My practice philosophy
Make an appointment
What you can expect to pay
Payment and insurance
About me
My views on subjects of current interest
Patient resources
Notice of Privacy Practices
My home page
Dr. Carol Meynen, M.D., F.A.C.O.G

Practice Limited to Gynecology. Hours by Appointment
Make an appointment online
333 Anjou Drive
Northbrook, IL 60062
847-446-4370

See a map
Driving directions

My views on ...

How often should I have mamograms?
Should I have an Automated Breast Ultrasound After a Normal Mammogram?
How often should I have a Pap smear and HPV screening test?
How Do I Protect Myself from Osteoporosis?
Cervical Cancer (HPV) Vaccine
Other Vaccines - influenza, H1N1 flu, shingles, Pertussis, Pneumococcus
HPV Screening
Emergency Contraception (The "Morning-After" Pill)
New drug for female libido is now available. Is Addyi appropriate for me?

How often should I have a mammogram?

In the absence of detailed information, I recommend annual mamograms. However, every woman is different.

What is the lastest information on routine mammograms?

In October 2015, the American Cancer Society (ACS) published updated guidelines for routine mammograms in women of average risk for breast cancer. Based upon new evidence, and emphasizing the elimination of as many screening harms as possible, the new guidelines cover the age for initial screening use of mammography and the subsequent frequency of screening mammograms. The new guidelines have the stated goal of "supporting the interplay among values, preferences, informed decision making, and recommendations."

This guideline update attempts to reduce the incidence of patient anxiety that may result from overly conservative management of breast cancer risk. Each clinical examination or mammogram may show a minor indication of potentially cancerous tissue leading to patient anxiety and further fears of additional tests and invasive procedures. Attempting to eliminate "as many screening harms as possible" translates into reduced onset and reduced frequency of screening mammograms.

What constitutes "average risk" of breast cancer?

The guidelines speak most directly to women of "average risk" for breast cancer, which the ACS defines as:

  • No personal history of breast cancer
  • No confirmed or suspected genetic mutation known to increase risk of breast cancer (e.g., BRCA)
  • No history of radiotherapy to the chest at a young age
  • No significant family history of breast cancer
  • No prior diagnosis of benign proliferative breast disease
  • No significant mammographic breast density

What are the ACS recommendations?

The ACS recommendations fall into two categories: strong recommendations and qualified recommendations. A strong recommendation is one that the ACS advocates most women of average risk should follow. A qualified recommendation is one that ACS believes should be discussed between the patient and her doctor to arrive at a plan in keeping with the patient's values and preferences.

  • Strong recommendations (favored for women of average risk)
    • Regular screening mammography should start at age 45 years
    • Screening should be biennial (every other year) at age 55 and thereafter
  • Qualified recommendations (acceptable options as agreed between the patient and her doctor)
    • Women who desire to initiate annual screening between the ages of 40 and 44 years should be accommodated
    • Between the ages of 45 and 54, screening should be annual
    • Screening may continue annually after age 55
    • Screening mammography should continue as long as the woman is in good health and has a life expectancy of at least 10 years
    • Clinical breast examination by a doctor is not recommended at any age

Has there been any professional reaction to the ACS recommendations?

Shortly after publication of the new ACS guidelines, the American College of Obstetricians and Gynecologists (ACOG) issued a formal statement in response:

ACOG maintains its current advice that women starting at age 40 continue mammography screening every year and recommends a clinical breast exam. ACOG recommendations differ from the American Cancer Society's because of different interpretations of data and the weight assigned to the harms versus the benefits.

ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.

Are there areas of agreement between the ACS and other professional groups?

There are 7 areas of agreement between ACOG and ACS recommendations, using both strong and qualified recommendations:

  • Screening from age 40 to 69 years is associated with a reduction in breast cancer deaths.
  • Annual screening for women in their 40s [although the ACS' 'strong' recommendation is that regular screening begin at age 45 instead of 40].
  • Screening for women 70 and older who are in good health (10-year life expectancy).
  • Annual screening yields a larger mortality reduction than biennial screening.
  • These recommendations still leave the "over-diagnosis/overtreatment" issue uncertain.
  • Insurance should cover screening at all ages and intervals (not just USPSTF 'A' or 'B' recommendations).
  • The patient should be involved in informed decision making.

What do these recommendations mean for the "average" woman?

Women may have an "elevated" risk of breast cancer related to many conditions not usually considered. In addition to genetic predisposition (race/ethnicity, family history), breast density may contribute-it may increase risk, and it certainly makes a mammogram harder to interpret. Hormone replacement, delayed childbearing (first child born after age 30) or lack of sufficient breast feeding (cumulative under 12 months), early menarche/late menopause all are factors that tend to increase breast cancer risk. There may be other environmental risk factors that contribute as well.

The recommendations emphasize that the patient should be educated and involved in formulating the screening plan. Ultimately, while the science and the doctor can help identify the relevant risk factors for a particular women, the plan will rest upon how much risk that individual can tolerate. Let us also not forget that the overall incidence of breast cancer is 11% in all women - perhaps not a low risk in itself.

I am concerned that the simultaneous ACS recommendations to stop self-breast exams, stop clinical breast exams and reduce the frequency of mammography may result in an unacceptably high incidence of relatively advanced breast cancer. While treatments are now more sophisticated than they were even 10 years ago, the majority of breast cancers are discovered at a relatively early stage and thus are eminently treatable. Delaying diagnosis cannot be helpful.

What I will be recommending to an "average" woman

I will continue to abide by the ACOG guidelines and suggest that women with an average risk profile begin annual screening mammograms at age 40. I also believe that self-exams and clinical exams have their place. However, each woman is unique and I want to discuss the alternatives with you.

If you would like to talk about your personal need for an annual mammogram, I am happy to discuss it with you at your next appointment. My role is to help you decide what is best for you.

November 2015

Back to top
Back to Home Page

New drug for female libido is now available. Is Addyi appropriate for me?

Many women over the age of 45 notice a significant decrease in their sex drive. Recently the FDA has approved the first drug, Addyi (filibanserin), to address that issue. Are you wondering if you are a candidate for this medication? Consider the following points:

  1. Addyi has only been approved for premenopausal women. That does not mean postmenopausal women cannot use it, but the FDA believes that the risks outweigh the benefits in that age group.
  2. The medication must be taken daily to be effective. Unlike Viagra, and the other ED medications, you don't take it just when you want the effect, you have to take it every day.
  3. The side effects include hypotension and fainting. This might not be a problem if you were taking it for its immediate effect and planning to stay in bed, but if you're taking it all the time it could be a serious problem - such as operating a car or heaving machinery. At this time, any long-term effects are unknown.
  4. Cost of treatment has yet to be determined. It is anticipated to be about the same as a month's ED treatment, or about $400 per month. This is unlikely to be covered by Medicare, since it's not approved for postmenopausal women.
  5. Results of study trials reveal very small improvements. The studies showed that whereas the beneficial effects of placebo were close to 100% over baseline (e.g. a doubling of sexual encounters in the course of a month), the additional improvement with Addyi was only about 20% (e.g. 120% of baseline). While this is statistically significant, it only translates to 0.7 additional sexual encounters per month.
August 2015

Back to top
Back to Home Page

How often should I have a Pap smear and HPV screening test?

Guidelines for cervical cancer screening continue to be refined. As our understanding of HPV (human papilloma virus) disease has grown and our techniques for establishing an accurate diagnosis of both cervical pre-cancer and invasive cancer have improved, we have become more capable of discerning the appropriate level of evaluation and management.

Risk factors

Prior to the introduction of pap screening in the 1950's cervical cancer was the scourge of women under the age of 50. It remains so in the developing world where women generally go unscreened. Even now, over 10,000 women in the US are diagnosed with cervical cancer every year. The goal of cervical screening is to identify changes in the cervix before they become cancerous and to isolate and remove the abnormality, leaving a healthy cervix. Pap screening initially resulted in a 75% reduction in deaths from cervical cancer but at the expense of many unnecessary invasive procedures such as hysterectomy.

In the past 40 years it has become evident that virtually all cervical cancer is due to HPV. Recent changes in guidelines have to do with the technologies that have come about in the past 20 years or so--liquid based Pap smears, screening tests for HPV, and more specifically, certain high-risk strains of the virus. Abnormalities that occur in Pap smears that are not due to these strains will almost certainly never result in cancer, but not all abnormalities that are due to these strains will progress to cancer either. Screening for high-risk HPV enables us to focus our attention on those women who are at high risk for developing cervical cancer.

Exposure to these certain strains of HPV appears to occur only with sexual activity. The HPV which affects the cervix only affects other similar tissues-the oral cavity, the anus and the male genitalia. Most women will be exposed to HPV from partners when they begin to be sexually active. In most cases, the immune system will suppress the HPV within a few years. For reasons that are not clear, sometimes HPV is not permanently suppressed. I have seen HPV in women as old as 80, including women who have previously tested negative. I have also seen cervical cancer in elderly women.

Frequency of tests for teens

About 70% of women are exposed to HPV during their lifetime, based on previous studies of large populations. About 25% of young women (under the age of 30) will test positive at any one time. Therefore, we don't recommend HPV testing of young women as a general rule. New, current guidelines recommend beginning screening at age 21. This is a change from the prior guidelines which recommended initiating screening 3 years after beginning sexual activity. I am more comfortable with the prior guideline since I have experience of a 19-year-old woman with a pre-cancerous condition 3 years after becoming sexually active. I have also seen 20 and 21-year-old women with cervical cancer. For this reason, if I see a young woman who has been sexually active, then I will recommend Pap screening. If I see a 21-year-old woman who I am convinced is not sexually active, I have no problem delaying initiating Pap screening (but not delaying evaluation!)

Testing for ages 21 to 30

Between the ages of 21 and 30 the new, current guidelines recommend a Pap test every three years. However, because a liquid-based Pap test is at best 80% accurate, and recognizing that women at these ages are likely to be the least responsible about their health (due to lack of money or high mobility), I still suggest an annual Pap smear without the HPV co-testing. (Most women with HPV will not have cervical dysplasia.) If the Pap is abnormal, I request that a high-risk HPV test be done on the specimen. If that is positive, a colposcopy is the next step.

Testing for ages 30 to 65

Between the ages of 30 and 65 the new, current recommendation is to have a Pap test plus an HPV co-test every three-to-five years. I am perfectly comfortable with that. If a woman catches HPV the day after I have received normal Pap and negative HPV screen test results for her, then the probability that she will develop cervical cancer before I repeat her Pap test in three years is very remote. It does make remembering when the Pap needs to be repeated more difficult for both patient and physician.

Frequency of tests for women over 65

After age 65, the recommendations get fuzzy again. Several organizations recommend that we cease screening at 65-and that may be appropriate if a woman has negative Pap and HPV tests and she doesn't acquire (or her partner doesn't acquire) a new partner. Now that women commonly live to be over 90, I am uncomfortable letting a sexually active woman who will live for another 25 years go unscreened. Cervical cancer is as dangerous as ovarian cancer, so I would recommend screening with Pap and HPV co-tests every three years for any woman over 65 who is sexually active and every five years for one who isn't.

Testing for women after hysterectomy

Regardless of age, a woman who has had a hysterectomy in which the cervix was removed no longer needs either a Pap smear or HPV test, unless the surgery was done for cervical or uterine cancer.

HPV testing alone

HPV testing without Pap is currently being studied and recommended. In this case, if there is high risk HPV, colposcopy would be the next step.

Colposcopy

This is an evaluation technique done to evaluate abnormal Pap or high risk HPV. An instrument that works like a combination binoculars/microscope is focused on the cervix, vinegar is applied to emphasize cells with large or abnormal nuclei or irregular vascular patterns. If an abnormality is visualized, small biopsies can be obtained and sent to the laboratory for evaluation.

Summary

  1. Initiate Pap screening within 3 years after sexual initiation. (This is my preference.)
  2. Until age 30 screen as indicated with Pap alone. If Pap screening is abnormal, then add HPV co-test.
  3. Between 30-65 screen every 3-5 years with a Pap and HPV co-test.
  4. Screen sexually active women over age 65 with a Pap and HPV co-test every three years. Screen other women over 65 every five years.
  5. Cease screening after hysterectomy.

An annual gynecologic exam remains important

Remember that a gynecologic exam is not just about Pap screening. General health screening, breast exam and preventive counseling are also important aspects of the gynecologic visit. Most internists have neither the time nor the expertise to deal with these women's issues. An annual gynecologic exam is an investment in good health and quality of life for years to come.

January 2018

Back to top
Back to Home Page

How Do I Protect Myself from Osteoporosis?

As women live longer and longer after menopause, the risk of an osteoporotic fracture increases. Osteoporotic fractures result in considerable disability in the elderly and many who sustain a hip fracture will be unable to live independently thereafter. Our evaluation and management of this health problem has changed significantly in the past 40 years.

Calcium is "stored" in the bones and regulated in the body by several different hormones and the kidneys. Overall calcium level must be kept within a very narrow range to protect normal cell function. Excess intake of calcium may result in kidney stones as the kidneys attempt to excrete the surplus. Insufficient intake of calcium may result in bone loss. Adequate dietary intake of calcium can be achieved with about 1000 mg of calcium per day, the equivalent of 3-4 servings of dairy products, or a supplement.

Vitamin D is necessary for calcium metabolism as well. Although our skin can metabolize Vitamin D from the sun when we are younger, it is much less efficient at it as we age. Very few foods contain Vitamin D, so a daily supplement of 500-1000mg is often recommended after menopause. Serum levels are sometimes tracked-current thinking is that a level around 30 is appropriate. A higher level is not considered to be better.

Evaluation

Bone loss is part of the normal aging process and occurs to different degrees in different people. Men have stronger bones to begin with and generally have a much lower incidence of fracture. Women are relatively protected by estrogen until their ovaries stop producing estrogen at menopause. Bone loss and fracture risk are affected by many factors, including initial bone strength, genetic proclivity, diet, exercise, weight, use of estrogen supplements and other medications, smoking, etc. Currently bone density screening is recommended to start at age 65 in women, but many women have an initial evaluation after menopause to determine "risk". Followup studies may be done every 2-10 years, depending on initial results. Generally, there is a loss of about 1% of bone per year in a healthy woman after menopause is complete. Greater loss may indicate a metabolic problem.

Treatment

If the bone density evaluation indicates a level less than 2.5 standard deviations below "normal" (Tscore less than or equal to -2.5) or if a "fragility" fracture occurs (meaning a fall from standing level, not involving additional force) treatment is usually recommended. If the bone density measured on DEXA is abnormal but not to the "osteoporotic" range, the person's risk factors are evaluated to determine if treatment is advisable. If bone loss is occurring more rapidly than expected on the basis of serial DEXA studies, the person is evaluated for a metabolic cause and managed accordingly.

Several treatments for low bone mass or increased risk of fracture are currently available. Bisphosphonates are often the first recommended treatment as they have been available longest and we know the most about them. Bisphosphonates such as alendronate (Fosamax) or risedronate (Actonel or Atelvia) have an excellent risk:benefit ratio. They may not be tolerated due to irritation of the digestive tract, but they are also available by infusion. Risks of atypical hip fractures and jaw necrosis after dental work are low, but it is often recommended that treatment be limited to 5 years duration to minimize these risks. Bisphosphonates are known to be stored in the bone for a long time, so fracture risk reduction will continue for several years after cessation of treatment. For patients who tolerate the medication, and continue to be at high risk, bisphosphonates may be continued or the treatment may be switched to Prolia. Both result in about a 40% reduction of fracture risk.

Newer treatments include Forteo, which is self-administered by injection every day for two years. This treatment actually grows new bone. Treatment is limited because of concerns about stimulating bone cancer. Prolia is administered by injection every six months. Neither of these have any "carry-over" effect. When they are discontinued, fracture risk returns to baseline.

Estrogen protects against bone loss after menopause but is not usually recommended solely for osteoporosis prevention and never for treatment. If a woman discontinues estrogen, she will lose bone at an accelerated rate for 2-5 years afterward. This may then cause her to need other treatment for bone loss.

As with most problems of aging, the best defense is a good offense. Good genes, good calcium intake throughout life, regular weight-bearing and strengthening exercise, calcium and vitamin D supplementation as appropriate falling are all contributors to bone strength. Bone density assessment, medication if indicated and prevention of falls by being conscious of one's surroundings and avoiding hazards that may contribute to loss of balance will reduce the risk of fragility fracture.

January 2018

Back to top
Back to Home Page

Cervical Cancer (HPV) Vaccine

Many people are asking about the new cervical cancer vaccine. Recently released by Merck, it involves a six-month course of three vaccinations at 0, 2 and 6 months. Each vaccination costs $130 for the vaccine alone, so the total cost of treatment will exceed $400. Researchers estimate the vaccine to be about 70% protective against cervical cancer in addition to protecting against vulvar warts and potentially against vulvar cancer as well. These are relatively short-term studies — the trial group has only been vaccinated since 2002 so researchers do not know yet how long the vaccine will last or if there will be any side-effects.

Cervical cancer results exclusively from exposure to the HPV virus from a sexual partner. Condoms are about 80% protective. Most young women are exposed to HPV without being aware of it, and their immune systems are able to clear the virus within a few years. This is the reason gynecologists recommend that young women wait for three years after becoming sexually active before starting Pap smears — there were many abnormal Pap smear readings which were treated when they would have resolved spontaneously. It is unlikely that a cervical cancer will develop in less than ten years except in a person with a compromised immune system (someone with HIV or a kidney transplant); therefore, waiting three years to begin Pap smear screening is thought to be safe. Eating a healthy diet, limiting sexual partners, using condoms, avoiding stress, and particularly avoiding smoking cigarettes are all ways to reduce risk. Once screening begins, it should continue annually with a Pap smear. Alternatively, an HPV test could be administered every three years (see below).

Even if the new HPV vaccine is used, Pap smears must continue because they detect about eight other HPV viruses that can cause cervical cancer. The vaccine should be effective against vulvar warts or condyloma, but these are relatively easy to treat if caught early and have no long term health consequences. Cervical cancer is extremely rare in women who receive annual Pap smears (I haven't seen a case in over 10 years) and vulvar cancer is rarer still. It is exciting to think that these diseases are preventable with a vaccine; however, given their rarity — about 1 case in every 10,000 women — and the cost of $400, we would expect that 10,000 women would spend $4,000,000 to prevent just one case. If we could predict who would be at risk (i.e., promiscuous, not using condoms, no health care), then those would be the women who should be vaccinated before they become sexually active.

That being said, I am in favor of vaccination for young women between the ages of 12-25, ideally before they become sexually active. Even if they have been sexually active the vaccine is recommended since the number of women who have been exposed to all four of the HPV strains the vaccine targets would be very small. In an ideal world, both boys and girls - all humans - would be vaccinated and HPV would be eliminated like smallpox has been. Until that happens, at least we can minimize the damage to young women, physiologically, psychologically, and economically, by vaccinating them against HPV and preventing them from getting several STDs that can cause significant havoc in their reproductive tracts.

September 2009

Back to top
Back to Home Page

Other vaccines

  • Influenza - About 30 million people seek care for seasonal influenza every year, most of them either the very old or the very young. Over 90% of influenza related deaths are people over 65 years of age. The seasonal flu vaccine reduces infection 70-90% in those under 65 and 50% in those over 65, but it also reduces hospitalization and death by over 50% in those over 65. For this reason, the CDC recommends annual vaccination for all persons over age 50 in addition to people who are immune compromised or have chronic diseases, international travelers, caregivers and providers of essential community services.

  • H1N1 - The 2009 "Swine flu" or "Novel Influenza" vaccine is due in mid October 2009. So far, this virus seems to particularly afflict younger people who have not perhaps been exposed to similar influenzas in the past. For this reason, the early doses are recommended for people between the ages 6 months and 24 years or those who care for them, healthcare personnel, and those over 24 with chronic disease or compromised immune system.

  • Shingles vaccine - Shingles will afflict one third of adults who were exposed to chicken pox as children. Severity increses with age and 50% of adults will have shingles by age 65. Recurrence occurs in 15%. The vaccine reduces both the incidence and the severity of shingles and is recommended for all adults over age 60 whether or not they have had a prior episode of shingles.

  • Pertussis - Whooping cough is primarily a disease of infants and children but is highly communicable. The pertussis vaccine administered in childhood does not prevent disease in adults and they remain a huge reservoir of disease to afflict infants and children. A single pertussis booster is recommended for adults when they receive there next tetanus booster.

  • Pneumococcus - There are over 500,000 cases of pneumococcal disease reported in the US each year. with a fatality rate of over 5%, up to 60% in older adults with pneumococcal pneumonia. Vaccination reduces the incidence of invasive disease 65-85% and is recommended for all people over age 65 and for those under 65 with chronic disease or immune compromise, including asthma and cigarette smokers.
September 2009

Back to top
Back to Home Page

HPV Screening

Many women are seeing advertisements or commercials for a combined HPV screening test and Pap test as a more accurate way of predicting cervical cancer. The HPV test has been available and used for several years as a "reflex" test after an abnormal Pap smear to determine if there is anything serious. Used proactively along with the liquid-based Pap tests, the HPV screening test can ascertain if there is any current HPV infection that will lead to an abnormality within the next few years.

Most insurance companies will now pay for a combined Pap smear plus HPV test once every 3 years (since it costs three times as much as a regular Pap smear). Women still need to visit their physician each year for a gynecologic exam (breast exam, ovarian functions, etc.). If the patient were to contract HPV in the meantime, it is unlikely to progress to cancer in someone whose immune system is intact. This does not preclude an ANNUAL exam, at which time women should be checked for breast and ovarian disease and vulvar health and other health issues may be addressed. Please see my views on the frequency of Pap & HPV tests.

There were over 11,000 cases of invasive cervical cancer in the USA in 2008. This is a completely preventable disease. The combination of HPV vaccination and HPV testing should allow us to eliminate this scourge.

July 2006

Back to top
Back to Home Page

Emergency Contraception (The "Morning-After" Pill)

An ounce of prevention is worth a pound of cure-proactive contraception is preferable to after-the-fact prevention. But after-the-fact contraception is better than an unintended pregnancy. Emergency contraception is now available in a variety of ways. A woman can simply go to a pharmacy within 3 days of unprotected vaginal intercourse and request "Plan B" (also available by other brand names) or request a prescription for "ella" from a physician within 5 days. For those who also want ongoing contraception, insertion of a copper IUD within 5 days is equally effective. The pill is a strong progestin which makes the endometrium inhospitable for implantation. It is 95% effective and has essentially no side effects. The earlier it is used, the more effective it is. If the woman is already pregnant, the short duration of use will not harm the embryo in any way. It will not abort an ongoing pregnancy. It is the same drug which has been used safely in birth control pills for over thirty years. The only limitation to its usage is its cost - if you were going to use it more than once a month, you might as well take birth control pills.

So when would you need an emergency contraceptive? Fertilization of the egg can occur with sperm that has been in the reproductive tract as long as ten days, so the only time a woman is "safe" from pregnancy is after ovulation has occurred - from about ten days before her next menstrual cycle through the first day or two of menstruation. A woman with a particularly long cycle (32 days or longer) might get away without protection for the first week after her menses, but this is like playing Russian Roulette. Breakage or slippage of a condom would warrant Plan B from about the third day after bleeding starts through about ten days before the next menstruation is due. Failure to start your birth control pill on time can result in an unanticipated ovulation, as can failing to take two or more pills in a row. There is no circumstance when it would be unsafe to use emergency contraception, but using it for every act of intercourse could be quite expensive. It also might make your menstrual cycle unpredictable. It is much better to choose a form of ongoing contraception and use it consistently. Women who often forget to take oral contraceptives may want to use an IUD or implant, or the vaginal ring (which is changed monthly. Condoms are additionally advised when there might be risk of a sexually transmitted disease.

January 2018

Back to top
Back to Home Page

Should I have an Automated Breast Ultrasound After a Normal Mammogram?

In the past two years more and more radiologists are suggesting Automated Breast Ultrasound (ABUS) for women with dense breasts after a normal screening mammogram. This is an additional separate study done at a separate time, after a routine mammogram in an asymptomatic woman at otherwise normal risk has been reported as normal.

For many years ultrasound has been used as an auxiliary tool for evaluating breasts when a mass is detected or mammography reveals an abnormality, but its use as an independent screening tool was abandoned over 25 years ago. We have also known that mammography misses a small number of malignancies in asymptomatic women of normal risk when used as a screening tool. In an effort to improve diagnostic efficacy, over the past 10+ years ABUS has been studied after normal mammography in women with dense breasts to determine if there is a benefit or not. The answer to that question is uncertain.

According to the best review studies I can find, ABUS does detect a very small number of malignancies in asymptomatic low risk women. About 3 per hundred women who have ABUS will have an abnormality reported; however, only one-tenth of those findings are true positives for a malignancy. All the malignancies found were early invasive cancers with negative lymph nodes. The studies evaluated were not consistent in criteria used for assessment or in their study populations. The number of these studies is very limited and there is no long term follow-up of women with negative exams (Were any subsequently diagnosed with cancer?). There is also no evaluation of frequency or interval of ABUS (Should it be done once? Annually? Every three years?).

There are a number of other elements besides dense breasts which increase a woman's risk for breast cancer. Tools have been developed to evaluate an individual's overall risk for breast cancer, but none of them include all pertinent factors. The two most widely tools used are available online at

(Note: there is an upper age limit beyond which using these calculators is not advised, because older women were not included in the defining analysis.)

How to interpret the calculated risk is another question. One possibility would be to perform additional screening (ABUS) if your breast cancer risk calculation is over 2.7%, or if it is twice that of a "normal" woman your age. Truthfully, nobody knows.

Paradoxically, the US Preventive Services Task Force believes we are doing too many breast cancer screenings, that all the additional women treated over the past 40 years based on mammography results has not affected breast cancer mortality, and that we should reduce screening to two years or even longer for "low risk" women (but they don't define "low-risk".) Mammography detects many more occult breast cancers than ABUS does.

To some extent, risk is in the eye of the beholder. I often ask myself: if I had to pay out of pocket, would I do it? Does it improve my quality of life? Others may have different criteria.

Ref: https://bmccancer.biomedcentral.com/articles/10.1186/1471-2407-9-335

January 2018

Back to top
Back to Home Page

© Carol A. Meynen, M.D. All rights reserved.