Dear Doctor: How do I get the most out of my relationship with my primary care physician? The appointments are so short these days, and I want to be smart about the way I use the time.

Dear Reader: That's a great question. As fellow patients who see our own physicians, we share your concerns. And as primary care physicians, we are keenly aware of the need to structure an office visit to make every minute count.

Here, drawn from what we do in our own practices, as well as thoughts from fellow physicians, are some ideas to help maximize the time you have with your physician.

-- Consider timing: Be strategic when making your appointment. Monday and Friday tend to be busiest. The first appointments of the morning are least likely to have a wait time, and your physician won't be feeling as rushed. And please, arrive early!

-- Plan ahead: Write down and prioritize your health concerns. Be prepared to describe them succinctly. Symptoms can be physical, mental and emotional. Include details like when the symptom began, how long it lasts, anything that makes it better or worse, and what you are worried about.

-- Look at the big picture: Bring a complete list of the medications you are taking, including supplements. Be sure to include specific dosages. If it's easier, bring the bottles themselves. If you have recently stopped taking a medication, be sure to include it in the list as well. If you have undergone testing with other providers, tell your primary care physician what prompted the tests and provide a copy of the results.

-- Be a partner: Let your physician know your specific goals for the visit. This allows him or her to manage time wisely and efficiently. Take notes. A lot of information is imparted during a medical appointment, and it's easy to miss important details. Some patients bring a spouse, relative or friend to be another set of eyes and ears.

-- Be assertive: If your physician says something you don't understand, ask him or her to repeat it. If you feel you are not being understood or heard, say so. When you require more time than a visit allows, ask whether a nurse or physician's assistant in the office is available to further answer your questions.

-- Stay focused: Stick to the topic that brought you to the office. Spending the time delving thoroughly into your main health concerns will have the highest yield.

-- Stay connected: Ask your physician for the best way to reach him or her in the next few days, when new questions are likely to arise. Here at UCLA, we have a patient portal that allows our patients to reach us directly via email. Ask your physician whether that's an option. If not, learn your physician's preferred approach, which includes how to reach him or her in an emergency.

-- Keep the conversation going: If you feel your questions or concerns haven't been met, don't be afraid to schedule a follow-up visit.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I'm 71, and after a recent bone scan, my doctors are insisting I take a bone-building medication. I couldn't tolerate Fosamax, so they want me to take Prolia. I'm worried about it, but my mother had severe osteoporosis, so I'm worried about that too. How can I choose what to do?

Dear Reader: Your worry is well-founded. Osteoporosis is defined as a decrease of bone density greater than 2.5 standard deviations below the bone density of a healthy young adult, and it's more than three times more common in women than men. Women ages 65 to 80 have a 21 percent incidence of osteoporosis; those over 80 have a 35.6 percent incidence.

In addition, women fall more often than men, making bone loss especially dangerous. Three-quarters of all hip fractures occur in women. Not only are such fractures extremely disabling, requiring surgery and hospitalization, but also the overall one-year mortality after a hip fracture is 21.2 percent. Spine fractures are even more common than hip fractures in people with osteoporosis. Although they often go undiagnosed, they can cause debilitating pain.

So, obviously, if there is a way to improve your bone density and decrease your chance of fractures, you should do it.

Taking 500 to 1,000 milligrams of calcium a day and maintaining an adequate blood level of vitamin D are important, but to increase bone density, the first-line drug therapy is a bisphosphonate. These drugs, including Fosamax, increase bone mass and decrease the incidence of fractures. I would assume that you couldn't tolerate Fosamax due to irritation of the esophagus and stomach. If that's the case, you could consider injectable bisphosphonates such as Boniva or Reclast.

That said, all bisphosphonates can have rare, but potentially serious, side effects such as osteonecrosis of the jaw, an increased risk of fractures of the femur, and in the case of Reclast, atrial fibrillation. Also, note that people with kidney failure should not take bisphosphonates.

Prolia, given by injection twice a year, is different. It's a monoclonal antibody that binds specifically to a receptor within bone, inhibiting the normal bone breakdown. Clinical trials showed that, after three years of use, Prolia improved bone density in the spine by 9.2 percent and, after eight years, by 18.4 percent. It improved bone density in the hip by a lesser amount, 4 percent after three years and 8.3 percent after eight years. The drug was also linked to a 68 percent decrease in the rate of spinal fracture and a 40 percent decrease in the rate of hip fractures. In a trial comparing Prolia to Fosamax, those taking Prolia showed a slightly greater improvement in bone density after one year.

That's not to say Prolia is for everyone. Like Fosamax, it can occasionally lead to osteonecrosis of the jaw and atypical fractures. And, for people with kidney disease, it can lead to drops in calcium levels that can cause muscle spasms and abnormal heart rhythms. Finally, because Prolia is injected into the skin and may affect immune function, it may slightly increase the risk of skin infections at the site of the injection.

In summary, if you cannot tolerate Fosamax, you should consider injectable Reclast or Prolia. These medications do have rare, but severe, side effects. However, their benefits appear greater than their risks.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: What are the updated guidelines for cervical cancer screening? I'm 62 and want to know what is recommended going forward. Is an annual pelvic exam still necessary if a Pap smear isn't being done? And have guidelines changed for teens and 20-somethings?

Dear Reader: You've asked a lot of excellent questions that will have a broad spectrum of readers interested. And you're right, screening guidelines are changing.

A Pap test, also called a Pap smear, is used to screen for cervical cancer. It's a routine procedure that checks for cell changes on the cervix, which is the opening of the uterus. The test looks for abnormal cells that might become cervical cancer if not treated appropriately.

During a Pap smear, cells and mucus from the cervix are collected and then examined under a microscope. Cells from the same sample can also be used for an HPV test, to check for presence of the human papillomavirus, the most common sexually transmitted infection. Women with HPV have a higher risk of developing cervical cancer than women who do not have HPV.

Guidelines from the American Cancer Society as well as the American Congress of Obstetricians and Gynecologists recommend that all women should begin cervical cancer screening at age 21. Between 21 and 29, a Pap smear should be performed every three years. In this age group, HPV testing should only be used if a Pap smear returns with abnormal cell results.

When a woman turns 30, the Pap smear should be used along with an HPV test. This co-testing should continue at five-year intervals until age 65.

For women at higher risk of cervical cancer, screenings need to be performed more frequently. The most important risk factor for cervical cancer is the presence of human papillomavirus, which is actually a group of more than 150 related viruses. Certain types of HPV, sometimes referred to as high-risk, have been strongly linked to cervical cancer.

Additional risk factors for cervical cancer include smoking, having a weakened immune system due to HIV or taking immunosuppressive drugs, being infected with chlamydia, a family history of cervical cancer, and exposure to DES, a hormonal drug given to some women between 1940 and 1971. If any of these risk factors apply to you, talk to your physician or gynecologist about whether you should increase the frequency of screening.

At age 62, you're on track for at least one more round of co-testing with both a Pap smear and an HPV test. At age 65, the guidelines change again.

Women 65 and older who have had regular screenings for the previous 10 years, and whose tests have not turned up any abnormalities in the previous 20 years, can stop Pap smears.

As for pelvic exams, that's another nexus of change. The U.S. Preventive Services Task Force has recently declined to say that pelvic exams are necessary. Pelvic exams may have diagnostic value for detecting conditions like genital herpes, ovarian cysts, uterine fibroids, genital warts and others. We recommend that you discuss your options with your gynecologist or primary care physician.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)