Posts tagged ‘pap smear’
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.
What happens in Vegas stays in Vegas (Sometimes)
I recently went to Las Vegas for a medical conference. Everywhere I went, I saw signs with the slogan “What happens in Vegas stays in Vegas!”. This led me to joke to one of my gynecologist friends– “Sure. Except if it’s herpes.”
I guess I thought that was funny at the time. But it occurred to me that it’s dangerous to propagate the idea that acting out (sexually or otherwise) is without consequences.
It’s not that there’s anything wrong with Vegas. And I’m not one to knock bachelor/bachelorette parties and a night of cocktails. But if being forewarned is being forearmed, then using a condom is some food for thought you won’t find at the $19.99 dinner buffet. And I’d like to give you, gentle reader, the skinny on a few souvenirs you don’t want to bring home with you.
Some sexually transmitted diseases can be cured with antibiotics. These include gonorrhea, chlamydia, syphillis and trichomonas. All of these can be diagnosed with simple tests available in your doctor’s office. Treatment of sexual contacts is important, and should occur for both partners at the same time. All can be prevented with the use of latex condoms.
Gonorrhea and chlamydia are often lumped together when discussing sexually transmitted diseased (STD’s). They are distinct diseases caused by different microbes, but are often found together in co-infections. Both can be asymptomatic. When symptoms occur, they often show up 2 to 3 weeks after infection. Common complaints include
- A yellow vaginal discharge
- Painful or frequent urination
- Burning or itching in the vaginal area
- Redness, swelling, or soreness of the vulva
- Pain in the pelvis or abdomen during sex
- Abnormal vaginal bleeding
- Rectal bleeding, discharge, or pain
Gonorrhea and chlamydia are diagnosed by laboratory analysis of samples taken from the cervix using a cotten swab. Timely treatment of gonorrhea and chlamydia can prevent infertility, which can be a complication of advanced infection. Treatment is usually oral medication or a combination of oral medication and a shot (like a flu shot) given in the arm. Advanced infections may need to be treated in a hospital with intravenous medication.
Syphilis first appears as a painless genital sore called a chancre (pronounced like “shank-er”). It lasts 10 days to 6 weeks after contact with an infected partner. Swollen lymph nodes in the groin m ay also occur. A rash on the palms and soles (of hands and feet) occurs durng a second stage of infection 1 week to 3 months later. Flat warts or a flu-like illness may occur at this time. Syphillis can be diagnosed with a combination of physical exam and blood tests. Early treatment is important to prevent long-term problems including birth defects in children of infected mothers. Treatment usually consists of antibiotics given as a shot (in the arm or buttocks) and may need to be given more than once.
Trichomonas vaginitis is a microscopic parasite that is spread through sex. Many people have no symptoms of trichomonas. When symptoms do occur, they include discharge from the vagina and vaginal itching and redness. Trichomonas can be diagnosed on a vaginal exam (sometimes in combination with testing samples of vaginal fluid). Treatment usually consists of oral antibiotics or an antibiotic gel which is placed in the vagina.
Some sexually transmitted diseases can’t be cured. Usually, these are due to viruses.
Human Immunodeficiency Virus (HIV), Human Papilloma Virus (HPV), Herpes Simplex Virus (HSV), and Hepatitis B and C can all be sexually transmitted. All can be treated with medication, but none can be cured.
Human Immunodeficiency Virus (HIV) is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). Transmission can occur during intercourse. It is possible for transmission can occur through orogenital (oral) sex too. Anal sex is particularly risky. Transmission rates can be significantly decreased with the use of a latex condom. It can be diagnosed with a blood test and is treated with antiviral medications. Untreated, it can cause compromise of the immune system, illness, and death.
Human papillomavirus (HPV) is one of the most common STDs in the United States. There often are no signs of genital HPV. However, a few types of HPV cause warts. These can appear on the vulva, vagina, cervix, and anus. In male partners, they may occur on the penis, scrotum, or anus.
Sometimes warts go away on their own. If they do not, there are several treatments for warts available at your doctor’s office. Treating yourself with over-the-counter wart medications (compound W etc.) is NOT recommended.
Even after the warts have cleared up, the virus may be present. The virus can remain in the body for weeks or years without any symptoms.
Certain types of the HPV virus are associated with an increased risk of cervical cancer. HPV also may be linked to cancer of the anus, vulva, vagina, penis, head, and neck.
Some types of HPV infection and pre-cancerous changes in the cervix are detected with a Pap Smear or Pap Test. So while your Pap Smear doesn’t test for sexually transmitted diseases per se, it can diagnose HPV-related conditions.
If abnormalities associated with HPV are found on your Pap Smear, your doctor will discuss diagnosis and treatment options with you. You may also want to discuss the HPV vaccine, which prevents several types of HPV infections, and can be given to most girls and women aged 9-26 regardless of whether they have had an HPV infection in the past.
Herpes Simplex Virus (HSV) causes herpes. It also causes “cold sores” on the face and mouth. Although people sometimes refer to the HSV 1 virus as “oral herpes” and the HSV 2 virus as “genital herpes”, both viruses can cause lesions in both areas, so this distinction isn’t particularly useful. The best description is to say that genital herpes is any herpes ocurring on the genitals, regardless of virus subtype (1 or 2).
The most common symptom of genital herpes is a sore on or around the genitals. These sores are often multiple, usually red or blister-like, and may be itchy or exquisitely painful. The sores can last from a few days to a few weeks. Herpes can be diagnosed by a combination of physical exam, viral culture of open sores, and blood tests.
The symptoms go away by themselves, but the virus remains in your body. The sores may come back at any time, usually in the same place they first occurred. Treatment can help heal the sores and reduce the number of future outbreaks, but it cannot kill the virus.
A person who has herpes can transmit the virus even in the absence of symptoms. If you or your partner have oral or genital herpes, avoid sex from the time of first symptoms until a few days after the scabs have gone away.
The Hepatitis B and C viruses can also be transmitted by sexual intercourse. Hepatitis may occur with limited or no symptoms, but often leads to jaundice, anorexia (poor appetite) and malaise. Hepatitis is acute when it lasts less than six months and chronic when it persists longer. Chronic hepatitis may be asymptomatic, but can cause cirrhosis (scarring of the liver), liver failure, liver cancer, and death. Hepatitis B and C can be diagnosed by blood tests. Treatment is directed at reducing symptoms and slowing the progression of the disease.
The Hepatitis B vaccine reduces the risk of contracting hepatits and is widely available. It is recommended to all children and to high-risk adults (those with multiple sexual partners, who use intravenous drugs, or who are in occupations which may involve exposure to blood or other bodily fluids). There is no hepatitis C vaccine.
Hepatitis A, by the way, is not sexually transmitted. It is food-borne and does not result in chronic infection. It causes an acute gastrointestinal illness and is often contracted by eating undercooked shellfish. So, You can still get it in Vegas. You’re welcome.
So, remember, there are some souvenirs nobody wants to bring home from vacation (or any other encounter). If you have a new sexual partner or have any other reason to think you may be at risk for sexually transmitted infection, visit your heathcare provider for simple tests.
And since I started this post with a poorly conceived joke, I’ll end with one. Practice safe sex: Use your head (and use protection when giving it)!
Tackling your first gynecologic visit – No fear!
At your first gynecologic visit, your doctor should introduce him or herself and discuss the reason for your visit. You should be open and honest about your reasons for needing gynecologic care.
THE HISTORY: Your doctor will take a complete gynecologic and menstrual history. Never be embarrassed to bring up concerns regarding bleeding or pain, sexual activities and concerns, current or past sexual or physical abuse, or questions about changes in your body.
**Believe me, you are NOT the first or only person who has these concerns. Your doctor should be familiar with them and make sure you are comfortable discussing them. If not, you should consider finding a doctor who DOES make you comfortable.**
Your doctor will also discuss your medical and surgical history, any medications you may be taking, any allergies you may have to medicines or foods, and will ask whether you drink alcohol, smoke cigarettes, or use drugs. Your doctor will be able to provide the best of care if he or she receives complete and honest information from you.
THE PHYSICAL EXAM: The majority of your physical examination will be very familiar to you from visits with other types of doctors. The examination of your head, neck, heart, lungs, abdomen (belly), and extremities will not differ much from that performed by your primary care physician.
The parts of your exam which may be new and unfamilar include the breast and pelvic exam.
The breast exam includes a visual inspection of your breasts. Then your doctor will examine your breasts by palpation (touch). He or she is looking for abnormal lumps or masses. Many breast lumps are benign (non-cancerous). Some are malignant (cancer). Your doctor may order tests such as a mammogram or breast ultrasound if he or she detects abnormalities of the breast during your exam.
Your doctor should also ask you whether you are performing breast self-examination. He or she can teach you how to do a good breast exam on yourself at home. If you have questions about how and when to do this type of exam at home, you should ask them during the breast exam.
The pelvic exam consists of two parts. The first part is usually the speculum examination. This part of the exam is often accompanied by a great deal of anxiety and trepidation. This is understandable, as the speculum examination can be uncomfortable. It should not, however, be painful. It helps if you try to maintain a relaxed, calm attitude as this REALLY can make the exam more physically comfortable.
A speculum is a metal or plastic instrument that is inserted into the vagina. It is usually warmed (if metal) and lubricated (with gel) to make the exam more comfortable. The speculum is not used to ‘clamp’ anything. This is a common misconception. The speculum is actually designed to gently open the vaginal canal to allow visualization and sampling of the cervix (which is the lowest part of the uterus, protruding into the vagina). Once this is done, the speculum is gently removed.
The speculum exam
The second part of the pelvic examination is called the bi-manual examination. The examiner will insert one or two fingers into the vagina, placing the other hand on your abdomen (belly). This is done so that the examiner can feel the size and shape of your uterus and ovaries. Ovarian cysts, fibroids, and some types of endometriosis can be detected this way.
A rectal examination may also be necessary to evaluate certain types of conditions and is a necessary part of the examination of any woman over 50 years of age. The examiner inserts a lubricated finger into the anus (the lowest part of the rectum). This may occur in conjunction with a vaginal exam (a recto-vaginal examination) or may include sampling of fecal material for blood (a stool sample).
THE WRAP-UP: After that, you’re all done! Your doctor may include certain types of testing such as a PAP smear or a cervical culture for STD’s as part of the gynecologic evaluation. Always ask your provider what tests you require and how you will be informed of the results.
The Gynecologist 