HPV HUMAN PAPILLOMA VIRUS

HPV stands for Human Papilloma Virus. It is a virus that is transmitted by direct contact and over 75% of the population has it. As a gynecologist, I will focus here on the sexually transmitted types.

It may surprise you to know that this virus can be transmitted orally, digitally and even if a condom is used. It may also surprise you to know that while an HPV vaccine exists, and I highly recommend it for both young men and women as it covers the four most common strains, there are over 100 strains of the virus. Some of the strains are regarded as ‘high risk’ because they can act aggressively and cause a cancer. Other strains are considered ‘low risk’ because they can’t kill you, but I can guarantee you that not one of my patients would want any form of that strain either as they can cause genital warts. This is why the screening well-woman exam is so important. When transmitted sexually, HPV prefers to invade the cervix, which is deep in the vagina. There are no symptoms. There is no pain, abnormal discharge or odor until a tumor exists. And this never has to happen. Cancer of the genitals is completely preventable with proper screening.

SO WHAT IS THE TEST?

We have traditionally recommended the Pap smear. To perform the Pap smear, the gynecologist passes a brush along the cervix to essentially exfoliate the cells that are on the surface so they can be looked at under a microscope. We want to see that the cells are not disfigured. The good news is that so much is known about how HPV transforms cells toward a cancer that the Pap smear can detect the stages that the cell goes through. Based on the stage of transformation, there are treatments that can get rid of those transformed cells and never allow a cancer to develop.

The bad news is that the Pap smear reading can be wrong up to half of the time. This means that up to 50% of the results that come back as “normal” may have missed an underlying abnormality. This is where HPV testing can help. We have the capacity to test for the virus itself from the same Pap smear sample. This result guides us as to whether we should believe what the Pap is saying or investigate further. It is not mandatory for a gynecologist to test for HPV at the time of a Pap. There are guidelines that are followed based on the patient’s age and history for testing it. In my office, I do offer the testing to all my patients. I test not only for the presence of the virus but which strain may be present. I also test for something called HPV E6/E7.

HAVE YOU HEARD OF E6/E7?

E6/E7 is a specific gene within the virus itself, though not all of the HPV strains have it. The evidence suggests that if you have been exposed to one of the strains that does have this gene, your cells would be more likely to progress to cancer than if you have been exposed to an HPV that does not have that gene.

This is a brand new test that is cutting edge. In fact, it is so new that the medical community has not yet decided how it will be incorporated into routine screening. Based on alarming results of an ongoing observational study that I am conducting in my practice, I have no doubt that this will change how we screen in the near future.

So get your screening exam and ask your doctor which testing is best for you. Cervical cancer is a completely preventable disease. While there is not yet a cure for the virus, there is a cure for what the virus can do.

HEAVY PERIODS (MENORRHAGIA)

Most women have a menstrual cycle every 24-35 days. During this menstrual cycle, a woman loses approximately three tablespoons (35 -40 ml) of blood in a period ranging from four to seven days, but there are women who lose more than that amount. This may be due to losing a great deal of blood in a normal length period or the period lasting longer than normal. Menorrhagia, meaning heavy or prolonged periods, is said to occur when a woman loses more than five to six tablespoons (75-80 ml) of blood. This is concerning because it can lead to medical problems, such as anemia, and can be a sign of an abnormal mass in the uterus.

WHAT CAUSES THESE HEAVY OR PROLONGED MENSTRUAL PERIODS?

There are several causes of this issue, but the most common ones are: fibroids or polyps in the uterus, not ovulating on a monthly basis or a medical condition that causes increased bleeding. Less often, but a serious concern, is cancer of the uterus. Let’s talk about each one of these briefly. Fibroids or polyps in the uterus: These are primarily non-cancerous growths that occur in the inside layer of the uterus and, at times, within the muscle layer of the uterus. Not ovulating on a monthly basis, or “anovulation,” is also a common cause. This is when the ovaries do not produce an egg each month. This is relatively common in women who are approaching menopause, in adolescents and in women with what is called Polycystic Ovarian Syndrome (PCOS). Increased bleeding tendency is when women have a bleeding disorder or are taking certain medications that cause abnormal bleeding. Some examples of these include women with a low platelet count, because platelets help the blood to clot normally; genetic diseases and certain medications such as “blood thinners” (ex. aspirin, warfarin). At times, the inner layer of the uterus increases in size, called “endometrial hyperplasia.” This can lead to cancer. Obesity is the greatest risk factor for this.

HOW DO I KNOW THAT I HAVE HEAVY PERIODS?

This is one of the most common questions I receive in my daily practice. Some of the signs that you may be having heavy periods include bleeding for more than seven days, changing pads or tampons during the middle of the night, passing clots greater than 1 inch wide, soaking a tampon or a pad every one to two hours on the “heavy” days of the period, having to use a tampon and a pad because of too much bleeding or feeling weak after each period due to blood loss. If you have any of these signs or symptoms, please call your gynecologist for further evaluation of this problem.

Arriving at the cause of heavy or prolonged menstrual periods involves a visit to your gynecologist. It is necessary to undergo a general physical exam including a pelvic exam. By doing the pelvic exam, your gynecologist may determine the presence of masses or irregularities in your uterus or ovaries that may explain these abnormal periods. Other tests may be necessary, and these may include a pelvic ultrasound, blood tests to determine the presence of anemia, hormone problems or genetic diseases. When the answer is not clear, minimally invasive methods may be necessary and these include looking inside the uterus with a hysteroscope (high-definition camera) or a biopsy of the inside of the uterus. Both of these can be done in the office.

HOW DO WE TREAT HEAVY OR PROLONGED PERIODS?

This depends on the cause. For example, as one of the most common causes of heavy or prolonged menstrual bleeding is a hormonal imbalance, it’s not unusual for your gynecologist to try hormonal birth control methods as the first measure. These methods include the pill, intrauterine devices (IUD), vaginal ring, monthly hormonal injections, implants under the skin, etc. These methods are generally effective in regulating the menstrual periods as well as reducing the monthly pains and cramps associated with them. For women whose heavy or prolonged periods are caused by benign growths in the uterus, there are several treatment alternatives. If the mass is in the inside of the uterus, such as a small polyp or fibroid, it can be removed without any incision with the use of the camera passed through the vagina. For larger benign masses, one option is an embolization of the uterine artery (cutting the blood supply to that part of the uterus. Some cases can only be treated surgically with a hysterectomy (surgical removal of the uterus) or of the large mass.

Surgical techniques have evolved through the years. Whereas it was customary to remove large fibroids and conduct hysterectomies by making a large incision in the abdomen, today many gynecologic surgeons are performing these surgeries with a robot. This approach allows us to see much more clearly and with higher magnification. For the patient, the recovery period is much shorter and the incidences of infection and complications are much lower than with previous methods.

For patients who have heavy bleeding not due to masses, a 90-second “ablation” procedure is available. This procedure is able to destroy the lining inside the uterus that would potentially be bleeding over the next 2 years of menstrual cycles. I offer this procedure in my office, without the need to go to a surgical center. It is a great option for patients who bleed heavily due to hormonal imbalances but do not want to get on hormones or have major surgery, and are done with child bearing.

Which treatment is the most adequate one for you will depend on the cause, your expectations with regards to future pregnancies and the recommendations given by your gynecologist. It is important to know that each of these treatment modalities have their benefits but also carry their inherent risks; therefore, it’s crucial that you have a discussion with your gynecologist in order to determine the best course of action for you.

Talk to your doctor if you are having heavy periods. Prevention is the key to good health. Stay healthy.

INFERTILITY

During this month, there is much love to celebrate. Naturally, Valentine’s Day is a time when many find themselves mourning the loss of a loved one or wrapped in the inability to have children. Many couples begin their journey to have children full of excitement. But some meet challenges they never saw coming. Doubt, worry and stress set in. They wonder why they can’t get pregnant. There are many factors that influence a successful pregnancy.

Here are just some to consider:

  1. Is ovulation occurring?
  2. Are there enough eggs in the ovaries?
  3. Are enough required hormones being produced to hold the pregnancy?
  4. Is there a blockage in the cervix, the uterus or fallopian tubes that doesn’t allow the sperm to reach the egg?
  5. Is there enough normal sperm?
  6. Are there genetic abnormalities that either partner may have, or don’t even know they have?

The first thing is to realize that in a normal menstrual cycle, there are only about three days when it is even possible for a woman to conceive. When that window of time exists depends on how long her cycle lasts. To calculate fertile days, document the first day of each menstrual cycle. Then, count how many days pass from the first day of one cycle to the first day of the next cycle. Do this for several months to see if the cycle is regular. Do 28 days, 30 days, 35 days consistently pass from day one of one cycle to day one of the next? If the cycle is consistent, no matter the number of days, ovulation is likely occurring each month

WHAT IS OVULATION?

Ovulation is when an egg leaves an ovary and is sent to the fallopian tube where it lives for a maximum of three days waiting for a sperm to reach it. If the sperm does not reach the egg within those three days, the egg dissolves and the next chance of conception is the next month’s ovulatory window. The female reproductive system consists of two ovaries, but typically women don’t ovulate from both ovaries each month. It’s most common to ovulate from one ovary one month and the other ovary the next. However, it is possible that ovulation from one ovary occurs more often than from the other.

In general, sperm live for approximately two days and within those days it needs to travel through the channel of the cervix, into the cavity of the uterus and finally into the fallopian tube where the egg is waiting. The sperm will typically go to the right and left tubes randomly as they do not know which tube is holding the egg. Even if all goes correctly, there is only a 20% chance of conception with each try.

To complicate the issue, women do not necessarily ovulate every month. It’s actually possible for the body to experience menses but not have ovulated in that month. If ovulation has occurred, menses will begin 14 days after ovulation, unless the egg was fertilized.

When trying to get pregnant, timing and knowledge of predicted ovulation days are critical. Couples should start trying to conceive a few days before to a few days after calculated ovulation. Because an egg can live up to three days on its own and sperm can live up to two days, the overlap of efforts around the day of ovulation tends to be successful. For example, if a couple tries to conceive two days before the woman ovulates, it is possible that by the time the sperm reach the fallopian tubes, the egg may have just arrived to meet it. In the same sense, if the egg were to be released early from the ovary, the sperm still have time to reach it.

NOW DO YOU HAVE ENOUGH EGGS IN THE FIRST PLACE?

We’ve all heard of the saying “her clock is ticking.” This is because women are born with all the eggs they will ever have in their lifetime. Every day, the eggs undergo a process of dying, called cell atresia. When a woman was still in her mother’s womb, at about 32 weeks of the pregnancy, she had nearly 7 million eggs present. At the time of her birth, she was down to about 2 million. By the time she grew up to have her first period, she was down to 500,000. The eggs continue to die off after that. Unlike men who make sperm daily, for women the situation is the complete opposite!

Obviously, the process that takes place in order for pregnancy to occur is very complex and intricate. There are many steps that couples can take to help achieve a normal pregnancy. However, there are many factors that are far beyond their control. When you think of it, pregnancy truly is a miracle.

Not ovulating is the most common reason couples are infertile. Thankfully, a gynecologist can assess a woman’s hormone levels at specific times during the menstrual cycle to answer any questions regarding ovulation times and egg count. An ultrasound to see the developing egg can also be done in order to have the full picture of the process.

The second most common problem is with sperm, which is why a semen analysis is important. It is recommended that this be done at least two different times in order to have a good idea if the results reflect what is consistently happening.

In screening other reasons for infertility, we also evaluate if the patient has or has had:

  1. A sexually transmitted disease or pelvic inflammatory disease;
  2. Endometriosis;
  3. Fibroids;
  4. Polycystic ovarian syndrome;
  5. Certain medical conditions or medications for either partner; or
  6. If either has or is a carrier of a genetic mutation; or
  7. If either is a nicotine smoker.

The answers to these questions guide the testing that needs to be done. For example, if the answer is yes to the first on this list, it can mean that there is a blockage in the path of the sperm before it meets the egg. The uterus and ovaries can be evaluated by ultrasound. The fallopian tubes can be evaluated by a special X-ray test. Also, a hysteroscopy can be done for direct evaluation of the inside of the uterus where a baby would grow.

There are exceptions to every rule, but if both parents-to-be are younger than 35 without any risk factors, it is normal to take up to a year to get pregnant. Whether a couple has been trying to conceive or is planning to do so, it is important that the woman see her gynecologist for a consultation to help identify and correct factors to help you not only get pregnant, but have a healthy baby.