Oy! (Probably not the best word to start my website this week, but I couldn’t come up with a different one.) Right after I wrote about the recommendations for women who were found to have dense breasts during their screening mammogram, I, and everyone in the media, read the article published in last week’s JAMA titled ” A Systemic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions”.

The authors, who are on the faculties of Brigham and Women’s Hospital and Harvard Medical School, reviewed articles that were published between 1960 and 2014. They searched for information on the benefits of mammogram, harms of mammogram and modes of individualized mammography screening decisions including communication of risks and benefits. The article is long and the citations many, but basically, the conclusion is that there was an overall 15 to 20% decrease in the relative risk of breast cancer-specific mortality as a result of mammography screening. Broken down by age groups, mammography screening was associated with a 15% decrease in breast cancer mortality for women in their 40s and 32% for women in their 60s.

So that’s the good news. The bad news is (according to the article) that the risk of a false positive diagnosis was high… For a 40- or 50- year old woman undergoing 10 years of annual mammograms, the risk of false positive results over that period of time was about 61% and for women aged 66 to 74 who had annual mammograms over 10 years, the false-positive rate was 49.7%. (A false positive result raises suspicion for breast cancer and leads to further testing, additional imaging and/or biopsy but does not result in a cancer diagnosis.) The authors also considered the statistics from published trials on overdiagnosis. (I know this term is difficult to understand when we are discussing breast cancer but basically it means that the type of tumor that was detected, such as DCIS, will not eventually lead to invasive or life-threatening disease and/or the patient will die of something else and not from her breast tumor.)

In order to better convey the context of these statistics, the authors discuss lifetime risk of breast cancer as well as risk at any age. For a woman in United States, the average lifetime risk of breast cancer is 12.3%. However, the 10 year risk of invasive breast cancer at age 40 is “only” 1.5%, at age 50, it’s 2.2% and at age 60 it is 3.5%. (These numbers may somewhat decrease the concerns for many of us who worry about our breast health risk in the decade to come.) The high 12.3% number represents a risk over an entire lifetime… well into our late 80s or even early 90s.

So how do we look at risk-benefit when it comes to screening mammogram? If dollar cost is the issue, it accounts for almost $8 billion in annual health care expenditures in United States. But for those women whose lives have been saved or who had to undergo lesser procedures in order to treat their breast cancer, national cost is probably not an issue. Therapies have improved and most women diagnosed with breast cancer do not die from the disease, even if their tumors were detected without mammography. However, as pointed out in an editorial in the same JAMA issue “many women diagnosed with late stage disease who were not screened recently wrongly blame themselves, encouraging others not to make the same “mistake”. Others attribute their survival to screening mammogram received even when this is unlikely to be the case.”I hope this doesn’t sound too cavalier. These were statements in the articles and I, like many women and physicians, feel that any deaths from breast cancer are tragic.

So how do you decide if and how often you should get screened? The authors give a a list of pointers that should be considered by each woman when she considers making her mammogram appointment and by her physicians who suggest she get screened, especially at an early, under 50 age.

* Many cancers will be found, but most women diagnosed with breast cancer will survive regardless of whether the cancer was found by a mammogram.

* Some cancers that are found would have never caused problems.

* Often, women are called back for further testing because of an abnormality that is not cancer.

* Mammography decreases the number of women who will die from breast cancer. This benefit is greater for women who are at higher risk for breast cancer based on older age or other risk factors such as family history.

* The number of women whose lives are saved because of mammography varies by age. For every 10,000 women who get regular mammograms for the next 10 years, the number whose lives will be saved because of the mammograms over each age group is approximately

- 5 of 10,000 women aged 40 to 49 years
- 10 of 10,000 women aged 50 to 59 years
- 42 of 10,000 women age 60 to 69 years

* If your breast cancer risk is higher than average, you may benefit more from a mammogram than someone with average risk.

* About half or more of women who have a mammogram yearly for 10 years will have a false positive mammogram and need additional studies. Up to 20% of these women will need a biopsy.

* In some women the mammogram will find an invasive cancer or noninvasive conditions such as DCIS that would never have caused problems. We cannot tell which these are so they will be treated just like other cancers. There is about a 19% chance that the cancer is overdiagnosed and treatment may be unnecessary.

I know this all sounds complicated and makes decisions about screening more difficult. But in the end it really has to do with your values and your personal philosophies regarding healthcare. Do you prefer to do more to insure that a diagnosis of this malignancy be made or do you think less is more and want minimize the risk of a false positive result that could cause anxiety, procedures and cost? I prefer the former but realize that many women don’t.

Firm is good, dense may not be… I’ve written articles on the current California law that requires imaging centers to send you a letter if, at time of mammogram, it’s noted that your breasts are dense. And as I expected, I’ve received quite a few phone calls with queries as to what sort of follow up “dense” mandates. The official committee opinion from the American College of Obstetricians and Gynecologists on this subject was published in April 2014 in (you guessed it) the Journal of Obstetrics and Gynecology.

Perky, firm and dense (breasts) are not always synonymous. Dense breast tissue is usually found in younger women. When we are (were) young, our breasts lack abundant fat separating the glands. And some of us stay that way breast-wise… Dense glands in breast tissue absorb more radiation during mammography than fat and look radiographically white whereas fatty tissue allows the radiation to pass through and appears more translucent in the image. A small tumor or calcification that could be the hallmark of a very early cancer or DCIS will also appear white on mammogram. White on white does not allow for good differentiation. And to somewhat complicate the matter it turns out that women with dense breasts i.e. glands that are close together with less surrounding fat, have a modestly increased risk of breast cancer in addition to a reduced sensitivity of mammography to detect cancer.

Just so you know how we categorize breast density by mammogram, the percent of the women within each category and what that means, here is a chart:

DENSITY

PERCENT

MAMMOGRAM
SENSITIVITY

RELATIVE RISK CANCER
(compared to average density)

Almost entirely fat:

10 %

88%

-

Scattered densities:

43%

82%

-

Heterogeneously dense

39%

69%

Relative risk 1.2

Extremely dense

8%

62%

Relative risk 1.4

Once the imaging center lets you know that your mammogram demonstrated that your breasts are dense, their letter then states that this increased density limits their ability to diagnose cancer (which also covers their tuches) and they usually go on to suggest that you discuss this with your physician. In turn, we then may recommend that you get additional ultrasound tests and perhaps even an MRI to address your newly induced concerns. Offering these exams also diminishes potential physician neglect and culpability and, of course, also gives reassurance that a diagnosis of early breast cancer is not missed.

I wish I could leave it at that, but the committee opinion does not agree with this line of action. They negate the need for these extra tests stating they are not appropriate in women with dense breasts who do not have additional risk factors. They state that “current published evidence does not demonstrate meaningful outcome benefits (eg, reduction in breast cancer mortality) with supplemental test (eg, ultrasonography and magnetic resonance imaging) to screening mammography or with alternative screening modalities (eg, breast tomosynthesis or thermography).” They go on to say “evidence is lacking to advocate for additional testing until there are clinically validated data that indicates improved screening outcomes.”

But before we all feel frustrated, please note that the committee did bless mammogram, especially digital mammogram as the best diagnostic screening tool that has consistently demonstrated a reduction in breast cancer mortality. The College does not, however, recommend routine use of alternative or adjunctive test to screening mammogram in women with dense breasts who have no symptoms and no additional risk factors.

I still urge you to call your physician if you get that “density” letter. We can then discuss your risk factors such as family history, previous biopsies, excessive alcohol consumption, obesity, even hormone therapy and try to figure out how to best to assess and reassure you.

It’s been 50 years since the 1964 Surgeon General’s report that stated that smoking was harmful to our health. The Smoking and Health Report (what it was formally called) was based on a review of an estimated 7000 documents. It concluded that “cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking outweighs all the factors; and the risk of developing lung cancer increases with the duration of smoking and number of cigarettes smoked per day, and diminishes by discontinuing smoking.” Just so we women don’t feel left out, subsequent studies and reports stated that it was just as harmful and perhaps even more addictive for women, but I digress…

The January 8 issue of JAMA was dedicated to the last 50 years of tobacco control. In an editorial, some fascinating statistics were presented that I would like to share:

Half a century after the release of the 1964 report, tobacco dependency continues to devastate US society. Nearly 42 million smokers still struggle with this addiction. Unfortunately, even though 70% want to quit only 3 to 5% annually can do so on their own. New estimates of annual tobacco related deaths now approaches half a million in the United States and more than 5 million worldwide. Children and adolescents are especially affected by tobacco dependency through secondary smoke an onset of smoking. Other vulnerable populations include the poor, those with mental illness or substance-abuse disorders, lesbian, gay, bisexual and transgender population as well as the homeless and those who are incarcerated. The tobacco industry spends more than $8 billion a year in the United States to advertise and market cigarettes and smokeless tobacco, while also promoting cigars, pipe-tobacco and newer products which include dissolvable tablets and electronic cigarettes.

But before you grasp your head and begin to shake it and moan oy! there are some encouraging statistics. Although there have been 17.6 million smoking attributable deaths in the last 50 years, it’s estimated that 8 million premature deaths have been prevented because of tobacco control measures. It’s estimated that one-third of the gains in life expectancy for men (30%) and 29% of the gains for women during these past 50 years were due to declines in smoking. Moreover six nations, including the United States, have had reductions in smoking prevalence of greater than 50% during the past 25 years.

Another article in JAMA points out the factors that have helped smoking cessation in the U.S. Firstly, documentation of the danger of environmental tobacco smoke which has led to a flurry of clean indoor air legislation. Currently, 26 states and the District of Columbia ban smoking in enclosed public spaces. Secondly, the 1988 Surgeon General’s report documenting tobacco use as an addiction changed public perception of tobacco use from habit to “of free choice” to true drug dependency similar to that of heroin and cocaine.Thirdly, cigarette tax increases, clean indoor air laws and efforts to prevent adolescents from purchasing tobacco or starting to smoke have proved effective. Fourthly, there has been some very public litigation by private individuals, the States and the US Department of Justice against the tobacco industry. Indeed, there was a settlement in 1998 mandating that the tobacco industry pay the States $246 billion over 25 years. (The tobacco companies are bad… to add to their list if immoral and death producing offenses, in 2006 they were found guilty of racketeering.) But let’s get back to “the making a difference” factors… There are current evidence-based smoking cessation treatments – both counseling and FDA approved medications – that can markedly increase cessation rates among smokers trying to quit. And these will now be paid for by the Affordable Care Act

When an article about cancer risk among children born after assisted conception came out in this week’s New England Journal of Medicine, I definitely paid attention. So many of my patients have used IVF and indeed so have members of my family. Since the introduction of in vitro fertilization in 1978, 5 million children have been born world-wide withy his type of assisted conception. Research has shown that there can be some prenatal complications in children born through IVF, including low birth weight, prematurity and and rare forms of congenital malformations. There has been a concern that IVF can also increase risk of cancer because of a phenomenon called in printing disorders. (This becomes somewhat complicated but just remember that genes and chromosomes might potentially be impacted when they are manipulated and have to come together in an artificial environment.)

The recent article is based on research done in the United Kingdom. Basically the study linked data on all children born through IVF between 1992 and 2008 and data from the United Kingdom National Registry of Childhood Tumors in order to determine the number of children children in whom cancer developed before the age of 15. There were 106,013 children born after IVF. Altogether, they only found 108 cancers. The expected number based on all other non IVF children would have been 109.7. The cancers they looked at where leukemia, cancer of the nervous system, retinoblastoma (a rare cancer of the eye), kidney cancer and liver and muscle cancer.

Before I continue with the long words used to define the types of cancer they accounted for, let me reassure you (and myself) that they found no increase in the overall risk of cancer among British children born after IVF during that 17 year study period. They did find a very slight increase risk of cancer of the liver and muscle but felt that the absolute risk were small. In their discussion the authors stated that “this is reassuring for couples considering assisted conception, children conceived in this way and their families and clinicians”. Yes indeed. As we continue to enter the brave new world of treatment of infertility this is one less thing we should be concerned about.

Now that I have reviewed this article, I don’t want end this week’s website website without adding the following: We have all heard the reports and seen the pictures of the devastation caused by the typhoon in the Philippines. Currently, we know that 10 million people were affected including 3.9 million children. At last count, as many as 1 million people have been displaced and over 23,000 houses were damaged or destroyed. Save the Children’s team is in the Philippines and working on the ground in the hardest hit areas. The organization has doctors and logistic experts there and they have pulled supplies from their warehouses on three different continents and are sending planes filled with blankets, medical equipment, newborn kits, buckets, tents and more to the Philippines. They arrived Thursday in Cebu and the staff immediately began distributing supplies. As we sit safely in our homes, offices or wherever it is we access the Internet (and hopefully this website), we should remember how lucky we are. If you would like to know more and hopefully donate, you can find information about Save’s response (yes, I’m on the board) at www.savethechildren.org. Thank you!

Philippine Typhoon Haiyan Response: every small donation counts: Give online: www.savechildren.org

Many of my patients have noticed that when they come for their exam my nurse asks if they have ever smoked and then enters their response into our electronic medical record. It’s not just that we want to be compliant with the government request for EMR attestation, we also want to know if specific screening should be considered. A recent article in JAMA reviewed a new recommendation statement issued by the US Preventative Services Task Force (if you want to know their acronym it’s USPSTF). In the future, this recommendation will be used by doctors who refer patients for screening and hopefully insurance companies who pay for preventive services. The USPSTF recommends that CT scans be used to target lung cancer in men and women without signs or symptoms of long cancer who are between the ages of 55 and 80 years and who have had a 30 pack year or longer history of smoking or have quit smoking within the last 15 years. A 30 pack year history means that either the person has smoked one pack a day for 30 years or, and here is where mathematics come into play, three packs a day for 10 years (I’m not sure how one could possibly smoke three packs a day but according to some of my patients it was possible, especially in the 60′s!)

There are about 160,000 deaths a year from lung cancer and the estimate is that this strategy would lead to a 14 to 16% reduction in mortality. The significance of this recommendation is that under the Affordable Care Act, private insurers and Medicare will begin reimbursing for the service. According to the article as many as 9 million to 10 million people could be eligible for screening. (Wow!) They also discussed the fact that over diagnosis and over treatment are concerns since in some cases indolent cancers that would not prove fatal would be diagnosed and treated. (This becomes a philosophical question, would we rather over diagnose and get the right ones out? …Also there is currently no way of knowing ahead of time which tumor will be fatal.) And not everyone who is a candidate for screening will want it.

In the end, we all agreed that a lung cancer screening program, no matter how accurate or how well done is never a substitute for smoking cessation and prevention. A 16% decrease in mortality is great, but we would prefer much higher numbers. As we all know it’s better not to start and certainly, the sooner this source of mass mortality is stopped the better… In the meantime, in our world in which people smoked (and unfortunately are still smoking and supporting the tobacco industry), the appropriate individuals should consider getting scanned.

I have obsessively discussed the positive health aspects of the various forms of contraception in my newsletters over the past few years. (Clearly a part of my Planned Parenthood background!) I have also proclaimed gender health success when the Affordable Care Act (ACA) stated that after August 1, 2012, preventive health services recommended by the Institute of Medicine and endorsed by the Department of Health and Human Services would be covered by insurance companies. These services are meant to promote the development of a health system that sustains health rather than merely treats illness. The services include all FDA approved forms of contraception, the morning after pill as well as sterilization procedures. And women will now be afforded health mandated services for cervical cancer screening, screening for sexually transmitted infections, mammograms and maternity care. But as we all know, some religious organizations and private employers have demanded exemptions from providing contraception stating that this violates their religious beliefs. Many of us have been outraged. Our umbrage was beautifully voiced in a “viewpoint” article published in the May 15th Journal of JAMA. Three physicians from the Northwestern University Feinberg School of Medicine in Chicago, Illinois contributed to the article and I would like to share their arguments with you.

That “one in eight” lifetime risk for breast cancer is scary for every woman but unfortunately, it remains a valid statistic. Too many of my patients have been told (often by me) that  they had breast cancer, but with appropriate therapy most are now doing well. Of course, they and I have a continued concern about appropriate follow-up. How intensive and frequent should it be? Is there a point at which a woman who has had breast cancer can “relax” and get the same screening as women who have never had  breast cancer?

The American Society of Clinical Oncology recently came out with their updated recommendations for follow-up care for breast cancer survivors; but actually, they made no changes from the guidelines they released in 2006. The Society formed a special practice guidelines committee which then studied outcome data on disease free survival, overall survival, quality of life and cost-effectiveness. (I know the latter may not be that important to women who actually have had this disease but every public health organization has to assess cost.) They studied nine reviews on the topic and five randomized controlled trials. Here are the old, and now new recommendations for follow up of breast cancer survivors:

  • A physical exam and history every 3 to 6 months for the first three years after initial therapy. Subsequently a history and physical exam every 6 to 12 months for the next two years, then yearly.
  • If breast conserving surgery i.e. lumpectomy was done, the first mammogram should be performed at least six months after completing radiation therapy, followed by a mammogram every 6 to 12 months. Once mammographic findings are stable, mammography can be repeated yearly.
  • Monthly self breast exams. Women should report any symptoms such as lumps, bone pain, chest pain, breathlessness, abdominal pain or persistent headaches to a physician.
  • Genetic counseling for the following reasons: Ashkenazi Jewish heritage; a history of ovarian cancer at any age in the patient or any first or second degree relatives; any first degree relative with a history of breast cancer diagnosed before the age of 50; two or more first or second degree relatives diagnosed with breast cancer at any age; a patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative.
  • Regular annual gynecologic care. Women who take tamoxifen should tell their doctor about any vaginal bleeding since they are at higher risk for endometrial cancer.

I assume most of my patients who are breast-cancer survivors are doing all of the above and indeed I make sure they do so when I see them, as do their oncologists and surgeons. But if you or a friend or relative have had breast cancer, please make sure that these guidelines are followed. So many of us have come through this disease and continue on with our normal lives as well as having an expectation for a healthy, long life span. We just have to make sure that our follow-up is appropriate.

We have all heard about Plan B . The  Plan B One-step consists of  one pill containing 1.5 mg (in case you want to know the dose) of a synthetic progestin , levonorgestrel . This is a progestin that is found in lower doses in many birth control pills. Id taken within 72 hours of unprotected intercourse it prevents or deregulates ovulation nd fertilisation and hence prevents pregnancy by up to 89%. If it is taken within 24 hours it is 95% effectiv. We also know about the controversy that has become a political issue reguardng those younger than 17. Currently girls under the age of 17 have to get a doctor’s prescription to obtain emergency contraception. (Many young women cannot get to a physician within the first few days of unprotected intercourse , and are too embarrassed to even attempt to do so….So should they be punished for their youth? The mistake was already made! Moreover multiple studies have shown that access to or knowledge of emergency contraception does not increase sexual activity in teens and young adults. I guess you know how I feel. And I won’t even begin to voice my protests about the issue of payment for contraception…. of course it should be covered by all health plans.)

There is another emergency contraceptive, which has been approved by the FDA as of June 2010. It’s called ellaOne. The generic name is Ulipristal; it is a selective progesterone-receptor modulator. Essentially it sits on the receptors of progesterone and blocks the action of the hormone. It is available as a 30mg pill that is taken once and can decrease pregnancy by two-thrds if taken with 72 hours and 50% for up to 120 hours  (5 days) after unprotected intercourse. It works by delaying the release of an egg thus preventing ovulation. It is currently available by prescription.

The very same medication, but in smaller doses, has now been shown to be effective for treating fibroids, at least prior to surgery.

This was the conclusion of a recent article published in The New England Medical Journal, titled (sorry I know this may not be necessary but it keeps my author credentials valid) “Ulipristal Acetate versus Placebo for Fibroid Treatment before Surgery”. The investigators from several centers in Belgium, Hungary, the Ukraine and the United Kingdom randomly assigned 242 women who had symptomatic fibroids that caused excessive bleeding to either 5 mg of ulipristol, 10 mg of the medication or placebo daily for 13 weeks before they underwent surgery. They found that even the smaller dose of ulipristol controlled bleeding in 91% of the women (whereas only 19% had less bleeding on placebo) and that up to 82% on the higher dose stopped having periods altogether (amenorrhea) compared to 6% on placebo.They also found that the volume of the fibroids decreased up to 21% in the women treated with daily ulipristol, whereas the volume increased during those 13 weeks by at least 3% in the women given placebo.

The authors did point out that the treatment was given for only 13 weeks and before planned surgery. But treatment with ulipristol may become one of the nonsurgical options that are available for women who have symptomatic fibroids. I’ll end this promising statement with the usual “more long-term studies are needed.”

Apparently yes… but before you buy stock in Bayer or stock up on years’ worth of aspirin at Costco, let me give you the result of some pooled (meaning statistically conjoined) studies: A recent article published in the medical journal Lancet analyzed 8 aspirin trials which included a total of 25,570 patients. Most of the trials were originally conducted in order to establish the effect of aspirin on prevention of vascular events such as stroke and heart attack. The patients were randomized to daily aspirin versus no aspirin over a mean duration of treatment for 4 years or longer. The trials included 3 large United Kingdom studies in which follow-up of over 20 years was done by reviewing death certificates and data from cancer registries. During that time, a total of 674 cancer deaths occurred.

The Lancet article presented some complicated particulars with charts and tables… I’ll spare you the details. But yes, aspirin reduced the risk of certain types of cancer deaths by approximately 20%. (This refers to relative risk; those who took the aspirin for 4 years or more had 20% fewer cancer deaths than those who did not.) The lessening of relative risk for cancer death was apparent just 5 years after starting the aspirin for esophageal, pancreatic, brain and lung cancer, but was delayed for stomach, colorectal and prostate cancer. Long-term aspirin was found to reduce only certain types of lung and esophageal cancers, (adenocarcinoma, which develops from gland-forming cells). The decrease in cancer rates had no correlation to dose; 75 mg was sufficient and higher doses made no difference. This means that daily “baby aspirin” which contains 81mg is more than enough. And most importantly, there were no gender differences found in the analysis! (The studies included sufficient women to make this statement… in the past studies were done primarily on men and extrapolation from male driven studies was used when it came to giving advice to women.) Moreover, aspirin worked to diminish the relative risk of these types of cancer deaths in those who smoked. (Although we always have to remember that smokers will have more of these cancers and are more likely to die from them compared to nonsmokers; unless, of course they stop). The benefit of long-term aspirin increased with age, so that the absolute reduction in 20-year cancer risk of death was 7.08% at or beyond the age of 65.

Bottom line: According to these studies, the effect of aspirin on reducing cancer death is not immediate, but takes 5 to more than 7.5 years and requires consistent dosing of 75mg a day. The 24 million dollar (or should I say the 20-year) question is whether complications from long-term aspirin use, especially bleeding (ulcers and hemorrhagic stroke) ultimately negate its positive impact. We each have our own risk profile. Before embarking on a very long course of this medication (even if it is over-the-counter), I would urge you to discuss the risks and benefits with your doctor.

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As you know when you come for your annual gynecologic visit, the receptionist requests that you update your information, sign a confidentiality form, and she checks on your insurance. The nurse then hands you a small plastic cup and asks you to give a urine sample. So there you are in a cramped bathroom trying to aim the stream into what now seems like an impossibly narrow container and thinking: (a) this is humiliating, (b) why is this necessary, I have no problems with my bladder? and possibly (c) I can’t go, so what am I supposed to do now?

A new article in the Journal Obstetrics and Gynecology aptly titled “In the Trenches” emphasizes the importance of checking your urine.

An immediate urine test can be performed with a “dipstick”, a strip of paper that is specially treated to check for white cells (often present if there is an infection) red blood cells or RBC’s (and the rest of this newsletter will deal with this… if blood is present in the urine, the medical term is hematuria), protein (if elevated, a sign of kidney or even systemic disease), glucose (present in urine if blood levels are high), ketones (elevated with kidney problems or dehydration), bilirubin (elevated in liver disease) and pH (acidity).

The journal article dealt specifically with microscopic hematuria in women. “Microscopic” simply means that there is blood (or red blood cells) in urine but the urine doesn’t look bloody to the naked eye or toilet paper…(I realize this is getting a bit gross!) According to the American Urological Association, “significant microscopic hematuria” means there are three or more red blood cells (RBC’s) per high power field (magnified 40 times) on microscopic examination from two to three properly collected urinalysis specimens. To get a proper sample, the first drops of urine should not be included, just the midstream…all the more difficult to get into that cup. If you have your period, recently exercised vigorously, just had sex or vaginal trauma, obviously blood cells in the urine will not count and the test should be repeated another time.

Once a dip stick test is positive for RBC’s …I (or any doctor) will probably send the urine out for a complete urinalysis. The urine is spun down and the sediment is examined for the number of RBC’s, white cells, and/or bacteria. Often we also do a urine culture to rule out infection. (Most women, however, do know when they have a bladder infection…. they have urinary urgency, frequency and burning.)

So why is it so important to detect microscopic hematuria? Before I relate the possible causes and consequences listed in the journal article, I’ll tell the tale of a patient that I saw a few weeks ago. She was menopausal, had no signs of vaginal bleeding or urinary problems, but a routine urine dipstick test was positive for RBC’s. Her urine was sent out for culture (it was negative) and complete urinalysis. The latter confirmed the presence of a significant amount of RBC’s.. I asked her to repeat the test 2 weeks later and once more it showed RBC’s. I then referred her to a urologic specialist for a complete workup.. This ultimately consisted of cystoscopy and a CT scan of her pelvis and kidneys. She was found to have bladder cancer. It was resectable and curable.. This simple urine test probably saved her life.

The two most frequent causes of microscopic hematuria in non-pregnant women (46% of women do have hematuria during their pregnancy) are cystitis (bladder infection) and kidney stones. Additionally, some women seem to shed RBC’s in their urine without any pathology. But the cause that should be ruled out, especially in women over 40, is cancer. Bladder cancer is the 17th most common cancer in women worldwide. In the United States in 2008 there were 17,770 new cases of bladder cancer diagnosed and 4,270 deaths …that means that there were more deaths annually from bladder cancer in women than from cervical cancer! (A personal aside…. many years ago my paternal grandmother died from bladder cancer.)

The risk factors for urologic cancers in women include age over 40, smoking, a history of exposure to chemicals or dyes, a history of gross hematuria (the “gross” here is a medical term and means that urinary blood is visible), analgesic abuse and a history of pelvic radiation. And here is a fact that seems to appear whenever we discuss most cancers: up to 35% of female bladder cancer cases may be attributable to cigarette smoking!

The recommendations put forth in the article state that a complete work up of microscopic hematuria should include an evaluation of the lower urinary tract (the bladder) and upper urinary tract (the ureters and kidneys) in any “high-risk” patient. Once more, you are at risk if you are over 40, have smoked, have had chemical exposure (hair stylists), have a family history of bladder cancer (I guess that’s me) and/or recurrent urologic disease. The work up should include cystoscopy, x-rays with dye and CT scans.

We all know about the need for Pap smears. It turns out that a urine test is just as important. So please don’t bewail that request to pee in a cup.

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