Good evening and welcome to doctors on call.

I'm Dr.

Chissa Kitey, a hospitalist with Aspirus St.

Luke's and faculty member at in the department of family medicine and behavioral health at the University of Minnesota Medical School here in Duth.

I'm your host for our episode tonight on women's health.

The success of this program is very dependent on you, the viewer.

So, please call in with your questions or send them in to our f to our email address ask at pbsnorth.org.

Our panelists this evening is Dr.

Colleen Evans from Essentia Health in Duth.

Our medical students answering the phones tonight are Sophie Lemir from St.

Paul, Minnesota.

Amy Dedrich from Bloomington, Minnesota, and Paige Kaski from Two Harbors, Minnesota.

And now on to tonight's program, Women's Health.

So maybe I'll just start.

Dr.

Evans, would you explain?

I know you're a a gyne gynecologist who specializes in oncology.

Could you tell our listeners what exactly you do?

Sure.

So as a gynecologic oncologist, I take care of women who have a diagnosed um gynecologic cancer either of the uterus, cervix, ovary, fallopian tube, vagina or vulva.

Um I take care of patients who have a suspected malignancy and I take care of patients who have complex um pelvic problems that might potentially need surgery.

Good.

And then I was just um so so you could take care of things that are non-cancerous for example.

Um one thing that I know that you do a lot with our abnormal pap smears for example and not all of them are for example cancer right away.

Could you explain maybe to our audience what happens when you have an abnormal pap how that's handled and and what to expect?

Sure.

So pap smears in general are a screening tool for cervical cancer.

There's two parts.

Uh the first part is looking at the cells underneath the microscope, trying to decide if they look normal or abnormal.

And then the second part is trying to determine if those cells have been infected with the HPV virus.

Um once you have your pap result, if it is abnormal, then it typically reflexes to further testing if that's necessary.

Sometimes that means repeating your pap smear.

uh several months later.

And sometimes that means doing a procedure called a culposcopy.

A culposcopy is a detailed exam of the cervix and the vagina, occasionally the vulva.

Um and it involves biopsies.

If those biopsies show precancerous changes or cancerous changes, that's typically when I become involved.

It's typically the general obstatrician gynecologists or trained family practice doctors who take care of these initial culposcopies.

Good.

Okay.

You mentioned HPV so it might be a good chance to talk a little bit about that because I know we have a a vaccine for that and that vaccine helps potentially cure a cancer.

Um so when do we give that vaccine?

Do you know like for example if I had an abnormal pap would I want to still get the vaccine?

Do you could you help guide our audience and who might want to get the vaccine and how it might be helpful?

Sure.

So the HPV vaccine has been around for a long time.

It is incredibly effective at preventing precancerous and cancerous changes not only in the gynecologic tract but also in anus because anal cancer is also related to HPV and also head and neck cancer can be related to HPV.

So there is new data that was just released by the American College of OBGYn that was talking about how we in the United States are now at a point where we're starting to achieve herd immunity.

And that means that we've had enough patients and males and females who have been vaccinated with the HPV vaccine that we're seeing reduction in precancerous and cancerous changes.

Even in those patients who have not received the vaccine, they are reaping the benefits of having had this vaccination.

Wonderful.

Um I was wondering um let me think more on the vaccine just a little bit perhaps.

So it would be beneficial if you are maybe somebody who hadn't received the vaccine but are older, you could still get that vaccine until age.

Sure.

I think that the current guidelines are up until about age 46.

The vaccine can start at the age of nine.

We know that children who receive vaccines have a more robust immune response than adults who receive vaccines, but it does not mean that if you have not been vaccinated for HPV that you would not benefit from receiving the HPV vaccine.

Good.

Thanks for that discussion.

I think it's such a good discussion because it's one of those vaccines that we could potentially use to cure cancer.

So, we could get rid of cervical cancer if we were to maximally vaccinate our population.

Um, let's just change subjects for a little bit if that's okay.

How about if we talk a little bit about everyone's favorite topic these days, which is menopause.

Sure.

All right.

So, menopause is such an interesting phenomenon.

It's um something that is seen in humans and in some whales.

I think orcas and narwhals and sperm whales and like the short fin pilot whale maybe why I know this is not useful and there's been a recent podcast about it.

I listened to this.

No, they thought it used to be just a human phenomenon, but they are realizing that menopause happens in lots of other species, right?

And the nego chimpanzeee, I believe from Uganda was another population.

And anyways, I find it very fascinating being of this menopausal age to be curious about why humans go through menopause and sort of what the benefit is of going through menopause.

But then perhaps I think about like for example elephants.

They do not go through menopause.

They can get pregnant their whole life.

They carry babies for 20 years and I would not want to be an elephant.

Yeah, thank goodness that doesn't happen to us.

I do have a question from our audience.

Thank you for sending in questions.

It says, "Do I still need a papsmear every year if I'm 84 years old?"

Oh, that's a great question.

So um typically so there are guidelines that are set forward by the ASCCP.

It is a governing body about cervical cytology which just means papsmears.

And the typical patient would start initiating papsmears at the age of 21.

And then if you've never ever had an abnormal papsmear in your life, you are done at 65. as long as you have had what we describe as adequate screening, which means multiple papsmears over your lifespan.

Now, if you have ever had a precancerous or cancerous change in the cervix or vulva or vagina, then you may potentially need more papsmears as your life goes on.

Once you've been infected with an HPV uh virus that we consider ancogenic, meaning that we know it can cause cancer, you are at risk of forming an abnormality either precancerous or cancerous um for your lifespan.

It's very similar to shingles where if you had chickenpox as a child, you'll have no problems with chickenpox until you potentially have shingles as an older person.

So the answer to the question about do I need a papsmear at 85?

If you've never had an abnormal papsmear, no, you should typically stop at 65.

But if you do have a h a history of precancerous or cancerous changes, um then yes, you should continue on.

So unfortunately, especially if you have HPV present, that's an indication to continue to screen for that individual.

It is if the HPV has caused precancerous or cancerous changes.

If if you've had HPV that's been persistent but never caused a problem, that's a more in-depth discussion with um your primary care or gynecologist.

Okay.

Thank you for that.

Well, since we haven't had more questions, maybe I'll just ask some if you don't mind.

All right, let's go back to menopause.

Let's do it.

All right.

So can if I am your patient and I'm really struggling with symptoms of menopause first maybe let's talk about some of those symptoms and then let's talk about what you can do for those patients.

Sure.

So menopausal symptoms start in what we describe as the pmenopausal time of life that can start um anywhere between the age of 40 or um up until you know mid50s to 60s.

is the average age of menopause in the United States is 51.

Um, menopausal symptoms typically include hot flashes, night sweats, skin changes.

Um, sometimes you'll experience vaginal dryness.

Sometimes you'll experience um weight redistribution on your body.

Uh, that one's fun.

Yeah.

All right.

And so, um, if you are having those symptoms, can you talk to me about maybe, um, maybe I'm a patient, I've seen patients like this as an internist, um, I get nervous about maybe being exposed to estrogen, for example.

I know that's one of the medications we use to treat it.

Maybe my sister had breast cancer.

What would you tell me as a patient about that?

Sure.

There are both uh, hormonal and non hormonal uh, ways to treat menopause.

Um, estrogen is a very popular way and a very effective way to treat menopausal symptoms.

And not everybody is a candidate to have a hormone.

There are restrictions and uh risk factors that you might have that might not make you a candidate for estrogen.

Specifically, if you have uncontrolled high blood pressure, if you have had a personal history of a blood clot in your leg or in your lung, if you have um sometimes a history of migraine headaches with aura, um you might not be a candidate for estrogen.

Similarly, if you have a uterus and you take estrogen only, that does increase your risk of having a uterine cancer.

So the treatment for women who have uteruses who would like to try estrogen, you have to use estrogen and progesterone together to eliminate the risk of developing a uterine cancer from being treated inappropriately.

Thank you.

Um I did get one question from our audience.

I thought it was good.

If I've had endometriosis when I was young, does that increase my cancer risk now that I'm older postmenopausal?

So endometriosis, that's an interesting question.

And I'll just sort of preface this by saying endometriosis is a word to describe when you have the lining of the uterus that grows outside of the uterus.

Oftentimes it can form cysts on ovaries.

It can cause implants in the pelvis.

It can cause pelvic pain.

And endometriosis does have a very small risk of forming or developing into a cancerous change in the future.

That's usually when it has implanted on one of your ovaries and caused an ovarian cyst.

It's incredibly rare and it's so rare that we don't have good statistics about how that would increase your cancer risk.

But it doesn't change how we would screen for any gynecologic cancers if you have a history of endometriosis.

Okay, we have some really good ones.

Okay, I love this.

If you have had a total hyctomy, should you get a pack smear?

Well, that depends.

So it depends on why you had your hysterctomy.

So if you have had a removal of your uterus and your cervix because of HPV related problems, specifically dysplasia is one word that we use to describe it, then yes, you might be required to have papsmears in the future.

If you have had a hyctomy for reasons related to bleeding or fibroids or a non-HPV related thing, then no, you should probably not need papsmears in the future.

Wonderful.

Okay, we're going to transition a little bit into breast health.

I think we should take team this one.

Okay.

Okay.

I'm 76 years old and have no personal or family history of breast cancer.

Do I still need a mammogram every year?

I'm gonna let you I'm gonna let you start with that one.

All right.

So my answer to that is we usually there are two um big organizations that give guidelines on screening for breast cancer and um there's the US preventative health services task force and there's American College of um um oncology American Cancer Association sorry um anyway I would say this 76 years old never had an abnormal no family history we can argue that at 75 you can actually stop and it should be a discussion that you have with your doctor.

Um so the usual guideline would suggest that at age 40 um to 45 you should have a discussion with your physician and the US preventative health services task force suggests an every other year mammogram and the American Cancer Society suggests an annual mammogram.

As a practicing internist, I would usually offer an annual mammogram for one reason and that is because one myth is does the radiology hurt me?

Does the amount of radiation um it's very small risk and there's a higher risk if you are somebody who flies across the country or eats food for example.

So everything has radiation um so the bit the risk outweighs the the benefit outweighs the risk for screening.

Um but every other year is US pres pre oh this is hard to speak US preventative test force versus the American college uh the American Cancer Society.

So um in that case it would be um an annual mammogram up until about age 75 and then it's a personal decision with your physician.

I often would use whether the patient is really healthy and worried and wanting to continue their mammogram.

Some people feel very good about getting a mammogram knowing that there's no cancer there and like I said the risk is small.

So do you have anything to add to that?

Yeah, I mean I come from the oncology world, so I I talk with patients who have been who have said, "My doctor said I don't need a mammogram anymore."

And then I say to them, well, I mean, you live independently.

You are on one medication, which is probably a vitamin or maybe a blood pressure medicine.

You know, you you have no other medical issues.

I'm like, so if you were to be diagnosed with an early stage breast cancer, would you do something about it?

meaning would you consider surgery or chemotherapy or radiation and they say yes and I said well then you should probably have a mammogram because if you would do something about it then you should probably have that test that's fair also I want to point out that one in six breast cancers are associated with a genetic risk I want to say that's right maybe it's one in eight sorry I didn't brush up on that but it's so that means that there's more spontaneous um episodes of breast cancer that come from non genetic risk situations.

There's many things that increase your risk for breast cancer.

Um prolonged exposure sometimes to estrogen is a long conversation, but um adiposity, people who are heavier are more at risk.

Um certainly all the other risk factors for cancer.

So it certainly is a personal decision.

Um I do have one more question and we have about less than 10 minutes left.

If someone has a precancerous cell history for a thickened endometrium, are you at higher risk for cancer?

Good question.

Sure.

So, if you have been diagnosed with a thickened lining of your endometrium and you are post-menopausal, then yes, you do have an increased risk of having a cancer.

If you have something that has been diagnosed that's called endometrial hyperplasia, which means overgrowth of the lining of the uterus, which is considered a precancerous change, then yes, you are at increased risk for having a uterine cancer.

Good.

Um, there's one question just to answer briefly and then we have some fun ones.

Um, so does tmoxifen cause cancer?

Oh, tmoxifen does not necessarily cause cancer, but it is a medication that's if you are on you are at increased risk for forming a cancer in the lining of your uterus or endometrial cancer.

That is because it is a medicine that acts sort of like estrogen does and it acts in a very beneficial way in the breast if you've had breast cancer, but it can act in a detrimental way in the lining of the uterus and it can cause it to be thickened and cause a polip which occasionally can be cancerous.

Thank you.

Okay, these are libido questions.

So, oh gosh, right at the end, we'll save save the best for last.

Um, I'm postmenopausal.

Is it normal to have no interest in sex anymore?

I won't let you answer that one first.

You're the undercover person.

I feel like I could have asked that.

So, okay.

Um, so we have a natural attrition of our hormones and so people certainly have things that make interest and um participation in intercourse much less pleasurable.

Um, for example, you don't have as much estrogen.

You can have loss of um all kinds of the the androgen hormones like testosterone.

And so it makes um one's interest in um in sex much less.

For example, um you can have vaginal dryness.

Sex can hurt.

But there's many things that you can do to help that.

And I really would encourage um anyone who feels this way to have a good conversation with their physician about it because certainly um there are things that we can help you with to improve if that is what you would want.

Um, and then another person asks, "What's the what's the utility of testosterone use in menopause?"

Oh, these are hard.

These this that is kind of a hard one because there's not a ton of data about testosterone use in menopause, but there is a lot of interest about testosterone use in menopause.

It's hot right now.

it is and there's not a lot of safety data out there from the you know studies that could be done.

So I think that this is sort of a really you know detailed conversation with your physician and please have it with a physician who is versed in hormonal therapies and knows the risks and knows the benefits because with testosterone use there is some irreversible things that can happen in terms of viralization which means having some more male characteristics if you in fact become female.

if if in fact you are a female, like hair growth that you might not want, changes in your voice that you might not want, and other things.

Great.

Um, we don't have that much time left, but here's a really good one, I think, especially for women's health.

How do I prevent urinary tract infections?

Yeah, that's a hard one, especially in the post-menopausal uh set of women because as we lose our estrogen, the tissue in the vulva and vagina and near the urethra becomes thinner and more susceptible to urinary tract infections.

Sometimes it's as easy as using a little bit of topical estrogen right near the urethra at bedtime to help plump up those tissues.

Um, sometimes it can be a structural issue if there is prolapse that's happening related to your gynecologic organs.

So, you should see a gynecologist or a urologist and have a detailed exam and discussion.

Yep.

I would say too, your internist can help you with that, at least getting started with it.

that your little urethra, that channel from your bladder to the outside world is so short.

And so it it lends itself to a nice super highway, especially post menopausally when we don't have the tissue and the um immunity in that tissue to fight off infection.

So um but I've helped a lot of women with that problem and it's an important one to because it sure causes a lot of morbidity which means illness and any any person doesn't really want to be ill with something that can be prevented.

Right.

Absolutely.

So um anyways uh let's see one last maybe a person in their 70s has some cysts in their breasts.

Do they um they've been told it's not cancerous but can anything be done to relieve them?

So like a benign cyst, we do drain those.

Yeah, occasionally they can be drained.

Um I would say if it is not causing symptoms, then you should probably not do anything about it necessarily.

Um but if you are really worried about it, there are breast surgeons that could potentially help you with that.

Occasionally radiologists can help you with that as well.

Yep, good question.

Oh, I guess one more.

Do you surgically remove fi fibroids that bleed?

That's a good uh yes, I surgically remove fibroids that bleed.

Um fibroids can occasionally be cancerous.

Um they can cause lots of abnormal bleeding.

Uh fibroids, which are typically benign muscular tumors within the uterus, can cause abnormal bleeding.

They can cause bulky symptoms like pressure on your bladder or pressure on your rectum.

And yes, surgical removal is an option for them.

Good.

All right.

Well, we've come to the close of our our questions.

I just want to thank Dr.

Colleen Evans for being here with us.

I have worked with her personally and I know that she's very easy to speak with about a lot of the female um reproductive and gynecologic and cancerous problems and certainly can put your mind at ease and she's always been willing to help.

Do you have any fun stories to end with or anything?

I know that like let's see you get to see say a lot of fun words when you're here sometimes right um but it's important to just I know it's a difficult conversation sometimes to have and to ask about um we're all human and um talking about those parts can be really difficult but um very important to your health and well-being and so um if you can find a doctor that you feel comfortable conversing with and maybe even if you're having trouble, just maybe start somewhere.

And um there's many of our OB/GYNs in town are wonderful at addressing uh gynecologic issues.

And of course, that area is prone to cancer.

And so um it's important to have preventative health care there also with things like um papsmears and genetic testing if you have a predisposition for breast, ovarian or uterine, colon.

Yep.

There are two big um genetic syndromes that affect women in their gynecologic cancer health, specifically Lynch syndrome, which is hereditary colon and uterine cancer.

And then there's hereditary breast novarian cancer.

So know your family history, talk to your physician about it.

Um it can really prevent something from happening to you in the future.

Right.

So in closing, I want to thank our panelist, Dr.

Clean Evans.

Please join doctors on call next week where Dr.

Ray Peters Ray Christensen leads a program on men's health with a panel of experts including doctors Umar Sadiki from Aspirus and Dr.

Nathan Hoffman from Essentia.

Thank you for watching and joining us for season 44 of Doctors on Call.

Have a good night.