Can you tell me about the new HPV vaccine?

In June, the Food and Drug Administration approved a vaccine to prevent infection with several strains of the Human Papilloma Virus (HPV). Why is this important? HPV is the name of a group of viruses that include over 100 types. More than 30 of these can be passed through sexual contact and many have been known to cause abnormal pap smears and cervical cancer.

HPV is very common and approximately half of sexually active women become infected at some time in their lives. Fortunately, most women’s immune systems clear the virus and no health problems develop. However, some types of HPV can cause cervical abnormalities that can sometimes progress to cancer. The usual screening for cervical cancer–the pap smear–has been remarkably effective in reducing cervical cancer in the US. Cervical cancer rates have decreased 75% in the past 50 years due to regular pap smear screening. Sadly, in spite of this, about 10,000 women will develop cervical cancer this year and 4,000 will die from their disease. In the US today the vast majority of women with cervical cancer have not had a pap smear in the previous 5 years! In fact, worldwide almost 500,000 cases of cervical cancer have developed, mainly in countries where health screening is not possible for most women.

Research in the 1970’s turned our attention to HPV as the causative agent in cervical cancer. Additional work identified the high-risk types of virus associated with cancer and its precursors. For the past 10 years gynecologists have been using the presence of the virus as a helpful tool in managing abnormal pap smears. Thirteen subtypes of HPV have been specifically associated with cervical abnormalities and cancer. Further research has resulted in the development of a vaccine.

The currently available vaccine “Gardasil” will be joined by a competitor in 2007. Both are effective against two types of HPV, 16 and 18. These account for 70% of cervical cancers and abnormal paps. It has been 100% effective in preventing infection with HPV over 4 years. In unvaccinated women, 2-3 out of 100 developed abnormal pap smears over the same 4 years. This is remarkable success and the antibody levels appear to show long-term immunity!

“Gardasil” also provides immunity to HPV types 6 and 11 which are responsible for 90% of genital warts. These are skin lesions of the genital area, which, though not dangerous, do cause discomfort, irritation, and distress and also result in significant cost in treatment and doctor’s office visits.

The CDC and the American College of Obstetrics and Gynecology have recommended that the vaccine be promoted to be included in routine vaccine schedules. The primary group has been selected to be 11-12 year-old females. At this time no recommendations have been made for males as the efficacy studies have not been completed. It is also recommended that sexually active women aged 13-26 years be vaccinated. This is NOT used as a treatment for abnormal pap smears! The intent is to provide immunity prior to first sexual contact for maximum effectiveness.

The vaccine is given in three doses spaced at 1, 2, and 6 months. It is expected that this will be included in the Vaccines for Children Program. Though most insurance companies pay for vaccines included in the above program, it may take a while for them to get up to speed and it should be remembered that many plans have high deductibles for preventative services. The vaccine is expected to cost about $120 per dose.

As with all new therapies, it is expected that HPV vaccine will take some time to be incorporated into the routine care of young women. It took a number of years for both the chickenpox (Varicella) vaccine and Hepatitis B vaccine to take root as a part of routine care, but the advantages have been shown to be much greater than the cost. We may have a longer time to wait before we see a decrease in cancer cases, since there is a 5-to-20-year interval between infection with HPV and precancerous or cancerous changes on the cervix. However, in our office, the majority of patients seen in consultation for abnormal pap smears are under 30 years of age. They must go through an office procedure called colposcopy and possible treatment, plus several years of frequent pap smear follow-up. The anxiety and inconvenience are not insignificant and the cost is much more than the vaccine.

All of us will be happy to discuss the vaccine, HPV, and how you can help you and your daughter understand this new and exciting preventative treatment for a cancer that was once the most common of female cancers.

I suffer from painful periods. How do I go about treating them?

Painful cramping during the menstrual cycle (dysmenorrhea) is a common and often troubling complaint for women of reproductive age. Described as pain or discomfort in the lower abdomen which often radiates to the lower back and thighs, dysmenorrhea usually occurs just before or with the onset of menstrual flow. Painful cramps typically last for several hours or longer, but rarely longer than two days. Complaints of discomfort range from mild to severe, and may involve associated symptoms of nausea, vomiting, or diarrhea. In fact, dysmenorrhea affects 50% of all women and is the leading cause of school absenteeism in adolescent females.

What causes the pain associated with menses? Under the influence of the natural hormonal changes which occur late in the cycle after ovulation, the uterine lining (the endometrium) begins to break down, preparing to shed (menses). This process leads to the release of hormones called prostaglandins. It is this release of prostaglandins which leads to uterine contractions which then causes uncomfortable, sometimes painful cramping. When this pain occurs early in a woman’s reproductive life and is purely associated with ovulation and the subsequent prostaglandin surge, it is referred to as ‘primary dysmenorrhea’. Some women, however, will develop painful menses later in life, frequently as a result of a pelvic or gynecologic abnormality. In this circumstance, the menstrual pain would be described as ‘secondary dysmenorrhea’. Uterine fibroids, endometriosis, pelvic infections, and adhesions are all examples of conditions which can lead to secondary dysmenorrhea. With this type of dysmenorrhea, symptoms are often more severe, last longer, and may require approaches to treatment which lie beyond the scope of this discussion.

How, then, to manage the symptoms associated with dysmenorrhea? There are a variety of treatment modalities which have been found to be helpful in alleviating menstrual discomfort ranging from lifestyle changes to pharmacologic options. For instance, there is evidence that simple changes in diet can have a positive impact on symptoms. Increasing complex carbohydrate intake, decreasing salt, and increasing intake of natural diuretics (i.e., peaches, melon, celery) have all been shown to reduce pain. Engaging in exercise and in stress-reducing activities such as breath-focused meditation or yoga have proven beneficial. The use of heat (i.e., hot water bottle, heating pad, shower, thermacare) is often very comforting with pelvic cramping. Dietary supplements can also be helpful – particularly calcium, magnesium, B-6, and the EFAs (essential fatty acids). There is also evidence that certain herbs such as red raspberry leaf and black cohosh root can reduce pain in menses. It is always recommended to discuss the use of supplements or herbs with a practitioner trained in this area of practice.

Finally, there are pharmacologic options available and widely used in treating women with dysmenorrhea. Most commonly, women employ the use of NSAIDS (non-steroidal anti-inflammatory drugs), for their effect on inhibiting the release of prostaglandins. It makes sense that if a surge in prostaglandins is the factor which leads to menstrual cramps, then preventing the release of prostaglandins will significantly affect the amount of discomfort. Of note, it is important to start NSAID therapy as soon as possible with

the onset of symptoms (or even a day before is possible, in order to prevent the release of prostaglandins) in order to achieve the best possible results. In some cases, a prescription strength NSAID is necessary to afford symptom relief. We also know that some NSAIDS have a greater effect than others in reducing symptoms. Your health care provider can help you to ascertain what type and amount of NSAID therapy may be recommended (if at all) for your particular symptoms. For women who do not respond to NSAID therapy or for whom it is not recommended or preferred, there is also the option of using an oral contraceptive pill (OCP) to manage symptoms. Because the use of OCPs suppresses ovulation, the typical hormonal changes which occur in the menstrual cycle (prostaglandin surge) do not occur. Therefore, most women who take OCPs report significant improvement in menstrual pain and discomfort. Of course, oral contraceptives are not an ideal choice for all women and therefore should be discussed with a health care provider.

To learn more about any of these treatment options to alleviate pain associated with menses, contact your health care provider or feel free to contact us at Harbour Women’s Health.

What is bacterial vaginosis?

Bacterial Vaginosis (BV) is an imbalance of bacteria that live in the vagina, and actually is not an infection. It is caused by the loss of protective acid-producing bacteria called lactobacilli. As the vagina becomes less acidic, other bacteria can overgrow, causing symptoms.

BV has a discharge with a burning sensation and a strong, offensive odor. Oftentimes this occurs after frequent sexual intercourse. It is the most common vaginal complaint for which women come to the office. However, many have never heard of it. Symptoms can be mistaken for yeast and will not clear up with antifungal medicine such as Monistat. The discharge can be white to grayish, watery or creamy, sometimes staining underwear. It can cause mild vaginal itching or burning. Fifty percent of women will have no symptoms at all; however, it is seen by her clinician on the routine exam.

It is important to treat BV as it has been linked to other health-related problems such as abnormal pap smears, or infection in the fallopian tubes and uterus which can subsequently affect fertility. Pregnant women have the risk of it causing premature rupture of membranes, preterm delivery, and it has been associated with postpartum endometritis (infection of the uterus after the baby is born).

Diagnosis is made by examination in the office and looking at the discharge on a slide under the microscope. Treatment can be an oral antibiotic or an antibiotic inserted into the vagina. Both are daily doses for about a week.

Recurrence is frequent as much as 30% within 3 months and 80% within a year. This has led many women to use boric acid in a vaginal suppository a couple of times a week to keep the acidity of the vagina at a high level. Other natural treatments may be worth trying in recurrent problems – but most have not been subjected to careful scientific testing.

What are some of the myths and realities in regard to HPV?

Last month we answered questions about HPV…Human Papilloma Virus. Here is a fact sheet recently compiled by a group at Dartmouth Hitchcock Medical Center which helps to clarify some of the myths and realities about this all too common sexually transmitted disease. Being truthful, honest, and well-informed in your communication with a sexual partner is always the best way to prevent infection of yourself and others.

Dartmouth/Northern New England COOP Project

  1. HPV is the most common sexually transmitted infection in North America . Studies suggest at least 3 out of every 4 people will contract an HPV infection during their lifetime.
  2. There are more than 100 subtypes of Genital HPV that have been identified; 30 of them affect the genital tract.
  3. All types of HPV are spread by SKIN TO SKIN contact. Sexually related transmission of the anogenital sub-types can come from scrotal to vulvar contact and from genital to oral or anal contact. Sex toys and fingers can theoretically pass the HPV back and forth.
  4. Risk factors for HPV including previous treatment for cancer or precancer, HIV infection, weakened immune system, exposure to DES before birth, multiple sex partners, older age, long term use of oral contraceptives, high parity (5 or more full-term pregnancies), and smoking.
  5. As with many STIs, there are often no signs of genital HPV, except with the few subtypes that cause condyloma acuminata (venereal warts).
  6. HPV is the only cause of cervical cancer. HPV may also be linked to cancer of the anus, vulva, vagina and penis.
  7. HPV testing for women is now available and may be performed along with a pap smear. This testing can check for the “high risk” subtypes of HPV that may lead to cervical cancer. Screening is only recommended over age 30 because the prevalence is too high in younger population.
  8. Women with ASCUS pap smear results and high risk HPV should pursue further testing by colposcopy.
  9. Currently there is no testing available to detect HPV in men.
  10. Condoms have not been shown to be effective in preventing the spread of HPV, probably because they only cover the penile shaft.
  11. Routine HPV testing is not recommended in women younger than 30 years of age because HPV is very common in this age group and cervical cancer is very rare.
  12. Currently there is no cure for HPV, although a vaccine is being developed which may become available by 2010.This bivalent vaccine has been shown to be safe and effective in preventing infection with subtypes 16 and 18, which are responsible for nearly 75% of all cervical cancer.
  13. If someone was exposed to a type of HPV that causes genital warts, it is unlikely that he or she will become re-infected with that same type, since immunity will be established at some point.
  14. The types of HPV that cause genital warts do not cause warts on other body parts such as the hands and feet, and vice versa.

What is HPV and how do I get tested for it?

For 50 years pap smears have been done during the annual gynecologic visits to screen for cervical cancer. This practice has reduced the occurrence of cervical cancer by 75%. A new screening tool has been added to our pap smear test which is called Human Papilloma Virus Testing (HPV). HPV is a skin virus and more then 100 types have been identified. Thirty of these types affect the genital skin and almost 15 have the potential to cause cancer. HPV types have been classified as low-risk or high-risk depending upon the cancer potential.

HPV testing is performed whenever the pap smear results are slightly uncertain. In the past mildly abnormal results were handled by simply re-testing. Since cervical cancer takes a long time to develop this was satisfactory. However now with HPV testing we can take mildly abnormal results and determine the risk that a patient might have to develop cancer in the future.

HPV is a sexually transmitted disease and is usually cleared by the immune system in 8-24 months after contact. Though condoms help prevent transmission of the virus it is found in genital tissue which makes condoms not foolproof. The virus also can be passed between homosexual partners. HPV is usually not visible to a woman and is only found by the pap smear. Low risk types of HPV can cause lesions of genital warts which do not have cancer potential and can be easily treated.

If a woman has a pap smear which showed atypical cells of undetermined significance, this is where HPV testing can be most beneficial. If a woman is positive for the virus or if the pap smear is more abnormal, further evaluation is advised by a procedure called colposcopy. During colposcopy the cervix is examined under magnification and biopsy is taken if needed.

The addition of HPV testing to our armamentarium allows us to more perfectly categorize patients according to the need for further follow up or not. Of course, the first step is to have regular pap smear testing. You should speak with your medical provider about these issues if you have other questions.