HPV Vaccination – Protection for you and your daughters

What if there was a vaccine that offered you protection against the second most common and fifth deadliest cancer in the world.  

Would you take the vaccine? 

Would you give it to your daughter? 

 These aren’t rhetorical questions.  Because that vaccine exists.  Its  was approved by the Food and Drug Administration (FDA) in 2006 and is intended to prevent cervical cancer. 

The human papilloma virus (HPV) can be linked to the development of almost all cases of cervical cancer.  Although there are over 60 different types of the HPV virus, approximately 70% of all cases of cervical cancer can be linked to only two specific, high-risk types.  These HPV types are known as HPV type 16 and 18.    So, vaccines preventing high-risk HPV can significantly reduce the risk of cervical cancer in women receiving the vaccine.

hpvdiagram-afp

The first vaccine against HPV, Gardasil, was developed to target types 16 and 18.  It also targets HPV types 6 and 11, which are linked to the development of genital warts (but not cervical cancer).  It was approved in 2006 for girls and women ages 9 to 26.   Gardasil is also approved for use in boys and young men aged 9 to 26, but that’s beyond the scope of this post.

Another HPV vaccine was approved in 209. This vaccine, Cervarix, is designed to prevent infection from HPV types 16 and 18, and offers some protection against HPV types 45 and 31.  Cervarix also contains an ingredient believed to boost immune system response to the vaccine.  It is given to girls and women ages 10-25.

Both vaccines are most effective at preventing HPV disease when given before a young woman becomes sexually active.  That’s because vaccines are designed to prevent infection, but don’t treat infection once it has occurred.  Both vaccines are given as a series of 3 injections over a course of 6 months.

Some people ask whether the HPV vaccine can be given to women who are already sexually active.  Yes!  It can even be given to women who have already been diagnosed with an HPV-related condition (such as an abnormal pap smear or genital warts).  While an individual who has been diagnosed with an HPV-related condition has probably been exposed to at least one strain of the HPV virus, that doesn’t mean she’s been exposed to all of them.  So the vaccine may protect against one or more strains of the HPV virus to which she is currently vulnerable.

Studies have shown that both Gardasil and Cervarix prevent nearly 100 percent of the precancerous cervical cell changes caused by the types of HPV targeted by the vaccine for up to 4 years after vaccination among women who were not infected at the time of vaccination

That’s some pretty dramatic stuff.  And If I’m gonna make a statement like that, I’m gonna cite a source (“Human Papillomavirus (HPV) Vaccines”. National Cancer Institute (NCI). 2009-10-22. Retrieved 2009-11-11.). 

Most health insurance companies cover one or both HPV vaccines for women and girls within the recommended age range (9-26 for Gardasil, 10-25 for Cervarix).  Some health care providers will administer the vaccine to women over the age of 26, but that can be discussed with the individual provider and won’t be discussed here.  Women without insurance, or those whose insurance doesn’t cover the vaccine, can pay for it out of pocket, but the cost is often prohibitive.  A doctor’s office or clinic can give an estimate of cost.

The Vaccine Information Statement for Gardasil gives a tremendous amount of useful information.

So does this HPV Vaccine FAQ sheet from the American College of Obstetrics and Gynecology.

For more information and individual advice, speak to your healthcare provider.

May 24, 2013 at 7:55 pm Leave a comment

HPV 411: The scoop on Human Papillomavirus

HPV (human papillomavirus) is a big topic nowadays. Patients are asking about it because it has been addressed as a topic in popular media (The HBO series ‘Girls’), because of commercials for the HPV vaccines (Gardasil and Cervarix), and because the have heard about it in the context of an abnormal Pap smears.  There’s a lot of misinformation out there (particularly in the media) and I’d like to combat it with some facts.

First, let’s review what the virus is and what it does. HPV is not just one virus. It’s a family of viruses, of which over 30 different types (identified by numbers such as ‘Type 16′) infect the anogenital area and can be transmitted by sexual activity. 

**Barrier contraception (such as condoms or dental dams) can prevent most HPV transmission between partners.** 

Some types of HPV cause genital warts. These types are typically described as ‘low-risk’ for subsequent development of precancerous or cancerous lesions. Genital warts are visible on the skin and mucous membranes. They are often noticed by patients on self-examination. They can also be diagnosed by a doctor at the time of an annual visit during a visual inspection of the genital area.

Some HPV types are described as ‘high-risk’ for the development of precancerous or cancerous lesions. That’s these types of HPV infection are the cause of nearly all cases of cervical cancer and may be linked to rarer cancers of the vulva (female external genitalia), vagina, anus, penis, and oral region. Most infections with even these ‘high-risk’ types resolve spontaneously (i.e. without treatment) and do not cause disease.

HPV screening in women is done indirectly through the use of Pap smears or Pap tests. A Pap smear is a microscopic evaluation of cells obtained by swabbing the cervix. These cells are examined for the types of cellular changes typical of HPV infection. A Pap smear is often performed by a doctor or other health care provider at the time of a woman’s routine annual visit.  An abnormal Pap test requires further evaluation, usually with colposcopy (see below).

HPV testing can be performed directly by a laboratory. A sampling of cervical cells (obtained by a healthcare provider at the time of a Pap smear) is sent to a lab to detect the presence of DNA from the HPV virus. This test is usually reserved for women over 30 or those who have already had an abnormal pap smear. HPV testing is not routinely performed on men, nor is it routinely performed in the anal or oral region. That’s because cancers of these other organs are rare in comparison to cervical cancer.

Most HPV infections in young women are self-limited (i.e. they resolve on their own and without treatment) and have no long-term health consequences.  Up to seventy percent of HPV infections resolve in 1 year and ninety percent may resolve in 2 years.  However, when the infection persists — in 5% to 10% of infected women — there is a significant risk of developing precancerous lesions of the cervix.  Over 10-15 years, these lesions can progress to invasive cervical cancer.  The long interval between precancerous lesions and their development into cancer allows ample opportunity for detection and treatment of the pre-cancerous lesion. Progression to invasive cancer can be almost always prevented when regular screening detects precancerous lesions and treatment is provided in a timely fasion. 

A colposcopy (from the Greek kolpos “hollow, womb, vagina” + skopos “look at”) is done to evaluate the cervix after an abnormal Pap result.  The colposcope itself is just a microscope with a light allowing a doctor to examine an illuminated, magnified view of the cervix, vagina and vulva.  Many premalignant and malignant lesions have specific characteristics which make them look ‘suspicious’ when examined in this fashion.  These areas can then be targeted for biopsy (taking a piece of tissue to be evaluated by a Pathologist). The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early so that they can be treated before they become malignant. 

Treatment of precancerous or premalignant lesiosn usually involves minor surgical procedures (a LEEP or a cone biopsy) in which uses a cauterizing loop or other small cutting instrument to remove the affected part of the cervix.   Patients are usually advised to avoid sexual intercourse for at least 6 weeks to allow complete healing.  Cryotherapy (freezing the affected portion of the cervix with liquid nitrogen) is also used in some areas where the aforementioned procedures are not feasible (i.e. in the developing world).  Cryotherapy is not usually used for premalignant lesions because it is less likely to remove the entire lesion and  because there is no way to reliably identify the extent of tissue destroyed.  Therefore, it is considered a less effective therapy and is used only for lesions which are not precancerous or in situations in which a LEEP, LETZ or cone biopsy cannot safely be performed.

There is some increased risk of reduction or loss of fertility and an increased risk of certain pregnancy complications (including preterm birth) with some of these procedures, especially if they need to be repeated several times.  A doctor who performs these types of procedures can go into greater detail about the risks of a specific procedure he or she recommends.

**In summary: HPV can cause cervical cancer.  The best defense against cervical cancer is to get reguar screening with Pap smears and HPV tests as recommended by your healthcare provider.  An abnormal screening test deserves prompt follow-up and may require colposcopy.  Medical procedures (LEEP, cone biopsy) which are performed on individuals with HPV infection at the time they are diagnosed with precancerous lesions are effecive at preventing cervical cancer.   These procedures may carry a risk of pregnancy-related complications and should be discussed with your healthcare provdier.  Condom use and HPV vaccination may prevent some HPV infections.**

I’ll be blogging about HPV vaccination next.

July 23, 2012 at 8:02 pm 5 comments

Learn more about Minimally Invasive and Robotic Surgery

I’d like to invite you to my website www.MinimallyInvasiveGYN.com

I’m a strong believer in laparoscopic and robotic surgery for a single, simple reason. It’s better for the patient. Minimally invasive surgery, a catch-all term which includes laparoscopy, hysteroscopy, and robot-assisted surgery, has proven benefits.

The benefits of minimally invasive surgery, compared to conventional “open” surgery include:

• less post-operative pain
• reduced need for pain medication
• faster return of normal appetite and bowel function
• smaller incisions
• less scarring
• faster recovery and return to work

Robotic surgery in particular has advantages which allow the surgeon to perform more complex procedures via a laparoscopic approach than might otherwise be possible. The robotic system gives the surgeon the benefits of:

• greater magnification with the laparoscopic camera
• 3 dimensional (3D) vision
• greater range of motion for laparoscopic instruments
• increased comfort, which may reduce a surgeon’s fatigue during long procedures
• reduction of biologic hand tremor

The robot doesn’t bear much resemblance to what we’ve come to expect from science fiction. It doesn’t have artificial intelligence and it cannot operate independently. In fact, the robot is just another instrument. It is controlled by the surgeon who sits at a console next to the patient.

The Da Vinci Robotic Surgical System

The robot has arms whose attachments are miniature versions of conventional surgical instruments (i.e. scissors, clamps, needle and suture-holders). These tiny instruments mimic the surgeon’s movements at the console (but on a much smaller scale). This allows the surgeon to perform surgical procedures with extraordinary precision.

Laparoscopy revolutionized surgery by making many major surgeries into outpatient procedures. Robotic surgery is revolutionizing laparoscopy by broadening the range of surgeries which can be performed with a minimally-invasive approach.

Take charge of your health by learning more about minimally invasive and robotic surgery. An educated patient is an empowered patient!

February 25, 2012 at 12:51 am 2 comments

2011 in review

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 19,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 7 sold-out performances for that many people to see it.

Click here to see the complete report.

January 4, 2012 at 5:50 pm Leave a comment

So, you think you have heavy periods?

Whenever I ask a patient “do you have heavy periods?”  I feel like I deserve the kinds of answers I receive.  I’m just as likely to hear “Yes.  I have to change a panty liner every few hours.” As to hear, “No.  I only go through one box of super-overnight maxi-pads per day now.  It used to be two boxes.”  Which is to say that every woman perceives whether or not her periods are heavy through the filter of her own personal experience.  

So, what exactly is a heavy period?  Well, the standard definition is a period that lasts longer than 7 days or in which a woman loses more than 80 millileters of blood.   The first definition is easy.  You just count the days on a calendar.  The second is much more difficult to determine.  (Unless you go wringing your sanitary products into graduated cylinder flasks.  In which case, maybe you need a psychiatrist, not a gynecologist.) 

So, how is the average woman to know what constitutes a truly heavy period?  If you’re saturating your pad or tampon every hour, it’s a good bet your period is heavier than average.  Similarly, if you tend to bleed through your tampon, onto your pad, and soak your pants, you probably need to see a doctor (and a good dry cleaner).  

There are lots of reasons why women get heavy periods.  The medical term for them is menorrhagia. Heavy menses aren’t just an inconvenience.  They’re a real medical problem which can result in anemia (a reduced blood count) and fatigue.  They can also be a sign of other serious medical conditions. 

Adolescents and teens may have heavy, irregular periods as they begin to establish their menstrual cycle.  These natural fluctuations in the menstrual cycle are often temporary, and usually resolve when monthly menses begin over the next few months to years.  Adolescents and teens with very heavy menses, or whose cycles do not become lighter on their own, may need to be evaluated for bleeding disorders, such as von Willebrand disease.

Women in their reproductive years may have heavy menses or irregular cycles because of hormonal conditions, such as polycystic ovarian syndrome (PCOS), which can cause irregular menses and heavy menstrual bleeding on the rare occasions when menses take place.  Another hormonal condition which can case heavy menses is an underactive thyroid gland (hypothyroidism).  Both of these conditions can cause excess weight gain.  Being overweight (even in the absence of other medical conditions) can worsen heavy menstruation.  This is because adipose (fat) tissue produces excess estrogen, thickening the lining of the uterus.  When the lining is shed at the end of the menstrual cycle, heavier bleeding occurs.

Hormonal conditions may be suspected on the basis of a physical exam, history, blood tests, ultrasound (sonogram) or a combination thereof.  A combination of medication and dietary and/or lifestyle changes may be helpful in regulating the menstrual cycle and reducing bleeding.

Certain medications can lead to heavy menses.  Blood thinners (Coumadin, Lovenox) and Non-steroidal anti-inflammatory medications (Motrin, Advil, Ibuprofen and Aspirin) can increase menstrual bleeding.  Missed doses of oral contraceptives can also lead to heavy menses or irregular cycles.

Some women have heavy menses due to abnormalities of the uterus and its lining.  An endometrial polyp is a growth of tissue in the lining of the uterus.  Because polyps have a rich blood supply, they can cause heavy bleeding either during or between menses.  Uterine fibroids can also cause heavy menses.  Fibroids are benign muscle tumors which can impinge on the lining of the uterus, causing heavy menstrual bleeding.  They can also cause other symptoms (such as pain, pelvic pressure, frequent urination, miscarriage) which likewise bring them to a doctor’s attention.  Both endometrial polyps and uterine fibroids are readily diagnosed by an ultrasound (sonogram).  Bleeding due to polyps and fibroids can often be managed with the use of minimally invasive surgical techniques (such as hysteroscopy and laparoscopy).

The most serious cause of heavy menstrual bleeding, especially in women who resume menstrual-like bleeding after the cessation of normal periods (menopause), is endometrial cancer.  This type of cancer is rare in women under the age of 35 and is much more common after menopuause.  Endometrial cancer may be suspected on the basis of an ultrasound (sonogram).  It can be diagnosed by a biopsy or by a surgical procedure called a dilatation and curettage (D and C).  Endometrial cancer is often responsive to treatment when caught early.  

In summary, heavy menses are very common.  They may represent a normal variation in a healthy woman’s cycle, or they may be due to a medical condition which requires treatment.  Attention from a skilled healthcare provider can help determine whether additional care is needed.

A Good Resource:

ACOG Guide to Abnormal Uterine Bleeding

One Last Cartoon:

October 7, 2011 at 3:34 am 15 comments

Before Baby

Often, patients who come see me ask whether I deliver babies.  Indeed I do!  And it’s always nice to build a relationship with patients before they get pregnant so that they are more comfortable with me during the 9 months we’ll spend caring for mom and baby.

In addition to what usually happens during an annual gynecologic visit, good pre-pregnancy care deserves special consideration.  The peroid of thime before you get pregnant is the best time to improve control of any chronic medical conditions you may have (high blood pressure, asthma).  A doctor should talk to you about any medications you may be taking which pose a potential risk to a developing fetus.

One medication is routinely recommended for all pregnant women.  Folic acid (folate) supplementation should begin prior to conception.  Ideally, it should begin at least 2-3 months prior to trying to conceive.  Most women require 400 micrograms (mcg) of folic acid to prevent a specific birth defect (Spina Bifida, which can cause a child to be unable to walk).

Some women require more folic acid (800-4000 micrograms) depending on their risk factors for delivering a baby with spina bifida.  These risk factors can include certain medications (especially anti-seizure drugs), certain medical conditions, and a prior history of a child or other family member with spina bifida. 

Prenatal vitamins usually contain 400-800 micrograms of folic acid in combination with other vitamins and minerals.  You can bring your prenatal vitamin (in the bottle) to your doctor’s visit to review whether it contains everything you’ll need during pregnanty.  Alternatively, ask your healthcare provider to recommend a prenatal vitamin or other supplements for you.

Good pre-pregnancy care also includes certain blood tests.  A test may be required to determine whether a prospective mother is immune to Rubella (also called “German measles”) and Varicella (a.k.a. “Chicken pox”).  That’s because both of these disease can cause birth defects if the virus that causes them is contracted during pregnancy.  Immunizations are available for both Rubella and Varicella and should be administered to non-immune women several months prior to attempting to get pregnant.  Neither vaccine is administered during pregnancy.

Testing for infections, including HIV (Human immunodeficiency virus), gonorrhea, chlamydia, and tuberculosis may be a good idea for women who are at risk for these conditions.  A conversation with your doctor can help him or her determine whether you are at risk and require screening.

It’s always a good idea to maintain a healthy weight.  This is espceially important before and during pregnancy.  Managing your weight before you get pregnant may help reduce your risk of diabetes and blood pressure problems during pregnancy.  Avoiding excess weight gain during pregnancy can make for an easier delivery and a faster return to your pre-pregnancy body.   A healthy diet and regular exercise will help you manage your weight.  Advice  from a doctor, nutritionist, or weight-loss counselor may help if you’re having trouble.

Lastly (and perhaos most importantly) avoiding alcohol, cigarettes, illicit drugs and other toxic substances is of tremendous importance when you are pregnant.  All of these substances can seriously impair maternal health.  They may also contribute to to an increased risk of miscarriage, preterm birth, low birth weight, and (in the case of alcohol) low I.Q. and birth defects.  The best time to stop using these substances is before conception.  Again, assistance from a doctor or substance-abuse program may help.

It’s a good idea to schedule a visit with your gynecologist to discuss the best way to prepare for a healthy pregnancy.

For some great resources on pre-pregnancy health and pregnancy planning, check out these links from the American College of Obstetrics and Gynecology.

June 29, 2011 at 7:48 pm Leave a comment

Buyer Beware – Suspect Supplements and Hurtful Herbals

As an obstetrician/gynecologist, one of the things I do is take care of pregnant women.  And, while this blog is dedicated to gynecology, I thought I’d share with you a cautionary tale about my recent care of a woman in her first trimester of pregnancy.

She was asked to try a remedy for morning sickness.  The remedy  is described on its own website as  “a safe, non-addictive, FDA registered natural remedy containing 100% homeopathic ingredients formulated to relieve nausea (morning sickness) during pregnancy.” 

I was asked to look at the product to determine if it was safe for my patient.  At the bottom of a website with abundant testimonials and positive reviews, I found a list of ingredients.  5 of the 7 ingredients were safe and nontoxic.  These were:

Two ingredients posed serious potential health risks (regardless of pregnancy status).  These were:  

  • Nux Vom (Nux Vomica– derived from the Strychnine tree).  That’s right, I said strychnine.  As in the stuff they use in rat poison and gopher bait.  While very small doses of strychnine cause an increase in bowel motility, which can releive nausea, larger doses can cause neurological toxicity, seizures, and death.
  • Nat Phos (Sodium Phosphate — another salt) Oral phosphates were widely used in bowel preparations for colonoscopy. They have been withdrawn in the United States because evidence suggests that sodium phosphate causes serious kidney damage, a condition called phosphate nephropathy

I told my patient that I had serious concerns about the safety of the ingredients listed on the website.  I told her that, although the remedy is very unlikely to cause injury in the small amounts in which it is administered (it is sprinkled on foods throughout the day), I could not recommend that she take it when safe alternatives exist. 

And, just to clarify, I am not recommending for or against the use of this (or any other product) on this blog.  I am sharing this anecdote to remind you to share with your healthcare provider ANY vitamins, nutritional supplements, herbal or traditional medicines you desire to take. 

That’s because only a medical professional, who is familiar with your medical history and has an inventory of the other medications you may be taking, is qualified to help you determine whether a particular product is safe for you.  He or she can determine whether the product interferes with other medicines you may be taking .  Your healthcare provider may also have valuable instructions on how to take the product safely (i.e. on an empty stomach, not with grapefruit or acidic juices, etc.)

Vitamins and nutritional supplements are not governed by the same strict set of rules which regulate drugs and medications.  While an herbal remedy, supplement or nutritional product may be registered with the FDA, this should not lead you to believe that a particular product is safe for you (or anybody else).

And, as for morning sickness, my advice to the patient was that peppermint tea, ginger ale, and ginger candies were likely just as effective and by no doubt safer than many of the specialty products marketed to relieve the gastrointestinal suffering of pregnant women. I also recommended small, frequent meals of bland, starchy foods. 

As for over-the-counter treatments, I often recommend vitamin B6, which is safe and non-toxic.  I often recommend this in combination with doxylamine  (found in Unisom), an antihistamine which can alleviate nausea (especially when combined with vitamin B6), although it does cause drowsiness.  

If that’s not enough, I said, call me for a prescription.

February 4, 2011 at 7:26 pm 1 comment

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Linda M. Nicoll, MD

Welcome to my blog! Here you will find information about minimally invasive gynecologic surgery as well as some more general information about common gynecologic disorders such as endometriosis, ovarian cysts, fibroids, infertility, and pelvic pain.

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