conventional doctors. Function vs. Pathology Prevention of disease early intervention.

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Case CA-125 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 =

Who we have seen The numbers Agenumber 704

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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. Satisfactory for evaluation 2. Transformation zone component identified. 3. Negative for intraepithelial lesion or malignancy.

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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.

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What we have seen - PAP