The recommendations for cervical cancer screening appears to be changing rapidly in the last decade. This will cause more confusion among physicians and patients as well. It is important to stay aware of the latest research and findings.
When in comes to PAP tests, more is not better. This can be clearly observed if we compare two countries: USA and Netherland. American women undergo 3 to 4 times as many Pap tests as their Dutch counterparts. Despite the vastly different screening rates, the overall mortality data suggest no substantially different trends between the 2 countries. This suggests that more frequent screening for cancer of the cervix using PAP testing is not necessarily more beneficial.
So what make physicians do more than a patient needs? Most physicians will follow guidelines. With more research and evidence guidelines change and some physicians takes longer to catch up than others. Some physicians are resistant to change: “We have always done it this way and it always worked”. Others believe screening more often would not harm, a belief contradicted by evidence. Frequent PAP testing can result in more anxiety and unnecessary interventions, additional cost to the patient and system.
On the other hand, all patients I diagnosed with cervical cancer had not had a PAP test for the last 7 years or more. I have yet to see a patient with cancer of the cervix who had recent normal PAP tests. So less can be dangerous.
Here is the latest, all you need to know in a nutshell:
Begin screening at age 21 regardless of sexual activity.
Younger than 21? There is no need for PAP or HPV testing regardless of sexual history. Cervical cancer is rare and HPV is very common in this age group.
Between 21 & 29? PAP is needed every 3 years. HPV testing is not needed.
Between 30 & 65? You need both PAP and HPV testing every 5 years (preferred) or PAP alone every 3 years (acceptable).
Older than 65? No need for PAP testing if you never had cervical dysplasia (precancerous cells) in the past 20 years.
Older than 65 with new sexual partner? No need for PAP testing
Following a total hysterectomy (surgery to remove uterus and cervix)? No need for PAP testing
Following a partial hysterectomy (surgery to remove uterus and retain the cervix)? Follow the same recommendations as if you did not have a hysterectomy.
Following the HPV vaccine? Follow the same recommendations as if you did not receive the vaccine.
It is worth noting that the above guidelines are for general screening and do not address high-risk populations as patients with a history of cervical cancer, exposure in utero to diethylstilbestrol, or those who are immunocompromised (example: patients with HIV/AIDS or organ transplant).
The above concerns performing a PAP test. Every woman will still need an annual pelvic examination (some call it ‘vaginal exam’, ‘speculum exam’, ‘bimanual exam’, and the misnomer ‘PAP test’) wether a PAP test is being obtained or not. Such exam is essential to assess the vulva, vagina, cervix, uterus, tubes and ovaries for any masses or abnormalities.
On Aug. 22 2011, the American College of Obstetricians and Gynecologists (The College) announced new recommendations to prevent blood clots during Cesarean Deliveries.
"Wearing the Inside Out ..." by Lebanese graphic designer Rasha Rahal
The new guidelines will be published in Sept. 2011 issue of the Green Journal. Blood clots, medically known as venous thromboembolic events (VTEs), are a leading cause of maternal mortality in USA and Canada. The College now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The most cost effective method would be sequential compressive devices (SCDs) to be placed on the lower extremities of a patient before a Cesarean and removed after surgery only when adequate ambulation is attained.
The risk of developing blood clots is increased four folds during pregnancy and two folds during and after a Cesarean delivery. Blood clots can block blood flow and cause damage to certain organs. The most common site of a blood clot in a pregnant patient is the left lower leg but other sites are commonly affected. Symptoms include swelling and pain in affected limb. If a clot gets dislodged, it can travel to the lungs causing a life-threatening condition known as pulmonary embolism (PE). Symptoms include sudden shortness of breath, chest pain, and coughing.
The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. “It’s important for ob-gyns to adopt these recommendations to help reduce maternal deaths.” said Dr. Andra H. James who helped develop the guidelines.
The Society of Obstetricians and Gynecologists of Canada (SOGC) has no clear recommendations on using VTE prevention during a Cesarean delivery for patients who are at low risk. Regardless of the plethora of new research on this topic, the SOGC guidelines were last updated in 2000. (See Prevention and Treatment of Venous Thromboembolism (VTE) in Obstetrics).
If you or someone you know are undergoing a Cesarean delivery ask the doctor about methods of VTE prevention she/he are implementing.
I just got my Flu Shot today. You should too, especially if pregnant.
It is NOT “just the flu”. When you are pregnant influenza virus can have serious implications on your health and the health of your baby. The best treatment is prevention.
If you are pregnant or recently delivered a baby, I strongly advise you to get vaccinated against seasonal influenza.
The flu vaccine was proven to be safe and effective. It has been given to millions of pregnant women over the past decade and has NOT been shown to cause serious harm to women or their babies.
As an added bonus, vaccination during pregnancy will pass on immunity, protecting your baby until she/he is old enough to receive her/his own vaccinations. Remember, your newborn baby can not receive the flu vaccine before she/he is 6 months old.
You can receive the flu vaccine in any trimester and after you deliver even if you are breast feeding.
You should NOT receive the vaccine if you are sick with a fever or if you are allergic to eggs.
If your care provider does not offer the vaccine, make sure she or he refers you to someone who does.
I understand you took it last year. You do need it again:
Influenza virus has many types. Each year the flu vaccine is designed to prevent the most commonly circulating types. The vaccine changes every year. So even if you received the vaccine last year, you still need to be vaccinated with this year’s vaccine for best protection.
DO NOT take the nasal spray vaccine during pregnancy:
There are two forms of the vaccine. One is given as a shot in your muscles (flu shot: contains inactivated virus) and the other as spray in your nose (nasal spray: contains live virus). After you deliver either form of the vaccine is appropriate.
5 Reasons why you should receive the vaccine:
To protect yourself. Influenza is more likely to cause severe illness, even death, when you are pregnant as compared to when you are not.
To decrease your chances of having preterm labor or delivering a premature baby if you catch the flu
To offer protection to your new born baby during the first 6 months of her/his life. During this period, your newborn baby is 10 times more likely to be hospitalized if she/he catches the flu.
Severe illness in postpartum women was also documented. Last year’s H1N1 (Swine flu) is expected to circulate this influenza season so it is included in the seasonal trivalent influenza vaccine this year.
By not catching the flu you help avoid communicating the infection to other people and family around you
“But isn’t it controversial?”
No, it is not controversial. It is strongly recommended by all of the following medical organizations in a joint statement released on Sept. 15th 2010:
Two weeks ago, a nice young woman presented to my office for excessive vaginal discharge that she had for the past year. The moment I saw her cervix, I knew what I was looking at: Cancer. Her last gynecological exam was 5 years ago.
Who is to blame? Is it the responsibility of the patient, the physician or the health care system? With all the recent advancements in cancer prevention and early detection, it becomes unacceptable to allow any woman to develop cervical cancer. We are all responsible.
Breaking cancer news to my patients and their families is the second least favorite part of my job. We have the means to put an end to cervical cancer. We should raise awareness about this cancer and its causes, more so in less developed countries. My next post will be about cervical cancer awareness and barriers encountered in Lebanon.
Can a virus cause cancer?
Human Papillomavirus or HPV is the most common sexually transmissible infection. It is the leading cause of cancer of the cervix. HPV can also cause cancer of the vagina, vulva, penis and anus. There are more than 100 different types of HPV. Low risk types like 6 and 11 usually cause warts. High risk types like 16 and 18 are responsible for 75% of cervical cancer cases. Generally, men and womyn are silent carriers. They will carry and transmit the virus without having any symptoms at all.
There are no medications to treat the virus. It takes months to years for your immune system to defeat it. Cigarette smoking, high risk sexual behavior and having multiple sexual partners are among factors that might make the progression to cancer faster.
Is my partner unfaithful?!
If you are in a long-term monogamous relationship and were recently diagnosed with HPV, do not jump to conclusions about the faithfulness of your partner. Attempts to know who gave it to the other are futile. I tell my patients that there is no need to start using condoms or dental dams for the sole reason of preventing transmission of the virus to your monogamous partner. He or she likely has the same HPV types already.
Now, it is not all gloomy! Here is the bright side. For womyn, a vaccine can prevent HPV infection and a PAP test can detect early cancer allowing complete cure.
Yes, we can prevent HPV infection!
Condoms do not offer full protection. HPV transmission can occur by skin-to-skin contact. The good news is that you can now be vaccinated against HPV.
Two HPV vaccines are available:
Gardasil (By Merck & Co, Inc.): Quadrivalent HPV vaccine (protects against 4 types of HPV: 6, 11,16 and 18). It was FDA approved in 2006 for use in females aged 9 through 26 years.
Cervarix (By GlaxoSmithKline): Bivalent HPV vaccine (protects against 2 types of HPV: 16 and 18). It was FDA approved in October 2009 for use in females aged 10 through 25 years.
The vaccine is given in three-dose series. Get in now. Your second shot will be in 2 months and the third in 6 months.
In addition to preventing cancer, the vaccine also lowers your chances of developing genital warts, which can be as psychologically burdening.
The vaccine works best when given to individuals who have never been sexually active. Nevertheless, there is still a proven benefit even if you are sexually active and had HPV or precancerous cells on your PAP test. The vaccine might prevent re-infection or re-activation of the virus.
Yes, we can detect cancer early (even before it happens)!
The Pap test has significantly lowered the incidence of cervical cancer among womyn. Cells are taken from the cervix and examined. If abnormal, your provider might ask you to have a colposcopy. With colposcopy, the vagina and cervix are washed with acetic acid or vinegar. A light and magnifying lens allow your doctor to visualize and biopsy any abnormal tissue. If early cancer or precancerous cells are confirmed after biopsy, your doctor can burn, freeze, laser or cut out the affected part of the cervix, thus slowing or arresting the progression to cancer.
So if you are between ages 21 and 29, you should get a PAP test every 2 years, then every 3 years once older than 30 according to the most recent guidelines by the American College of Obstetricians and Gynecologists. If, however, you have high risk factors or previous abnormal PAPs then you might need more frequent PAP tests. Always discuss with your doctor.
What lies ahead! Recent research, future approaches
Vaccinate the boys!
On October 16th, 2009, the FDA approved use of Gardasil for the prevention of genital warts (condyloma acuminata) due to HPV types 6 and 11 in boys and men, ages 9 through 26.
In July 2010, the 26th International Papillomavirus Conference in Montreal, Canada addressed the importance of the recent shift towards a “gender-neutral” vaccination policy. The conference discussed the significant decline in HPV-related disease in men and womyn after the Australian national HPV vaccination campaign was introduced in mid-2007.
Anal “colposcopy” for womyn!
The September 2010 issue of the Green Journal (Obstetrics & Gynecology) published a study that suggested screening for anal cancer (Anoscopy) all womyn with pre-cancerous cells in the cervix, vagina or vulva. I agree with Dr. Linda Eckert: “We are not ready for such recommendation” she wrote in Editorials of the same issue. More research is needed to support such guidelines.
Anal PAP test for men!
In Sept. 2010, the 28th Annual Conference of the Gay and Lesbian Medical Association (GLMA) in San Diego, USA took the discussion one step further. There were four plenary and breakout sessions on anal dysplasia and cancer, anal PAP test, and HPV vaccination in men. Even though recommendations for anal PAP testing have not been endorsed widely by medical organizations, few centers in USA have developed the experience in performing and reading anal PAP tests. The results are promising, but again, much more research is needed in this field.
Vaccinate womyn older than 26!
If you are between ages 26 and 45, you might be a candidate for the vaccine. Discuss it with your doctor. A large well-designed study published in the Lancet in 2009 showed favorable results for HPV vaccination in womyn ages 24 to 45. No recommendations for this age group have been made yet.
Can we do better?
It appears that we should do a better job at vaccinating. Over the three years since Gardasil was approved, only 18% of adolescent females have received all 3 doses. Many marginalized group of womyn do not receive adequate PAP testing.
It is unjust for a woman anywhere in the world not to benefit from the available means to fight cervical cancer.
We need to raise awareness.
We should aim at eradicating HPV like we eradicated small pox in 1977.
The recommendations for cervical cancer screening appears to be changing rapidly in the last decade. This will cause more confusion among physicians and patients as well. It is important to stay aware of the latest research and findings.
