Cervical cancer screening

One topic that I discuss on a daily basis is cervical cancer screening.  After all, this is the reason that most of us go to the gynecologist.

For years, women have been told that they needed annual Pap smears.  This was an arbitrary recommendation, not based on scientific evidence, when Pap smears were initially done in the 1940s.  Since scientists and doctors did not understand at the time what caused cervical cancer, and what the risk factors were, it was thought that once a year should be adequate to pick up precancerous changes on the cervix before they turned into cancer.  For an interesting read on the development of the Pap test, click here:

Dr. George Papanicolaou's discovery

Fast forward about 70 years...so much more is known now about cancer in general, and specifically cervical cancer.  With the knowledge we now have, it is possible to prevent cervical cancer, and even minimize risk factors for its development.   Unfortunately, cervical cancer still exists, mostly for women who have not been adequately screened, or have not been appropriately treated.  In 2011, over 12,000 women were diagnosed with cervical cancer in the United States, and about 1/3 of them died from it. 

It has been known for many years now that cervical cancer almost always arises from infection with the human papilloma virus (HPV).  There are nearly 100 strains of HPV.  Some can cause annoying warts on the hands, feet, or genitalia.  Some "high-risk" strains can cause cancer of the cervix, vagina, vulva, throat, penis, and anus.  These high-risk strains are sexually transmitted, and it's been stated that 80% of sexually active people become infected with some strain of HPV.

The good news is that our immune systems frequently clear this virus.  Most of the time, people do not get cancer from HPV.  People can get cancer from HPV if their immune systems do not clear the virus. Any coexisting condition which causes the immune system not to work well (such as smoking, HIV infection, some immunosuppressive medications) also increase the risk of HPV not being cleared.

This rationale is the basis for the development of the vaccine for HPV (Gardasil or Cervarix).

We offer Gardasil in our office, which is a quadrivalent vaccine, meaning that it vaccinates against 4 strains of HPV.  Types 16 and 18 cause about 70% of cervical cancer, and cause the most rapid changes to cervical cells after infection.  Types 6 and 11 are responsible for the development of external genital warts.  This is the first cancer that can be prevented by vaccination!  Gardasil is now recommended for boys and girls ages 9-26, and is best given before the onset of sexual activity.  See my HPV vaccine blog for more info...

This HPV vaccine podcast details a personal story of why HPV vaccination is important.

So...back to screening.  Of course I recommend the HPV vaccine, but that's only only one piece of the puzzle.

Because it takes many years (5-10) after HPV infection to cause cervical cancer, it is not recommended to screen women until 21 years of age.  Often there are other reasons to see a gynecologist before that age, but not for routine Pap tests.

If a woman's Pap is negative at age 21, screening is repeated every 3 years.  Why not every year?

This goes back to the fact that most often, our immune systems clear HPV.  If someone has been infected with HPV, sometimes it can cause transient mild changes to the Pap that eventually resolve.  If we screen annually, we are more apt to pick up those small changes. We then feel compelled to act on it, requiring biopsies, and potentially freezing or excising part of the cervix.  These treatments are likely unnecessary, as mild abnormalities usually resolve on their own.  If we screen every 3 years, we are less likely to find these inconsequential changes, and more likely to pick up PERSISTENT changes.  These are the abnormalities we need to act on.

However, if the Pap is not normal at age 21, we do follow more closely, with more frequent Pap tests, occasional biopsies and treatments.  We are not ignoring changes, just acting on those more likely to be harmful.

At age 30, the recommended approach is to add testing for high-risk HPV to routine Pap screening.  Why don't we do it earlier?

Because most sexually-active women become infected with HPV, and the infection is frequently cleared, we would find a lot of high-risk HPV in the younger population that will be eventually cleared.  However, if it is still present by age 30, that signifies a more likely persistent infection, which is more likely to cause pre-cancerous changes.

If the Pap and high-risk HPV test are both negative after age 30, women can safely go 5 years until their next screen.  The risk of high-grade precancerous changes or cervical cancer in 5 years in this population is roughly 0.1%.

If women have had consecutive negative screens, Pap tests can be safely discontinued at age 65.  Cervical cancer is different than other cancers.  Because it's sexually transmitted, and takes at least 5-10 years from infection to severe changes or cancer, its peak incidence is in a woman's 30s and 40s.  It is rare to diagnose cervical cancer in women over age 50 who have had adequate prior screening.

Remember that these guidelines apply to women who have had negative screening.  If any abnormal result is found, we follow more closely, either with repeat Pap tests or biopsies.

Even though the Pap does not generally need to be done every year, it is still important to see your doctor annually.  Much more is done at the annual well-woman exam, including breast exam, pelvic exam, check of blood pressure, height and weight, and preventive health counseling.

Much more information can be found by clicking these links:

American College of Obstetricians and Gynecologists

American Cancer Society

Centers for Disease Control

Nutrition during pregnancy

I've been into learning about nutrition lately.  It's something we learn very little about during medical school, only skimming the surface.  We all know "healthy foods" vs. "junk foods" but how do we optimize our health with diet?  If you think about it, food is a type of medicine, and very definitely affects how our bodies function.  I plan to write a series about nutrition, and thought it best to start with nutrition during pregnancy.  I get asked on at least a weekly basis "Can I eat _______?" 

To start off, it's important to talk about weight gain during pregnancy.  It's good to know whether you're at a healthy weight at the beginning of your pregnancy, and your doctor/provider can then advise on a recommended amount to gain.  For women of normal weight (i.e. body mass index (BMI) 18.5-24.9), a 25-35 pound total weight gain is recommended.    If you're underweight (BMI less than 18.5), plan on 28-40 pounds.  If you are overweight (BMI 25-29.9), shoot for 15-25 pounds, and if you're obese (BMI greater than 30), minimal weight gain to a maximum of 20 pounds.   Most of your weight gain should come in the second half of pregnancy.

If you're pregnant with twins and are of normal weight, 37-54 pounds of weight gain is recommended.  This decreases to 31-50 pounds for overweight women, and 25-42 pounds for obese women.

Of course, it is impossible to control exactly how much weight you gain during pregnancy, but being aware of these guidelines and paying attention to how much weight you've gained to try to stay within these ranges can decrease your risk of complications such as gestational diabetes, preeclampsia, and gestational hypertension.  Gaining too much weight also increases your risk for c-section, and having a large infant.

 

In general, pregnant women should follow the same food guidelines as before pregnancy.  You should take in more calories, but only about 300 more than usual. 
Click the link to learn more about Healthy Food Choices During Pregnancy and calculate your BMI.

The most important nutrients you need to pay attention to during pregnancy are:

Folic acid - helps to prevent neural tube defects (problems with development of the baby's brain and spine), and ideally should be supplemented before pregnancy
Iron - protects against anemia as your blood volume increases during pregnancy
Calcium - helps to protect your bone health

When it comes to specific foods, there are certain food-borne illnesses that can cause birth defects or other problems during pregnancy.  One specific issue that I get asked about frequently is listeriosis.  Listeria is a type of bacteria that can be present in unpasteurized dairy products and undercooked meat, however there was a listeria outbreak in 2011 as a result of unwashed cantaloupe.  Listeria usually causes flu-like symptoms such as fever, abdominal pain, and diarrhea, but can be passed to the fetus through the placenta and has been linked to miscarriage, stillbirth, and preterm delivery.  This is a very rare infection (about 0.3 cases per 100,000 people per year), but in order to avoid these issues, make sure you only drink milk and eat cheese that has been pasteurized.  You don't need to avoid deli meats and hot dogs, but make sure they are heated until steaming hot.  Make sure you wash all produce before you cut it or eat it. 

Another concern is mercury exposure.  Mercury can be present in high levels in certain types of fish.  High levels of methylmercury in a pregnant woman can cause problems with development of a baby's nervous system, causing altered memory, attention deficity-hyperactivity disorder, or problems with language development and coordination.  It is advised to avoid eating shark, swordfish, king mackerel, and tilefish during pregnancy, as these have the highest levels of mercury.  Fish does have great nutritional value, however, so you should not cut it out entirely.  Recently, the FDA and the American College of OB/GYN released a statement encouraging pregnant women to eat 8-12 ounces of low-mercury fish each week.  Click here to read:  FDA recommendation on fish consumption during pregnancy.

 

 

Of course, fish should be cooked well, so avoid raw sushi.

 

A good source of information if you have any questions about what is safe to eat during pregnancy can be found by clicking the following link:

FDA food safety guidelines

 

In general, the most important things to remember are to eat a variety of foods, avoid excessive salt and sugar intake, cook your meat thoroughly and wash all produce well.    These simple steps will help to ensure the safest pregnancy for you and your baby.

 

 

 



Long-acting reversible contraception

After a year-long hiatus, I'm back...

I find myself talking to many patients every day about contraceptive options.  Contraception has been quite a hot topic in the news lately, mostly related to insurance coverage mandates.  It is and has always been something important to discuss, as roughly half of all pregnancies are unintended in the United States.  Pregnancy is a "natural" state, but should be planned to minimize risk to both mother and fetus.

There are so many options for contraception, including hormonal, non-hormonal, short-acting, long-acting, pharmaceutical, natural - each with its own pros/cons and efficacies.

Today, though, I'd like to focus in on long-acting reversible contraceptives (LARCs).  LARCs include the intrauterine devices (IUDs) and contraceptive implant.  These are highly-effective long-term birth control options that have been gaining popularity over the past few years.

 

LARCs can be used by women of any age.  For many years, health providers discouraged use of IUDs in women who have never had children, but this is no longer the case.  We are now frequently using the contraceptive implant as well as IUDs in young women or women who have never been pregnant.  There really are very few women who cannot use LARCs.

One of the best features of LARCs is their effectiveness.  Pregnancy occurs less than 1 in 100 users.  That's over 99% effective.  LARCs have been found to be just as effective as tubal ligation, but are immediately reversible.  In fact, many women who may otherwise have undergone tubal ligation are now choosing to use this most effective birth control and avoiding surgery.

The IUD is a small T-shaped device that is placed into the uterus during a simple office procedure.  There are 2 different types of IUDs.  One is non-hormonal.  It is made of copper and lasts for up to 10 years.  The other contains progestin, a hormone that acts locally within the uterus to thin the uterine lining.  One advantage of this type of IUD is that over time, a woman's menstrual periods become very light or go away completely because the lining gets so thin.    Many women choose the hormonal IUD for this reason.  Because it keeps the uterine lining from becoming thick, it also decreases the risk of uterine cancer. One hormonal IUD lasts for 3 years, the other lasts for 5 years.

The IUDs are thought to work mostly by inhibiting the sperm from reaching the egg.  The hormonal IUD also thickens the cervical mucus, making it difficult for sperm to even enter the uterus.  In the case of the hormonal IUD, the thin lining of the uterus is also likely less receptive to implantation of a fertilized egg.  Fertility normally returns immediately after removal of the device.

Placing the IUD involves placing a speculum in the vagina and cleaning the cervix with Betadine. A small clamp is placed on the cervix to hold it steady.  The uterus is then "sounded" - a thin rod is placed through the cervix until it touches the top of the uterus to measure the length of the uterine cavity.  This is important because the IUD applicator is then set to that length to be sure the IUD is placed right at the top of the uterus.  The arms of the IUD are drawn into the applicator, and it is then advanced into the uterus.  Once inside, the arms are released, the IUD is advanced to the top, and the applicator is removed.  The strings on the end of the IUD are then trimmed to about 1" outside the cervix.  The clamp and speculum are removed, and it's done!  The entire procedure takes only about 2 minutes.  Most women experience a cramping sensation during the procedure, but it is temporary, and can be lessened by taking ibuprofen before the office visit.

As with any medication or procedure, there can be side effects or risks.  With the hormonal IUD, it is common to have unpredictable bleeding for up to 6 months after insertion.  The nonhormonal IUD can result in slighly heavier periods for up to 6 months.  There is a chance the IUD can be expelled from the uterus.  During placement, the uterus can be perforated, resulting in a chance of the IUD being placed into the abdominal cavity.  This happens only about 1 per 1,000 insertions.  If this occurs, it can only be removed surgically, usually with an outpatient procedure.  It is rare to have any long-term complications.  Although pregnancy is very rare with an IUD, there is a chance that if pregnancy does occur, it will implant within the fallopian tube, resulting in an ectopic pregnancy, which may require surgery. 

All of this sounds scary, but is exceedingly rare.  The IUD is an excellent form of contraception, and it's no coincidence that most of the female OB/GYNs I know use an IUD.  It is easy to use, extremely effective, and readily reversible.

The implant is a small plastic tube containing a progestin that is placed just under the skin of the upper inner arm.  With this device, the progestin hormone acts systemically, meaning through your whole body.  It acts mainly by stopping ovulation.  It, like the hormonal IUD, also thickens the cervical mucus and thins the uterine lining, making fertilization and implantation less likely. 

Placing the implant is also a simple office procedure.  The inside of the upper arm is injected with a local anesthetic.  The arm is cleaned with Betadine, then using a sterile applicator, the implant is injected under the skin.  After placement, you can feel the implant under the skin, but it is difficult to see.  A bandage is placed over the site.

The most common side effect of the implant is unpredictable bleeding.  For many women, this improves over time.  Complications can include bleeding or bruising during insertion, and difficulty with removal.

The benefits of long-acting reversible contraception greatly outweigh risks for most patients.  Their ease of use and efficacy make them a good choice for almost anyone.  It's important to note that these forms of birth control do not protect you against sexually-transmitted disease.

Women should discuss pregnancy prevention with their health care providers and determine the best method to allow a planned low-risk pregnancy when the time is right.

Check out these links for more information:

Mirena IUD official website

Skyla IUD official website

Paragard IUD official website

Nexplanon insert official website