Gynaecologist? What Gynaecologist?

Cervical cancer is the leading cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years.

New Media Fellows 2013

By Anindita Sengupta

December 01, 2013

Also published by the Bangalore Mirror

I'm 35. I have a child. I don't have a gynaecologist. I certainly did not have a 'gynac' when I was younger—and going by conversations with friends, I'm not the only woman (educated, middle-upper class) to reach this late age without establishing a trusted gynaecologist. A question about this on the Facebook group Mums of Bangalore led to a flurry of replies. Of ten women who replied, only three had a regular gynaecologist. Many said they had not had time to go back even once after the baby. One said: "Nope. I didn't see one till I conceived. If everything is normal, I see no need to visit docs." It's a sentiment that finds its echoes in centuries of traditional belief. Many of our grandmothers have an instinctive distrust of modern medicine and excessive testing. Given the increasingly commercialized nature of private hospitals, who can blame them?

But this reluctance and scepticism can have far-reaching effects when it comes to certain, serious health concerns. In an article in PLOS Blogs, researcher and cancer prevention advocate Pooja Yerramilli points out that the most prevalent cancers in India can be prevented and this includes cervical and breast cancers which can be handled by timely surgery. But "in India, Pap smears are commonly seen as overly invasive and embarrassing. A woman who seeks a Pap smear is presumed to engage in sexual activity, which in India, is rarely openly discussed. This stigma not only discourages women from seeking Pap smears, but also affects the design of preventative programs." Women in the urban middle and upper classes may be able to overcome this stigma if there is significant encouragement from their parents and if they have a gynaecologist advising them. But to begin where we started, how many of us have a gynaecologist?

Some scary facts: Cervical cancer is the leading cause of cancer mortality in India, accounting for 17 per cent of all cancer deaths among women aged 30 to 69 years, according to a paper published in The Oncologist earlier this month. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025. Nearly 70 per cent of cervical cancer cases in India are diagnosed at an advanced stage, which means Stage three or four. After diagnosis at this late stage, most women will die within five years.

In the US, Canada, Australia and Europe, prevention of cervical cancer is promoted through regular Pap screening and through the Human Papilloma Virus (HPV) vaccination. HPV has been found to be present in a majority of the cases of cervical cancer and vaccines effective against two strains of this family of viruses have been licensed in these countries. In India, it gets complicated to adopt this route. The vaccines should ideally be given to women before they start sexual activity. In Indian homes, there are two implications to this. One is that both the girl and her parents would need to be at peace with the idea that she might engage in sexual activity, whether she is married or not. Secondly, the age at which parents assume that the girl will become sexually active is not necessarily the age at which she actually becomes sexually active. Many teenagers and young people do engage in sexual activity without requisite knowledge or protection but can never ask because we're mired in hypocrisy. Even the most progressive people balk at accepting young people's sexuality. Even the most aware parents believe that adolescent sexuality will wash neatly over their children without affecting them.

There are also mixed opinions on the vaccination among educated women. A well-known feminist writer and teacher tells me that she's read that the vaccine is a money spinner. This perception is fairly common. When my daughter is older, she says, I will do more research so that I can give her more options.

Given the confusion around the HPV vaccine and the fact that it can only be given to women below a certain age, Pap screening remains our most effective form of preventing cervical cancer. But many middle class women sheepishly admit that they have no gynaecologist and have thought of getting Pap screens but "...haven't gone since my daughter was born— no time. Madness I know." One woman in her thirties, a blogger, writer and mother of two, puts it down to laziness but also calls herself the "the average middle class Indian woman who puts herself last!" Possibly that applies to many of us but in the interests of health, it may be time to stop. Pick up the phone. Make that appointment.

The author writes about maternal and reproductive health with a grant from the International Reporting Project in Washington DC