Medical Mondays 2

 

Dr. Patricia Yarberry Allen is a collaborative physician. January is National Cervical Health Awareness Month; in this week’s Dr. Pat Consults, Dr. Allen asks gynecologic oncologist Monica Prasad Hayes, a member of our Medical Advisory Board, to counsel a woman with HPV who is greatly concerned about the reliability of the new guidelines on cervical cancer screenings.

 

 

Dear Dr. Pat:

I am 44 and divorced. I have been in several longish relationships after the divorce five years ago. I am enjoying my new single life and have been very good about taking no risks . . . I always use condoms.

I had my first abnormal Pap smear four years ago and discovered that I had been infected with HPV, the virus that causes cancer of the cervix. I had a colposcopy and was told that everything was normal but that I should have a Pap smear every six months. I had several more mildly abnormal Pap smears, and the HPV was always there. Finally, I had two normal Pap smears and was told that the HPV was gone.

Then, 18 months ago, same story. The Pap smear was “ASCUS,”  which I was told was nothing to worry about. But the HPV was back.  Even with condoms!  I have had two normal Pap smears since that “nothing to worry about” smear, but am still positive for HPV.

The gyn group I’ve always used joined a hospital system in our city this year. I had trouble getting an appointment, and the doctor I had seen for 10 years retired early and changed careers.  Now I am seen by a nurse practitioner. She told me that since I had two normal pap smears in a row over the last year, she had to follow the new screening guidelines  [released last year], and could perform a Pap smear only every two years. Then she said that if the Pap smear in two years was normal, I would need a Pap smear only every three years. She dismissed my concerns about HPV with “Everyone has this.”

Is this true?  What about my visit to the gynecologist for a breast exam, pelvic exam, time to discuss contraception and symptoms, along with a few minutes for the doctor who knew me for years to catch up with my work and personal life? Is this new world of women’s health not only impersonal, but—my greatest concern—are these guidelines safe, or will we find out in 10 years that infrequent Pap smears have led to an epidemic of cervical cancer?

Sandy

 

Dr. Pat Responds: 

Dear Sandy:

You and millions of other American women are part of the first wave of cost-cutting and health care “reform” that will be required so that more Americans have access to health care. Insurance companies are for-profit organizations, after all, and the only way that they can make money for their CEOs and board members, and keep their stock price up, is to provide the minimum care necessary based on what appears to be safe under the current buzzword, Evidence Based Guidelines. Patients will find out if the new guidelines for Pap smears, mammograms, and other preventive tests are safe in five to ten years, when the number of patients who develop invasive cancer will be available for evaluation.  It is very important that women become informed about their personal health and their risk for all diseases—and make their request for preventative testing part of their medical record.

You are right to be concerned about the importance of the annual well-woman gynecologic exam.  Continue to keep these visits, and insist at each visit that the nurse practitioner do a speculum exam—that is, at least look at the vagina and cervix and perform a pelvic exam, even if a Pap smear is not done.   In this transition to a different kind of brief-encounter visit, patients must be more prepared. So, before you go to the exam—

1.  Create a typed document of your family and personal medical history.
2.  List all medications, supplements, and allergies.
3.  Describe any current symptoms that you have, with a focus on female health issues.
4.  Include the description of your self­–breast exam, along with any questions you have about contraception and sexual health.
5.  Request that your document be scanned into the Electronic Medical Record.
6.  Remember that you have a right to review your medical records at any time, and you can make corrections or ask for explanations of results or decisions that you disagree with.

In the past, the annual gynecology visit was often the only medical visit that a woman had.  If this is still the case for you, ask for up-to-date vaccinations and screening for cholesterol, hypertension, and diabetes. If you provide all of this information in writing to the nurse practitioner, perhaps there will be time left for discussion of matters that are less important to the cost-cutters; personal matters that affect stress levels, sleep disorders, weight management, mood disorders, sexual health, menopausal concerns, and family relationships.

It will be in your best interest, over time, if you help the new health care provider to get to know you and look forward to seeing you. The health practitioners in this transition to some new kind of health care will be under significant pressure to check the boxes of required questions and tests, and will be graded by their employers and the insurance companies on how many patients they see and how many boxes are checked.  I am optimistic, however, that those of us who care deeply about relationship-based medicine along with evidence-based medicine can mentor younger health-care providers during this time of trial and error to improve their capacity to focus on the whole patient.

You are right to be concerned about the recurrence or reinfection with High Risk HPV. You do need more intensive monitoring of your cervix, vagina, and vulvar areas, since you do remain at greater risk for cancer of these areas as long as you are HPV positive, and perhaps even after the HPV test is negative. We don’t know if the HPV “goes away.” We just know that a test shows that the virus is not detectable..

Thanks for writing, Sandy. We hope that you and our readers will benefit from the discussions of medical conditions that are available here every week on Medical Mondays.  Change in medical care is necessary, and we are pleased to be part of the discussion that will help women make good choices for their health.

I have asked Dr. Monica Prasad Hayes, a gynecologic oncologist at Mount Sinai Hospital in New York City, to address your specific concerns about evaluation of your symptoms.

Dr. Pat

 

Dr. Hayes responds:

Dear Sandy:

You are right to be concerned with your HPV status. The 2012 American Cancer Society and ASCCP (American Society for Colposcopy and Cervical Pathology) Screening Guidelines recommend continued close surveillance of women who are positive for high-risk HPV strains, which are the HPV subtypes that can cause cancer (HR-HPV), in particular cervical, vaginal, and vulvar cancers of the female genital tract.  These recommendations are regardless of whether the Pap test is negative. The new guidelines specifically address situations of negative Pap smears with +HR-HPV. The guidelines now include subtyping for HPV strains 16 and 18, which are known to cause approximately 70% of cervical cancers, with  the other oncogenic strains responsible for the rest. It has been found that women with HPV 16 and 18 and a negative Pap have a greater than 10% risk of CIN  3+ (the immediate precursor to invasive cervical cancer) within 5 years of  testing positive. The risk of development of precancer for the other high-risk HPV subtypes is lower.  The options for following a patient with a negative Pap and +HR-HPV are:

1) Follow up in one year with a Pap and HPV cotesting, and if either the Pap is  abnormal or the HPV is still positive, then the patient should undergo a  colposcopy of the cervix.

2) Immediate HPV subtyping and referral to colposcopy for +HPV 16/18. 

3) Immediate HPV subtyping and if the HR-HPV is non-HPV 16/18, then repeat Pap  and HPV cotesting in one year. If in one year either the Pap is abnormal or the  HPV is still positive, then a colposcopy should be performed.

So in your case, if you have had two years of testing positive for HR-HPV, then you should be referred to a gynecologist for a colposcopy, which is an office exam during which the cervix is inspected more closely to look for areas of dysplasia  (abnormal cells), and biopsies may be taken and sent to the pathologist to  evaluate for precancerous lesions. The nurse practitioner is correct that HPV is the most common sexually  transmitted disease, and the CDC estimates that “Approximately 79 million Americans are currently infected with HPV. About 14 million people become newly infected each year. HPV is so common that nearly all sexually active men and women will get at least one type of HPV at some point in their lives.”  However,  many people will eventually clear the infection and revert to a negative HPV status.

It is important for clinicians to continue to monitor patients who maintain a positive HR-HPV status, since these are the women who may go on to develop pre-cancerous lesions or even invasive cervical cancer.  The current guidelines extending the time period for performing Pap smears apply to women at low risk for the development of cervical cancer, such as women ages 30-65 who have a negative Pap smear AND a cotest negative for high risk HPV. As with all guidelines, it is important to remember that these evidence-based recommendations are to be used as tools to help manage patients, but they are by no means an absolute rule that will apply to all patients in all situations. In addition, as new data becomes available, the guidelines are continually modified at interval time periods.

Dr. Hayes