Doctors question need for yearly pelvic exams

Healthy adult women don't need Pap smears every year and that time could be spent on other more pressing health matters, a group of doctors reports. Not all healthcare providers agree.

It's an annual rite most women would prefer to skip: a trip to the doctor for a checkup that includes shedding every stitch of clothing, donning a paper gown, placing feet in metal stirrups and enduring a pelvic exam.

For a healthy adult woman, the exam typically doesn't hurt. However it can be uncomfortable, cold, embarrassing, time-consuming and, perhaps, unnecessary.

Some doctors are beginning to question the need for every woman to have the exam every year. One of them is Dr. Carolyn L. Westhoff, a professor of obstetrics and gynecologyat Columbia University. Last month, she and several colleagues wrote in the Journal of Women's Health that the routine pelvic exam is "obsolete" for women who have no symptoms that might suggest a problem. They argued that the time could be better spent on other, more pressing, health matters.

Westhoff notes that pelvic exams are not routinely performed in many European countries. "We have a more aggressive tradition in the West," she said. "It's kind of an American medical culture thing to just do more."

An annual doctor's visit to talk over concerns is "a fine idea," she added. "But a pelvic doesn't have to be part of that encounter."

The article comes about a year after the American College of Obstetricians and Gynecologists released new recommendations relaxing the number of Pap smears women need. For many healthy women, a Pap test every two years from ages 21 to 29 is sufficient, followed by every three years for women ages 30 to 65, according to the college. And Westhoff notes that scientists are working on a vaginal swab test that women can perform themselves and submit to a lab for detection of human papillomavirus, the cause of cervical cancer. Such a test would further reduce the need for Pap tests.

She said there were other reasons to abandon the annual pelvic exam:

• Pelvic exams are also done to screen for sexually transmitted diseases, particularly chlamydia. But there are now reliable self-swab tests that women can use to collect samples to send to a lab.

• Pelvic exams were once routinely performed before a healthcare provider would prescribecontraception. Though this is still needed for a diaphragm or intrauterine device, several health groups specifically state that the exam is not necessary for a woman to receive hormonalcontraceptives.

• A manual examination of the pelvic area, in which the doctor uses two fingers and applies abdominal pressure to feel the uterus and ovaries, has never been proven effective for earlier detection ofovarian cancer.

• The examination can lead sometimes lead to unnecessary tests, such as when the doctor feels a mass on the ovary that, in most cases, is a benign cyst that would disappear on its own.

"If we want to do some of the newer stuff that is helpful, all sorts of prevention services that we should attend do, we have to let go of some old stuff that is unhelpful," Westhoff said.

Not all physicians agree with Westhoff's stance.

Doctors and patients do need to rethink how to best spend their time together, agreed Dr. Lisa Nicholas, an assistant professor of obstetrics and gynecology at the UCLA David Geffen School of Medicine. Doctors and patients today should discuss nutrition, physical activity, complementary and alternative medical practices, substance abuse and mental health issues, she said.

But the pelvic exam, Nicholas added, may still have value beyond the major reasons stated as its goals. During the exam, a doctor will inspect the pelvic area for unusual bumps, lumps and rashes that a woman may not see. On rare occasions, a dangerous type of skin cancer called melanoma may be detected on the genitals.

And she worries that a relaxation in pelvic exam recommendations might lead some women to skip a yearly checkup altogether. "I'm fearful of saying to patients 'You don't need this.' They may interpret that as 'I don't need to see the doctor.'"

Even minor symptoms such as light bleeding, minor discomfort, bloating or abdominal pressure are good reasons for an exam, said Dr. Cheryl Iglesia, chairwoman of the committee on gynecological practice for the American College of Obstetricians and Gynecologists and an associate professor atGeorgetown University School of Medicine.

Westhoff "makes a compelling argument," Iglesia said. "But I think the key is the word 'asymptomatic.' That means someone not having any issues."

Though the American College of Obstetricians and Gynecologists still endorses an annual pelvic exam, it continually reviews its guidelines, Iglesia said. For example, the group formerly recommended that pelvic exams and the Pap test begin three years after initiation of sexual activity or at age 21. The new recommendation is for the first Pap test at age 21.

"We are always looking at data … and we revise policies," Iglesia said. "I would rather spend those 15 minutes with a 15-year-old talking about prevention of STDs."

Family Health History is Important Screening Tool

Washington, DC -- All women should have a family health history on file and it should be reviewed and updated regularly, according to The American College of Obstetricians and Gynecologists (The College). Family history screening is especially important in reproductive planning.

"Our goal is to help improve our patients' health by promoting family history as a screening tool," said W. Allen Hogge, MD, chair of The College's Committee on Genetics. Certain diseases and conditions run in families, such as breast and colon cancer, heart disease, type 2 diabetes, depression, and thrombophilias (blood clotting conditions). "If we know about the family history, then we can better help our patients identify their own risk factors, decide on certain screenings, and modify their lifestyle to prevent or minimize the problem.


"When a woman is planning a pregnancy, it's an ideal time to review her family history as well as her partner's," said Dr. Hogge. In addition to obtaining the family and medical history of the woman and her male partner, it's also important to include their ethnic backgrounds, any family or personal negative pregnancy outcomes they've had separately or together, such as miscarriages, preterm birth, or birth defects, and any known causes for infertility. Some couples may decide against pregnancy after genetic counseling and testing, choose to use donor sperm or eggs, or opt for preimplantation genetic testing of the embryos.


There are a couple of standard methods that physicians can use to obtain family health histories: a questionnaire orchecklist, and a family pedigree. A common screening tool is the family history questionnaire. Patients can fill them out at home which gives them extra time to contact family members and provide more accurate information. The other family history tool is known as a 'pedigree' that ideally goes back three generations. The pedigree indicates the ages, health histories, and ethnicities of each family member, as well as dates and causes of death. Of course, family history screening tools can be difficult or impossible to obtain for adopted individuals and their usefulness may be limited for people with very small families.


Although many adult-onset health problems have complex genetic and environmental interactions, obtaining thatinformation in a family history can help patients modify their diet, lose weight, or exercise to improve their outcome or delay the onset of symptoms. "For instance, if you are at high risk for developing heart disease, then you need to watch your blood pressure and keep your cholesterol levels in the healthy range," said Dr. Hogge.

Committee Opinion #478, "Family History as a Risk Assessment Tool," is published in the March 2011 issue ofObstetrics & Gynecology.

Tubal Ligation Reversal

Tubal Ligation Reversal

A common dilemma many individuals face if they've previously had a tubal ligation is whether they should undergo a microscopic tubal ligation reversal vs. an In Vitro Fertilization (IVF) procedure. While a tubal reversal does require more skill than an IVF procedure, a tubal reversal is actually the better option for most patients. A tubal reversal requires one operation to restore fertility, enabling the patient to have as many children as she wants, whereas an IVF procedure offers a lower, 20% to 35% chance of success for each try and can be much more costly in that it could take several attempts before becoming pregnant. Our success rate with microsurgical tubal reversal is about 95%. (We actually were the first to develop this procedure in the U.S., and therefore have the largest experience with it.) The procedure involves a relatively small incision and only one day in the hospital. There is very little pain, and you can go back to work within a week. However, the microsurgery must be performed very expertly and delicately.

The fallopian tube is a tiny passageway that begins at the fimbrial end where the egg is picked up from the surface of the ovary, and leads through a microscopic opening into the uterus. As long as the fimbrial end has not been destroyed we can achieve an excellent micro-anatomical reconnection.

If a large amount of tube was destroyed by your original sterilization, that will not interfere with our achieving an accurate surgical reconnection. However, your chance for pregnancy is related to the length of the tube. If at least one-half of the tube is still intact, the chances for pregnancy will be over 90%. If there is a shorter length of tube, the chances for pregnancy will be less. As the amount of tubal length diminishes, the chance of pregnancy diminishes despite an accurate reconnection. Pregnancy can never be promised. However, a good microscopic operation is necessary to give you the best chance of restoring your fertility.

The diameter of the tube varies in different sections. Because your tubal sterilization has destroyed a certain segment of your tube, the two ends to be reconnected will most probably be of different size. Through the use of microsurgery we can beautifully reconnect these ends of the tube even when there is a difference in size. It is technically possible to connect the relatively large diameter near the fimbriated end to the tiny almost invisible cornual end. However, it is important to microscopically tailor such a reconnection to be as smooth as possible. This minimizes the risk of "ectopic" pregnancy. An ectopic pregnancy occurs when the egg, which is fertilized in the tube, gets stuck at the site of reconnection instead of passing into the womb to begin its growth into a baby. This risk is greatest when the site of reconnection is not a smooth, even transition.

The benefit of using the microscope for this surgery is that we can see the tiny inner opening of the tube clearly, and thereby accurately reconnect it. A meticulous microsurgical technique is necessary, and this, of course, requires considerable experience. We have performed over 8,000 microsurgical operations to reverse sterility in men and women, after developing these exacting microsurgical techniques on over 2,000 laboratory rats. It requires this kind of extensive practical experience to obtain the best results.

Questioning the Need For Routine Pelvic Exam

Commentary Argues It Deters Regular Gynecological Care

Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.

Many women find it embarrassing, invasive and even painful. And being instructed to "relax" frequently has the opposite effect.

Now, a commentary in the January Journal of Women's Health has raised a provocative argument: For healthy women with no symptoms of disease, a routine pelvic exam serves little purpose—and may be so disliked that it dissuades some women from getting regular gynecological care.

"If a woman is asymptomatic and feeling fine, getting naked on a table with stirrups and a speculum is not adding extra value," says lead author Carolyn Westhoff, a professor of Obstetrics and Gynecology at Columbia University Medical Center and of epidemiology at the Mailman School of Public Health. "We should be talking about diet and exercise and immunizations—and having time to listen to what she's worried about. We can let go of something that is uncomfortable and embarrassing and not that useful."

In fact, the American College of Obstetricians and Gynecologists (ACOG) is re-evaluating its recommendations on the subject. "We are looking at this very closely," says Cheryl Iglesia, chair of ACOG's Committee on Gynecologic Practice.

Traditionally, a key reason for doing a pelvic exam has been to take a Pap smear—a sample of cells on the cervix to check for signs of cervical cancer—long recommended annually. But in late 2009, ACOG revised its recommendations for Pap smears to every two years for women ages 21 and 30 with no symptoms or other risk factors, and every three years from 30 and older.

Given that change, ACOG is rethinking other elements of the annual exam as well, says Dr. Iglesia. "There may be times when [a pelvic exam] is not necessary and your 15 minutes of managed-care time may be better spent talking."

In addition to the Pap smear, an ob-gyn also traditionally uses a pelvic exam to check the ovaries and uterus for signs of cancer. The ob-gyn uses two fingers to palpitate the organs inside while pressing on the patient's abdomen from the outside, the so-called bimanual exam.

But Dr. Westhoff and her co-authors point out that bimanual exams don't lead to earlier diagnoses of ovarian cancer and aren't recommended for that purpose by ACOG, the American Cancer Society or the U.S. Preventative Service Task Force. They are seldom performed in the United Kingdom, where the proportion of women diagnosed with Stage 1 ovarian cancers is the same as in the U.S.

Bimanual exams do sometimes lead to additional tests and procedures, such as having ovarian cysts or fibroids removed that may have resolved on their own, says Dr. Westhoff, who notes that one reason ACOG moved away from annual Pap smears was that abnormalities seen there sometimes led to laser excisions or biopsies that could harm a patient's fertility unnecessarily. When women do have symptoms, such as abdominal pain, backache or irregular bleeding, ultrasounds can reveal more information than palpitation can, she adds.

Pelvic exams are also commonly used to screen for sexually transmitted diseases and before prescribing contraceptives. But the authors note that chlamydia and gonorrhea can be detected just as well via blood or urine tests or with swabs that women can administer themselves. And while a pelvic exam is needed to fit a diaphragm or insert an intrauterine device for birth control, there's no need for one before prescribing the pill or a patch.

"I don't want a young woman to be afraid to come in for contraception because she's afraid she'll get a pelvic exam," says Dr. Westhoff. "The pelvic exam is irrelevant to starting the pill. But a substantial portion of doctors still require one. I think a lot of them have just been taught that that's the thorough way to take care of patients, and nobody has stopped to ask, 'What are you looking for?' "

Some other ob/gyns say a pelvic exam can provide numerous clues to a patient's condition. "There's a treasure trove of information you can glean from a pelvic exam," says Laurie Green, a San Francisco ob/gyn.

For one thing, Dr. Green says she can gauge roughly how close a woman is to menopause from the color of her vaginal walls, and says she has occasionally spotted malignant melanomas. She has also spotted cancers during the rectal portion of the exam, and cervical polyps that can make intercourse painful.

Bimanual exams can sometimes detect early stages of endometriosis, an overgrowth of uterine lining outside the uterus, and fibroids that may be asymptomatic now but can pose problems later. "I've had patients who get pregnant and they come in with massive fibroids, and if the fibroids had been removed earlier, they would have a much lower risk for preterm labor," says Dr. Green. "You would lose all of that if you didn't do a pelvic exam."

And while many women detest the pelvic exam, some consider it a crucial part of the visit. Mary Jane Minkin, a professor of ob/gyn at Yale University School of Medicine, says that with the older women she sees in her private practice, "I'm discussing their general health, health habits, weight, exercise regimens, smoking, sexual issues—all of it important—but what sanctifies the visit is the pelvic exam."

Without it, she wonders, "Would they really come in regularly for the health counseling and would insurance reimburse for it?"

Another issue is litigation, Dr. Minkin says. "If something could have been picked up on a pelvic exam and a pelvic wasn't done, do we get sued?"

Dr. Minkin also cautions that while women in monogamous relationships aren't at high risk for cervical cancer, some women only think their relationship is monogamous, so an annual check provides additional protection.

Whether it's done every year or less frequently, a pelvic exam is still necessary periodically, and some doctors, at least, are focusing on ways to make it less uncomfortable for patients.

Robert Reid, a professor of ob/gyn at Queens University in Kingston, Ontario, has developed a video giving medical students more guidance on how to give a "compassionate" pelvic exam. The tips include warming the speculum and testing it on a patient's skin first as well as explaining every step so there are no surprises.

"This is from over 30 years of watching novices make mistakes," he says. The video has been adopted by Canada's Association of Professors of Obstetrics and Gynecology, which distributes it to all Canadian medical schools, and it will be demonstrated at a conference of U.S. ob/gyn professors in San Antonio next month.

10 Ways to Live Normally With a Leaky Bladder

Retrain your brain, your muscles, and your habits to control an overactive bladder.

Nervous about going out because your bladder sometimes leaks? Or constantly worried about getting to a bathroom on time? About one in five adults over age 40 has problems with urinary urgency and frequency, according to the National Association for Continence. But an overactive bladder (OAB), also called urge incontinence or irritable bladder, doesn't have to cramp your lifestyle.

Overactive bladder is often caused by a disruption in nerve signals from the brain to the muscles involved in urination. Symptoms include the need to go often or suddenly. It's the second-leading kind of incontinence, as well as part of the most common kind, "mixed incontinence" -- having both OAB and stress incontinence, a muscle weakness causing leaks when you cough or sneeze.

Here are ten ways to live a normal life despite bladder worries:

1. Be sure you're not drinking too much -- or too little.

Too much liquid, of course, will send you running to the bathroom too often, no matter what the condition of your nerves and muscles. A smart rule of thumb from ob-gyn Jill Rabin, coauthor of Mind Over Bladder, or I Never Met a Bathroom I Didn't Like and chief of ambulatory care and urogynecology at the Albert Einstein College of Medicine in Hyde Park, New York: Divide your body weight in half, and that's roughly the number of ounces of liquid a day that should be your maximum. So if you weigh 150 pounds, aim for 60 to 80 ounces of liquid a day. (That's about 10 cups total, including water, tea, juices, milk, soup, and so on.)

Drinking too little, on the other hand, sets you up for constipation, which can lead to urinary tract infections. UTIs irritate the bladder, triggering the need to go. Not drinking enough also creates concentrated urine, which is itself a bladder irritant and smells even worse if there's an accident.

The very best beverage for the bladder: plain water. Try drinking it flavored with a slice of lemon or lime, or drop an herbal tea bag into a sport bottle, glass, or thermos of cool water.

2. Identify and avoid your trigger food(s).

For most people with overactive bladder, one or two kinds of food exacerbate the problem. Ob-gyn Jill Rabin's list of the top offenders: artificial sweeteners (especially Nutrasweet), coffee (and caffeine generally, including tea), alcohol, chocolate, tomatoes, red peppers, and spicy foods. Energy supplements can also contain ingredients that annoy the bladder. Other triggers in some people: acidic foods (citrus) or high-sugar foods.

Eliminate one food for two weeks and see if there's any difference, Rabin suggests. If not, pick a different substance to eliminate. Most people have just one primary trigger, not all of these.

3. Get the knack.

The muscles that help hold back urine until it's convenient to go are both involuntary and voluntary. There's a moment before coughing, sneezing, lifting a box, swinging a tennis racquet, or dealing with other physical stressors when you can consciously tighten the urethra to help hold back the urine. Doctors call this maneuver "the knack."

Because the knack maneuver is a voluntary movement, with practice you can teach yourself to do it at the moment you'll need it. Right before you cough or lift something (or whatever move you know creates your urinary leakage), consciously contract your pelvic floor.

Do this often enough, and the habit will become a reflex, Rabin says. The extra contracting of the knack movement can be enough to prevent any leaks.

4. Keep on Kegeling.

A therapy used to treat overactive bladder should be an everyday feature, doctors say. Most women know pelvic-floor exercises by the name "Kegel," after Arnold Kegel, the physician who popularized them. Kegels build the muscles used to control urine flow.

Because their effect is cumulative, the more you do them, the better you can resist an ill-timed urge to urinate. To remember to do the exercises often, build associations: Do them every time you're sitting at a red light, for example. Or leave yourself reminder notes in front of the bathroom mirror or on the dashboard of your car.

You can identify the muscles involved by stopping urine flow midstream. Do regular Kegel exercises when you're not urinating, however, to avoid the risk of urinary tract infections or other damage. Rabin recommends holding the contraction for a slow count of five ("one Mississippi, two Mississippi . . . "), then relaxing for a count of ten. Repeat five times for one set. Gradually work up to ten sets per day. "It takes up to six weeks to see results," she says.

5. Visualize a delay.

Since OAB is partly a signaling problem between the brain and the body, try using your mind to forestall an urgent need to urinate. Decide on a powerful mental image that you can turn to whenever you desire a distraction from urinating. Some people imagine a dam at a rushing river, or a drain plug, although for others the water in these images is too tempting. If that's the case, picture another form of blockage: a fence, a railroad gate, a stop sign on a desert highway. A picture that simply makes you calm and happy might also work, such as a child's or lover's face, a sunset, flowers.

When the urge strikes, return to your mental image and take deep breaths.

6. Quit smoking.

Reason number 5,999,999 to drop a cigarette habit once and for all: The chronic cough it causes isn't doing your bladder any favors. Nicotine irritates the bladder lining. Even worse, smoking produces chronic coughing, which triggers leakage.

7. Treat your bladder the same, seven days a week.

Doctors often see a phenomenon called "schoolteacher's bladder," ob-gyn Jill Rabin says. Overactive bladder symptoms worsen at night because during the day, the person simply doesn't use the restroom often enough, sometimes because of work constraints. The result: up all night with what seems like an overactive bladder.

Ideally, aim for using the bathroom every two to four hours (under age 50) or every two to three hours (over age 50).

8. Make sure all of your doctors know about a new prescription.

More than 300 different medications can cause incontinence symptoms, ob-gyn Jill Rabin says. A drug can either be the cause of your overactive bladder, or it can exacerbate the problem. Often a related alternative medication proves less irritating. Be sure that the doctor treating your urinary symptoms knows about any new drugs you're given by a physician for an unrelated issue.

9. Wear tampons or pads for extra security.

Reducing the odds of leaking in the first place (by changing diet, medications, muscle strength, and so on) provides the best freedom. In the meantime, given the range of discreet, absorbent personal products out there, it's easier to live your usual life wearing added protection than to hide at home.

Some women swear by a tampon worn during heavy exercise. (Many female athletes with stress incontinence know this trick.) Be sure to change them out often. Disposable underwear is another solution. Forget the "adult diapers" imagery of the past; current products, styled for either men or women, look more like classic undergarments.

Carry a change of clothing in your car, as well as a dark plastic bag to transport soiled clothes until you can wash them.

10. Get the right diagnosis.

The best way to live normally with an overactive bladder is to be sure of the source of the problem, so you get to the right treatment. Only 17 percent of baby-boomer women say they're likely to immediately contact their doctor when they experience an embarrassing health condition or symptom, such as incontinence, according to a 2011 Harris Poll. And more than half (55 percent) wouldn't contact their doctor at all, even if the symptoms got worse!

This is changing, doctors say, as more people become aware of the options surrounding incontinence. "Thank goodness, in 2011 overactive bladder is finally coming out of the water closet," Rabin says.

Study: Miscarriages, family heart disease linked

Study: Miscarriages, family heart disease linked

 There are new findings Friday that miscarriage could be tied to a family's heart disease history.

A study in the British Journal of Obstetrics and Gynecology found that women who miscarried twice before having their first child had a higher risk of having parents with heart disease.


The risk was even higher in women who'd miscarried three times before giving birth.


Scientists say the news can be used to serve as a clue for researchers studying how genes passed from parent to child affect both problems: heart disease and miscarriage.

Link between cocaine use, smaller babies strengthens

Women who used cocaine while pregnant -- even just once -- had a one in three chance of having smaller, more premature babies, according to a study.

While health care workers have long known of such a link, the latest study, published in the American Journal of Obstetrics and Gynecology, pooled the data from 31 previous studies for a more comprehensive look at the situation.

"This actually gives us concrete numbers to remind us once again of the association of cocaine use and (the) negative impact that it has not only on pregnancy but also on newborn babies," said Kellie Murphy, an associate professor of obstetrics and gynecology at the University of Toronto and co-author of the study, told Reuters Health.

Babies born to mothers who used cocaine -- which the study defined as any use during pregnancy at all -- had a one in three chance of being born before 37 weeks of pregnancy. Without cocaine use, this risk was one in eight.

Cocaine-using mothers also had a one in three chance of having a baby who weighed less than 2,500 grams, while women who did not had about a one in 10 chance.

They're "small in weight, size and head circumference, the brain's small, everything is smaller," Murphy said.

Other health care professionals pointed out that babies born to cocaine-using mothers can also have a higher risk of high blood pressure, heart disease and early death, meaning that the ongoing social costs require long-term health care policy to address the issue.

There is research that says that programs to get women to quit cocaine are helpful, so it's important for doctors to try to identify patients who have these problems, Murphy said.

"Pregnancy is often a time where women can change their lives. It's potentially an opportunity for women to get on the right track," she added.

WHY CANCER SUCKS

WHY CANCER SUCKS

QUESTION

Hi Irene,

I've been struggling with this problem for years, but it's finally taking a toll on me. I've had cancer for over 18 years. I was diagnosed when I was 21 so I've essentially had it my entire adult life. I've learned to cope with it quite well and live a normal, healthy life despite having a chronic illness.

When I was first diagnosed and going through surgeries and treatment a lot of my friends vanished. It hurt a lot, but we were all very young and I know that most of my friends just didn't have the maturity to deal with such a tough situation. I moved on, made new friends, but it still hurt a lot knowing I had so many fair weather friends.

Now I am 38. Most of the people in my life now know that I've had cancer, but they've never seen me sick so I suppose it's hard for them to comprehend all that I went through. I recently had a recurrence and again, many friends are falling by the wayside. I don't know how to cope with this anymore. I learned long ago that it was best to not talk about it too much and to exude a positive attitude. I've tried reassuring the people close to me that even though this is a set back, I've always responded well to treatment in the past so there's no reason to think I won't continue to do so. I am constantly reassuring my friends and family that everything will be okay, but even with all my attempts to comfort those around me, still I am getting the cold shoulder.

So today I am angry and hurt. My phone has not rung in four days. I've sent a couple emails to one best friend asking if she'd like to meet for coffee next week and I received no reply. This isolation is the absolute hardest part of this illness. I feel completely alone and unloved and I know I do not deserve to feel this way. I am getting involved in a support group again which is wonderful, but I miss my friends. I miss my regular life. I miss being able to call a friend knowing that she's going to be excited to see me calling. Now I know she cringes and puts the phone to voice mail because it's easier to avoid me rather than face reality.

None of these people knows how frightening it is knowing I'm truly alone in this. If I can't count on my dearest friend to meet me for coffee then what the heck is going to happen if I'm too sick to drive myself to the hospital for treatment? Who's going to take me home after having surgery? And heaven forbid I might want to have someone visit me when I'm having a bad day. I am at a complete loss.
I can deal with the medical side of cancer. Treatment and surgery are tough but I can take it. The isolation I feel from the people around me though is the most horrible thing I have had to deal with in all of this and it hurts more than anyone can possibly understand. I will persevere. I always do. But, I fear that emotionally, I may not recover so well. I would like to find a neutral way to let the people around me know how hurt I am without making them feel bad. I can't think of a way to do this though. If I am upfront and tell them how much they've hurt me, it will only further drive them away. Is there anyway to resolve this and help strengthen my relationships with these people? Or should I cut my losses and try once again to make new friends and hope they don't do the same thing? I just don't want to be sad anymore.


Signed, 


Pam







ANSWER


Hi Pam,


With improved treatments, more and more people are living with cancer, which is now viewed as a chronic illness. While it has to be terribly disappointing to have family and friends scatter and hide when you need them most, this type of reaction is common.


Unfortunately, many people are so frightened of illness and their own mortality that they wind up turning their backs when their support is most needed. They're simply incapable of responding otherwise.
When you're feeling vulnerable and need all the love you can get, this can be extremely unnerving. Although it has to feel very personal, try not to take it personally. It has more to do with the their own frailties and limitations than their feelings about you. You've come to terms with this illness over the course of many years; you have little choice but to let them deal with this on their own terms and timeline.
In the meantime, seek out the people around you who are more capable of being supportive even if it means your friendships are limited to a paltry few. Let them know how they can help and support you in concrete ways.


Remind your friends that your life isn't defined by cancer alone. Perhaps, you can plan a fun event with a friend, maybe an overnight at a spa or casino, so she can see you in a different, more relaxed light. As you mention, support groups with people who have been there can be extremely important in your life right now.


I'm truly sorry about your recurrence and wish I had better answers. Perhaps your post will give others some food for thought and contribute to better understanding.


Warm regards,

Irene S. Levine, Ph.D.

Irene S. Levine, Ph.D. is a psychologist and award-winning freelance journalist and author who has written hundreds of articles-covering a range of topics, including health, mental health, relationships, and lifestyles-that have appeared in leading publications including Ladies' Home Journal, Reader's Digest, Self,AARP, Better Homes & Gardens, Health, Prevention, The New York Times, The Los Angeles Times, Chicago Tribune, and The Dallas Morning News.