I was the only nonpregnant woman in my ob-gyn's waiting room. I'd been there, done that. Did I still need a doctor who delivered babies? Flipping through magazine articles on childbirth, I was here to discuss vaginal irritation. Yet my long-trusted doc failed to identify what was wrong, offering no solution. I switched to a physician who limited her practice to gynecology, and she quickly diagnosed vaginal dryness — a postmenopausal condition I never knew existed. Her prescription for a hormone cream twice a week worked.
As we age, our gynecological needs change from birth control and pregnancy to menopause treatment and osteoporosis screening. The decision to remain with your obstetrician is a personal choice.
"It depends if you have a doctor you like and who knows your history,” says Lila Nachtigall, M.D., a professor in the Department of Obstetrics and Gynecology at NYU Langone Health. “Many patients use the same doctor who delivered their babies well after menopause.”
Obstetricians may have unpredictable schedules, but you can get top-quality care from doctors who deliver and those who don't. The two most important factors to keep in mind: Your gynecologic needs can't be generalized solely by age, and it's essential to continue with annual gyn exams to ensure overall good health.
Breast exams and mammograms: Necessity and frequency
Although there is debate in the medical community over whether clinical breast exams are needed, the American Academy of Obstetricians and Gynecologists (ACOG) recommends them annually at 40+, with shared decision-making between patient and doctor. Nachtigal agrees with ACOG, and stresses continued need for annual breast exams well into your 70s, since risk of breast cancer increases with age.
The most skilled practitioners in this area are ob-gyns. “Most radiologists no longer do clinical breast exams at the time of mammogram,” says Audrey Buxbaum, M.D., a gynecologist in private practice at Downtown Women OB/GYN Associates in Manhattan.
The U.S. Preventive Services Task Force (USPSTF) advises mammograms every two years for women 50 to 74 with average risk, and says there isn't enough evidence to conclude whether it's of benefit to women 75 and older. Some doctors disagree, claiming these guidelines are based on cost controls, rather than preventive care.
The older you are, the greater your risk for breast cancer. “Older women need annual mammograms,” Nachtigall says. “It has been shown over and over how early detection saves lives."
Menopause: During and after
Menopause takes center stage during exams in your 50s, but concerns can continue for 15 years.
Buxbaum focuses on symptoms: urinary, vaginal, sexual health — during and after menopause. “I also remind patients about other health maintenance, such as colonoscopies, vaccines and bone density tests."
Discuss the pros and cons with your doctor to determine whether you should get systemic estrogen therapy. “Make sure your doctor is comfortable addressing menopausal issues and prescribing HRT if needed,” Buxbaum suggests.
Nachtigall is also on board regarding hormone replacement therapy, in some cases recommending that women with hot flashes stay on medication well after menopause.
Vaginal dryness: Let's talk about it
"A lot of doctors don't bring up the sensitive subject of vaginal dryness or sexual problems such as pain with intercourse,” Nachtigall observes. Doctors may think it'll take too much time or be embarrassing for the patient. But after menopause, most women encounter vaginal dryness, which can cause pain, itching and uncomfortable sex. The good news: “There are now so many good treatments — some hormonal, others nonhormonal,” Nachtigall says. “Almost every woman can get beneficial treatment without side effects."
Pap smears: Should they be eliminated?
The current recommendation of ACOG is to forgo regular Pap smears after age 65 if you have no history of precancerous cells or cervical cancer.
Don't rejoice that you'll avoid another cold speculum exam, though. “Pap smears are nearly 100 percent preventative for cervical cancer — the one cancer we understand well,” Nachtigall notes. “It's caused by the HPV [human papillomavirus] virus, which you get from sexual contact, not from age."
She urges sexually active women to continue getting annual Pap smears — not only if your sexual partner is new but also if you've been long married and monogamous.
"We need to prevent cervical cancer, since there is no cure,” Nachtigall emphasizes. While cervical cancer tends to occur during midlife, more than 15 percent of cases are in women over 65.
Making the Most of Your Annual Visit
Doctors see more patients than ever before. Come prepared with a list of questions and concerns.
Buxbaum's advice: “Have recent bloodwork results — such as lipids, blood count, kidney function — as well as a current list of all medications and supplements. Update any new surgeries, medical problems and family history, as these become more complex as people age."
"Volunteering information saves time and gets you help,” Nachtigall adds. “Tell the doctor about any vaginal discomfort, pelvic pain, discharge or odor — or else the doctor may not see it during an exam.”