Dear Dr. Roach: I am a 65-year-old male, generally in good health and on no medication. I recently went for a checkup, and the doctor did not take a PSA blood test, nor did he perform a digital exam on me. I don鈥檛 have severe issues with urinating, but the stream is not as strong as it used to be. According to my doctor, I have prostate-gland enlargement, but he seems unconcerned with my prostate health. He said that they no longer perform PSA tests. I know a few people who have had prostate cancer, but they have been treated and are well, except they no longer have a prostate. Should I be insisting on these tests?
P.O.
I am disappointed by the quality of care you report. PSA tests are still done, but they aren鈥檛 right for everyone. The goal of screening is to identify high-risk prostate cancer so that it can be treated early. You should have a chance to hear about your options.
Many cases of prostate cancer, especially those found by screening, are what could be termed 鈥渓ow-risk鈥� prostate cancer. In this case, the best option is careful monitoring; this also is called 鈥渁ctive surveillance.鈥� Men with low-risk prostate cancer in an active surveillance program are carefully monitored and later can be reclassified as high risk, at which point treatment is considered. Men who are comfortable with active surveillance are good candidates for prostate cancer screening. Men who are uncomfortable not treating prostate cancer, even if it is low risk, will be more likely to see harm than benefit from prostate cancer screening.
In the less-common case that high-risk prostate cancer is found, the ability to intervene early may give some survival benefit. The goal of this screening strategy is to avoid unnecessary (and potentially harmful) treatment of low-risk prostate cancer while still trying to identify people who would benefit from early intervention.
A slow urinary stream is a near-universal finding in 65-year-old men, and is not a reason to change screening strategies.
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Dear Dr. Roach: I am a woman who just turned 70 and has not been sexually active for 20-plus years. I haven鈥檛 had a gynecological exam in about the same amount of time, and I also have not explored my own body for quite a while. The other day, I decided to check things out 鈥渄own there鈥� and was surprised to see that my labia have shrunk. They used to be long and soft; now they have shrunk up into my body and barely cover the openings. I am just wondering if this is normal and if there is some way that I can stretch them back to their longer length.
J.K.
This sounds like vulvovaginal atrophy. The vulva (including inner and outer labia) and vagina are dependent on estrogen to maintain their normal shape and function. At menopause, estrogen levels drop, and changes to the genitalia are expected. It is shocking to me that 70 per cent of women with symptoms of
vulvovaginal atrophy don鈥檛 discuss it with their doctors. Symptoms can include painful sex (for women who remain sexually active), frequent urinary tract infections, pain and bleeding. The diagnosis usually can be made by physical exam.
There are many treatments, the most common of which is topical estrogen cream. Without treatment, the condition is likely to continue or worsen, and some women will develop fusion of the labia.
Women with no history of abnormalities on Pap smear, no longer need screening tests after age 65, but I recommend continuing to get a regular exam by a gynecologist, internist or family doctor.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected].
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