Senolytics - A Promising Anti-Aging Therapy, But Not There Yet

Senolytics are a new and emerging therapy that target aging cells known as senescent cells. Senescent cells, also referred to as ‘zombie cells,’ accumulate with aging, release pro-inflammatory markers, and are resistant to apoptosis, the process that shuts down/kills a cell. Senolytics aim to reduce the number of these cells, and thus impair the processes that lead to adverse conditions associated with aging, such as frailty, cancer, heart disease, dementia and more.

Not surprisingly, many companies that offer supplements and herbal therapies have jumped on this prematurely and are offering over the counter senolytics marketed as a cure all anti-aging miracle. While there is a lot of interest in senolytics, there are only a handful of clinical trials currently underway. These all tend to look at the role of senolytics in a particular disease state, such as osteoarthritis or diabetes, as opposed to aging prevention. Generally, it is far too early to demonstrate the benefit of these therapies, and still even too soon to comfortably describe long term risks and side effects.

Therefore, I do not recommend any over the counter use of senolytics, nor any off label prescribing of these therapies as of yet. It’s an exciting area of research and one that I will certainly pay attention to, but evidence is lacking on their exact benefit and safety profiles. So for now, keep to the practices that we know to be safe and beneficial for staying young and healthy - exercising with a cardio goal of 150 minutes per week, a diet high in vegetables, fruit, lean proteins, and whole grains, stress management strategies, adequate sleep, sun protection, smoking avoidance, alcohol moderation and so on!

Perioral Dermatitis

Perioral dermatitis is a skin condition that is commonly seen in women between the ages of 15 and 45, though it can also present in men, older individuals, and younger children. This rash is located around the mouth, and usually appears as small 1-2mm red bumps or blisters. We don’t fully know what causes this skin condition, though often it is linked to the use of topical steroids (like hydrocortisone) or other skin irritants (like from cosmetics).

Perioral dermatitis is challenging to treat, because most often the recommendation is 'zero therapy.’ Essentially this means stopping all lotions, creams, make-ups, topical medications etc. It can be very distressing for patients to experience this facial rash and yet not be given anything to make it go away! Further, they are advised to not try and conceal the rash as well, lest make up further irritate the skin and prolong the condition.

Most of the time the rash will resolve, albeit slowly - generally a few months of ‘zero therapy.’ In more than mild cases, there are a few anti-inflammatory or antibiotic ointments that could help, or at least not exacerbate the rash the way steroids would. And in severe cases, an oral antibiotic called tetracycline can be used - this medication is also used to treat severe cases of acne.

Unfortunately perioral dermatitis can recur, even a few years after successfully treating. The best prevention available is to stick with gentle skin cleansers and bland, fragrance free non-occlusive lotions or creams.

Manage Menopause with Direct Access Primary Care

The symptoms of menopause go well beyond the commonly portrayed experience of hot flashes, night sweats, and mood swings. Estrogen plays a role in most systems of the body, and it’s loss can be felt in them all.

About 70% of women will experience the musculoskeletal syndrome of menopause, which presents as body pain - muscles, joints, generalized stiffness. Also common is sleep disturbance, and not just from night sweats. Women in menopause often have trouble falling asleep and staying asleep. The lack of estrogen in brain tissue leaves menopausal women with a sense of brain fog, forgetfulness, and/or word finding difficulties. And unsurprisingly, low estrogen levels affect the genitourinary system, resulting in vaginal pain, pain with sex, frequent urinary tract infections and so on.

Often the direct effects of loss of estrogen in one area are made worse by indirect effects from loss of estrogen in other areas. For example, as mentioned above, low estrogen levels affect women’s memory and sense of mental sharpness, plus their ability to get a good night’s sleep. Having poor sleep further effects memory and sense of mental sharpness, creating a negative feed back loop.

The best approach to treating the symptoms of menopause is hormone replacement therapy, to raise the levels of declining estrogen which seems to be at the heart of menopausal misery. Many studies show the benefit of hormone replacement therapy on treating hot flashes and vaginal dryness/pain. More research is also starting to show that estrogen replacement can help address the other menopausal symptoms, like joint pain or brain fog.

While hormone therapy does carry some risk and might not be for all women, it is generally safe and preferred for women under the age of 60 suffering from menopausal symptoms. The first step is discussing symptoms with your doctor. For recent decades, women have generally suffered the symptoms of menopause in silence, believing them to be inevitable and the treatment too risky. Lately however, following a NY Times article in 2023 (titled Women Have Been Mislead About Menopause, definitely worth a read!), renewed public interest has encouraged women to seek out relief from what are often intrusive and overwhelming symptoms.

Sometimes women’s menopausal concerns are brushed aside by their doctors, either because of time constraints or lack of education about menopause or mislead beliefs about risks of treatment. With direct access primary care, I have more time and opportunity to work with women suffering the effects of menopause. From avoiding misleading over the counter products, reviewing certain lifestyle adjustments to avoid triggers, implementing a strength training program to limit effects of weight gain, muscle wasting, and fat redistribution, to talking through the risks, benefits and various formulations of hormone therapy, I am here for the menopausal journey!

Home Monitoring for Blood Pressure

High blood pressure, or hypertension, is something that I commonly manage as a primary care physician. Most people know when they go see a doctor or even sometimes a dentist, they will have their blood pressure checked. More recently though, we are moving away from using these in office blood pressure readings to make a diagnosis of high blood pressure or manage medications.

This is because blood pressure is not a static number - it goes up and down over a 24 hour period based on many factors, such as your mood, what you had to eat or drink, what your activity level is, and even what time of day it is! When diagnosing and treating high blood pressure, we are ideally trying to gauge a person’s resting blood pressure. That can be hard to do if you only have one blood pressure reading every few months as you are rushed through a cold and clinical environment.

Now of course, with direct access primary care, visits are not rushed and I aim to make my office feel more like a relaxing spa than a clinical space. Still, the blood pressure reading that I take is just one point in time and not your typical home environment. So instead of relying on in office blood pressure readings, I find it’s much better to have patients check their blood pressure several days a week at home and record the readings to bring to the office visit.

I also encourage patients to bring their home blood pressure cuff to an appointment, so we can compare the automated reading with a manual reading to calibrate the cuff. Knowing how to correctly take a blood pressure at home is also essential to getting the most accurate readings possible. Here are some tips:

Sit comfortably with your legs uncrossed and feet flat on the floor for at least 5 minutes. Rest your arm on a counter or a table, about the level of your heart. Apply the blood pressure cuff and hit start as per your cuff’s instructions. Ignore the first reading that you get. Rather, wait 2 minutes and check again, recording this second reading instead. Note the time of day and anything you think might be relevant - how you are feeling, if you just ate, if you took any medication etc. Bring this record to your appointment and review with your doctor!

Having more data points like this will help you and your doctor determine the best treatment course to improve your blood pressure and thus lower your risk of cardiovascular disease!

Heel Pain - Plantar Fasciitis

Plantar fasciitis is a common cause for foot/heel pain evaluated by primary care providers. It’s something that happens in adults of varying activity levels, from those who are sedentary and overweight to those who are avid long distance runners. The presentation is classic, and usually all that is needed to make the diagnosis is a history and physical exam (meaning usually no need for x-rays!). Patients with plantar fasciitis experience pain at the bottom of the heel, most pronounced when first starting to walk. For example, the first steps getting out of bed in the morning can be excruciating, but then all is well by the time you leave for work. The pain returns with walking after periods of inactivity throughout the day.

The plantar fascia is a thick white tissue that connects the heel bone to the toes, and provides support for the arch of the foot. Having flat feet is a risk factor for developing plantar fasciitis, and walking around bare foot usually exacerbates the pain. The good news is that plantar fasciitis usually improves with time. Doing stretches and exercises at home can speed recovery, and using arch support with inserts or supportive shoes may help as well. Persistent cases may require a referral to podiatry or orthopedics for a steroid injection, but usually this is not necessary - about 80% of patients will have complete resolution of their symptoms within a year.

So if you recently started getting outside and going for walks thanks to this gorgeous weather, but are starting to notice discomfort in one area or another, consult with your DPC provider now! Addressing a pain while it’s whispering rather than screaming will likely give you a better chance of preventing a more serious injury!

Plan Your Garden!

One of my favorite things about spring leading into summer is planting my garden. I did not, unfortunately, inherit my Dad’s green thumb, but nonetheless I very much enjoy growing various vegetables and fruits in my back yard. I find lots of success with peppers, squash, green beans, cucumbers, and even watermelon.

You don’t have to have a large outdoor space to be able to experiment with gardening. Many plants do very well in pots placed on a back or front porch, and some can be grown indoors as well if you have an area with enough sunlight. It’s a great activity to do with kids - a chance to get outside and get their hands dirty! It’s fun to check in on the growth progress each day, and teach kids the responsibility of watering and weeding.

Plus, growing your own fruits and vegetables is so healthy. I find people tend to eat much better in the summer, thanks to the abundance of road side locally grown fruit and vegetable stands Harford County has to offer. But maybe this year you can make your own little (or big!) garden to enjoy! Just remember to apply plenty of sunscreen before going to work!

Pre-Travel Consultation

Many people take advantage of the opportunity Spring Break offers to travel internationally. Amidst the excitement of planning and packing, a visit to your primary care is often overlooked. For those traveling abroad, and especially off the beaten path, it’s a good idea to sit down with your doctor before taking off and discuss a few relevant topics:

Immunizations - some countries or specific areas of countries will have immunization requirements or recommendations. Not all primary care offices will carry the needed vaccines, but your PCP can review with you what vaccines are recommended, what the risks/benefits are, and where you can go to get them. It’s also a good idea to make sure you are up to date with all age appropriate (Shingles, Pneumococcal etc) and season appropriate (Influenza, COVID etc) vaccines.

Malaria Prophylaxis - travel to certain parts of the world may expose you to more than just itching and discomfort from mosquito bites! Your PCP can review ways to prevent mosquito bites (clothing, DEET, bed nets) and also prescribe you medication to prevent malaria, if that’s a risk in the area you are traveling. Depending on the type of prophylactic treatment advised, you might need to start a few days to a week before you leave, so don’t put off your PCP appointment to the last day!

Antibiotic Prophylaxis - sometimes, again depending on where you are traveling and your personal history, your PCP might want to give you a prescription for travel antibiotics. This way you can be counseled on how to self treat illnesses like traveler’s diarrhea, urinary tract infections, and/or sinus infections.

Medication Review - A thorough review of your current chronic medications is wise before leaving for a trip. Your PCP can also print you a copy of your active medications and a summary of your health conditions, so you can pack these in your bag along with your pill bottles.

Special Considerations - Some trips may require additional discussion, such as treatment and management of altitude sickness or sea sickness, sun protection and management of sun burns, water and car safety, DVT prevention etc.

Safe travels to all!

Spring Has Sprung! Here Comes The Pollen…

Spring is finally here, and though the days keep flipping between bitter winds, glorious sun, and dreary rain, the pollen persists! My household is a very atopic one - that’s the medical term referring to a genetic tendency to develop allergic diseases, like allergic rhinitis, asthma, and eczema - and so this time of year can be tough. My boys love playing outside, rolling in the grass and sliding in the dirt. Besides coming in with ruined clothes and dirty hands, they also sport constantly running noses, puffy eyes, and itchy skin!

Avoidance of allergens is near impossible for my family. I convince the kids to shower or bathe after playing outside to manually remove as much pollen/grass/etc as we can, and right after apply lotion to high yield eczema spots (usually elbows, knees, and behind the ears for us!). Nasal saline sprays or irrigation (like Neti Pot or Navage) is a safe non-medicated way to relieve allergy symptoms, though not something kids are always willing to let you do.

In terms of medications, there are generally three different pathways of attack to combat allergies. Over the counter allergy pills are usually antihistamines, like Loratadine and Cetirizine and Diphenhydramine. Some are more sedating than others, but all work to block histamine receptors. Histamine is the substance that is released during an allergic reaction and leads to most of the typical allergy symptoms.

Another pathway to combat allergies is using a nasal steroid spray to reduce inflammation. The inflammatory pathway is also activated with allergies, further producing reactions like swelling and hence nasal congestion. Nasal steroid sprays, like Flonase and Nasacort, are also available over the counter. Studies suggest that using a nasal saline irrigation prior to using a medication nasal spray can help it work better, which makes sense - flushing out all the dried crusted mucus will clear the way for the medication to reach the spot it needs to get absorbed.

The third pathway to combat allergies is via a medication called montelukast, or Singulair. This one is by prescription, and works by blocking leukotriene receptors, which are another type of inflammatory causing substance involved in the process of both allergies and asthma. This medication should be taken at night - not because it is sedating, but rather because it takes several hours to start working, so best to take at night so it’s at peak effect when you wake up the next morning!

Because all of these medications work differently, those with severe allergy symptoms can use them in combination to survive allergy season. If that doesn’t work, or you can’t tolerate them for some reason, then the next step is to the Allergist! Allergy shots, or immunotherapy, is a long process that requires a lot of dedication, but also has a lot of great success in the end.

Good luck to all my fellow allergy sufferers out there!

Open House 3/29

Looking forward to hosting an open house this weekend, Saturday March 29th, to show off my brand new beautiful office! It’s going to be a beautiful warm day, so while you are undoubtedly already out and about in Harford County, come stop by between 11am and 2pm to say hello! You can bring family and friends, grab a snack, enter a raffle, peruse the office, and enjoy the art gallery of local work that is now my hallway! Opening Slack Family Practice and bringing direct primary care to Harford County has been a dream come true. The response in the community has been so supportive, which is really not surprising at all. People are ready for a change in healthcare, ready to embrace direct patient and physician communication, and eager to shrug the constraints, hidden charges, and frustrations of the typical insurance based system. The flexibility, personalization, and laid back nature of direct primary care is refreshing and welcomed. So if this is something you have been considering, or a new concept that you would like to hear more about, come chat on Saturday! I look forward to seeing you there!

Shout Out to PT!

I had a lovely lunch with my neighbors at Drayer Physical Therapy! I find many reasons to refer patients for physical therapy as a first line treatment. It’s a great way to approach various conditions without using medications, thus avoiding the potential for medication side effects and interactions. Most people are probably aware of physical therapy for orthopedic issues - things like tennis elbow, sprained ankles, rotator cuff tears etc. But PT offers so much more!

One common medical issue I refer for physical therapy is vertigo - see my other post about BPPV. Vestibular therapy is quite successful in replacing misplaced crystals. I also use physical therapy for acute treatment of migraines with a technique called dry needling. Pelvic floor physical therapy addresses urinary incontinence issues. I learned the therapists at Drayer can do splinting, orthotics, and even measure for custom DME like walkers and wheelchairs.

Physical therapists do an excellent job of assessing patients, creating treatment plans, and educating about home routines and self care. They can help address acute pain, manage chronic issues, and (my favorite!) teach preventative measures. The group I met today is clearly passionate about patient care, and I plan to take full advantage of this close resource!

Day Light Savings

Time to Spring Ahead this weekend! I know, I don’t look forward to it either - no one likes losing an hour of sleep. But looking on the BRIGHT side, we do get some extra time in the sun. Soak up some extra sunlight Sunday morning, preferably combined with some physical activity like taking a walk. Both the light in the morning and the exercise will help you fall asleep better that night, despite the time difference.

If you are very sensitive to disturbances in sleep schedules, start now - try going to bed 15 minutes early each night leading up until Saturday. This might help out with kids too!

Be extra strict with your sleep hygiene right now - avoid caffeine in the afternoon, eat dinner at least a few hours before bed, and limit your screen time as well.

Luckily most devices that tell time update automatically these days, but for anything that doesn’t, especially like bedside alarm clocks, change the time as you are going to bed Saturday to avoid confusion when you wake up.

Mostly though, keep in mind that day light savings is just another signal that SPRING IS ON THE WAY!

Lymphedema

Lower leg swelling is a common concern brought to primary care doctors. While leg swelling can be a sign of other underlying disorders, such as blood clots and heart failure, it is also commonly caused by lymphedema. Lymphedema is an accumulation of fluid and/or adipose tissue as a result of an issue with the body’s lymphatic drainage system. Often the underlying issue is from damage from something like an injury, surgery, cancer treatments, or lymph node removal, but other times the cause is genetic, hereditary, or simply unknown.

The swelling with lymphedema generally starts slowly and progresses. At first it is usually ‘pitting,’ which means the kind of swelling you can poke with your finger and see the finger mark remain. As the swelling progresses and becomes more chronic, it may no longer be pitting but rather measures as an increase in circumference of the extremity. Often the swelling is asymmetric, with one leg or arm measuring bigger than the other.

Sometimes patients with lymphedema complain of a heavy sensation in the affect limbs, with aching discomfort and stiffness. Depending on the degree and duration of swelling, rashes and other skin lesions can develop. Others are primarily bothered by the appearance. Either way, treatment options are available! Exercising the affected limbs helps to prevent swelling from getting worse. It is also recommended to wear compression garments, including with exercise. I have also had patients see great results going to a lymphedema center, where a specialized physical therapist does manual lymphatic drainage massages.

If you are having concerns about lower leg swelling, definitetly make an appointment with your doctor! Your PCP can help rule out the more dangerous threats, and then guide you towards the best way to manage going forward!

Weekend Warrior Exercise

Often when I counsel my patients on exercise recommendations from the American Heart Association, I am met with a scoff and an eye roll. It’s not because my patients don’t want to exercise - most people readily acknowledge how much better they feel, both mentally and physically, when they get into a regular exercise routine. Rather, the response comes as a skeptical ‘sure, I totally have time for that’ reflex. Trying to find 30 minutes in a day between commute, work, helping the kids with homework, transporting to various sports and after school activities, figuring out dinner, prepping for the next day, and finally getting to that load of laundry that has sat in the washer now for so long it needs to get re-washed (just me?) is daunting if not impossible.

The good news is that recent studies show that meeting the goal of 150 minutes of moderate physical activity per week over 1-2 days offers similar health benefits compared to spreading that exercise out over 5-6 days! Doing this pattern of exercise that concentrates physical activity into one or two days on the weekend is known as a weekend warrior workout. An example might be an hour of cardio Saturday morning - running, biking, swimming - with a strength training session later in the day - body weight exercises, pilates, weight lifting etc. Then on Sunday, 30-60 minutes of activity like hiking or tennis, followed by a light activity such as yoga.

Rather than stress about trying to squeeze in a work out on a packed week day, thereby counteracting the stress relieving benefits of exercise, plan out a weekend warrior workout! Mix up your work outs to keep them interesting, and choose activities that you enjoy for the positive reinforcement. If you are just starting an exercise routine after a long hiatus, start light and gradually increase intensity over time. Remember that about 80% of your exercise should be done at a light or moderate intensity. If it hurts to exercise, you might be doing something wrong or just need to pull back the intensity for a bit! Remember to stretch, remember to hydrate, remember to refuel with healthy foods, and of course remember to have fun!

Now get moving this weekend!!

Dealing with Dry Skin

I always find this part of winter to be tough - once Valentine’s day comes and goes, it feels like we should be turning the corner towards spring, yet the cold lingers, and we often get hit with one more snow or ice storm. Typically this time of winter is marked for many by dry skin. Hands are often hit the worst, as we are constantly reminded to keep up with washing and hand sanitizer to avoid the many circulating illnesses, on top of exposure to the cold and dry climate.

Dry skin is irritating, itchy, sometimes painful. Like most conditions, prevention is much more successful compared to treatment. Don’t wait for your skin to be cracked and bleeding before starting a good moisturizing routine! I recommend thick creams or ointments, such as Cetaphil, Eucerin, Aquaphor, and good old Vaseline. Avoid harsh and overly perfumed soaps - again I like Cetaphil for cleaning. It’s best to lather on moisturizers right after getting out of the bath or shower, and keep up with applying at least twice a day.

For stubborn or symptomatic (itchy/irritated) areas, over the counter 1% hydrocortisone can be used without a prescription and can offer relief, though often stronger, prescription strength steroid creams are required for a short time. If you think this might be the case for you, reach out to your direct access primary care for help!

Influenza

Most of you probably already know, but there is A LOT of illness going around right now! My older son was recently diagnosed with Flu A, and he was one of about seven absences in his 4th grade class this week. Thankfully, albeit very reluctantly, he gets his flu shot every year and so his course was fairly mild. He complained of body aches, sore throat, headache, sinus congestion, and had a temp around 99 - 100 for a couple of days. Despite this, he was able to enjoy two days on the couch watching Netflix with just enough misery to also get spoiled with gatorade, blankets, and cuddles.

There are treatment options available for the flu, which help to lessen the severity of symptoms and shorten the course of the illness. The key to these medications being effective, however, is to start them early in the course of your symptoms. If you think you might have the flu, it’s worth going to urgent care (or much better yet, your direct access primary care!!) to get tested sooner rather than later. This is doubly important if you have other conditions that put you at risk for a rough go of it with the flu - things like asthma, diabetes, heart disease, COPD and more.

With such high rates of respiratory illness circulating right now, take extra precautions. Wash your hands often, wear a mask in crowded places if you are vulnerable, and stay home if you aren’t feeling well!

Weight Loss Medication at SFP

Now that my physical office space is up and running, I have also begun offering weight loss management, including medications! Initially I planned on offering this service to non-members, but I have learned that my primary care upbringing has made it difficult for me not to get involved in all aspects of a patients healthcare. When patients start taking GLP-1 medications like semaglutide and tirzepatide, they quickly find that they work - weight loss happens fairly efficiently. With those changes, there are often adjustments that need to happen with chronic medications like blood pressure medications or cholesterol medications. Side effects need to be managed, blood work needs to be followed, and counseling on nutrition and exercise is essential. This is why I decided to only offer weight loss medication to SFP members - those I am already seeing for primary care.

However, I recognize that joining SFP is not necessarily low cost, though I do feel it is high value. Still, in order to make the prospect of doing both affordable, I am offering access to medication at a significantly lower price. Many weight loss clinics in the area charge about $115 per injection of semaglutide or more. When considering the discounted price of the medication that I am able to offer, combined with the price of membership spread out over 52 weeks, the overall cost of both would still be cheaper - about $110 per injection!

So if you are thinking of starting a weight loss journey, reach out to learn more about the benefits of doing a program through direct access primary care! Not only will you be able to start these highly effective medications, but you will have access to email, text, or call your doctor should any questions or concerns arise. And that is not limited to questions/concerns regarding the weight loss medication - you would have the full benefits of direct access primary care, such as management of chronic conditions, preventative healthcare, and easy access for any urgent care needs. Get started today!

Coronary Artery Calcium Scoring - What is it, and who should have it done?

Coronary Artery Calcium (CAC) Scoring is done by a CT scan of the heart, looking for calcium plaque build up in the coronary arteries. This is a screening test, which means it is done on people who feel well - no chest pain, no problems breathing, no known heart disease. However, it is not a test that is recommended for everyone.

I find this test most helpful in patients who are at a higher risk for heart disease based on their cholesterol results or family history, yet aren’t certain they want to start taking a statin medication (such as Crestor, Lipitor). In these patients, having additional data to gauge heart disease risk helps in making the decision on how aggressively to treat.

There are some potential down sides to getting this test done. For one, a CT scan exposes a patient to radiation (though a small amount, about the same as a mammogram). Further, though the scan is intended to evaluate the heart, it will show the entire chest. This brings the risk of incidental findings, which I and most doctors dread, because it often leads to unnecessary testing, procedures, and cost. This is one reason why it’s always important to think critically about ordering tests. One good question to ask is, will this test change what I plan to do?

So if you have high cholesterol or other risk factors for heart disease, talk to your primary care about your personal risks and benefits of Coronary Artery Calcium Scoring!

First Week Down!

We are wrapping up the first week at SFP! On Monday this week we spent the day hanging and decorating and organizing, as well as last minute electrician fixes, but since then we have had a steady stream of in-office appointments and I am loving it! I say ‘we’ now because I am thrilled to have brought on my office manager, Melissa. We worked together for many years before SFP, and like riding a bike we are seamlessly into our routine of patient care.

The office has come together beautifully, and I look forward to hosting an open house with date TBD. Part of the reason I am waiting to set a date is because the Harford County Art Society is allowing my office to be a satellite location for local art work to be displayed and purchased! I want to be able to showcase their work during the open house, so I am waiting for that installment before setting a date. Still, the office is open so if you are a part of the SFP family reach out for an appointment. If you are interested in becoming a member, please do the same!

As I have said before, every patient interaction I have further reinforces my decision to adopt the direct access primary care model. This is even more true with seeing patients in the office. I love that visits are unhurried, more relaxed, and comprehensive. I’m looking forward to catching up with even more patients next week!

How Often Do I Need A Pap Smear?

January is cervical cancer awareness month, so today I want to talk about updated guidelines for pap smears. These updates are really not new (2012 for ACS, 2018 for USPSTF, 2021 for ACOG) but I still find that patients are surprised when I tell them they no longer need a pap smear every year. Some patients even push back, worried that something will be missed if a pap smear is not done every year. However, studies have shown that testing every 3 years results in similar rates of cancer detection compared to testing annually. Further, testing annually leads to about triple the number of downstream interventions like colposcopies and surgical procedures. So essentially, testing every year leads to more invasive tests/procedures without actually detecting more cancer!

In women aged 30-65, testing for HPV with the pap smear can be done instead of just doing a pap smear. With this co-testing method, paps only need to be done every 5 years. HPV is the virus that causes cervical cancer. There are several variants of HPV, and the test can detect the ones that are highest risk to cause cancer.

Pap smears can be stopped at the age of 65, if there has been adequate prior screening that has been negative. Some prefer to continue screening longer, through age 74, assuming a healthy population with a life expectancy of at least 10 years. High grade abnormalities on pap smears are actually rare in the older population of women who have had previously negative screening. If screening history is abnormal, unknown, or incomplete, then it’s best to continue to screening.

As with anything, my approach is always to have a discussion with patients about risks and benefits. Keep in mind, these are general recommendations for a healthy and low risk population. If you have conditions that place you at higher risk, such as HIV or long term immunosuppressive therapy, or a history of abnormal pap smears, then there are different recommendations to follow.

As a direct access primary care physician, I offer routine GYN care including pap smears and HPV testing if indicated.

First Mammogram - Check!

I got my first mammogram done today! I am slightly behind schedule, compared to when most women start routine screening mammograms, but I would not say I am delinquent. The recommendations for breast cancer screening for women vary, with some organizations (American Congress of Obstetrics and Gynecology, American College of Radiology, United States Preventative Services Task Force) advising a start age of 40, and others (American Cancer Society, American College of Physicians) suggest age 45 or even 50.

The discrepancy comes from weighing risks vs benefits of mammography at age 40-49. Younger women who are pre-menopausal have denser breast tissue, which makes the images taken with mammography difficult to see and interpret clearly. This tends to lead to the need for call backs, with requests from the radiologists for more images at different views to try and determine if they are seeing something of concern or not. That question of a potential abnormality often leads to even more additional testing, like ultrasounds and biopsies. All of this can cause a lot of anxiety in patients, as well as increased medical spending and exposure to risks associated with invasive procedures.

On the flip side, if mammogram screenings are not started until later in life, there is a potential that cancer can be missed. And breast cancer is so well publicized now, it feels like we all know someone - personally, professionally, celebrity - with breast cancer. So most women scoff at the idea of missing a breast cancer and are ready at 40 and a day to get started.

My approach with patients is always to have an open discussion about risks and benefits to determine when the right age to get started with mammograms is for them. For all of my patients going for their very first mammogram, I make sure to let them know how common it is to receive a call back, to try and offset some of the anxiety that this can trigger. In addition to the likely denser breast tissue reducing visibility, there are no prior films for comparison. In the future, a baseline mammogram is used for comparison and helps to reduce the need for more images.

In reality, the process of getting a mammogram was no big deal. Shout out to Advanced Radiology in Aberdeen! I had a great experience this morning. The new facility there is beautiful, the appointment was quick, and the mammography tech was cheerful, offered clear instructions, and even shared with me the same warning about call backs that I do with my patients! Fingers crossed I won’t need to go back for more images, but if I do, I would definitely return there.

So if you have been dragging your feet on getting a screening test done, there is no better time than now to reach out and get something scheduled! With direct access, making appointments to discuss preventive care is easy and seamless, so get started today!