Welcome to UAB MedCast,
a continuing education podcast for medical professionals. Providing knowledge
that is moving medicine forward. Here's Melanie Cole.

Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole.
And joining me is Dr. Ashley Wright. She's an obstetrician-gynecologist and an
Associate Professor at UAB Medicine. And she's here to highlight gynecologic
care at UAB. Dr. Wright, it's a pleasure to have you join us today. And as
we're talking about what's involved in routine gynecologic care, tell us about
the training you need to be in your field. Are more women entering this field?
How do you feel the field is advancing right now?

Dr. Ashley Wright: Great. Thanks for having me. In
general, so when you think of a general OB-GYN, that requires the typical four
years of college, four years of med school, and then four years of general
OB-GYN residency. There are several different subspecialties of OB-GYN that
require additional fellowship such as high-risk OB or GYN-oncology that
requires usually three extra years of fellowship. But just for general OB-GYN,
it's a four-year residency. As of recently, well probably really over the past
20 years, over 80% of OB-GYN residents are actually females. And so since we're
taking care of women, I think that's kind of great for many different reasons.
But I think in general, it's a good thing because we're taking care of other
women. Not that having a male OB-GYN is a bad thing, but I think we can just
have great communication and really be able to be in more intimate scenarios
with women which I think ultimately makes them more comfortable as well.

Melanie Cole: I agree with you, and there's nothing
wrong. Men have been in that field for years. But agree, I think that it is
wonderful that women are now really going into these fields that were male
dominated and really being able to help women one-on-one. Such an important
point. Are there age ranges where women's healthcare may be different? What are
some of the highlights of care during the years? And you can even start and
give us a brief overview of the teen years as they start to see the
gynecologist for the very first time, and then all the way up through where I
am, somewhere in the menopausal years.

Dr. Ashley Wright: Yeah, so great question.
Specifically, I do get this question a lot, is when should my daughter or when
should my friend are whatever the age may be, when should they start coming to
the gynecologist? Whether it's a 15-year-old or a 25-year-old, when should this
really start? And in regards to adolescents specifically, one thing that has
changed over the past couple of years, which I know we'll get to a little bit
later, but when do women really need to start getting Pap smear screening? And
that's really at age 21. And so prior to that with adolescents, we are
concerned about vaccinations, STI screening if they are sexually active, and
certainly contraception as well. Because if they are sexually active, we don't
want them to have an undesired or unplanned pregnancy because that can be much
more difficult to manage. We can also start at that age to approach family
history, because that's becoming more and more important particularly when it
comes to breast cancer screening, ovarian cancer screening. And I think that's
just going to become more and more important through the years.

Through the reproductive years, of course, we want to be
talking about contraception and when they desire pregnancy and help optimize
their risk factors potentially for making a pregnancy more high risk.
Additionally, we want to do cervical cancer screening. And something that also
has changed recently is the age of colonoscopies has actually now dropped to
age 45 in all individuals, just because the risk of colon cancer is not
necessarily increasing, but the rates of colon cancer have started increasing
more. So those recommendations have changed over the past couple of years.

And then when you get to be a menopausal, we want to talk about
mammograms and bone density screening, and then of course, continuing
colonoscopy screening and cervical cancer screening, if that's indicated.

Melanie Cole: Well, that was a comprehensive list. Thank
you so much. Very well done. In regards to gynecologic care, one of the things
I find most interesting about your field Dr. Wright, is how do you guys know?
How are you so smart that you know and you can figure things out because so
many of our symptoms that women have, whether it's irregular periods or heavy
bleeding or the most common things, bloating, and all of those things that go
along with women as we grow are so nonspecific and we come to you and we say,
"This is what's going on," and then you take it from there and try
and figure out whether it's fibroids or ovarian cysts or whatever it is. Tell
us a little bit about what we're supposed to do. What are some of those
symptoms that you feel are most important if a woman is talking to her primary
care provider or coming to her gynecologist?

Dr. Ashley Wright: Certainly, one of the big things that
makes us always concerned for multiple reasons, but particularly when it comes
to menstrual health would be abnormal bleeding. And it's hard to know if your
bleeding is abnormal, because certainly when an adolescent or young woman
starts her period, it is going to be irregular for a couple of years and that's
normal, that's physiologic for that even to happen for two years. But if you
don't know, it's always better to ask and ask lots of questions and then come
in for regular screening, whether that's every year, which is most of the time
what we recommend for your pelvic exam and your cervical cytology screening or
Pap smears, as well as STI testing. But you're right, sometimes bloating can be
a very non-specific symptom. And unfortunately, there can be a lot of causes of
that. And so I always use the mantra of, "Well, if you don't know, just
ask." And so, that's the nice thing about our field is that when you take
care of a woman through her pregnancy or through multiple pregnancies, a lot of
times they can just say, "Hey, this wasn't going on before the pregnancy.
What's this about?" And a lot of times that helps us because we've taken
care of them for so long, just to have that relationship.

Melanie Cole: Well, you are really like detectives in so
many ways, and women's bodies are so complicated. You mentioned cervical
cytology recommendations. Let's speak about that, Dr. Wright, because due to
HPV tests and what we've learned about the links to cervical cancer, some of
those have changed. And there's been some controversy between those and
mammograms. I'd like you to speak to cervical cancer and what you're looking
for and what you want women and their providers to know.

Dr. Ashley Wright: Sure. Absolutely. So really it was
2011, 2012, that major changes to the cervical cytology recommendations happened.
The first of which I mentioned before, but no Pap smears are indicated or
needed prior to the age of 21, period. It used to be that women, for example,
or adolescents would have to have a Pap smear, let's say, at the health
department when she was trying to get birth control pills. And that is not the
case any longer. It's just not necessary.

From ages 21 to 29, it's recommended to do cytology alone every
three years. And then beyond that, from ages 30 to 65, you have a couple of
options. You can do both cytology and HPV testing every five years or cytology
alone every three years. There's some other studies that have shown we don't
necessarily do this here for insurance reasons, but you can also do primary HPV
screening alone because it's HPV that's active that can cause cervical cancer
and that can cause cervical pre-cancers as well, and so that's what we really
want to pick up on.

The other thing that's important with this that I still have
patients referred all the time is that after a total hysterectomy, which
includes removal of the cervix, their Pap smears are not indicated any longer
as long as the hysterectomy was not done for CIN 3 and was done for benign
reasons. And so it is not necessary to do a Pap smear after a hysterectomy,
which takes a lot of women by surprise because a lot of times they've been
coming every year for exams, and then all of a sudden you tell them,
"Wait, you don't need a Pap smear anymore," and so there's a lot of
education that I know personally I've done and I know our group has done
through the years, just educating women about what that means.

Melanie Cole: That's so interesting. And what great
information. What about breast cancer screening? What's changed there?

Dr. Ashley Wright: Yes. So a lot of the things that are
interesting about breast cancer screening is family history. And so that has
changed dramatically over the last 10 to 20 years, because of the rise of
genetic testing and the more availability there is now. And so, family history
is essential when you're trying to determine not only when to start breast
cancer screening, but also how early. So there's different scientific bodies
throughout the United States that make recommendations on breast cancer
screening. And that's where the controversy is because some say, "Well,
no, you really don't need to do this at age 50," and some say, "Well,
no, we really should do it at 40." But this is what we really recommend
now, and this is based on the Women's Preventative Service initiative that includes
ACOG, the American Academy of Family Physicians, American College of
Physicians, Nurse Practitioners in Women's Health. So multiple different bodies
have come together to try to determine, "Okay, what should these
recommendations really be?"

And it is, so you can start at age 40, but talk to a woman
about this, depending on the family history and that there is an increased risk
of a false positive, which means they'll be more likely to find something
abnormal there, which can cause a great deal of anxiety, understandably. And so
having that conversation at age 40, just so that she can be aware of what to
expect. Definitely start by age 50. Try to do at least biannually and as
frequently as annually and continue through at least age 74.

Now, again, family history here is essential. So let's say we
have patient with a family history of a BRCA mutation, then she needs to really
be seen by a genetic counselor and possibly have genetic testing as well. In
which case, the just recommended breast cancer screening may be earlier for
her, if not more comprehensive, such as breast MRIs. And then certainly, there
are some people even without the BRCA mutation that have an increased risk of
breast cancer because of their family history. And so those are the patients
that you really want to be able to identify earlier, maybe even earlier than
age 40, which is why having that family history is so important.

Melanie Cole: Certainly true. And as we get ready to
wrap up and we learn more about gynecologic cancers, but survivorship is continuing
to grow as well, where do you see your field and the coordination of care
between gynecologic-oncologists, other healthcare providers, medical and
radiation oncologists, the patient's own OB-GYN, the patient's own
obstetrician-gynecologist, to allow for compliance with cancer follow-up care
and routine health maintenance as you've been discussing here today.

Dr. Ashley Wright: Right. Yeah, absolutely. And
sometimes that's tricky depending on what specific area we're talking about.
This is where knowing genetic testing and knowing family history is really
essential because certainly at UAB we have through the gynecologic-oncology
department called the Lynne Cohen Clinic where we can send patients that may
have an increased risk of family history of ovarian cancer and other GYN
malignancies.

And so a lot of times what we'll do is we may make that initial
recommendations for them to be seen. Let's say, it's somebody who wants to have
children and so obviously she doesn't want to have a hysterectomy yet. And so,
we may make that initial consultation to that clinic and then take care of the
patient and survey that patient through the years and then maybe make a
referral back when childbearing is complete. Sometimes, let's say a patient
does have cancer. And then she is cleared of cancer and then the patient comes
back to see us just for routine care, whether it's Pap smears annually, then we
make those recommendations. Luckily for us, we have a pretty good working
relationship with those groups. And I think that's also important and
essential, just to be able to make sure that we are doing the appropriate
management and follow-up. But OB-GYN is a team sport, for sure. It's a team
specialty, whether it's taking care of women in pregnancy or whether it's taking
care of women maybe in menopause with an increased risk of different types of
cancer. And so I think that communication amongst all providers is essential to
make sure that patient gets the appropriate care that she needs.

Melanie Cole: Certainly is, and thank you so much, Dr.
Wright, for highlighting gynecologic care at UAB and through the years for
women. Thank you again for joining us. And a physician can refer a patient to
UAB Medicine by calling the MIST line at 1-800-UAB-MIST, or you can always visit
our website at uabmedicine.org/physician.

That concludes this episode of UAB MedCast. For updates on the
latest medical advancements, breakthroughs and research, be sure to follow us
on your social channels. I'm Melanie Cole.