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Young Woman's Health Care

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Women are often surprised that we do provide "routine" gynecologic care—although we feel that there is nothing "routine" about it.

Aside from our special interests in hysteroscopic surgery and abortion services, the majority of our practice time is devoted to a variety of gynecological services. These include annual examinations (including pap smears), STD testing, contraceptive counseling (including permanent sterilization), management of abnormal pap smears (including colposcopy and LEEP procedures), infertility, as well as the management of a host of other gynecologic problems including abnormal menstrual bleeding, uterine fibroids, ovarian cysts, premenstrual disorders, sexual dysfunction and menopause management. We often provide primary care to our patients who require preliminary management hypertension, hypercholesterolemia as well as diseases of the breast.


             Pap smears, HPV testing and HPV Vaccines













                          



                        

                                 

A Pap smear involves the painless removal of cells from the cervix


You and Your Pap smear

A Pap smear involves the painless removal of cells from the cervix

What is the Pap smear?

The Pap smear is a screening test for cervical cancer. The cervix is the lower part of the uterus and the entry to the birth canal. Despite what most women think few women die in the United States each year because of cervical cancer. You may know a friend who had a pap smear showing a pre-cancerous condition of the cervix, known as dysplasia. You may even know a woman who had a condition called carcinoma in situ of the cervix, but these abnormalities are not life threatening as long as a woman is under a doctor's care and doesn't ignore the condition.

The Pap smear was developed by Dr. George Papanicolaou in 1954. This painless technique has been responsible for saving tens of millions of lives world-wide since its use became popularized. The Pap smear is nothing more than an exam, by a health care provider, that involves the gentle brushing and removal of cells from the cervix to be examined under the microscope by a trained cytologist.

If you're reading this you may be a woman trying to learn more about Pap smears or you might be someone who recently found out that she has an abnormal pap smear. Before we get started let's put things into perspective about cervix cancer. In year 2005 the American Cancer Society reported that 662,870 women in the United States died of all forms of cancer. It breaks down as follows:

  • Lung cancer deaths                  79,560
  • Colon cancer deaths                 56,660
  • Breast cancer deaths                 40,410
  • Rectal cancer deaths                 16,810
  • Ovarian cancer deaths              16,210
  • Pancreatic cancer deaths          16,080
  • Leukemia deaths                        10,030
  • Lymphoma deaths                       9,680
  • Uterine cancer deaths                 7,310
  • Multiple myeloma deaths           5,640
  • Stomach cancer deaths               4,780
  • Kidney cancer deaths                 4,640
  • Bladder cancer deaths                 4,210
  • Cervical cancer deaths                3,710
  • Esophageal cancer deaths          3,300
  • Melanoma deaths                        2,860

For more information on the risk of various cancers in women visit

http://www.cancer.org/downloads/STT/CAFF2006PWSecured.pdf

You can plainly see that although many women are afraid of cervical cancer very few women, comparatively die of this diseaser. That's why the National Institutes of Health lists cervical cancer as a rare disease (remember I'm not talking about carcinoma in situ which is almost 100% curable, and is different from invasive cervical cancer!).

This is wonderful news and it means that visiting your health care provider regularly is tremendously important. Most of the women in the US who die of cervical cancer did not get regular pap smears! So, before you read any further understand that the Pap smear, which has been around for over 50 years, has made invasive cervix cancer a rare disease and death from cervical cancer rarer still!

The last point I'd like to make about Pap smears is that they are a screening test and not a definitive diagnosis. Pap smears help the health care provider determine which women need specific diagnostic tests such as colposcopy and cervical biopsies. If a pap smear indicates need to that a woman needs further diagnostic tests the actual diagnosis will require a biopsy.

So, exactly what is the cervix? What does it do? What is it made of?


The cervix is the lowest portion of the uterus. It can be seen through the vagina with the use of a vaginal speculum. During pregnancy the cervix acts as a valve and keeps the uterus from opening until a child is mature enough to be born. During labor the cervix opens to about 10 cms (4 inches) and allows the baby to enter the birth canal.

The cervix is covered with a thin skin called "epithelium". It is a smooth surface very similar to the type of tissue that covers the inside of your lip.

The cervix represents an area where two types of epithelium (think of this as similar to skin cells) join. The "skin" of the cervix is covered with cells called squamous cells. 


                                                         
Squamous cells (stacked like omelets)       Columnar cells (bunch of beer cans)

Squamous cells look like "omelets" stacked up 6 or 8 deep. The "skin" of the inside of the uterus is made up of columnar cells (think of these as being arranged like a column of beer cans). The cervix contains a vulnerable area where these two cells types join. This area is called the squamo-columnar junction or transition zone (T-Zone) and represents the changeover from one cell type to another. THE IMPORTANT PART to know is that it is specifically in the squamo-columnar junction or transition zone that cancer occurs.                               



When should I get my first pap smear and how often should I get one?

The American Cancer Society recommends that you get your first pap smear at age 21 or within 3 years of becoming sexually active---whichever comes first.

Since the Pap smear has been adopted over 50 years ago, this country has seen a sharp decline in the number of women suffering from invasive cancer of the cervix. Pap smears are performed annually. Women over the age of 50 may not need pap smears annually but they be seen annually by their health care provider as other cancers become more prevalent in post-menopausal women.

Modern pap smears are both painless and accurate. The cells that are obtained can be tested to see if they are abnormal in appearance and even for the presence of cancer-causing viruses.

How common are Pap smear abnormalities?

About 55 Million Pap smears are performed in the United States each year. 3.5 Million of these Pap smears or 6% are abnormal and will require medical follow up. So just to put things in perspective remember that there are approximately 3700 cervical cancer deaths in this country each year. So, for every death attributed to cervix cancer there are 1000 abnormal pap smears! Calm down….you're not alone if you have an abnormal pap smear.

What are the risk factors for Pap smear abnormalities and specifically for pre-cancerous changes?

The major risk factors for Pap smear abnormalities are:

  • Having sex at an early age (before 18)
  • Having sex with multiple sexual partners
  • Having sex with someone who has had multiple partners
  • Having sex with uncircumcised men
  • A history of Chlamydia infection
  • Obese women
  • Multiple pregnancies
  • Smoking
  • The HPV Virus
  • A family history of cervical cancer

What are the types of abnormalities that a pap smear can detect?

Pap smear abnormalities cover a range from the very mild to those that are of far greater concern. Before we can discuss pap smears, however, we need to discuss (a) the range of cervical cell abnormalities and (b) what these abnormalities look like on a tissue biopsy.

The Pap smear is NOT a biopsy, however. Instead, it takes a sample of cells that are normally shed by the cervix and let's the health care provider know when a biopsy might be necessary. The definitive diagnosis of an abnormality is made with a biopsy. Now here's a photomicrograph of what a cytologist might see when looking at an abnormal cell.

                                                  
                                                Pap smear showing large abnormal cells

Based on these Pap smear readings the cytologist will sometimes recommend further studies, including colposcopy and biopsy.

I. ASCUS (Atypical Squamous Cells of Undetermined Significance)

The very mildest abnormalities detected on Pap smear are referred to as ASCUS (atypical typical squamous cells of undetermined significance). This term is used for reporting Pap smear findings and indicates that some flat (squamous) cells look unusual and may or may not be pre-malignant. Of all Pap tests that reveal ASCUS reading, 80-95% are caused by benign conditions, chiefly infections. The remaining 20% prove to be precancerous when further testing, such as a colposcopy is performed.

In general, women and their gynecologists find this category the most annoying. The vast majority of these are "it's probably normal but I want to keep an eye on things". Women become concerned that they're harboring invasive cancer---which is virtually never the case. Gynecologists would rather tell a woman "it's completely normal and you can return next year". Most women whose Pap smear reveals ASCUS are best managed by repeating the smear in 3-6 months or performing an additional test called a colposcopy (See below). In general, the best treatment for ASCUS is observation combined with colposcopy, since most of these lesions will spontaneously disappear without treatment. Some cases that co-exist with a vaginal or cervical infection will require antibiotic treatment.

As I've already stated, a pap smear that reveals ASCUS should not be ignored as some of them, on closer examination will reveal a more significant lesion. However, once that additional test has been performed, and dysplasia has been ruled out, this abnormality can be safely watched with repeat pap smears and occasional colposcopies—they do clear up given a little time and patience.

One of the "dangers" of ASCUS is that it tends to make women anxious and they often lose sleep—especially after talking to a friend whose well-intended advice often amplifies her anxiety. Unfortunately, many women hear the words "you have an abnormal pap smear" and insist on aggressive surgery. This is generally not recommended and often produces more problems that it solves.

II. The Dysplasias (Cervical Intraepithelial Neoplasia)

"Plasia" means growth. Dysplasia refers to the disorganized growth of cervical epithelial cells. But before we discuss disorganized growth we should look at what "organized" or "normal" growth looks like. If we look at the left hand portion of the picture just below,       


Graphics provided by Dr. Paul D. Indman you may visit his site WWW.gynalternatives.com

we can see that the bottom layers of cells are plump and contain nuclei. The top layer of cells is flat (like an omelet) and contains either small or no nuclei. Additionally, the cells are small and do not take up much stain.

The middle portion of the drawing reveals the appearance of dysplastic cells.                    


Notice that the cells at the bottom are darker (they take up more stain) and the nuclei are very large compared to the cytoplasm of the cell. This is disordered (or dysplastic) growth and can be categorized as "mild" "moderate" or "severe". When the disordered growth occupies the lower third of cervical "skin" or epithelium we consider it "mild". It is considered moderate when dysplasia occupies the lower half of the epithelium and when dysplasia occurs in the full thickness of the cervical epithelium we call it carcinoma in situ (CIS).

Many women in the U.S. have carcinoma in situ (or severe dysplasia). However this is almost 100% curable and is not the same as invasive cervical cancer, which is very dangerous and fortunately very rare. In carcinoma in situ (CIS) the full thickness of the epithelium has abnormal cells but they do not invade into the underlying tissue.                       


Invasion into the surrounding tissue is what defines a true cervical cancer.
             


To try and get an understanding of this try rubbing the skin on the back of your hand and notice that it is free of the underlying muscle and tendons---it moves freely with only gentle rubbing. If the entire thickness of that skin were affected with abnormal cells it would be called CIS. If the entire thickness of that skin were rubbed and found to be attached to underlying muscle and tendons that would be an example of invasive cervix cancer.

III. The Bethesda Classification System

The current method of classification of Pap smear abnormalities is known as the Bethesda System. Under this classification, moderate and severe dysplasias are combined into a single classification known as high grade squamous intraepithelial lesions (HSIL). What used to called "carcinoma in situ" is now considered part of the HSIL classification.

Mild dysplasia is also referred to as LSIL (low grade squamous intraepithelial lesion). Researchers believe that most of these lesions are caused by a less aggressive HPV type. The majority of these lesions spontaneously regress.

What is the relationship between Human papillomavirus (HPV) and cervical dysplasia and cancer?

HPV is a very common virus that causes papillomas or warts. There are over100 different types of HPV that affect the skin surface as well as various mucous membranes. Certain types can cause warts on the hands and feet (plantar warts). Additionally, there are about 30 types of HPV strains that cause venereal warts--also known as condylomata accuminata—as well as pre-cancerous and cancerous lesions of the cervix, vagina and vulva. In addition, other papillomas viruses cause warts in the throat and around the anus.

This is an electron photomicrograph of a type of human papillomavirus (HPV). You should visit www.hpvfaq.com and www.cancer.gov/cancertopics/factsheet/Risk/HPV for additional and helpful information regarding HPV.
 
                                                       
                                                             Electromicrography of HPV

HPV is very common. An estimated 5.5 Million cases are diagnosed each year making it responsible for about 1/3 of all STD infections in the US. Several quick facts about HPV

  • It is acquired through skin to skin contact—not through fluids
  • It can remain dormant for a very long time (years) making it possible for the virus to spread from one partner to the next without any warning such as visible lesion.
  • Most people with HPV don't know they have the virus—it is asymptomatic.
  • At any given time about 20 Million men and women in the US have an active HPV infection.
  • Nearly ¾ of Americans ages 15-49 have been infection with HPV in their lifetimes
  • Some types of HPV (6, 11, 42, 43, 44) cause genital warts
  • Some types of HPV (16, 18 and less commonly 31, 33, 35, 39, 45, 51, 52, ,56, 58, 59, 68 and 69) cause cervical dysplasia.

We know that the majority of cervical cancer and genital warts is caused by certain strains (6, 11, 16 and 18) of the human papillomavirus (HPV). These viruses are responsible for about 70% of all HPV infections in women.

As of 2006 the FDA has even approved the use of Gardasil, a vaccine to prevent some of the more harmful HPV infections. We are happy to discuss this vaccine to determine if it is right for you. Gardasil may prevent infection from HPV types 6, 11, 16 and 18. While it is helpful it is certainly not a guarantee that you will never develop an HPV infection.

What is colposcopy?

A colposcopy is nothing more than a procedure where the cervix is viewed through a magnifying lens after being stained with a dilute vinegar (acetic acid) solution. It is a painless procedure.
                                 

The photograph below reveals the cervical "os" or opening of the cervical canal. There are several areas of the SCJ or squamo-columnar junction that are visible. This is precisely where one type of epithelium, squamous (think omelets), transitions to another type of epithelium—columnar (think beer cans). Occasionally an abnormal area shows up as unusually "white". These areas are called "aceto-white" epithelium or AW. These AW areas are often where dysplasia can be found.

                             

      Example of mild dysplasia                    Example of severe dysplasia

What is a LEEP or a LLETZ Procedure?

LEEP stands for Loop Electosurgical Excision Procedure. Some doctors use the term LLETZ (Large Loops Excision of the Transformation Zone) which is an identical procedure.

This procedure is done, following a colposcopy which tells the physician exactly how large and where the lesion is located. The tissue is then submitted to a pathologist who examines the entire lesion looking for the presence of dysplasia and cancer. Additionally, the pathologist can tell if the entire lesion has been removed.

Although the LEEP procedure is a surgical procedure it is safely performed in our office. Many patients are given a combination of medications that result in conscious sedation—a type of "twilight sleep".


During this procedure an electrical energy generator is attached to a fine wire loop that when energized, functions as a precise and rapid surgical tool. This instrument is then directed toward an abnormal area on the cervix and may be used quickly, effectively and painlessly to remove the abnormal tissue. The procedure takes about 15 minutes to perform and you may expect to spend another 40 minutes in the office as your medications wear off.



How long is the recovery?

Most women return to work in 1-3 days. You should avoid heavy lifting for 3-4 weeks afterwards. You should avoid intercourse for a full 6 weeks postoperatively.

How effective is it?

LEEP is extremely effective, with a 90% success rate; however, there are cases in which the procedure has to be repeated.

What are the risks and consequences?

The risks and consequences are rare, but an LEEP can cause damage to the other pelvic organs or the wall of the vagina. There can be excessive bleeding or pelvic infection (particularly if you have sex before the recommended 3-6 weeks for the cervix to heal.) There also can be a reaction to the local anesthesia. Another rare consequence is the risk of preterm birth in some pregnancies. However, the likelihood of these complications is quite small—especially in experienced hands.

If I have a LEEP Procedure how often will I need to be followed? Your doctor will request frequent check ups and pap tests following this procedure. This may be as often as every 3 months during the first postoperative year.


                          GARDASIL THE NEW HPV VACCINE
          ADVICE TO WOMEN, PARENTS AND THEIR CHILDREN*

Should I get the new Gardasil (Quadrivalent Human Papillomavirus Types 6, 11, 16 and 18) Recombinant Vaccine?




Merck's new HPV vaccine, Gardasil, protects against 4 types of the human papillomavirus. But before you receive this vaccine or advocate its use for your child it's worth your while to learn some cervical cancer and genital wart "basics" and put this disease in its proper perspective as a threat to you or your children's health.

Invasive cervix cancer is a terrible and fortunately rare disease. Genital warts, while unseemly and embarrassing are, in fact, among the more "benign" STDs—unfortunately, there are worse diseases out there! The vaccine protects against two of the more than dozen viruses that cause warts. This discussion, however, will focus on the vaccine and its protection against invasive cervical cancer.

Since the 1954 invention of the Pap smear by Dr. George Papanicolaou, invasive cervical cancer, once the leading cause of cancer deaths in women, is now a rare disease1 according to the National Cancer Institute. The NICI reported thirty-seven hundred deaths from cervical cancer in 2006. . That same year 79,560 women died of lung cancer, 56,660 of colon cancer, 40,410 of breast cancer and over 16,000 women died of each of the following 3 cancers—rectal, ovarian and pancreatic. Uterine cancer claimed 7,310 women while cervical cancer was 14th on the list

Unfortunately, the aggressive marketing of the new Gardasil vaccine would have you believe that many women are dying of this disease. Consider that during 2006 almost 600,000 women died of strokes and heart attacks. In other words for every woman that died of cervical cancer 160 died of heart disease and strokes. But because the only "cures" for heart attacks and strokes involve lifestyle changes, no one advertises very much about these very real threats to a woman's health. As a result of this unbalanced marketing of real health threats we have an enormously misguided perception that women everywhere are at risk of a cervical cancer fatality.

Invasive cervical cancer typically follows a succession of stages that starts with abnormalities detected on Pap smear. These pre-cancerous changes, called dysplasias, are caused by HPV types 16, 18 as well as over a dozen others. Gardasil protects against types 16 and 18—which are responsible for an estimated 70% of cervical dysplasias. The other protection provided by Gardasil is against genital warts (types 6 and 11) which is a self limiting and an easily treated infection. The cause for excitement among the medical and pharmaceutical industry is, however, that this vaccine may provide protection against invasive cervical cancer.

It takes about 10 years for a cervical dysplasia to progress to invasive cervical cancer. The average age of American women with invasive cervical cancer is 50-55 and the vast majority of them are poor and didn't get regular Pap smear screening. Additionally, most cases of cervical cancer are associated with lifestyle choices—early onset of sexual activity, multiple partners, partners with multiple partners, cigarette smoking and obesity. If you're really concerned about cervical cancer consider, what Gardasil doesn't protect against--HIV, hepatitis, syphilis, herpes, gonorrhea, Chlamydia, bacterial vaginosis, pelvic inflammatory disease, many other forms of venereal warts and a host of other viruses that also cause cervical cancer. And Gardasil doesn't protect against an unplanned pregnancy. Indeed what this vaccine may offer is possibly a very false sense of security.

If you're thinking about Gardasil for your self please understand that's effect on your overall health is probably minimal at best and unknown at worst.

If you're a mother or father wondering whether your pre-teen or adolescent daughter should get the vaccine I don't have any clear answers for you. I can tell you what I, as the father of 3 daughters, what I would have advised them if they were young adolescents. 

    First. I would strongly impress on my children the consequences of dangerous lifestyle choices-- sexual irresponsibility, multiple partners, early onset of sexual activity and cigarette smoking --not only a risk factor for cervical cancer but, worse, lung cancer, heart disease and strokes. According to a recently published Swedish study—one of the largest to date on the subject-- women who smoke cigarettes and who are infected with high levels of human papillomavirus type 16 (HPV-16) increase their risk of cervical cancer as much as 27-fold (2700%!). The researchers2 found that women who are positive for HPV-16 on their first smear and who smoke are "only" six times more likely to develop the disease than an HPV-16-positive nonsmoker. Not smoking makes a big difference! 

    Second. I would instill the habit of seeing a woman's health care provider at an appropriate time. For young women who are not sexually active and are not having any problems they should get their first internal exam and Pap smear at age 21. Young women who are sexually active should seek professional advice regarding sexually transmitted diseases and contraception. The US Preventive Services Task Force (USPSF) and the American Cancer Society (ACS) recommends that a first pap smear be performed within 3 years of the onset of sexual activity. 

    Third. I would remind myself and my children that sexual activity is far from the only hazard of being an adolescent. Adolescents are the only segment of the U.S. population with a rising mortality rate --11% in the last 20 years! Tragically, teen-agers today are as likely to die before reaching their 20th birthday as they were in the 1940s and 1950s. What are they dying of? The number one cause of death from the age of 1 through 21, by far, is accidents. Homicides are the next most common cause of death followed by suicides. Accidents, homicides and suicides are responsible for 77% of deaths in the age group between 15 and 24! Know your kids. Discuss motor vehicle safety, the hazards of driving with reckless friends, the risks of speeding, alcohol, cocaine, ecstasy, heroin, methamphetamine and other illicit drugs. Know who their friends are and whether or not your children are undergoing a significant personality change.

So if you're a concerned parent don't stop being concerned—be vigilant. But keep it in perspective. As responsible parents we want to be in control of our children's health. We want to protect them against all the tragedies of the real world. This vaccine gives us some sense of being in control. The problem is that if you put cervical cancer into perspective and begin to understand the real risks of adolescence and early adulthood you quickly realize that the vaccine is a very small corridor in a very large maze that our children must negotiate safely—a maze that we ultimately have very little control over once they leave our homes.

If you're considering Gardasil for yourself this is a good opportunity for you to ask yourself if your own lifestyle needs adjustment. If you have a responsible approach to sex and driving, avoid illegal drugs, alcohol and don't smoke or abuse alcohol and get regular annual exams by a woman's health care professional you have already done a great deal more for yourself than the HPV vaccine ever could—and then some.

Gardasil costs about five hundred dollars—the cost of the 3 vaccinations and the office visits for its administration. You should really ask yourself if you would spend that amount of money if the vaccine wasn't covered by your insurance carrier. That's a lot of money for an unproven vaccine against a cancer for which we already have an excellent screening tool. We do not yet know the risks of this vaccine in a large study population over a period of 20 years. Let me also emphasize that the long term efficacy in reducing invasive cervical cancer is yet unproven. All that Gardasil is known to prevent is "pre-cancerous" conditions such as dysplasia or carcinoma in situ (which is not invasive cervix cancer and is virtually 100% curable). We don't yet know whether a booster will be required much less how often.

In time we'll know the value of this vaccine. While we're waiting for answers there are things you, as a woman, can do for yourself and your children now. Be responsible about your sexual activity and teach the same behavior to your children. If you're a smoker quit! Children are much more likely to smoke if one of their parents is a smoker. Make regular visits to a women's health care provider or a family doctor who is comfortable with providing those services. Teach your daughters to do the same.

Many one-time "wonder drugs" produced unintended consequences or simply didn't live up to their marketing hype—hormone replacement therapy, Fen-phen, Celebrex and Vioxx are just a few examples.

Lastly, if you're going to take advice from someone (or a televised commercial) take it from a knowledgeable individual who doesn't stand to profit from that advice. 

  1. www.rarediseases.info.nih.gov/html/reports/fy1999/nci.html 
  2. Gunnell AS, Tran TN et al. Synergy between cigarette smoking and human papillomavirus type 16 in cervical cancer in situ development. Cancer Epidemiol Biomarker Prev. 2006;15:2141-2147

*This article expresses the sole opinion of Dr. Morris Wortman. Any individual who is considering the vaccine should make an informed decision with their health care provider.

Contraception


Obesity


Two–thirds of American adults are overweight with one out of three considered obese. We are now witnessing a health care epidemic. Between 1976–1980 and 2003–2004, the prevalence of obesity among adults aged 20–74 years increased from 15.0% to 32.9%. The problem cannot be overstated. In my opinion we will soon witness the first decrease in life expectancy in the United States since 1900. If current trends are not reversed we can expect to see an increase in early deaths due to diabetes, hypertension, heart disease and strokes. Presently 300,000 deaths per year are linked to obesity.

Obesity is generally defined as having a body mass index (HMI) of 30 or greater. One is considered overweight with a BMI or 25-30.

Weight is largely determined by the balance we strike between the calories we take in from food and the energy we expend during our daily activities. If we take in more calories than we use the unused calories get stored as fat.

What are the risk factors?

·Diet. The regular consumption of foods that are calorie-rich, frequently found in fast foods, fatty foods, soft drinks, candies, deserts are the general culprits. The average American skips breakfast and often eats the bulk of their calories late in the afternoon and evening. This provides a cycle of fasting and binging which is another problem with the average American's lifestyle.

·Inactivity and lack of exercise. Sedentary people are more likely to gain weight because they don't burn calories through physical activities.

·Psychological factors. A lot of women don't realize that they eat when they're not actually hungry. Many women overeat to cope with daily stresses or to deal with difficult emotions. Some women eat out of boredom.

·Genetics. If one or both of your parents are obese, your chance of being overweight is greater. Your genes may affect your chances of becoming obese and even where fat is distributed. But a family history of obesity does not mean that you have no ability to control your weight.

·Age. The older we get the less active we become. Muscle mass also declines with age (especially without exercise). Since muscle mass is related to calorie consumption, the loss of muscle mass also slows down our metabolism and increases our chances of gaining weight. Again, this doesn't mean that we're helpless. It does mean that in order to prevent weight gain we have to take a disciplined approach to exercise.

·Cigarette smoking. Many women smoke in order to control their food cravings and maintain their weight. When you quit smoking you're at greater risk for gain weight. Why? Nicotine, apart from suppressing your appetite, increases your metabolic rate. With smoking cessation (unfortunately) your appetite may increase along with your slowing metabolic rate. The net result is that when smokers stop, they burn fewer calories and often gain weight. However, cigarette smoking is still considered a greater threat to your health than the extra weight.

·Pregnancy. During pregnancy a woman's weight should and does increase. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.

·Medications. Corticosteroids and tricyclic antidepressants, in particular, can lead to weight gain. So can some high blood pressure and antipsychotic medications. Depo-Provera has been associated with some weight gain. Birth control pills, on the other hand, are not associated with significant weight gain. While this may have been true of oral contraceptives in the 1960s and 70s this argument doesn't pertain to today's very low dose pills, contraceptive patches and rings.

·Medical problems. Uncommonly, obesity can be traced to a medical cause, such as low thyroid function, excess production of hormones by the adrenal glands (Cushing's syndrome) or other hormonal imbalances, such as polycystic ovary syndrome. A low metabolic rate is rarely a cause of obesity. A medical problem, such as arthritis, can also lead to decreased activity, which can result in weight gain.

·Alcohol. Many women are surprised to learn that just one regular beer contains about 150 calories. Many people are unaware that the calories in 2 glasses of wine taken every day can add up to some serious weight gain over the course of time. Additionally, excessive drinking can stimulate your appetite and make you less likely to control portion sizes.

When should I seek medical advice?

·BMI (Body Mass Index)

Unfortunately, few women actually seek medical advice regarding their weight and most have no idea what their BMI is. If you wish to make a quick calculation visit this link:

http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm

The BMI is not a perfect tool. It doesn't make allowances for women with a high muscle mass—unfortunately unless you're a weight lifter this probably doesn't apply to you.

If you're BMI is between 19 and 24 you're considered in a healthy weight range for your height. At a BMI between 25 and 29 you're considered overweight and with a BMI of 30 or greater you're considered obese. If you're in the latter two categories it's a least worthwhile getting some advice.

·Waist Circumference

Weight distribution varies from one person to the next. Some women carry most of their weight around their hips, thighs and lower body and are "pear shaped". Others carry most of their weight in their upper body and waist and are "apple shaped". When it comes to your overall health it's better to be "pear shaped". Women with a waist over 35 inches have an increased incidence of various serious diseases including hypertension, diabetes, heart disease and the metabolic syndrome. So if you're apple shaped with a BMI over 25 you now

·Weight-related medical condition

A BMI over 25 increases your risk for hypertension, hypercholesterolemia, diabetes and arthritis. These conditions often improve (and even disappear) with weight loss.

·Life-style issues

If you smoke, drink excessively and have a sedentary lifestyle coupled with a great deal of personal stress take action sooner rather than later. This is not a problem that gets better by itself.

Think about this

There are no magic pills or quick fixes to accomplish weight loss. Obesity, whether mild, moderate or severe is a national epidemic. Changing your weight is one of the most challenging things you can do and requires a tremendous commitment to an ongoing lifestyle change. Your weight is an important factor that will affect your risk of heart disease, strokes, diabetes, arthritis, sleep apnea, gall bladder disease, "fatty liver", gout and even cancers (breast, colon and uterine).

The good news is that even modest weight loss can fix a world of ills—lower your blood pressure, lower your cholesterol, improve your diabetes, sleep apnea and arthritis. It can even lower your risk for developing some cancers. For many people the loss of 10 lbs is the difference between taking blood pressure medications or statins for their hypercholesterolemia. The best weight loss happens, not with crash diets that are not sustainable, but with slow and steady lifestyle and dietary changes. Exercising is an invaluable part of a weight loss regime. Don't even start by saying you don't have the time. Make an appointment with yourself at least 4 times a week for an hour and exercise.

Getting started on a weight loss program

There are many ways to successfully lose weight and there are many ways to fail. The best way to get started, in most cases, is to get some help. Start with your health care provider to put this issue in its proper perspective. Some women who think they have a weight problem don't. Still others are quite naïve about the degree of the problem they do have and how it's affecting their overall quality (and quantity) of life. If you've tried losing weight on your own and have not succeeded call and schedule an appointment. We can get you pointed in the right direction. You might be interested in some of these websites:

http://www.consumer.gov/weightloss/setgoals.htm
http://www.cnn.com/HEALTH/library/HQ/01625.html
http://exercise.about.com/cs/weightloss/a/weightsuccess.htm


 Smoking Cessation



Smoking increases your risk for heart disease, strokes, chronic obstructive pulmonary disease (emphysema or COPD), lung cancer, cataracts, macular degeneration (which causes blindness), Graves disease, thyroid cancer, cancers of the lips, mouth, throat and larynx (voice box). Smokers also have an increased risk of other cancers including esophageal, stomach, kidney, bladder, skin and pancreatic cancer. Apart from cancer smoking causes premature aging of the skin and increases your risk for peptic ulcer disease.

According to the CDC between the years 1997-2001 "The three leading specific causes of smoking-attributable death were lung cancer (123,836), chronic obstructive pulmonary disease (COPD) (90,582), and ischemic heart disease (86,801)."

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5425a1.htm

There are many, many other reasons to quit if you're a woman. Smoking has potentially devastating effects on fetal well-being for women who smoke during pregnancy. Smoking increases the likelihood of stillbirths, low birth weight infants, premature births and even sudden infant death syndrome (SIDS). Smoking is associated with an increased risk of cervical cancer, osteoporosis and urinary stress incontinence.

Smoking is deadly and is responsible for the deaths of nearly 430,000 people a year--more lethal than AIDS, automobile accidents, homicides, suicides, drug overdoses and fires combined!

Smoking diminishes the quantity and quality of life. On average, female smokers reduce their life from by 14.5 years! Apart from that, smoking also decreases the quality of life and is associated with many disabilities.

The smoke contained in cigarettes contains tar along with many other inhaled chemicals. Some of the chemicals are known carcinogens—cyanide, benzene, formaldehyde, methanol, ammonia and acetylene.

No wonder the U.S. Surgeon General has stated" Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives."

No matter how old you are right now you can improve your life expectancy by quitting. Quitting before the age of 50 reduces by half your risk of dying in the next 15 years. Former smokers also have a reduced rate of bronchitis and pneumonia.

Why is quitting so tough?

The answer is nicotine. Nicotine is a drug naturally found in tobacco. It is highly addictive. Arguably, nicotine is more addictive than heroin and cocaine. Nicotine causes a real psychological and physical dependence in exchange for a temporary pleasant and calming sensation for most smokers. As the nervous system adapts to nicotine, smokers tend to increase the number of cigarettes they smoke in order to overcome to the tolerance they develop.

When smokers try to cut back or quit, the absence of nicotine leads to withdrawal symptoms. These include dizziness, depression, frustration, anger, irritability, sleeplessness, headaches, restlessness, fatigue, an increased appetite. No wonder Mark Twain once said "quitting smoking is easy. I've done it a thousand times."

Why should I quit?

The simple answer is "your health". The Centers for Disease Control (CDC) estimated that the average female smoker loses 14.5 years of life!

Smoking is related to a long list of cancers (see above), progressive non-cancerous lung diseases (chronic obstructive pulmonary disease) and other diseases that dramatically shorten life expectancy. In all age groups smokers are twice as likely to die of a heart attack as non-smokers. Smoking also dramatically increases the risk of strokes and peripheral vascular disease. Just as smoking narrows medium and small blood vessels it also causes narrowing of the large blood vessels to the arms and legs.

There are plenty of other reasons to quit too. There many workplace restrictions today on smoking. Some employers may not hire you if you're a smoker. Public buildings, hospitals, concerts and sporting events all have restrictions on smoking. New York State doesn't allow smoking in restaurants and bars. In the last 10 years smoking has gone from being socially acceptable to unacceptable. With evidence mounting against second-hand smoke you also have the health of others to consider—especially if those "others" are your children or loved ones. If you have children you need to think about setting a good example for them too. And if that isn't enough consider this—you'll pay twice as much for life insurance if you're a smoker.

Lastly, many work places from large corporations to small businesses are beginning to require not only smoke free environments on the job but that you lead a healthy lifestyle. Some businesses go so far as "drug testing" to see if you are "smoke-free". This issue is still working its way through the court system to determine whether or not it's legal for businesses to do so. In the meantime, business have fired smokers and refused to hire them.

Common reasons for not quitting

· It's stressful—this may "lead the pack" in realistic reasons that women don't want to quit. Nicotine does cause psychological and physical dependence.

· I'll gain weight—no question this happens in most cases. In every case the cigarettes are worse for you health than the weight gain. Deal with one problem at a time. Expect to gain some weight and then make sure that your next lifestyle change you will address are the issues of diet and exercise.

· I worry about the side effects of medications—not all women who quit require medications. But even if you're taking medications remember that whatever side effects they may have (a) you're not going to taking them for the rest of your life and (b) they are far less risky to your health than cigarettes!

· I can't afford the medications—that's ridiculous! Consider that a pack of cigarettes are now costing 5-7 dollars a pack. If you're smoking a pack a day that's $1800 – 2500 dollars per year! You can pay for your medications and still have a lot of money left over. Landlords may not rent to you and friends may not allow you to smoke in their homes. Public buildings, hospitals,

· Now is not a good time—perhaps you're right about this one. If you're in the midst of a divorce, a legal action, mourning over the loss of a loved one or dealing with an acutely sick family member or job loss it might be best to put this decision off for a few weeks or even a few months. But don't use this as a chronic excuse. In most cases there's never a better time than right now.

How do I get started?

There is no one right way to quit. Success has come from "going cold turkey", acupuncture, hypnosis, nicotine replacement (lozenges, patches, gum), bupropion (Zyban or Wellbutrin) and verenicline (Chantix). And all of these methods have failed.

The key elements of successfully quitting involve four crucial steps:

  • Make a decision to quit
  • Set a quit date, and choose a quit plan
  • Manage withdrawal
  • Maintain success

Learn more about ways to quit by visiting the American Cancer Society's "Kick the Habit" web page:

http://www.cancer.org/docroot/PED/ped_10_3.asp

Generally speaking smoking cessation requires a combination of approaches—behavioral and often medical. There is no single and simple approach for most people.

The American Cancer Society web-link above is a great resource. Additionally,

New York State has a great many resources available to its residents through the following link:

http://www.nysmokefree.com/newweb/default.aspx

If you need help here are some resources available in Monroe County

American Lung Association                 1595 Elmwood Avenue                   585-442-4260
                                                                 Rochester NY 14620

Greater Rochester Area                       220 Alexander St. Suite 409            585-530-2050

Tobacco Treatment Center                      Rochester NY 14607

NYS Smokers' Quitline                               1-866-NY-QUITS                         1-866-697-8487

Medications you should be aware of

We are not advocating the use of medications as a "one size fits all approach". However, many women have found medications very helpful for them while others experience no relief from nicotine withdrawal whatsoever. As of this writing Chantix has recently been approved by the FDA and we are just now getting more experience with this particular medication.

Some commonly used medications are:

Nicotine replacement therapy (NRT)—The AHA (American Heart Association) believes that nicotine replacement in the form of patches, lozenges, spray, inhaler and gum can help smokers quit as part of a comprehensive approach to smoking cessation. NRT almost doubles the chances of someone being able to successfully quit smoking. As already noted nicotine is a very addictive substance whose withdrawal leads to irritability, depression, food cravings and headaches. Learning the skills to quit smoking while dealing with nicotine withdrawal just makes it harder to successfully quit.

If you're planning on using NRT it's best to select a "quit time" for smoking cessation and plan the use nicotine replacement immediately. Remember that symptoms of nicotine withdrawal start in hours after smoking cessation. If you are using NRT use it consistently in the beginning and not just "every now and then". Some experts even advocate a combination approach to NRT such as using a patch as a form of baseline suppression along with lozenges, gum or spray when cravings become more acute.

If you're pregnant or have heart disease you should have a thorough discussion with your health care provider before using NRT.

What about smoking while taking NRT? It's not unusual, in the early stages of cessation for someone to smoke a few cigarettes while using a nicotine patch or other forms of NRT. If you're smoking only 2-3 cigarettes per day it's okay to use the NRT with the understanding that your goal is stop smoking completely in a short period of time. However, if you find yourself smoking as much as you did before attempting to quit you should stop taking NRT and consult your health care provider.

Bupropion (Wellbutrin, Zyban)

Buproprion has a long history as a very useful adjuvant to smoking cessation. It can be used with nicotine replacement therapy and is generally very well tolerated provided that one starts it at a very small dose. Some women are very sensitive to this medication's temporary side effects which include rapid heart rate, jitteriness, anxiety, headache, insomnia, nausea and dizziness. If you find that you're experiencing severe side effects stop the medication but ask to be re-started at half the dose. These side effects may last 2-4 days but improve quickly thereafter. Generally, this medication is started at 150 mg and increased to 300 mg per day after a week. Some women require only a minimal dose to appreciate profound improvement in the withdrawal cravings. It is recommended that you avoid excess alcohol with this medication especially if you have alcoholism or severe depressed. Ask your health care provider, however, about alcohol use while taking Bupropion.

Bupropion is an anti-depressant in a category of medications known as dopamine-reuptake inhibitors. These medications are not sedating and do not have the sexual side effects in selective serotonin reuptake inhibitors (SSRIs). Some women are able to take bupropion for a few months and then taper themselves off the medication. Other women require bupropion for long periods of time in order to stay smoke free. Just remember that the long term use of bupropion is safe—that's not true of cigarettes.

If you are taking bupropion you can minimize any sleep disturbance by taking it first thing in the morning.

Varenicline (Chantix)

Chantix was introduced by Pfizer in May of 2006 and is currently a less well known drug. As with any new drug its true effectiveness over a long period of time has not been studied on large populations. It has two mechanisms of action. First it mimics the effects of nicotine on the brain and helps stave off nicotine cravings. When used with nicotine it blocks some of the pleasurable effects of smoking. In clinical trials the main side effect was nausea (40%). Other significant side effects are insomnia (18-19%), headaches (15-19%) and abnormal dreams (9-13%). Many of the side effects can be reduced by starting at a low dose and gradually increasing the medication to a maintenance dose.

For the first week Chantix is taken at the dose of 0.5 mg per day for 3 days, followed by 0.5 mg twice a day for the next 4 days. That completes the first week on Chantix. Thereafter Chantix is taken at the dose of 1.0 mg twice daily for another 11 weeks. The total treatment program is 12 weeks though it has been approved for longer use in patients who have successfully quit.



Sexually Transmitted Diseases (STDs)

Introduction

The Reality of Sexually Transmitted Diseases (STDs)

Viral infections
    Human Papillomavirus (HPV)
    Genital herpes virus (HSV)
    Hepatitis B Virus (HBV)
    HIV/AIDS

Bacterial infection
    Pelvic inflammatory disease
    Chlamydia
    Gonorrhea
    Syphilis
    Bacterial Vaginosis

Parasites
    Trichomonas vaginitis

Rare infections
    LGV (lymphogranuloma venereum)
    Chancroid


 

Introduction

There are many reliable websites available to obtain information about sexually transmitted diseases. My hope is not to replicate them but to distill them, to provide you with some valuable information and to address some issues that you may not find in your internet or library searches.

It is rare to find a sexually active individual who has not had an STD. What? How can that be? STDs are common, most existing in an asymptomatic form. Most of the STDs I'm referring to have never been a problem and never will be a problem for those that have them. Other sexually transmitted diseases, however, can have devastating consequences to one's health. In addition to the threat to a woman's health, an STD may have enormous consequences to her emotional well-being and self-esteem. A woman's initial reaction to the news that she has a sexually transmitted disease includes:

  • Depression
  • Despair
  • Betrayal
  • Loss of self-esteem
  • Anger

This is quickly followed by numerous questions that include:

  • How did I get this?
  • Can I give it to someone else?
  • How long have I had it?
  • Did he cheat on me?
  • Who did I get this from?
  • Can I pass it on to someone else?
  • Will I be able to have children?
  • Do I have to let my partner know?
  • Will I always have this problem?
  • Does this make me "dirty"?
  • How can I live with myself?

The Reality of Sexual Transmitted Diseases(STDs) is the Following:

Reality # 1: They are common!

STDs are common--especially among young people. The Alan Guttmacher Institute (AGI) analyzed and published an important survey in January of 2004 [Perspectives on Sexual and Reproductive Health, 2004, 36(1):6-10]. In their study they note the following:

  • 18.9 Million new cases of STDs were reported in the year 2000
  • 15-24 year-olds represent 25% of the sexually experienced population
  • 9.1 Million of the newly diagnosed STDs reported in 2000 were among 15-24 year-olds
  • 3 STDs (human papillomavirus, trichomoniasis and chlamydia) accounted for 88% of all new cases of STD among 15-24-year-olds.

Additionally, consider some additional information:

  • In March 2007 the National Cancer Institute reported that the overall prevalence of HPV in the U.S. in women ages 14-59 was 26.8%
  • At any one time there are 20-40 million Americans with HPV
  • About 60 million Americans have had the virus that causes genital herpes
  • As estimated 3 million Americans are infected with chlamydia each year
  • In 2005 there were 339,593 cases of gonorrhea reported in the United States.
  • About 10,000 women are diagnosed with HIV each year in this country—80% of these cases arise from heterosexual contact.
  • Each year in the U.S. more than 1 million women experience an episode of acute pelvic inflammatory disease (PID)--more than 100,000 women become infertile as a result.

Reality #2: Not all STDs cause symptoms

Many STDs cause symptoms such as foul odor, vaginal discharge, redness, soreness, warts and other visible lesions. The majority of STDs, however, cause no symptoms at all but exist in an asymptomatic or dormant state—at least for a while. It is this asymptomatic state that allows an individual to unknowingly pass it on and cause a serious infection to his or her partner. Examples include HPV, genital herpes, hepatitis B, chlamydia, gonorrhea and HIV.

Reality #3: STDs cover a broad spectrum of diseases.

Some of these diseases are not serious and do not generally have a large emotional component for most women (examples include bacterial vaginosis and trichomoniasis).

At the other end of the spectrum are diseases that can be life-threatening such as HIV/AIDs and viral hepatitis.

There are diseases which are not life threatening but can pose a significant threat to one's future fertility—gonorrhea, chlamydia, and pelvic inflammatory disease (PID).

There are diseases which are not life threatening and generally do not pose a significant threat to future health but are not completely curable either. Examples of such STDs are human papillomavirus (HPV) and genital herpes. The emotional reaction most women have to HPV is quite variable and to some extent depends on how the disease manifests itself—warts or abnormal pap smears.

Still there are other diseases that are serious but easily eradicated such as syphilis.

There are sexually transmitted diseases that carry a tremendous emotional stigma well out of proportion to the actual damage caused by the disease—genital herpes is perhaps the perfect example of an STD that often causes an emotional breakdown well beyond what can be justified by its implications for potential harm.

Finally, there are rare diseases that you've never even heard of but should be aware of such as lymphogranuloma venereum (LGV) and chancroid.

Reality #4: The risk factors of STDs are well known. They include:

  • Young age (15 to 24 years old)
  • African-American race
  • Unmarried status
  • Geographical residence
  • New sex partner in past 60 days
  • Multiple sexual partners
  • History of a prior STD
  • Illicit drug use
  • Admission to correctional facility or juvenile detention center
  • Meeting partners on the internet

Reality # 5: There's lots of misinformation out there!

For over 30 years I've talked to professional women who believed that herpes increased their cancer risk, that HPV would make them sterile and that HIV wasn't as serious a problem as it "used to be". Many of these women claimed to get their information from the internet, their friends, television commercials, their parents, magazines and even another health care provider. Some women admit that their beliefs aren't based on any known facts, but instead harbor beliefs based largely on their own fears. I'm constantly amazed by the apparent willingness of ignorant, unqualified and "well meaning" individuals to offer their "help". Still more surprising is that many women accept the information they get from unqualified individuals or from dubious sources (women's magazines, paid advertising by pharmaceutical companies). Few things are as dangerous in the medical world as the intersection of good intentions, ignorance and panic.

Perhaps the only thing worse than no information is too much information! In order to obtain sound advice be certain of two things—that your information source is qualified and that they have no financial interest in the information they dispense.

So be careful of your information source! This includes your best friend, a neighbor who happens to be a nurse, your mother, boyfriend, most newspaper and magazine articles and many websites.

Also be skeptical of individuals and corporations that stand to profit from the information they dispense—various websites and pharmaceutical companies that advertise heavily on TV and in magazines.

Oftentimes, government websites are some of the best sources of information available. Consider some of these.

Reality #6: In many cases, even knowledgeable health professionals don't have all the answers to your questions

In some instances it isn't possible to know the medical answer with certainty. For example, if you've had a positive chlamydia culture but not had symptoms it's unlikely that it will impact your future fertility but there is virtually no way to be certain about your ability to conceive in the future—at least not until you try. If you've been diagnosed with genital herpes should you take medication to prevent possible recurrence or to decrease the likelihood of infecting your partner? The answer will depend on many factors, but ultimately involves some "guesswork" on the part of your health care provider as well as your own comfort level. Your health care provider will not be able to provide you with exact statistics on the likelihood that you'll suffer a recurrent infection or the likelihood of infecting your partner.

Reality #7: Even when medical information is available the decisions you make may depend on personal psychological factors.

For instance, it may not make much "medical sense" for someone who had a mild case of genital herpes to take prophylactic anti-viral medication for the rest of their life. Yet, rarely, some women insist on doing so. For them, the psychological benefit of feeling that they are actively preventing even a small risk of recurrence or transmission is worth the cost and burden of taking daily medications for extended periods of time.

Reality #8: In many cases there is no "one size fits all" answer.

If you had venereal warts 10 years ago and have not had a recurrence since, is it necessary to tell your partner? The answer to this question will depend on many circumstances and there is no "one size fits all" answer.

Reality #9: Asking your health care provider to "test me for all STDs" is often not realistic—worry about the ones that are important to you.

Health care providers generally test for serious STDs that can affect your health. For instance we encourage testing for HIV, hepatitis, gonorrhea and chlamydia. Whether or not routinely screen for syphilis, herpes and HPV is a more complex issue and depends somewhat on your medical history, your symptoms and lifestyle. Routine testing to determine if you've even been exposed to oral or genital herpes may or may not provide helpful information to you. The same may be true of routine HPV screening for women with negative pap smears and no physical findings. The extent to which you require testing will depend on your risk factors (see above), your understanding of these diseases and your need for reassurance. Ironically, women who seem most concerned about STDs are often at lowest risk while woman at very high risk for STDs frequently avoid testing altogether. Another irony is that women often wish to be tested for comparatively benign diseases such as bacterial vaginosis or herpes while refusing HIV or hepatitis screening.

Reality #10: Medications alone cannot heal the psychological trauma

I'm often stunned to hear the following from women: "I'd rather have cancer than herpes". What an incredible statement! Genital herpes is an STD that in the vast majority of cases causes little pain, few recurrences, does not affect future fertility and does not cause cancer. The real implication of herpes is its "stigma". So powerful is that six-letter word that it has driven some women to thoughts of suicide and even homicide--the assumption being that their husband or boyfriend "gave" it to them. But the fear and stigma associated with the word "herpes" often blocks out rational thought to such an extent that conversation isn't even possible until the crying, the anxiety and the hurt begin to subside.

Reality #11: STDs are the result of lifestyle choices

It comes as no surprise that STDs are more prevalent in younger age groups (15-24). Youth is a time of growth, experimentation and often poor choices. Many errors—some serious—result from testing the limits of vehicular speed, alcohol, drugs, sex and emotional fulfillment. No one passes through life without making some bad judgments, but a wise person learns to minimize risks, learn from mistakes and commit to self improvement. Making mistakes is human foible— to not learn from them is a human tragedy. Multiple partners multiply your risk. Condoms offer some, but only limited protection. The best protection against STDs is a mutually monogamous long term sexual relationship with a trustworthy partner.

Putting STDs in perspective

Once a woman has entered the arena of sexual expression the risks of sexually transmitted infections become real. Those who are too frightened to assume even the slightest risk of a sexually acquired infection may avoid contact altogether. Those who are careless, reckless and thoughtless expose them selves and their partners to emotional and physical pain. Most men and women live in the midst of this spectrum—desirous of an intimate relationship and intelligent enough to avoid needless risk. Arm yourself with as much knowledge as possible, practice a disciplined approach to sexuality and be thoughtful to your partner. Life is fraught with risks but a wise person learns to manage them.


Human Papillomavirus(HPV)



Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States. With more than 6 million new cases reported each year it occurs more frequently than trichomoniasis, chlamydia, gonorrhea, syphilis, genital herpes, HIV and hepatitis B combined!



The major implications of this virus for women are two-fold: first, it can cause venereal warts and second it has the capacity to cause cellular changes of the cervix that can lead to Pap smear abnormalities (usually transient and reversible) and, in rare instances, this virus can cause cervical cancer. Despite well-funded advertising campaigns that would have you believe otherwise, HPV is common while invasive cervical cancer is classified by the National Cancer Institute (NCI) as a rare disease.

It is estimated that at any one time there are 20-40 million cases of HPV infections in the U.S. (prevalence) and that over 6 million new cases occur annually (incidence). It is estimated that 75-80% of sexually active adults will acquire a genital tract HPV infection before the age of 50. The prevalence of cervical HPV infection decreases sharply in women after the age of 30. Those with persistent infection are at the highest risk for the development of high-grade precancerous lesions or invasive cervical cancer.

Human papillomaviruses are a group of viruses called "double-stranded DNA viruses". There are over 100 types of human papillomaviruses (HPV) that can divided into two groups—those that infect the skin (such as plantar warts) and those that infect mucous membranes (such as the tissues in the vagina, vulva, the cervix and the tissue around the anus. Flat warts of the skin are most often caused by HPV types 3 and 10. Plantar warts, very common in children and adults, are most often associated with HPV types 1, 2 and 4. HPV types 16 and 18 are most commonly associated with pre-cancerous changes of the cervix. However, HPV types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 and 69 are also associated with these pre-malignant changes. Genital warts, also called, condylomata accuminata, are frequently caused by HPV types 6, 11, 42, 43 and 44.

How do women get genital HPV infections?

Genital HPV is passed by skin-to-skin and genital contact, primarily during vaginal and anal intercourse. However, actual vaginal or anal penetration isn't necessary to acquire this virus. Skin to skin contact with genital contact or "outercourse" can also transmit this disease. It might also be possible to pass it during oral sex—though this is probably rare in the absence of visible lesions.

How do I know if I have an HPV infection?

Most women who have HPV infections never know it! Pap tests are excellent tools for detecting HPV-related abnormalities (click here). Your health care provider may also send an HPV test along with your pap smear to see if you are carrying a high-risk viral type. Another way you might know if you have an HPV infection is the presence of genital warts. These warts can grow inside the vagina, on the vulva or around the anus.

Who gave me HPV?

It isn't always possible to answer this question. You may have acquired it from your current partner or from one of your past sexual partners.

Is my partner unfaithful?

Not necessarily! Your partner may have acquired HPV from a previous partner and unknowingly became an asymptomatic carrier (a carrier with lesions so small that he never noticed). In fact, you may have harbored the virus in an asymptomatic form and then developed an infection.

Is HPV forever?

About 90% of HPV infections are transient and clear within 3 years without a woman ever realizing that she had the virus. The younger the person is when she gets infected the more quickly it clears. Sixty to eighty percent of new HPV infections clear within 1 year. This is true of women who have skin or mucous membrane lesions as well as women with mild Pap smear abnormalities, such as mild dysplasia (click here). Approximately 90% of young women with mild dysplasia will spontaneously revert to normal within 1 year.

Do condoms protect against HPV?

The answer is "not completely" and perhaps not at all. Condoms do not cover the base of the penis, the scrotum, anus etc. The HPV virus is easily spread during foreplay without penile penetration. Condom use is only one "piece of the puzzle" in reducing the risk of STDs and not as important as lifestyle choices. Simply put, the greater your exposure to different sexual partners the greater your risk.

Should my partner use condoms?

Given the fact that HPV is very easily transmitted from one partner to the next it's important to understand that condoms are of limited usefulness and then only partially helpful, even if used consistently.

What about the new HPV vaccine?

In 2006 Merck released its new HPV vaccine. This is a "quadrivalent" vaccine, meaning that it offers protection against 4 different HPV types (6, 11, 16 and 18). Remember that there over 100 various types of HPV and, therefore, receiving this vaccine provides only partial protection against genital warts and pre-cancerous changes of the cervix. The vaccine is best administered in children before they become sexually active. Since the vaccine has only been available in the U.S. for a relatively short period of time it has yet to be determined what its long term effect will be on reducing pre-cancerous changes of the cervix, cervical cancer and genital warts. It's also unknown if the vaccine will require a "booster" 5 or more years later. And like any new drug that is released by the FDA it will take many years before it's long term effects can be determined. For additional information on the new quadrivalent HPV vaccine click here.

Is HPV related to promiscuity?

Not necessarily. HPV has a very high prevalence rate in the population. Simply stated—it's out there! HPV is the most common of all sexually-transmissible agents. Additionally, HPV has a much higher risk of transmission than herpes or HIV during a single sexual act.

When should I get my first Pap smear and how often should I get one?

The American Cancer Society recommends that you get your first pap smear at age 21 or within 3 years of becoming sexually active---whichever comes first. Since the Pap smear has been adopted over 50 years ago, this country has seen a sharp decline in the number of women suffering from invasive cancer of the cervix. Pap smears should be performed annually. Modern pap smears are both painless and accurate. The cells that are obtained can be tested to see if they are abnormal in appearance and even for the presence of cancer-causing viruses.

If my Pap smear is negative can I be assured that I don't have HPV?

No. You can have HPV and still have a negative Pap test. And remember than most HPV typ