Ask the Experts: Questions on Pap smears and pills? Look no further
What is your approach when it comes to oral contraceptives and women who smoke? What is your facility’s standard practice for informing patients on Pap test results?
The following members of Contraceptive Technology Update’s Editorial Advisory Board share their insights on these questions: David Archer, MD, professor of obstetrics and gynecology and director of the Clinical Research Center at the Eastern Virginia Medical Center in Norfolk; Linda Dominguez, RNC, NP, assistant medical director of the Albuquerque-based Planned Parenthood of New Mexico; Michael Rosenberg, MD, MPH, clinical professor of obstetrics and gynecology and adjunct professor of epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm specializing in reproductive health; Sharon Schnare, RN, FNP, CNM, MSN, women’s health consultant and clinician with the Seattle King County Health Department in women’s and adolescent health care and the International District Community Health Center in Seattle; and Susan Wysocki, RNC, NP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health.
Question: Do you think women who smoke and take oral contraceptives (OCs) should be counseled on the potential for breakthrough bleeding (BTB)? If so, how much smoking is enough to potentially cause a problem?
Archer: I think that it is important to emphasis that smoking may increase the risk for breakthrough bleeding. The data from Rosenberg’s article support this.1 The clinical information is limited, but I think that it is significant.
Dominguez: I have found the amount of smoking impacting BTB is variable but a real contributor to this side effect. What is most important is that the clinician should not discount that the smoking is an often-overlooked reason for the problem of breakthrough bleeding and spotting. This is important because these unpredictable symptoms of unscheduled bleeding are a leading cause for patients to self-discontinue or for pill prescription changes by the clinician.
Rosenberg: Although there is very little research on the subject, smoking has an anti-estrogenic effect — probably by increasing the breakdown of estrogen and metabolites — and acts to effectively reduce the estrogen in OCs. Smoking has clearly been indicated in one investigation as an independent risk factor for spotting and breakthrough bleeding.1 I do regard smokers at being at increased risk for cycle control problems and recommend counseling.
Schnare: According to Speroff and Darney, smoking is associated with BTB.2 The authors cite the following study.3 I tell patients that their smoking may affect BTB. I also discuss smoking cessation with all women who smoke, and I let women know that the combined OCs are contraindicated once she turns 35 years of age. It’s also important to remind ourselves and our patients that women younger than 35 years who smoke and use combined OCs are also at greater risk of myocardial infarction when compared to nonsmoking women using combined pills.
Question: Is it legally necessary to notify a patient of the results of a "normal" Pap smear? As a nurse practitioner, in other clinics where I have worked, we notified all patients of the results of their Pap tests even if they were normal. Where I am at this time, we do not notify patient of "normal" results except by the statement at the time of the exam, "If your test is abnormal, we will call you. If it is normal, you won’t hear from us."
Archer: I am not sure about legality. I do believe that we should notify our patients in writing of the interpretation of their Pap smear. At present, the ASCUS [atypical squamous cells of undetermined significance] issue looms large, and I think that something in writing helps the patient, who may opt to go elsewhere for a second opinion. No answer implying normal findings does not seem appropriate today.
Schnare: I am not an attorney. I have worked in institutions where normal findings were not reported to women, and women were told that if their Pap smears were normal, they would not be called. I think this may be the standard of care in many institutions. I also have worked in the private sector where all women were informed of results by phone or letter, no matter what their Pap results were. My sense is that, as long as an institution has written procedures regarding Pap reporting to women and as long as the institution follows its own procedures, there should be no greater legal risk of not reporting normal results; of course, women should be told this is the policy.
Wysocki: There is no legal responsibility to notify a patient of normal Pap results, although many practices do notify patients. Your medical legal responsibility is to ensure that the Pap test taken that day is sent out, read, results returned to the practice, and recorded in the patient’s chart. There should be tracking systems in place, such as a log, to see that every Pap taken is sent out and returned.
If the results are anything less than "normal," the results should be compared to test results in the past. A series of low-grade Paps may be as important as a single high-grade reading. Results of Paps that are anything but normal should be shared with the patient.
(Editor’s note: Take a look at your facility’s practices to see that the following four elements are addressed when it comes to test results management: tracking tests until the results have been received; notifying patients of the results; documenting that the notification occurred; and making sure that patients with abnormal results receive the recommended follow-up care.4)
References
1. Rosenberg MJ, Waugh MS, Stevens CM. Smoking and cycle control among oral contraceptive users. Am J Obstet Gynecol 1996; 174:628-632.
2. Speroff L, Darney PD. A Clinical Guide for Contraception, Third ed. 2001. Philadelphia: Lippincott, Williams & Wilkins; 2001.
3. Rosenberg MJ, Waugh MS, Higgins JE. The effect of desogestrel, gestodene, and other factors on spotting and bleeding. Contraception 1996; 53:85-90.
4. White B. Four principles for better test-result tracking. Fam Pract Manag 2002; 9:41-44.
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