The stars have aligned for our January resolutions series. Not only is January designated as Cervical Health Awareness Month, but I’d say that the cervix counts as an “often neglected body part” related to our sexual health or well-being, which was the criterion for this January resolutions series.
The good news about the cervix is that there really isn’t anything you have to do to improve its function—no exercise, no diet, no special creams or lotions. Basically, it’s four centimeters of tough muscle between the vagina and the uterus. It keeps a baby in safely tucked inside the uterus and then dilates when it’s time for the baby to be born. That dilation is what labor is all about, as though you could ever forget. It really has no sexual function, contrary to previous belief.
The deal with the cervix—and why we have this special month devoted to it—is that you can almost ignore it if it’s healthy, but if it acts up, as with cervical cancer, then you have a problem, Houston.
And that’s why you can’t completely ignore it. So let’s give the lowly cervix a little blog luv.
Times have changed with the sexual revolution and advent of cheap, easy, and effective birth control. There’s a whole lot more sex happening with more partners, for one thing. And with that has come a lot more sexually transmitted diseases. We talked about that at length, beginning here, but as it relates to the cervix, here’s the rub.
The precursor for cervical cancer is what we call SIL (squamous intraepithelial) change (or dysplasia in physicians’ lingo). That change is nearly always caused by human papillomavirus (HPV; there are rare occasions where cervical cancer isn’t HPV related), and HPV is pretty much ubiquitous among sexually active people (80 percent). Plus, it’s a virus, so once you have it, there’s no cure. Usually that’s no problem. In 70 to 90 percent of cases, a healthy immune system clears it up within two years—kind of like the common cold.
But as we know, viruses are wily, shape-shifting critters. There are about 100 strains of HPV, only a few of which are considered high risk for cervical cancer. About 12,000 women get cervical cancer every year in the US, and one-third of them die. This isn’t a huge number, but the tragic thing about cervical cancer is no one should die from it because cervical cancer is extremely easy to detect and treat. In women older than 65 with cervical cancer, 42 percent had never been screened.
Screening guidelines and testing procedures have changed in recent years, however, so it’s no wonder if you’re confused about what to do and how often to do it. There is now a test for HPV, which is recommended for any woman over 30. There is also the tried-and-true Pap test that tests the cervix for precancerous cellular change, or dysplasia. This test is recommended to start at age 21.
A woman with a history of negative results and no other complications only needs a Pap test every three years. Combined with a negative HPV test, the wait can be five years.
Obviously, if your cervix was removed during a hysterectomy (and you DO know whether or not it was removed, don’t you?), and if you don’t have a history of cancer or dysplasia, you are done with Pap tests forever. Even if your cervix is intact, until recently the guidelines advised that women over 65 with no history of positive Pap results no longer need screenings.
All that may be changing.
In a 2013 study of women between 35 and 60 found that some women who had been monogamous or celibate for decades began testing positive for HPV. The results suggested that these women had been carrying latent and undetectable levels of the HPV virus from sexual encounters in their youth that had spontaneously reactivated during menopause. This is akin to a childhood case of chicken pox returning later in life as shingles.
“As long as you are controlling these infections, your immediate risk of [cancer] is going to be low,” molecular biologist Dr. Patti Gravitt explains in this article from Johns Hopkins. “But if menopause, or just getting old, increases HPV reactivation, then we need to look at what this means for screening these older women who came of age during the sexual revolution and are much more likely to reach menopause with latent HPV than the postmenopausal women we have screened in the past.”
In the face of this surprising finding, the North America Menopause Society now recommends that “all women who have had multiple partners should not stray too far from their Pap smear or HPV test at menopause until we know more about the increased risk of HPV flare up at menopause.”
Even women who have had their cervix removed should be aware that rarely HPV also causes vaginal and vulvar cancers. So more than ever it pays to be aware of your cervical health—and your HPV status. Being postmenopausal doesn’t give us a pass anymore.
You’ve come a long way, baby. You survived the sexual revolution of the 1960s and 1970s. You raised your family. You have a rewarding career. And you’re conquering menopause.
Now it’s time to face facts about human papillomavirus (HPV), the most common sexually transmitted infection.
It’s also the most common cause of abnormal pap smears, although a new abnormal pap result doesn’t mean you’ve been re-infected.
There are roughly 100 different types of HPV, and the most dangerous ones don’t have any symptoms.
And, just like other viruses, it can’t be treated with antibiotics.
Think you’re not at risk? Think again, because 8 of 10 sexually active people are infected at some point in their lives. And, according to a 2013 study, you can develop HPV after age 50 when a virus that was dormant for years "reactivates" decades later.
Kinda like getting chicken pox as a kid and then fighting shingles years later. Except worse, because some high-risk types of HPV (e.g., type 16, 18, 13) could lead to cervical cancer as well as head and neck, cervical, vulvar, vaginal, penile, and anal cancer.
HPV infections occur when the virus enters your body, primarily by skin-to-skin contact. In some cases you may develop genital warts, which look like flat lesions, small cauliflower-like bumps or tiny stem-like protrusion. They can show up on your vulva, cervix, vagina or near your anus. (Warts can be treated with creams or, in some cases, removed.)
You can also get HPV infections in your throat, tongue, tonsils, larynx and nose.
Women are twice as likely to develop STIs, especially after menopause when our genitals have aged and we’re more likely to develop small tears and cuts. (By the way, moisturizers and lubricants can help with that.)
Keep these tips in mind:
The bottom line: Although most HPV types are harmless, you’re always smart to be on guard.
So why am I beating that same, tired drum again?
Because it’s so darned important, that’s why.
The North American Menopause Society (NAMS) just published yet another study reviewing the sobering uptick in STIs—sexually transmitted infections—in women at midlife and advising physicians to discuss the issue with their older female patients.
That’s what I’m doing here.
This latest NAMS study confirms what we all know experientially—that many of us suddenly find ourselves single again at midlife due to death, separation, or divorce. That we are still sexual creatures and want to be sexually active. But also that we tend to be more vulnerable to sexually transmitted infections and surprise pregnancies for several reasons.
Reason #1: When we reenter the singles scene after a long hiatus, we tend to be less assertive and more naïve. We don’t know the lingo or the rules of the dating game. We may also be unaware of how widespread and ferocious STIs are these days and of how to protect ourselves. After all, we haven’t had to think about prevention in a while. In this case, what we don’t know really can harm or even kill us.
Reason #2: Men are able to have sex later in life now due to erectile dysfunction drugs, thus creating a greater pool of potential sexual partners, according to the NAMS study. This isn’t a bad thing, necessarily, as long as everyone is being careful.
Reason #3: Loss of estrogen and the resultant thinning and drying of genital tissue makes us particularly susceptible to infection. Tiny tears and thin tissue along with a generally less acidic environment puts an older woman at greater risk of infection than a younger woman with healthy, intact vaginal tissue. Sorry, ladies, that’s just how it is.
Reason #4: If we do contract an STI, we may end up sicker than a younger woman. The NAMS study referred to Danish research demonstrating that women between 40-50 years are more likely to develop cervical cancer after contracting HPV than women aged 22-32.
Reason #5: Then there’s that pregnancy thing. Because of irregular menstrual cycles along with changing birth control options, and perhaps a new relationship status, women over 40 have the highest rate of unplanned pregnancy, second only to women under 24. (C’mon, ladies, we’re accidentally getting pregnant at the rate of 24-year-olds!)
We are also more likely to terminate these accidental pregnancies. Again, according to the NAMS study, “as many as two-thirds of midlife pregnancies are terminated.”
While the NAMS study urges physicians to ask their patients about safe sex practices—and I take that responsibility very seriously—you are also responsible for informing, protecting, and empowering yourself if you’re single and sexually active. And sometimes even if you’re in a committed, long-term relationship.
At the very least, insist that both you and any new partner be tested for STIs before you have sex, and that you discuss the results. Even then, use condoms for six months afterward because some infections, such as HIV, take time to show up.
Discuss your contraception options with your physician. Birth control options change at this point in life, and the guidelines state that you should be on some effective form of contraception for a full year after your last period.
But remember, just because you’re on birth control or no longer fertile, you can still contract an STI. So talk about that with your physician, too.
"Concern" is a relative term. If you mean should you lose sleep, no. If you mean should you work with your health care provider for an explanation or monitoring, yes.
Pap tests (also called a Pap smear or cervical cytology screening) are used to look for changes in the cells of the cervix; abnormal cells can be identified early and treated appropriately. Pap tests provide information on both whether cells have changed and how much cells have changed, so "abnormal" covers a range of possibilities.
The most common cause of abnormal Pap results is HPV (human papillomavirus) infection, and HPV also suggests a range: there are many types of HPV. Some lead to nothing at all, some are linked to genital warts, and some are linked to cancers of the cervix, vulva, and vagina. And, let me repeat, some lead to nothing at all.
When a Pap test returns an abnormal result, it's typical either to monitor (repeat the Pap test in six months or a year) or to take an additional diagnostic step. A colposcopy is the most common; it sounds scary, but it's really only a close visual exam of the cervix with a magnifying device. There are several tissue sampling procedures that take cells for additional lab examination.
About 70 percent of mildly abnormal results revert to the "normal" range at the next screening. That said, it's important to follow your health care provider's recommendation for a follow-up test. This is not the time to procrastinate on that office visit!
In our little roundup of sexually transmitted infections, maybe you’ve noticed that many of them have no symptoms, and others mimic common illnesses like the flu or a urinary tract infection.
The take-away? There’s no way to know if you’re carrying an STI without getting tested. And there’s no way to prevent reinfection unless your partner gets tested, too.
That said, here’s an overview of the most common viral sexually transmitted diseases. That’s right, they’re caused by viruses, and you know what that means. You may well be stuck with this bug and at risk of infecting others for the rest of your life.
Here’s the list of bad boys:
Herpes Simplex Virus (HSV)
How common is it?
Very. One in five women has genital herpes. There are two types: Type 1 is the oral virus that causes cold sores. Type 2 infects the genital area. But the oral virus can infect the genitals and vice versa.
How do you catch it?
Through genital contact or oral-genital contact. The affected area can be contagious even when the lesions have healed. Condoms can help reduce infection, but it may not cover all the affected areas.
What are the symptoms?
The first outbreak is the worst and usually occurs within two weeks of infection. It may be accompanied by flu-like symptoms as well as pain and burning in the area of the lesions. But many people hardly notice the infection. Several less severe episodes may occur in the first year, then with lessening frequency and severity after that.
As with other STIs, herpes compromises the immune system, making the person more susceptible to new infections.
Human Papillomavirus (HPV)
How common is it?
HPV is the most common viral STI in the U.S. today. There are many strains of HPV and about half of sexually active people have one or more of them. How do you catch it? Through genital contact during sex, even though the carrier may not have symptoms. It can also be passed through genital-oral contact. A person can carry—and pass on—the virus for years without knowing he or she has it. A person may also be infected with more than one strain of HPV. Latex condoms offer some protection, but the infected skin may not be covered by a condom. “To be most effective, they [condoms] should be worn with every sex act, from start to finish,” according to the CDC.
What are the symptoms?
HPV is usually asymptomatic, and about 90 percent of infections spontaneously clear up after a year or two, but for those that don’t some strains of HPV cause genital warts and others cause cervical cancer.
Genital warts (considered a low-risk virus) may be small bumps of various shapes and sizes on the genital area that appear weeks or months after infection, even if the partner doesn’t know he or she is a carrier. They may go away, become smaller, or grow, but they don’t become cancerous.
Cervical cancer (considered high-risk) has no symptoms until it is advanced. Abnormal cells are usually found in a Pap test; that’s why regular screening is important to determine whether the virus is high-risk. Vaccines are available against several strains of HPV HIV/AIDS
How common is it?
One million people have HIV/AIDS in the U.S., according to the National Institute of Allergy and Infectious Diseases. About 20 percent don’t know they’re infected. About 50,000 new cases are diagnosed every year.
How do you catch it?
Through contact with vaginal fluid, sperm, blood, and breast milk of an infected person. The virus is most contagious shortly after a person is infected, but it takes from 3 to 6 months for an accurate diagnosis of infection. Before that, tests results can yield false negatives.
People who have another STI are up to five times more likely to contract HIV/AIDS. People who have HIV/AIDS plus another STI spread the disease more effectively. For example, levels of the HIV virus are 10 times higher in men with gonorrhea. This is why it’s critically important to be tested and treated for other STIs. It’s also critically important to use latex condoms with a sex partner until you’ve both been tested and are sure enough time has passed for the test to be accurate.
What are the symptoms?
There may be no symptoms at first or the infected person may experience and intense flulike episode within a month of infection. The “flu” goes away; the system begins to produce antibodies to fight the infection, and the disease appears dormant.
Eventually, however, after several years, the compromised immune system collapses, and full-blown AIDS develops. Other infections take hold—pneumonia, diarrhea, and the telltale lesions of Kaposi’s sarcoma.
Medical science has progressed to the point that, with daily medication and close monitoring, a person can live with HIV for many years without the disease progressing to AIDS.
So, there you have it. But before you join a convent, remember how nice sex is, and especially with a special someone. Chances are, you both are infection-free. But why take chances when the stakes are so high and prevention is relatively easy?
HPV is an unlikely cause for pain with or after intercourse. It's associated with abnormal pap tests, which may require further investigation—like the biopsy you say you had. Much less commonly, it can cause genital warts. If the warts happen to be at the opening of the vagina, they can become irritated and cause discomfort, but that's really very rare.
It's more likely the discomfort is related to the atrophic changes of menopause, which you may not have been aware of between relationships. In the absence of estrogen, the tissues become thin and less distensible—meaning less stretchy and able to expand—and also more fragile and easily injured. This can happen even if you don't perceive dryness.
You didn't say how long you've been sexually active; this problem may resolve itself: It's the opposite of "use it or lose it"! But because menopausal tissues don't rejuvenate quite as well as younger, fully estrogenized tissues do, you might consider using a moisturizer or localized estrogen. But I wouldn't worry about HPV being a cause.
HPV is the most common cause of abnormal pap smears.
It is only fairly recently that we get more specific results with pap smears, telling us whether an ‘abnormal’ finding is related to a low-risk or high-risk HPV type. If it’s low-risk, we treat it like a normal pap smear, with a recommended annual test. High-risk HPV requires further follow-up, typically a colposcopy and possibly a biopsy. (Don't be alarmed by "colposcopy," by the way. I know it's a scary word, but it only means using a bright light and magnification to inspect the cervix.)
These more advanced pap smears, by telling us more about the HPV, save many women the inconvenience, cost, and discomfort of those further tests.
We’re not sure why women develop an abnormal pap smear 10 to 15 years after an initial exposure to an HPV type. It probably has to do with the viral type of HPV (remember most are low risk), your immune system, and other factors we don’t know. A new ‘abnormal’ pap smear result is not evidence that you have been re-infected. If you have been with the same partner, had an occasional abnormal pap, but nothing has progressed significantly, you are unlikely to have an aggressive, high-risk HPV type.
It's estimated that 60 to 85 percent of all adults have come in contact with HPV and are therefore carriers. Any HPV that you or he introduced to the relationship 20 years ago, you were both exposed to initially—and remember, we basically all bring HPV into every relationship! If you have been in the same, monogamous relationship for 20 years, you cannot be ‘re-infected’ by the same HPV type. There’s no need for concern--or for condoms or other preventive measures!
There are over 100 different subtypes of HPV. Fortunately, nearly all are ‘low risk,’ and only a few are ‘high risk’. The low-risk types are now felt to be mostly an inconvenience without any true long-term risk. The few high-risk types (e.g., type 16, 18, 35) have a risk of causing progressive cellular changes, putting a woman at risk for cervical cancer.
Relax and enjoy sex without a condom within your relationship! (Just remember, if over time you do have a new partner, you can expose him to the HPV type that you carry. A condom will reduce the risk of exposure).
HPV (Human Papilloma Virus) is so common that the lifetime cumulative risk of being an HPV carrier is 80 percent. In other words, we're nearly all carriers of HPV.
Fortunately, most people do not suffer adverse effects. Reactions to HPV exposure depends on our immune systems and whether we are exposed to high-risk or low-risk HPV types. The most common consequences for women are vulvar warts or abnormal pap smears, but, again, most women have no symptoms at all.
So you can assume two things: That your partner (like 80 percent of adults) is an HPV carrier, but that the likelihood of a health consequence is small. If this proves to be a long-term relationship, enjoying sex without a condom will be acceptable and safe for you.
For anyone entering into a new relationship: Getting screened for sexually transmitted infections is smart--and it's a way of signaling you care about each other and the new beginning you're making together.