GynoFiles

The long held belief about cervical cancer is that first there is HPV infection, then the infection begins to induce cellular changes from mild, to moderate, to severe, and then the infection unleashes the control of the cervical cell life cycle that makes it 'immortal' or in medical terms: cancerous. At any point the HPV infection can either be latent or completely resolved. Thus testing could either be for the cell changes, the HPV infection itself, or some sort of combination testing, which is what eventually has been adopted. Since the process is fairly slow in most cases, the thought is that screening can be performed less frequently in many women. We have a strategy to protect women from the first infection ever, but no strategy for infection resolution per se. Women who end up with procedures (biopsies, cones, LEEPs) are a bit more likely to begin testing negative for the HPV infection, so perhaps these procedures do help us eradicate HPV infection. New HPV therapeut...

    Did you realize the FDA has expanded the use of HPV testing for what they are calling primary HPV screening. In the past two years gynecologists, backed by data from large studies including, The Addressing the Need for Advanced HPV Diagnostics (ATHENA) trial that Dr. Trupin was a Primary Investigator for, gynecologists have been testing young ladies from 25-29 primarily for HPV. If that test is positive for HPV 16 or 18 the microscopic test and biopsy called colposcopy is used. If you test negative for 16 and 18 on the primary HPV test, but positive for one of the other high-risk types (31,33, 45, 51, 52, 56, 58, 59, 66, or 68) you then get a traditional pap test which looks for changes in the cells of the cervix. For those who test positive for the pap test, they will get their cervix evaluated by colposcopy. Women over 30 can be tested with a pap plus an HPV test together. The goal is early detection for less invasive therapies.   Primary screening test r...

A revolution in pap smear testing has occurred, women are being told they do not need yearly pap smears, but some experts are advising caution. Long term studies that were well done still leave gaps in knowledge based on the fact of how many pre-cancers are detected. Cervical cancer takes years to develop and it is not possible to follow women until they do get cancers. The new calculations indicate that there are additional women who will be diagnosed and some will even die during the extra years without a pap smear . Cervical cancer detection is more than just a pap smear, it's getting regular pelvic examinations, following up episodes of bleeding or pain, and having a personal gyno to consult regarding how to lower your cancer risks. But, ultimately, most women rely on regular pap smear testing to determine their risk for cervical cancer. Pap smears are a sampling of the cervical cells to determine whether the cells are normal, inflamed, infected, precancerous or can...

Dr. George Papanicolaou Inventor of the pap smear On Throwback Thursday we take a moment to celebrate Dr. George Papanicolaou who  invested the pap smear,. The degree to which this improved the health of women is untold, and like many other discoveries it was stumbled on, it was not something he set out to discover.  Dr. George began his career in a very different direction, and his doctoral thesis was on parthenogenesis. In his original appointment to Cornell medical school the research guinea pig colony had an over abundance of animals, and he decided to begin to look at material that might help him discover sexual differentiation from the x and y chromosomes to control the reproduction of the guinea pigs. They didn't have the tests we have now, and he was looking to figure out when the female guinea pigs were fertile. It was a messy and inaccurate business to constantly have to kill the animals to analyze stages of the ovary to obtain the cells doctors would use...

While Dr. Ben Carson, political discussions aside, is probably the most celebrated of all black physicians and with February being Black History month it gives us a chance to celebrate the contributions of those physicians and others who have contributed to medicine and in the general field of obstetrics and gynecology. Black physicians who's lives matter through history have made significant contributions to the lives of women and children, but still remain relatively unknown. Dr. James McCune Smith was thought to be the first African American physician in the unitied states and he practiced in the mid 1800s. Although an internist by trade he often took care of children in the orphanage where he worked and was known as a vaccine champion. Here at the University of Illinois College of Medicine one of those unsung hero was Dr. Helen O. Dickens , the only female who graduated from her class of 1934. She was a pioneer of pap smear testing as well as other causes and had an illustri...

A new report has been released by the CDC that highlights a new disastrous trend in the US: women are not getting their routine pap smears.  Over 10% of women with insurance and about 24% of women without insurance did not get a pap smear in the past 5 years. It is common for women to tell their provider "oh, it's really been that long". Guidelines for pap testing have changed , but one thing is sure, cervical cancer screening for pap tests is very accurate and successful and screened women do not have to die from cervical cancer. HPV vaccination protects many individuals, but not all cervical cancers have been associated with positive HPV test s. The CDC tracks many screening tests and the current data released is from the 2012 Behavioral Risk Factor Surveillance System survey. Although screening decreased the death rates has remained stable and relatively low. But should this trend of women not getting regular testing continue the death rate will climb. Not only do w...

Cervical cancer detection is more than just a pap smear, it's getting regular pelvic examinations, following up episodes of bleeding or pain, and having a personal gyno to consult regarding how to lower your cancer risks. But, ultimately, most do rely on regular pap smear testing to determine their risk for cervical cancer. Pap smears are a sampling of the cervical cells to determine whether the cells are normal. As such pap tests don't treat cancer, they seek it, as in a simple screening test. Pap smear testing cannot detect all cancer, just most of it, yet who to test, and exactly how to test has been under debate as we try to further eliminate cervical cancer, but focus on safety and cost for American women. Many organizations have produced pap smear guidelines. American Cancer Society recommendations can be found at this lin k  . The American Society for Colposcopy and Cervical Pathology can be found at this link , where they discuss the guidelines that were put in pla...

Close to the May 13th birthday of Dr. George Papanicolaou's the FDA approves HPV test as the first line test for cervical cancer instead of getting a pap smear  At Women's Health Practice we are excited to thank our ATHENA study participants for leading the way to one of the momentous FDA decisions of the decade. US Food and Drug Administration (FDA) today approved the cobas HPV Test (Roche Molecular Systems, Inc) for primary cervical cancer screening in women aged 25 years or older. This decision heavily relied on this test for their ruling. We have been following the FDA's position on this test. It was the first human papilloma virus (HPV) DNA test approved alone to detect high-risk HPV. The test is recommended for first-line screening, and can specifically identify HPV genotypes 16 and 18, which are responsible for about 70% of all cervical cancers. It also concurrently detects 12 other high-risk genotypes (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, ...

Most women have not ever had a Human Papilloma Virus.(HPV) test although we know that the root of cervical cancer resides with cells of the cervix being transformed into precancerous and then cancerous tissue. Many women are even told they should not have a HPV test because it is such a common infection without consequence, it may cause unnecessary testing if done too often on the wrong patients. Most women who have had HPV testing were first found to have an abnormal pap, although testing both HPV and the cells by pap together is starting to be more commonly performed. Roche's Cobas HPV DNA test got a unanimous "yes" vote by and FDA committee to becoming the "test instead of the pap test," as the first screen for cervical cancer. Final FDA approval is waiting.Pap tests then would only be added on to women who have a positive HPV test. The reasons for this lies in the accuracy and ease of this test and in the data that shows that while we do a great job now, w...

The Danish Cancer society the MERMAID 2 project has been looking in to a woman's risk of pre-cancer or cancer of the cervix based on whether they have high risk (HR) or low risk (LR)  HPV on a test. They also want to compare risks from women with normal pap vs women with negative HPV test. They found that negative HPV is a better predictor of having no cervical cancer in the next decade. Low risk HPV infection of the cervix has been shown to be associated with mild precancerous changes, but has never been shown to predict cancer or progression to carcinoma in situ or CIN III, the most advanced cervical pre-cancer. Thus the publications from the MERMAID 2 project and others have stopped endorsing testing for the low risk types of the HPV virus. Generally women getting a pap test have about a 1/100 risk for CIN III over the next decade. For women with Low Risk HPV there was only 1.7% risk vs 1.1%, over the 8 years of the study. So only about 1/2% difference in pick up of high grade ...

Most women worry about their pap smears showing cancer. We worry the most about a pap that shows high grade squamous intraepithelial neoplasia (HGSIL), but of women who have the low grade form, LGSIL about a third will still have serious precancer. And pap tests do show more than just cancer or precancer, they can help figure out infection or precancer. If you have culture tests, often they are the best check of infection. There are ways to detect infection, including tests on the pap cells themselves, or on the liquid that the pap cells are suspended in after collections. So if you get a pelvic exam, find out what types of infection tests. Years ago the only time we could identify an infection would have been to culture for it. Now tests of the organism with tests called PCR are actually done. With these PCR tests, technically we cannot say if it is still an active infection, or a newly treated infection, but eventually all tests go to negative if some one is treated. Infections ...

It’s not so surprising when you think about it. There is more information on your pap smears than is actually reported out. In one case cells seen in younger patients are considered so normal, they just aren’t reported, but they are after 40. It’s one of the reasons you may have to learn about a pap test problem you may have never heard of! Women over the age of 40 may receive an unexpected phone call regarding their pap smear: they are told they have a test that isn’t a sign of cervical cancer, but that they need to come and discuss the finding of uterine lining cells, or endometrial cells, on their pap smear. They are likely to be told they need additional testing, and that occasionally this may mean a cancer or pre-cancer of the uterus itself. Women who have had menstrual periods know that they do shed the actual lining tissue at the time of the menstrual bleeding. A little known fact is that over 1/10 pap smears have these lining cells present. Women will shed these cells a bi...

Pap tests can be used to judge your sexual health. This is the test called a Maturation Index: this is not a cancer test, but it is a type of pap smear. It is done with the same collection technique of getting cells from the cervix with a swab and placing them in fluid or on a slide. It is an analysis of the vaginal wall cells from the upper third of the vagina. 100 cells are evaluated and the proportion of the parabasal cells (the lower most layer that sits on the top of what is called the basement membrane), the intermediate and the superficial cells. Prior to menopause, if you have a normal healthy vaginal wall you will have somewhere between 40-70/100 intermediate cells and about 40-60/100 superficial cells, and no parabasal cells. If you have early menopause, and a bit of estrogen, you may start having some parabasal cells when your maturation index is taken. Once women are fully in menopause, and the vaginal walls become atrophic, then they may have as many as 65/100 cells as ...

Knowing what to do next after an abnormal pap can be both confusing, anxiety producing and a matter of the prevailing gynecologic thought. Your own gyno may not be practicing according to the most recent guidelines. The guidelines are confusing, the possible alternatives may involve tests that are very expensive or are not available in your area, and your gyno may be taking factors in your case into consideration that do not adhere to the guidelines exactly. So if you thing your gyno has been changing her mind, you are lightly right, but you may also have choices. We are most concerned with women who have been diagnosed with the most severe pap smear changes that are not cervical cancers, but have to be carefully monitored.Moderate and severe dysplasia, also called CIN II and III is diagnosed in 500,000 American women each year. It is out of this group that cervical cancer will develop. So when advising as to follow up testing, we are trying to give you the best risk prediction re...

UNCC Gardens I like sayings and numbers and acronyms to help me remember, but of course there are exceptions. We used to say: clinical gyno exams once a year "1" and mammograms once a year "1" pap smears once a year "1" and now we still say see your gyno for a clinical exam once a year "1" but consider mammograms every two years "2" and then get the pap smear every three years (some can go to 5 if you are having HPV testing that is negative) so the "3". Of course these recommendations do not apply if you have had prior disease or are being followed for a specific treatment or have other reasons for being more high risk, for that plan you need to speak privately with your gyno. I see too many healthy women not complying with recommedations and they often seem to be doing a "3, 3, 3" meaning if they didn't get a pap they didn't get a gyno exam annually, but are spacing all exams out too fare; and of course...

Pap smears don't treat cancer, they seek it. Pap smear testing cannot detect all cancer, just most of it. Under 21: You probably don't need one. Under 30: Get a regular pap ever 3 years, keep getting pelvic exams. Over thirty? Add a HPV test to your pap. Previous abnormal? You may have recurrence risk for over 20 years. We have told women that they need yearly pap smears for so many years that even though it's been a recommendation since 2003 to do fewer pap smears we are often sticking to the every year pap. And you and your gyno know more about your risks. Drs. Chelmow, Waxman, Cain and Lawrence writing a commentary on this topic in Obstetrics and Gynecology this month (April 2012) have said that the 'yearly' plan was 'chosen arbitrarily.' It's hard for gynos to switch gears, and we didn't embrace the every other or every third year smears as a group. Now again we have  extended the overall interval that pap smears are necessary, and it's all...

It's been assumed that HPV can only be transmitted by contact with the surfaces that the virus lives on, such as the skin or membrane layers known as epithelium. Many gynos will translate epithelium for the patients to be "skin like" because it has many flat layers. Knowing that the virus likes these surfaces, it's the genital tract surface is where we think the virus lives. The location of the virus can explain then the way transmission has most likely occurred. But recently it has come to light that HPV is one of the most common infections in semen. In Italy, and reported in the Andrology section of the November 20011 issue of Fertility and Sterility a group has now reported, that 1/10 young men, who have no symptoms at all, will have HPV detectable in their semen. Exactly what this new information means is confusing. For instance will this be a risk for women getting donor insemination, and how would it affect the quality of the sperm themselves, and can the pro...

Women have known that early detection is the key to successful prevention of cervical cancer, now that is for us that have not yet had a Gardasil vaccine. For those lucky women, prevention truly means not acquiring the condition at all. But for the rest early detection is still the best strategy. So the question is do you need a pap test. If you are over the age of 21 it's time to begin on a screening program. And for women who are offered pap tests the new study results indicate that the best test may be to detect the disease itself: the HPV infection. And to actually get tested for the most serious types of HPV. HPV genotype testing is the new buzz word in cervical cancer prevention. Finding out if you in fact have HPV 16 or 18 is the most important test you can have. It has not be yet determined who can skip the pap and just get the HPV testing, but it is thought that this is going to be the best test for the future. Especially for young women who were vaccinated prior to ...

HPV testing can help detect cervical cancer and cervical precancer. HPV infections are both common, and for the most part, not serious as most women rapidly clear their viral infection. According to current testing and an article by Schiffman and Wentzensen in Obstetrics and Gynecology in 2010, about half of infections no longer apparent within about 6 months and more than 90% unapparent by a few years. We have discussed much about the pap smear and the HPV tests that have arrived to be done in conjunction with the pap smear. A number of HPV tests are available. When to test and what test to use is a complex topic. A new concern for gynos about these tests has arrived.  Dr. Philip Castle, a brilliant researcher in the area of HPV disease and a member of the American Society for clinical pathology has accused physicians of abusing HPV DNA testing in fairly large numbers in a recent editorial. He bases his conclusions on looking at what tests are being ordered in a survey type r...

Dr. George Papanicolaou Inventor of the pap smear Dr. George's birth day was May 13th. Dr. Sam. Berkow quoted Aristotle when describing Dr. George Papanicolaou, the credited inventor of the pap smear. He quoted his discovery and his story as an epic, with the components of an epic, in Aristole's words: a dignified theme, organic unity, and an orderly progress of action. Dr. Sam. Berkow went on in one  of his famous essays to say" the theme (of the pap smear) was no less than an odyssey, in which the course of which a key is found which opens the gate of cancer detection and also fits locked doors of gynecologic endocrinology." Both the young Aristotle and the young Dr. George Papanicolaou walked the island of their birth Euboea, having another thing in common. From that small island there are forested walks from which one can see the Mediterranean and gaze out over Asia Minor, perhaps inspirational in thinking about the grand picture, at least we might like to th...