What is a pap smear? When should I have one?
What if my pap smear is abnormal?
What is dysplasia?
What is the HPV virus?
How can I prevent infection by the HPV virus?
What is the HPV vaccine?
Who gets cervical cancer?
How do I start the oral contraceptive pill (ocp)?
What should I do if I miss a birth control pill?
I’ve just started birth control (pill, ring, patch). What should I expect?
I’ve heard about a pill that allows you to have just 4 cycles per year. Is that safe?
I think I have a vaginal yeast infection. What should I do?
How does cyclic progesterone (provera, prometrium) work?
How is cyclic progesterone (provera, prometrium) given?
A pap smear is a screening test for cervical cancer. It is not a diagnostic test. It alerts the clinician to take a closer look. It is done during a speculum exam. Screening should start by 3 years after first intercourse or age 21, whichever comes first. Women aged 21-30 should have them done yearly. If a woman aged 30 and above has a negative result on 3 consecutive annual paps, she may be re-screened every 2-3 years. If the patient has a negative pap and a negative HPV assay, she should be re-screened in 3 years. Most medical bodies recommend discontinuing cervical cancer screening between ages 65 and 70, unless the patient has had high grade dysplasia. That patient needs to continue paps for 20 years.
A pap smear is just a screening test; it does not make a diagnosis. A diagnosis is typically made with a simple clinical procedure called colposcopy. Colposcopy involves a longer speculum exam. During this exam, a special scope is used to visualize the cervix closer. Typically, small biopsies are taken to arrive at a diagnosis. There is a spectrum of potential diagnoses. We don’t typically find cervical cancer. We very commonly find dysplasia. Dysplasia is a treatable condition which can be a precursor to cervical cancer. It is graded on biopsy as low and high grade. Low grade dysplasia or mild dysplasia will typically resolve on its own over a year or so in a woman with an intact immune system. By contrast, we typically treat a woman who is diagnosed with high grade dysplasia. High grade dysplasia encompasses several diagnoses of increasing severity: moderate dysplasia, severe dysplasia and carcinoma in situ.There are numerous treatments available. The most commonly utilized in our practice is LEEP or (looped electrosurgical excision procedure). This is an outpatient procedure where a small charged loop is used to shave the atypical tissue off the cervix. Some patients may be offered laser surgery or even cryosurgery in the clinic.
Dysplasia is atypia in the tissue of the cervix caused by HPV which has the potential of being precancerous. It is diagnosed via colposcopy after an abnormal pap smear. Colposcopy is a procedure performed in the office during which the provider looks closely at the cervix with a scope. Biopsies are typically taken to confirm the diagnosis. Dysplasia may be put into subcategories depending on the degree of atypia:
It is impossible to predict which of the lesions will eventually become cancer if untreated. Over 60% of patients with mild dysplasia will undergo spontaneous resolution over the course of a year. 90% resolve over two years. So it may be appropriate to watch a reliable patient without treating mild dysplasia for 1-2 years. Notably, patients with compromised immune systems should be treated more aggressively. Patients with higher grades of dysplasia are usually treated with simple out patient treatments. These treatments are highly effective for preventing cervical cancer.
HPV or human papilloma virus is a sexually transmitted virus which has been implicated as the cause of cervical cancer. Sexually active women have a 50-75% chance of being infected with HPV during their lifetime. There are over numerous serotypes of the virus. Some are more virulent than others. Most will cause no changes to the cervix. Some will cause only inflammation or other low grade changes to the cervix. Some will cause venereal warts. A select group of high- risk HPV subtypes are considered more virulent and likely to cause changes in the cervix. Some important things to remember are:
- It can be years before changes by the HPV are seen. Most likely, no changes are ever seen.
- The vast majority of patients with HPV will never get cervical cancer.
- Your immune system will likely clear the virus to the point it is undetectable.
- The controversial HPV vaccine Gardasil only covers 4 types of HPV (2 high risk types accounting for 70% of cervical cancer and 2 low risk types accounting for 90% of genital warts)
- Smoking cigarettes enhances the virus’s ability to cause tissue changes.
- A pap smear is a screening test for tissue changes caused by the virus; colposcopy is the diagnostic test. If you have dysplasia on colposcopic biopsy, you have HPV.
- There is a test available for the detection of the virus alone.
I advocate a abstinence-based approach to STI(sexually transmitted infection) prevention. The advantages of this approach are overwhelming. I realize that patients may choose other paths and that even married partners may have to deal with HPV based on any type of sexual contact in either partner’s past. Condoms are a helpful but, unreliable tool for prevention of STIs. They certainly have a role in contraception and disease prevention. The HPV vaccine certainly represents a new tool for primary prevention of HPV infection and should be considered even in patients who plan to be monogamous. With regard to the HPV vaccine, please see the question regarding recent information which has been made available regarding this vaccine.
With the recent news that Gardasil has experienced numerous fatal reactions to its administration, I have stopped recommending this vaccine until we have further information. There have been 32 deaths reported and numerous adverse events ranging from allergic responses to convulsions and serious illnesses.
The FDA approved Gardasil by Merck. It is the HPV vaccine developed from purified inactive proteins for four different HPV subtypes (6,11,16,18). The purpose of the vaccine is to prevent cervical cancer & genital warts and other rarer cancers of the vagina and vulva. Notably, there are numerous subtypes of HPV and this vaccine is designed to prevent infection from four. These are four of the most troublesome and the vaccine could prevent 70% of cervical cancers and 90% of genital warts. The take home point is that the vaccine will not cover 100% of the HPV viruses. Patients who are sexually active are still at risk for infection with HPV and other viruses as well as bacterial STIs. Patients who get the vaccine should continue cervical cancer screening with pap smears per established guidelines.
The vaccine is given over 3 injections:
- 1st dose
- 2nd dose 2 months after first dose
- 3rd dose 6 months after 1st dose.
Some side effects and issues:
- Serious illness and numerous fatalities have been reported
- Potential injection site side effects: pain, swelling, redness
- Risk of allergic response
- Doesn’t protect against all HPV types
- Doesn’t protect against other causes of STI (sexually transmitted infections) such as herpes, hepatitis, HIV, chlamydia and gonorrhea to name a few.
In the United States, over 10,000 women can expect to be diagnosed with cervical cancer each year. Over 3,700 will die from the disease. Most of these patients aren’t regularly screened with pap smears. Fortunately, in the US, screening with pap smears and colposcopy have been very effective. In developing countries, cervical cancer is a major cancer killer.
There are a couple ways to start the ocp. The first method is to wait for your next menstrual cycle. In doing so, you can wait until the Sunday, or start on any one of the days. Many of the packages will allow you to adjust the labeling so that you do not get confused by the labeled day versus the actual day. The other option is to not wait for your menstrual cycle. In this event, you should take a pregnancy test to confirm you are not pregnant. Again, you may start on a Sunday, or adjust the labeling.If you start during a menstrual cycle, you are required to use backup contraception for the first week. If you start in the middle cycle, use backup contraception for at least a month. To be safe, I usually recommend backup contraception for the first month.
If you miss one active pill( hormonally active pills are one of the 1st 21), take the missed pill as soon as you remember and then take your next pill at the regularly scheduled time.If you miss 2 active pills in a row, what you do depends on where in the pack the missed pills are. If the missed pills come from the first 2 weeks, take 2 pills the day you remember and then take 2 pills the next day as well, then finish the pack as you normally would. You must use a backup birth control method for 7 days after the missed pills.If the missed pills come from the third week, throw-out the rest of the pill pack and start a new pill pack that day. You must use backup birth control for 7 days after the missed pills. Also, note that you may not have a menstrual cycle that month. Of course, if you use Sunday as a reference, continue taking one pill a day until Sunday then throw out the pack and start a new pack on Sunday.
Most of the hormonal contraceptives contain a combination of estrogen and progesterone. They work by inhibiting the ovulation of the egg through inhibition of LH and FSH. They also make the cervical mucus relatively impermeable by the sperm.They don’t prevent STDs. The most common side effect is breakthrough or unplanned bleeding. This is going to be especially true in the first 4 to 6 months. It can take that long for the pill to regulate the cycle. Any change in formulation before 3 months is likely premature. Also, as the dose of estrogen decreases, so does cycle control. Many of the newer pills have only 20 micrograms of ethinyl estradiol; correspondingly, breakthrough bleeding will be increased with these products. Patients taking other hepatically (liver) metabolized medicines such as anti-seizure medicine or chronic antibiotics like doxycyline should consider a higher formulation. I would also consider a higher formulation in obese patients. Most of the side effects from the pill will be due to the estrogen component. These include nausea, breast tenderness, fluid retention and decreased libido.Occasionally, the pill will cause an increase in blood pressure. There are certain patients to whom we would not give the pill. These include smokers greater than 35 years old (increased risk of deep venous thrombosis), patients with liver disease, patients with a personal or family history of thrombophilia (make clots easily, that is, factor 5 leidon mutation) and patients with breast or endometrial cancer. Some potential, but not certain contraindictions include women with migraines and high blood pressure. Some of the side benefits of the pill include cycle control, decreased volume of menses, decreased cramping or dysmenorrhea, reduced risk of ovarian and endometrial cancer by 40 percent, reduced risk of pelvic inflammatory disease and reduced acne.
Yes, it is quite safe. Doctors have been prescribing the pill in this fashion for many years. Barr pharmaceuticals packaged a pill called Seasonale/Seasonique to take advantage of this. This formulation uses the same drugs and doses we have been prescribing for decades. The same effect may be achieved with any combined contraceptive ring, patch or pill by taking the 21 hormonally active pills or 3 patches and then skipping the 7 placebo pills at the end of the pack and initiating the next pack. The packaging of the pill to provide a monthly cycle was done because marketing experts thought women would feel safer with a familiar pattern to their bleeding. There is no health benefit to this monthly withdrawal bleeding, and for some there may be significant health benefits to the extended dosing regimen. The physician may consider any patient who has symptomatic menstrual cycles a good candidate. Patients with heavy bleeding, cramping and pain should consider this after other causes have been ruled out. Patients with endometriosis, PMS, menstrual migraines and epilepsy should consider this. Ultimately, this represents another opportunity for the modern woman to stay in control. There are some side effects to adopting this regimen. The most significant side effect is breakthrough bleeding. This is also the most frequent reason given for discontinuing. With the extended regimen, greater than 25 percent will have unscheduled bleeding in the first 3-month cycle. By year’s end, 80 percent have excellent cycle control, and that number continues to rise with use.
Yeast infections of the vagina tend to cause itching, irritation, burning with urination, and a white discharge. If the discharge is a different color and has a fishy odor there is a high probability you actually have a bacterial infection. In this case you should make an appointment to be seen in the office. If you suspect a yeast infection, I don’t discourage the use of over the counter yeast medicines such as Monistat. It is important to know that patients will frequently misdiagnose themselves and correspondingly, mistreat themselves.
Provera or medroxyprogesterone acetate is a hormone frequently given to women in order to achieve regular cyclic bleeding. Physiologically, this works well because it mimics what happens naturally during a normal ovulatory cycle. If you break the menstrual cycle into two parts, the follicular phase where the egg is developed and luteal phase, where the egg is fertilized and implanted, you may understand why cyclic provera works. In a normal cycle, during the follicular phase, a group of eggs develop in the ovary. That creates estrogen. That estrogen in turn stimulates the lining of the uterus to proliferate, or develop. At midcycle, the developed egg is released or ovulated.Now comes the luteal phase during which, the mechanism that made the estrogen during the follicular phase, starts to make progesterone which maintains the uterine lining throughout the luteal phase. That little progesterone factory lasts 14 days and unless rescued by a conception (pregnancy), involutes (dies). The subsequent sudden loss of progesterone results in a “withdrawal bleed” or menstrual cycle. A 10 day course of provera or progesterone mimics that little luteal phase progesterone factory. The subsequent withdrawal of the oral progesterone mimics the natural withdrawal of progesterone and should trick the uterus into menstruating. The patient that doesn’t ovulate regularly such as the patient with polycystic ovaries, never develops the little progesterone factory, thus the lining never has a progesterone withdrawal. In the absence of the regular orderly withdrawal, the uterine lining becomes unstable and unpredictable, susceptible to sporadic breakthrough bleeding.
Provera is typically prescribed during the second half of the month long cycle or, during the luteal phase. That is why the prescription typically describes taking the medicine days 16 through 25. Upon receiving the medicine at first, you will likely not know where you are in your cycle so you start the medicine immediately. Within 1-3 days of finishing your 10 day course, you should have a menstrual cycle. This cycle can be significantly heavier than your usual cycle. The day you start bleeding after the medicine, is CYCLE DAY #1. From that day forward, count to day 16 and that is when you initiate your next 10 day course and so on… Patients are typically put on at least a 3 month course. Each subsequent cycle should become more manageable.A couple words of caution:
- It is possible to bleed too much. If you are concerned about the volume of blood loss, go to the emergency room, especially if you feel like your heart is racing, you feel dizzy, or appear pale.
- Uterine/vaginal bleeding can be the sign of miscarriage, ectopic pregnancy, and different forms of uterine pathology. Further investigation is sometimes warranted.
- Pregnant patients should not cycle with provera. If you have any question about potential pregnancy, do a pregnancy test before taking provera.
- If you are bleeding when you originally start the provera, it probably won’t stop that bleeding. Also, sometimes, patients will get breakthrough bleeding in the middle of their course of progesterone. Most patients will complete the 10 day course with no additional bleeding.