Gynecology

Response To Recent Study Linking Hormonal Birth Control To Breast Cancer

December 8, 2017Gynecology

Many of us have read about a recent study published in the New England Journal of Medicine suggesting that hormonal birth control slightly increases the risk of breast cancer. While this is new information that has not had time to be fully evaluated by the American College of OB/GYN, we recognize how scary this information sounds on its face, but also want to highlight that the study showed a very small increase risk for women in their teens, 20s and 30s.

It’s also very important to understand that birth-control, in preventing pregnancy, lowers a number of other risks associated with being pregnant, and to also take into account that birth-control pills and other hormonal birth control methods that prevent ovulation significantly decrease ovarian and uterine cancer risk. Weighing all of that information together, we do not plan to make any abrupt changes in our prescribing patterns, and suggest that each individual patient speak with her physician about her particular risk, and make an informed decision based on balanced information.

As the attached article highlights:

That may sound scary (but) the illness is fairly rare among women in the age group studied.
“A 20 percent increase of a very small number is still a very small number,” says Mia Gaudet, an epidemiologist with the American Cancer Society. The risk contributed by hormonal contraception, she says, is similar to the extra breast cancer risk contributed by physical inactivity, excessive weight gain in adulthood, or drinking an average of one or more alcoholic drinks per day.

As more information is revealed about the study we will let you know what we find out.

If you would like to discuss this further with your provider please make an appointment and we would be happy to discuss the best option for you.

https://www.npr.org/sections/health-shots/2017/12/06/568836583/even-low-dose-contraceptives-slightly-increase-breast-cancer-risk-study-finds

What’s The Latest On Zika?

January 6, 2017Gynecology, Obstetrics

Many have our patients have expressed concern about the Zika virus outbreak which has been in the news recently. The Zika virus spreads through infected mosquitos and less commonly spreads via sexual transmission. The CDC (Center for Disease Control) issued a travel alert for people traveling to countries where Zika virus transmission is ongoing. There is currently no evidence of widespread, sustained local transmission of Zika at this time. The CDC website www.cdc.gov will keep an updated list of countries where transmission has been confirmed.

Since little is known about Zika virus in pregnancy, but pregnancy complications have been reported, we are advising our patients to postpone travel to these areas. If travel cannot be avoided, precautions to avoid mosquito bites should be taken. These measures include using an EPA-registered bug spray with DEET, covering exposed skin, staying in air-conditioned or screened in areas and treating clothing with permethrin.

If you are pregnant and have traveled recently to an area with ongoing Zika virus transmission, please let your provider know. The most common symptoms of Zika are fever, rash, joint pain, and red eyes but many infections do not cause symptoms. The need for testing and additional fetal ultrasounds and consultation with maternal-fetal medicine specialist and possible amniocentesis will be determined for at-risk patients since the virus can affect fetal growth and development.

Until more is known, pregnant women with male sex partners who have lived in or traveled to an area with Zika virus should either use condoms or not have sex during the pregnancy.

There is currently no antiviral treatment or vaccine for the Zika virus, therefore avoiding exposure is highly recommended for our pregnant patients and those desiring pregnancy in the near future. We will continue to monitor this evolving situation and adjust recommendations as needed.

Recent guidelines were issued regarding family planning. If a woman has been diagnosed with Zika or has symptoms of Zika after possible exposure, the CDC recommends she wait at least eight weeks after her symptoms first appear before trying to get pregnant.

If a man has been diagnosed with Zika or has symptoms of the illness, he should wait at least three months from those first signs before having unprotected sex, according to the public-health agency. That longer waiting period reflects the length of time the virus has been found in semen.

The CDC and World Health Organization (WHO) have both released recommendations that women with suspected or confirmed Zika infection continue to breastfeed according to established feeding guidelines. The presence of Zika virus has been reported in breast milk, but there have been no reports of transmission to infants via breast milk.

As new guidelines emerge, we will be updating our website to reflect the ongoing changes.

If My Tubes are Tied, What Happens to the Egg?

October 23, 2016Gynecology

Several times a month patients remind me that somewhere in high school health class, a myth is perpetuated about the function of the egg in relation to the menstrual period.

Many of us are taught at an early age that each month we release an egg (this part is true), and if no conception occurs, the egg comes out with the monthly cycle (not true). This misconception leads some of us to wonder what happens to the egg if the tubes are tied, or if we have no period due to an IUD, an endometrial ablation, or a hysterectomy. In reality the egg is a single cell, visible only under a microscope. While we generally release an egg each month, the egg travels into the fallopian tube awaiting fertilization, and if no fertilization occurs the egg simply dissolves. After all it is only one cell. So if the tubes are tied or we have an IUD, the same process still occurs. The egg is produced and simply dissolves since it is not fertilized. If we have a hysterectomy the same process occurs.

The hormones which are produced as a result of egg development and ovulation (egg release) usually cause the lining of the uterus to grow in preparation for pregnancy, and if fertilization does not occur the lining sheds. What we see coming out as menstrual bleeding is a combination of blood and uterine lining, not the egg itself. If we have had a procedure such as an endometrial ablation to get rid of the lining, have an IUD which reduces the formation of lining, or have had a hysterectomy, the hormonal signal from the ovaries will not be successful at causing lining to grow. The egg is still being released, the hormonal signal is still going out, but the uterine lining simply does not grow, so we don’t see bleeding. The egg is still being produced and is dissolving every month without coming out, as it usually does.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Isn’t it bad not to have a period on birth control pills after endometrial ablation? Don’t we have to have a period to stay healthy?

October 18, 2016Gynecology

A period happens when our body sheds the lining that was prepared to accept a pregnancy, when pregnancy does not occur. After we ovulate (release an egg) the uterine lining grows ready to accept an embryo, and if no pregnancy occurs then the lining sheds and the cycle repeats again. When we are on birth control pills we do not release eggs, so this process is halted.

On birth control pills we don’t really have a true period, but we do bleed during intervals when we stop taking the active pills (most pills have a 4-7 day pill free interval at the end of the pack allowing our hormone levels to drop and the lining will shed). Sometimes the lining gets so thin on pills that there is no lining there to shed and no bleeding occurs during the pill free interval. This is perfectly healthy. When the pills are stopped for a few weeks, the lining will come back as we start to release eggs again.

Some pills are packaged with no pill-free interval, so we don’t have a period at all. That is fine as well, since over time the lining gets very thin and there is simply nothing there. In comparison, if we are not on the pill, not having a period means there is something wrong with our hormones that is preventing ovulation. But when we are on the pill, not having a cycle is great. Similarly after endometrial ablation we may not have periods at all, since the lining is destroyed permanently and hopefully will never grow back even though our hormones are still normal.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Are The New Guidelines For Mammogram Frequency?

December 17, 2015Gynecology

Many of our patients have asked us about the recently publicized new guidelines for mammogram frequency. We know this is very confusing since different agencies make different recommendations, and currently 3 different organizations have published recommendations on mammogram frequency, the latest being from the American Cancer Society (ACS). The new ACS guidelines published in October 2015 were as follows:

Women with an average risk of breast cancer – most women – should begin yearly mammograms at age 45.
Women should be able to start the screening as early as age 40, if they want to.
At age 55, women should have mammograms every other year – though women who want to keep having yearly mammograms should be able to do so.
Regular mammograms should continue for as long as a woman is in good health.
Breast exams, either from a medical provider or self-exams, are no longer recommended.
The guidelines are for women at average risk for breast cancer. Women at high risk – because of family history, a breast condition, or another reason – need to begin screening earlier and/or more often.

These new guidelines fall somewhere in the middle between the guidelines released by the US Preventative Services Task Force (USPSTF) in 2010 and the guidelines recommended by the American College of Obstetrics and Gynecology (ACOG). The USPSTF made drastic changes in its recommendations for frequency of Mammography (MMG) screening in low risk patients, and this met great resistance amongst practicing Gynecologists. For instance, the USPSTF advocated not initiating screening until the age of 50, screening only every 2 years and cessation of screening in all women around the age of 74. ACOG (who we generally agree with) made no changes to its guidelines for Mammography screening, and we continue to suggest mammograms every 1-2 years in the 40’s based on the individual situation then annually after age 50, and patients considered to be high risk are offered screening even earlier than age 40. ACOG (and CWCC) felt that the USPSTF recommendations could allow for a missed opportunity to find early stage cancer in young healthy woman, as well as healthy woman in their late 70s and even 80s when the risk of breast cancer is still relevant. As a positive, the new ACS guidelines factor in the importance of patient education and individual discussion with your physician regarding your specific risk. Factors that make patients low risk include few family members with history of breast or other cancers, no personal history of abnormal lumps, or history of abnormal MMG findings.

It is important to remember that both ACS and USPSTF factor in many variables when making these recommendations including cost of screening, patient access to screening, number of cancers detected and lives saved. Many practicing gynecologists feel that delaying initial screening until the age of 45 and then spacing out screening to every 2 years in woman in their 50s will miss the opportunity to detect cancer at an earlier, generally less aggressive stage, improving patients’ ability to successfully fight the disease. So at CWCC, we share the opinion of most gynecologists that the ACOG recommendations for regular mammography starting at age 40 is still the safest and best option. We will continue to do annual breast exams, although we agree that it is very unlikely to feel an early breast cancer, and for those patients following the guidelines for mammography, any cancer would be picked upon the mammogram before it can be felt. So while we recognize that breast exam has very little use, it can occasionally be helpful.

We remind our patients that 1 in 8 women will fight breast cancer during her life. Think of sitting at lunch with 8 women, one of us will fight breast cancer. Our goal as gynecologists should be to recommend screening that allows us to detect early stage cancer that we know has the best survival rates. Mammography, albeit uncomfortable, is safe and our best chance at detecting early stage cancer before it is big enough to feel.

What Can I Do About Painful Sex After Menopause?

June 16, 2014Gynecology, Menopause

Menopause is a challenging time for many reasons, as we are forced to face the reality of our own aging and loss of fertility, as well as a myriad of unpleasant symptoms that come from a drop in our ovarian hormone production. While the average age for ovarian function to cease is 51, in many women it can occur much earlier, or even as late as 60.

Right at the same time as we are dealing with the emotional realties of menopause, seeing new wrinkles in the mirror and a new tire forming around our waist, we often are thrown another loop which is that sex becomes painful. Dropping estrogen levels cause very real changes in the vagina including a lack of moisture production and a thinning of the tissue which also becomes less elastic and prone to tear. The vaginal tissue becomes pale as blood flow to the areas is decreased, and the vagina can start to shrink to a point at which intercourse can be difficult or even impossible.

Luckily there are very good treatments for post-menopausal vaginal changes and this pain and dryness can almost always be resolved. Since the problem is caused by low estrogen, the mainstay of treatment is putting estrogen back into the tissue. For women experiencing a wide range of menopausal symptoms such as hot flashes, and night sweats as well as vaginal pain, taking an estrogen product that treats the whole body may be appropriate. For women with isolated vaginal pain and dryness, estrogen can be directly applied to the vagina at a much lower dose and this avoids some of the side effects (such as the potential for increasing breast cancer risk) that the systemic products may have. Even if a systemic product is used, additional vaginally administered estrogen can help in many cases.

There are three estrogen products on the market that we recommend to treat vaginal pain and dryness and each has pros and cons. They all contain the same product, which is bio-identical estradiol (biologically the same as human estrogen). The first is a cream which is applied with an inserter 2-3 times weekly (”Estrace”). It works well but is a bit messy and hard to keep up with. The second is a tablet which is also inserted with an applicator (“Vagifem”). It is less messy but also is hard to keep up with. The third is a circular flexible ring which is placed and removed by the patient and stays in the vagina for 3 months (“Estring”). Many of our patients prefer this as it is no trouble to keep up with and delivers a small even dose every day, and overall is the lowest dose product which has the best results. Interestingly studies on Estring show that such a minuscule amount of estrogen gets above the waist (it is almost all bound locally) that even breast cancer patients can usually safely use it once they are cancer free. None of these work overnight as they require time for new healthy tissue to replace the old unhealthy tissue, and results may take 3-6 months to be noticeable. In the meantime using a lubricant such as Astroglide can help to reduce pain.

A unique non-estrogen product is also available in pill form to treat post-menopausal vaginal pain and dryness. “Osphena” is a not estrogen but is in a class of drugs called “SERMs” (selective estrogen receptor modulators) which act like estrogen in some tissues but like anti-estrogens in others. Other very similar drugs include Tamoxifen which is used to reduce breast cancer risk but also helps bone density, and Raloxifene which is a bone builder but also reduces breast cancer risk. Osphena was initially being developed as a bone builder and it does have a good effect on the bone, but incidentally was found to have an estrogen-like effect in the vagina, so the decision was made to market it for that purpose. While it has not been studied enough on the breast yet to make this promise, it is certainly likely to decrease breast cancer risk since the other drugs in this class do.

One benefit is that it is a daily pill and some patients find that preferable to placing something in the vagina. Unfortunately the main side effect is hot flashes. Since Osphena is an anti-estrogen in some areas of the body, one of those areas is unfortunately the temperature sensors in our brain. For this reason we rarely recommend Osphena to a woman early in menopause who is already experiencing hot flashes, and also cannot give it to patients who are taking systemic estrogen for hot flashes (you should not take both estrogen and an anti-estrogen simultaneously). A good candidate for Osphena might be a woman in her 60s with vaginal pain and dryness who is past the point of hot flashes and prefers a pill to a vaginal medication.

Of course there are some non-hormonal reasons for vaginal pain after menopause and a physical exam with your provider is important to make sure there is not something more serious going on. While it is our job to ask, don’t be afraid to bring up this very intimate topic with your provider at your next visit.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Is This New Alternative To Pap Smears For Cervical Cancer Screening?

June 10, 2014Gynecology

Many of you may have heard in the news that the FDA recently approved a new screening test for cervical cancer. We are CWCC think this is very exciting news, especially for women in the developing world, and we know you will be interested to hear the details.

As you all probably know, cervical cancer is almost always caused by the virus called HPV (human papilloma virus). We discussed this is another blog and here is the link to get you up to date on that information. (http://cwccblog.com/do-i-still-need-a-pap-smear-every-year). The short version is that most of us are exposed to the HPV virus at some point in our lives through sexual activity, but in the majority of cases our immune system clears it up and no treatment is required. That is why it is not recommended to even test for it in women under 30, because it’s so common and usually goes away. If we still carry it when we are over 30 it is less likely that it will clear on its own and we start watching more closely for signs of pre-cancerous change which can be treated easily in most cases before any harm is done. For patients who follow these guidelines, cervical cancer is extremely unlikely to develop.

Traditionally we have done cervical cancer screening by doing a pap smear, which gets a sample of cells from the cervix to examine for precancerous changes. In addition to checking the cells, for patients over 30 an HPV test is added. In reality, for patients over 30 we are really only reacting to the HPV result, so the cellular part is of little or no value, since precancerous changes essentially go along with a positive HPV result, and if the HPV is negative we essentially disregard the cellular test results. Following that evolution in practice over the past few years, a new test has been approved which only tests for HPV, and this could theoretically be done at home with a vaginal swab that patients could do themselves. Essentially it is the exact same test that is currently done from a traditional pap smear in women over 30.

The test checks for the DNA of 14 types of HPV which are possibly players that could cause cervical cancer (there are over 50 types of HPV, but most of them don’t cause cervical cancer). The current suggested guidelines for this product are to ask patients with a positive test to come in to see the doctor if they have a positive test, and if they test positive for one of the most “high risk” types of HPV (either type 16 or 18) then the recommendation is to do a cervical biopsy to check for precancerous changes. That is also pretty much what we do already when handling traditional pap smear results, although we may wait a year in some cases to see if the HPV goes way before we do a biopsy.

Critics of the new test worry that if too many young women do this test that it may lead to over treatment of patients who are HPV positive when the virus normally clears on its own. We agree that women under 30 should NOT do this test, for the same reason that we haven’t recommended that for years with the traditional pap. We also are concerned that if this test is done at home and patients over 30 are negative for HPV, that they won’t come to their annual exams, and it is important to remember that there are many other disease processes that we screen for at an annual exam, including ovarian, uterine, breast, bladder, vaginal and vulvar issues. But overall we think it is a great development, and will be a fantastic tool for women to use in environments where medical care is hard to find, such as in the developing world, where most cervical cancers occur. In places like Africa this test could allow triage large numbers of women without the need for a medical exam, and follow-up of HPV positive patients, particularly those with HPV type 16 and 18, could be directed to a clinic that otherwise would be overwhelmed by screening the entire population.

While this test has been approved by the FDA, at the time of this blog it is not currently available to the public or to doctors. If a patient is in our office having an exam, we will currently continue using the pap smear and HPV testing for women over 30, but we look forward to finding out what the future holds for recommending that certain patients do this test themselves at home as an adjunct to their annual exam and will keep a close eye on this product so that we can keep you up to date.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Are Some Birth Control Pills More Dangerous Than Others?

January 6, 2014Gynecology

Frequently our patients ask us about the risks of taking birth control pills and if certain pills are riskier than others. The media has scared many people by reporting that pills such as Yasmin are dangerous, and it is important to understand the facts.

The risk of blood clots, which can be life threatening, is known to be increased on birth control pills and some other forms of hormonal contraception. Such blood clots usually form in the deep veins of the legs causing localized pain and swelling (called a DVT or deep vein thrombosis), but if pieces of the clot break off and travel to the lungs (a pulmonary embolus) or the brain (a stroke) this can be life threatening.

Studies show that certain pills (including Yasmin, Yaz, Beyaz, Desogen, Mircette, Cyclessa, Gianvi, Loryna, Ocella, Zarah, Kariva, Othocept, Emoquette and Velivet) have a slightly higher blood clotting risk than other pills. Non-oral forms of hormonal birth control including Nuvaring and the OrthEvra patch also have a slightly higher blood clotting risk than some oral pills.

The important thing to understand is that the risk of a life threatening blood clot on any form of hormonal birth control is very small, and that in most cases, the benefits of the pill outweigh the small risk. In fact since hormonal birth control prevents pregnancy, and pregnancy bears a much higher blood clotting risk than any form of birth control, simply not becoming pregnant reduces the risk of blood clotting for the majority of women on hormonal birth control.

All birth control pills contain two hormones; an estrogen and a progestin. All pills contain the same estrogen component (although the dose of estrogen differs between pills and can be “low dose” or “high dose”). The part that differs between pills is called the progestin component, and the slight differences in blood clotting risk between pills seems to be dependent on this component.

Pills containing the newer progestins including drosperinone (in Yasmine, Yaz, Beyaz and their generics) and desogestrel (in Desogen, Mircette, Cyclessa and their generics) have a slightly higher blood clotting risk than pills containing the older progestin called levonorgestrel. It is not understood why the non-oral forms of hormonal birth control (which don’t contain these newer progestins) have a slightly higher clot risk than levonorgestrel pills.

Two recent large studies each looking at over a million women on hormonal birth control over a 10 or 15 year period both showed similar results. The results were reported as the likelihood of an event for 10,000 women aged 15-49 over a year’s time. For example, these studies showed that for every 10,000 women aged 15-49, between 2-4 women who had never used any hormonal birth control developed a blood clot over a year’s time.

For women on a levonorgestrel containing pill the risk approximately doubled, to 6-7.5 out of 10,000 women over a year’s time. For women on pills containing the newer types of progestin (including Yasmin, Yaz and Desogen) the risk increased to 10 blood clots for every 10,000 women over a year’s time. The risk of clot with Nuvaring was 8 per 10,000 women per year, and for the patch was 10 per 10,000 annually. Women using the Mirena IUD had no increase in blood clotting over baseline.

While the blood clotting risk is important to consider, to keep these numbers in perspective, the incidence of blood clot in pregnancy and the immediate postpartum period is double that of the highest risk on pills. Also, of all blood clots reported, only about 1/4 were in the lungs or brain (acutely life threatening) and 3/4 were in a limb and were treated before becoming acutely life threatening, so the incidence of death or serious injury was extremely small.

Women with an increased risk of blood clot such as smokers over 35, morbidly obese women and those with a personal history of blood clot or a hereditary blood clotting disorder are often advised not use hormonal birth control as the risk of clot may outweigh the benefits. But for women with an average risk of blood clot there are a number of benefits of hormonal birth control that often outweigh the very small risk. These include pregnancy prevention, reduction in ovarian and uterine cancer risk, and reductions in menstrual blood loss, period pain, breast pain and ovarian cyst formation. Other quality of life improvements such as acne reduction, mood stability and menstrual predictability also need to be taken into account.

When choosing a birth control method we think it is important to pick one that you like, since you are more likely to be compliant. Some of our patients love Yasmin for example, as is great for their acne and moods and doesn’t cause them to gain weight. Others love the ease of Nuvaring and enjoy not having to remember to take a pill every day. Since pregnancy prevention is usually one of our primary goals, choosing a product that you like and will take reliably is more likely to achieve that goal.

Because the real difference in blood clotting risk between products is very small, this is rarely the main factor that we think about when prescribing a birth control product. But for first time users with no particular preferences, we generally will suggest a pill with the lower clot risk profile, all else being equal.

If you have questions about your particular birth control product, please talk to your provider!

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Is Endometrial Ablation? Can It Really Make My Heavy Periods Stop?

November 14, 2013Gynecology

Heavy periods are a curse, and can dramatically affect our quality of life. I still cringe remembering walking out of middle school class backwards with a sweater tied around my waist hoping no one would notice the blood on my chair, and when this happens to you in your 40’s at work, it is definitely time to do something! If heavy periods are adversely affecting your life, for example by causing you to reschedule or avoid activities that you like, there are good options to consider apart from just waiting for menopause.

There are a couple of common reasons for heavy monthly menstrual bleeding. Especially towards the beginning and the end of our menstrual lives, hormone changes can cause the uterine lining to be excessively vascular and more prone to grow thicker each month. Thicker lining means there is more the shed, and while this can occur at any age, it is particularly common in teenagers and women in their late 30’s and 40’s. Another common reason is the development of benign muscular growths in the uterine wall called fibroids. Fibroids occur in 40% of women and are usually asymptomatic, but they can also cause health issues including heavy bleeding and pain. Very rarely heavy menstrual bleeding is a sign of uterine cancer, but cancer is less likely to be cyclic (monthly) and is very uncommon in pre-menopausal women.

A pelvic ultrasound can determine if fibroids are present or not. If there are significant sized fibroids and they are symptomatic, generally we recommend surgical removal (either taking out the fibroids or the whole uterus depending on the patient’s age and reproductive desires). If a thick uterine lining is causing the problem, then several less invasive options are available. A couple of easy options that can thin the lining and reduce bleeding are birth control pills or the Mirena IUD.

But for many of us who do not need or want birth control, a more permanent solution to consider is an endometrial ablation. The medical term for our uterine lining that sheds every month is the “endometrium”. An endometrial ablation is an outpatient, no incision procedure that destroys the endometrium, permanently. There are several brand names of devices that have been designed for this purpose, including Novasure and Thermachoice, among others. All of them involve placing a device into the uterine cavity through the cervix (under anesthesia), then using an energy source to either burn or freeze the lining. If the procedure works well, once the lining has been destroyed it will never grow back, and patients experience either much lighter periods or no periods at all. The procedure takes less than 10 minutes (only 90 seconds for a Novasure) and patients can return to work and exercise the next day with minimal cramping.

Your CWCC doctors have done hundreds of endometrial ablation procedures over the past 10 years and have had no significant complications, and a great success rate. Amongst our patients over 50% have no period at all and over 95% state that it has been at least a substantial improvement. I personally had a Novasure procedure (done by the fabulous Dr. Jurney) 6 years ago and have had no cycle of any sort ever since, which has truly been life changing since I would bleed for 7 days and flood through a tampon in an hour! Some people are not good candidates for an endometrial ablation, including patients who desire pregnancy, patients with significant fibroids or patients with uterine cancer or precancerous conditions. (This is why we recommend that every patient considering an endometrial ablation have both an ultrasound and an in-office biopsy of the endometrium prior to the procedure, to make sure they are a good candidate).

While complications are very rare, there are some potential risks of any surgery that your doctor can go over with you if you are considering an ablation. If you have completed childbearing and are experiencing heavy menstrual bleeding, talk to your provider about your options and definitely consider endometrial ablation. I am happy to share my personal Novasure experience with you if you would like to contact me at the email below.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Should I Worry About My Abnormal Pap Smear?

October 17, 2013Gynecology

One of the most stressful conversations for our patients surrounds abnormal pap smears. Hopefully this information will help to reduce stress and provide helpful information. Starting with basics, a pap smear is a screening test for cervical cancer and generally can pick up changes in the cervix way before cervical cancer even develops. For these reasons cervical cancer is exceedingly rare in patients being followed at CWCC. In fact since 2002 when we began, CWCC has never had a case of invasive cervical cancer in a patient that we are following. We certainly frequently pick up pre-cancerous changes, which may or may not ever become cancer without treatment, and treat them. Keeping it in perspective, pre-cancerous changes can’t hurt you, and the whole point of pap smears is to prevent cancer by picking up these changes early.

When we have a pap smear, we check for two things. One is the appearance of the cells which are retrieved with the cervical swab, to see if they have any precancerous appearance. These changes, if present, are called “dysplasia” and are graded mild, moderate or severe. We also check for the presence of certain strains of the HPV (human papilloma virus) since HPV has been found to be the causative agent for cervical cancer. Patients who are negative for these HPV strains have an exceedingly low risk of cervical cancer and do not require frequent evaluation. Patients with dysplasia invariably carry the HPV virus (since HPV is what causes dysplasia). The pap tests for certain strains of HPV that can be associated with cervical cancer. It does not test for all strains of HPV. For example if a patient has genital warts which are caused by HPV types 6 and 11, they will test “HPV negative” on a pap smear since types 6 and 11 are not in the pap smear panel, because they don’t cause cervical cancer. The types of HPV tested for with a pap smear have unfortunately been named “high risk HPV”. Naturally when a patient is told that she has “high risk HPV” it sounds scary. Really they should be called “some risk HPV”. If we carry one of these strains we have some risk of developing cervical cancer if not treated, compared to essentially zero risk if we don’t carry one of those strains. Only a very small fraction of patients who carry a “high risk HPV” go on to develop cervical cancer, and those few were generally not being followed closely by a doctor.

When we diagnose dysplasia on a pap, the next step will be to do a procedure called colposcopy. A colposcope is a magnifying lens on a stand that allows us to look at the cervix with magnification and see areas of dysplasia that are not visible to the naked eye. If we see abnormal areas we take a small biopsy to confirm that the pap smear was correct. Sometimes what appears on the surface (sampled by the pap smear) is different under the surface, and the biopsy is the gold standard to decide if treatment is needed. In most cases the biopsy matches the pap smear, but not always. During the colposcopy we can also collect a sample from the cervical canal which is not visible, to make sure that there are no precancerous changes hiding up out of view. The results of the colposcopic biopsies are described as normal, or level 1, 2 or 3 precancerous changes. In general we will treat level 2 or 3 changes and often will offer observation to patients with level 1 changes. The reason not to treat immediately is that the HPV virus can go away, and in most cases our immune system clears it over time. So if a patient has mild (level 1) changes we don’t have to treat it right away, and it is safe to observe and repeat the pap every 4-6 months for a year or two to see if it resolves on its own.

If treatment is recommended there are two main types of treatment that may be offered. The first is called cryotherapy and uses liquid nitrogen to freeze the outer layer of the cervix and destroy the abnormal cells. This would be appropriate for level 1-2 changes which do not involve the cervical canal (since the freezing is only on the outside of the cervix and can’t treat the canal). The upside is that this is a quick (less than 10 minutes) procedure done in the office without anesthesia and has a high success rate. The downside is that is causes an unpleasant discharge for 2-3 weeks and we do not have a specimen to confirm that we destroyed all the bad cells. The second choice is a LEEP (loop electrocautery excision procedure), which is done in an outpatient surgery center under anesthesia and actually cuts a circular portion of the cervix off, encompassing all the visibly abnormal areas, and the specimen is then sent to the pathologist to confirm that we have clear margins. This would be appropriate for a patient with a higher grade problem or with abnormal cells in the cervical canal. The downside of a LEEP is that is can potentially be damaging to the cervix and is associated with higher pre-term delivery rates.

It is extremely unlikely that you will develop cervical cancer if you follow your doctor’s recommendations for follow-up, and we encourage you not to worry if you have been diagnosed with an abnormal pap. Just remember that precancerous cells can’t hurt you, and diagnosing them at this stage is a blessing.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Category: Gynecology

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