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In Answer to An Increasingly Common Question From Steven R. Goldstein

9/16/2013

Lately it seems that I have had a large number of patients with daughters “coming of age”. As a result I am recycling something I wrote a while back but may be even more pertinent today.

When should your daughter first visit the gynecologist?

I love to be a teenager’s first gynecologist.  It does not have to be a traumatic experience.  A positive first visit will ensure that she is not “ruined” as a gynecologic patient.  Even if her next several doctors in a row are rough or traumatic she will know it does no have to be that way.  My nurse and I love to teach young women “how” to have their first pelvic – what muscles to relax so that it doesn’t have to hurt.  Many of you have paid me the highest compliment by bringing your teenage daughters (some of whom I have actually delivered) to see me.  I am often asked when a teenager should first come to the gynecologist.  I feel that certainly prior to leaving for college they need to visit the gynecologist.  You can explain that they are a woman now and it is time.  If they are younger – seniors, juniors, even sophomores in high school it depends on 1) are they having any problems with frequency or severity of periods, 2) are their periods interfering with school or sports, 3) their level of maturity (some are 16 going on 13 whereas others are 15 going on 20!), and 4) are they sexually active (although this may or may not be information shared with you).  They must feel that their visit to me is private.  Some moms stay in the consult room during the intake interview.  If so, in the exam room I let them know that whatever they say is confidential, and if they want me to talk to their mom I will, but only with their permission.  When they are in the exam room we talk about sexual activity, contraception, STD’s, etc.  Let me assure all the parents out there that the young girls in my practice are very well informed – about contraception, HIV, other STD’s as well as very responsible.  In fact I often wish my 45-year old-recently-divorced patients were as knowledgeable and responsible!

 

As always, if you have any issues, comments, concerns or questions feel free to contact my office.

 

Yours in health,

Dr. Goldstein

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Fixing the Miscommunications of Non-Cancers

7/30/2013

The lead story in today’s New York Times, on the right hand column of Page One, is entitled “Scientists Urge Narrower Rules to Define Cancer”. The main thesis of the article, which chronicles a study published yesterday in the Journal of the American Medical Association, is something I have been saying to many of you for quite some number of years.

Perhaps the following anecdote will underscore the issue:

Several years ago a patient came to me for a routine visit. When I asked her “What’s new?” she replied that she had been diagnosed with breast cancer since our last visit. I was quite surprised and requested her records (It was a well known cancer institution slightly north of NYU Medical Center). It turned out that her final diagnosis was “Ductal Carcinoma-in-situ (DCIS)”. She had been told that she had “Stage 0 breast cancer”. I informed her that she did NOT have breast cancer.

On the first day of their pathology course in the second year of medical school, students are taught that one of the hallmarks of malignancy (cancer) is INVASION. The phrase in-situ means there is no invasion. This woman believed that she was a “breast cancer survivor”. The psychological ramifications of having had cancer had obviously taken their toll.

While it is true that some patients with Ductal Carcinoma-in-situ (DCIS) may proceed to invasive cancer, the accepted treatments for this are quite varied and have to be individualized. They include, prophylactic mastectomy, or radiation, or therapy with drugs such as tamoxifen or Evista, or even careful surveillance. I am not suggesting that such diagnosis be taken lightly, however it is inappropriate to tell such a patient that she has had cancer.

The same is true for Carcinoma-in-situ of the cervix. I’ve told many of you that have had cervical dysplasia, that Carcinoma-in-situ is more appropriately thought of as “super severe dysplasia”. It is unfortunate that is has that cancer word “Carcinoma” in it.

Furthermore, this article in today’s Times makes reference to “incidentalomas”. These are findings on an imaging study, which may have been there for quite some time and are often totally innocuous but can lead to increased patient anxiety, further testing, and even unnecessary surgery. When I was president of the North American Menopause Society (NAMS), I chose the topic “Incidental Findings in Imaging” for my Presidential Symposium at their 2011 annual meeting. Many of you have incidental findings on your pelvic sonograms ranging from fibroids to benign cysts to dilated benign fallopian tubes, etc. I have often warned many of you to be very careful that if you have an imaging study for some other reason your biggest jeopardy would be the misinterpretation of such findings, leading to unnecessary surgery in some cases.

In summary, I applaud the scientists from the National Cancer Institute in their attempts to fix the misclassification of many of these benign findings that are extremely frightening to patients as outlined above. To read the original New York Times article online, click here.

As always, if you have any further questions, please do not hesitate to contact us. Until then, I remain yours in health.

Dr. Goldstein

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Breast Cancer Prevention: What the NY Times Got Wrong

04/16/2013

In today’s New York Times (Tuesday April 16, 2013) there’s an article by Denise Grady which reports recommendations of the United States Preventive Services Task Force (USPSTF) who published a draft form of their recommendations for public comment concerning the drugs raloxifene (Evista) and tamoxifen (Nolvadex). As many of you are aware, I have published extensively on these drugs and participated in studies for both. Tamoxifen has been used for several decades, initially for women with breast cancer to prevent recurrence, and then more recently for women at high risk for breast cancer to prevent it in the first place. It is associated, however, with a small increased risk of uterine cancers. I was the first to describe an unusual ultrasound appearance of the uterine lining in some post-menopausal women who take tamoxifen. I was involved in the original studies for raloxifene (Evista) in order to prove that this drug was not tamoxifen-like in the uterus. As a result in 1997 raloxifene was first approved for prevention and treatment of osteoporosis and then in 2009 based on further study it was approved for breast cancer prevention in high risk women. I actually spoke before the FDA at the time that Evista was in the approval process. I’ve also authored the committee opinion on tamoxifen’s effects for the American College of Obstetricians and Gynecologists.

I’m taking this opportunity to write this email blast to my patients (and any of their friends to whom they want to disseminate this) because of some serious misstatements in the article in today’s Times. Evista (raloxifene) does NOT increase the risk of stroke as was reported in the article. Large studies of raloxifene in women with osteoporosis, in women at high risk of heart disease, and in women at high risk of breast cancer have NEVER shown any increase in stroke. What is true is that in the women with high risk of heart disease, in those women who did suffer a stroke there was a slight statistically significant increase in chance of dying. This was not true in osteoporotic women or women at high risk for breast cancer who were not also high risk cardiac patients. Furthermore, today’s article says that both of these drugs can cause “vaginal problems like dryness and pain that can damage a woman’s sex life”. This is not, in fact, true. Post-menopausal women are subject to increasing degrees of vaginal atrophy (dryness) which in fact can lead to painful sex. Evista does not make this any worse. However Evista does not make this any better. Thus, many of my patients on Evista are given a local vaginal estrogen cream, tablet, or ring to treat the natural vaginal atrophy that occurs in menopause. These women can do so with great impunity because if any of this local vaginal estrogen is in fact absorbed (and I believe it is not) the Evista is protecting their breasts by locking up the receptors.

Finally for those of you who follow my email blasts carefully, you will notice in the past I’ve had some differences with the United States Preventive Services Task Force. Their failure to recommend more than 400 I.U.’s of Vitamin D, and their failure to acknowledge the usefulness of transvaginal ultrasound in the early detection of ovarian cancer were in my mind rooted in some poor science and I have previously addressed this. While I currently applaud the USPSTF for their current stance,  I wonder why it took them 4 years to come out with this recommendation since the data on which it is based has been well known and published for at least the last 4 years.

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