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HPV
When The PAP Smear Suggests The Need For Further Evaluation
The Pap smear is a screening tests performed on cells from the uterine cervix. It is designed to detect some of the very early changes, which over a long period of time, if untreated, may result in cancer of the cervix. Sometimes, a report of your recent Pap test indicates that some cells were noted suggesting these very early changes. This does not mean that you have or will develop cancer.The surface cells of the outer part of the cervix are called squamous cells. They are much like cells of the skin. The cells of the cervical canal leading up to the uterine cavity are called columnar cells. They secrete mucus, much like the cells of the uterine cavity or endometrium. The point where these two types of cells meet is called the squamo-columnar junction. From birth to middle age, this junction moves from the outer part of the cervix towards the os, or opening of the cervix, and later up into the endocervical canal, leading into the uterus. The area in this junction where transformation from columnar to squamous cells is taking place is called the transformation zone. In general, it is within this T-zone that abnormalities are found.
As a result of clinical research, it is now believed that most abnormalities in the cells of the T-zone are initiated by infection with the human papillomavirus, called HPV. Involved tissue may reveal HPV cellular changes, called koilocytosis, cervical intraepithelial neoplasia, CIN, squamous intraepithelial lesion, SIL, or simply dysplasia, in a Pap report. Some lesions regress spontaneously, but some do not, and current practice is to treat all lesions.
During colposcopy the cervix is magnified so that small tissue samples may be collected from infected sites. If abnormal cells are found in the biopsy specimen, the treatment is usually freezing, cryotherapy, at a subsequent visit. Occasionally, a different method of treatment is required and referral to another physician outside of the Health Service will be necessary. The colposcopy, biopsies and cryotherapy are relatively minor office procedures with minimal discomfort.
The only charges for these services are for the biopsies, if obtained, because they must be sent to an outside laboratory for processing and interpretation. Currently, the charge is $54-$94 per biopsy. Up to $150 of charges will be paid directly by your student insurance policy. You may be reimbursed from the student insurance fund for any charges in excess of $150 after you file a claim. If you have other health insurance coverage through parents or work, you must file first for reimbursement from that coverage.
Remember:
On day of the visit for colposcopy or cryosurgery, eat regularly and
take 400 mg. of ibuprofen about one hour before the visit.
Genital Human Papillomarvirus Infections
The human papillomarvirus (HPV) causes warty lesions known as condyloma acuminata. Another name is venereal warts. Primarily found on the skin or mucus membrane of both men and women, it is usually spread by sexual contact. Some of the lesions are raised and easily visible, some are quite flat and can only be seen if 5% acetic acid (usually in the form of common white vinegar) is applied to the infected surface.The immune system plays a vital role in fighting this as well as other viral illnesses. Because of human variability, some individuals develop lesions after exposure and some do not. This may be due in part to the status of the individual's immune system or to the type of HPV causing the infection.
The incubation period from the time of exposure to the appearance of lesions is quite variable, ranging from a few weeks to months, and possibly even years. If either partner has ever had another partner, it may be impossible to determine the source of the initial infection.
When a women has warts on the external genitalia, it is common to find them also on the cervix and the walls of the vagina. The evaluation of both men and women must include visualization of all likely areas with and without the use of magnification and the application of vinegar.
It is very important that both partners be examined and treated simultaneously.
HPV infections of the cervix are believed to be the initiator of Cervical Intraepithelial Neoplasia (CIN) and Squamous Intraepithelial Lesions (SIL), also known as dysplasia. Untreated these conditions may over a number of years progress to cervical cancer. The individual course is also dependent on more than one factor, such as the status of the immune system and the type of papillomavirus causing the infection. Therefore, the evaluation of a woman with these changes must include colposcopy, a procedure for magnifying and viewing the cervix, and the collection of biopsies from the infected areas.
These are office procedures associated with minimal discomfort. Some HPV/CIN lesions may regress, but it is impossible to tell these from those which will progress, so all lesions are usually treated. The cells of the cervix appear to respond more rapidly to HPV with intraepithelial neoplasia than do the cells of the other genital areas (vagina, vulva, penis) of both men and women, so the risk of neoplasia in these areas in young adults is so low that it should not be of immediate concern. In order to minimize possible risks of long-term exposure, patients are strongly encouraged to follow instructions.
Several treatments are available, the choice dependent upon individual patient needs and the location and number of lesions. The cervix may be treated with cryotherapy (freezing), laser or LEEP (electrical cautery).
External lesions are treated with cryotherapy, laser, 5-fluorouracil cream, trichloracetic acid and some other topical preparations. Cryotherapy is available through the Health Service at no charge, as are the topical preparations that are applied at the time of a visit. Laser and LEEP therapy are not available through the Health Service. About 95% of individuals who require treatment can be cared for entirely within the Health Service. Referrals will be made to outside physicians in those few instances when necessary.
Healing from cryotherapy takes two to four weeks. A rather profuse watery vaginal discharge starts within an hour after the treatment. It may be slightly yellow in color. It gradually thickens and becomes darker as it slows, and should stop completely in two weeks. Wear a small tampon or absorbent pad and change it frequently during the first days when the discharge is plentiful. Discharge persisting after two weeks is not normal and, if it does persist, you should be examined promptly at the health center that initially referred you for colposcopy, to determine what further treatment, if any, is required. The discharge should never be bloody, contain pus, or be foul smelling.
It is important to drink lots of fluids while the discharge is present, especially water, and fluids and solids containing generous amounts of potassium, such as citrus fruits and juices, bananas, and raisins. Cut back on beverages containing caffeine.
Cryotherapy brings about healing and a disease-free state of the cervix over 90% of the time. Most treatment failures are thought to be due to re-exposure to other types of HPV. With any medical treatment the initial course may not be totally successful, and it may be necessary to treat additional lesions that appear. Treating the cervix does not necessarily rid the genital tract of the HPV, even if other visible lesions are not present. It is too simplistic to assume that the virus exists only on the cervix. You must assume that it is also present in the vagina, and outside on the perineum and perirectal areas. Though condoms provide significant protection, and should certainly be used every time you have intercourse, over time your partner will become infected whether you use condoms or not. As with you, your partner may or may not have visible lesions when infected, but it is safe to assume that, when individuals are regular partners, they are both infected.
That is the bad news. There is good news also. HPV infection is not a lifelong infection as herpes is thought to be. Even untreated the majority of individuals will eventually become disease free, but this can take months to years. The lesions that look worst are usually the ones that have the best prognosis. Visible lesions of the female and male genital tracts and organs, including those only visible with the use of magnification and vinegar, are the most contagious, and should be removed, even though such removal does not eliminate the virus from the remainder of these areas. Currently, there are no good, applicable testing methods to tell clinicians who is and is not infected, and who is most likely to develop cancer of the cervix if not treated. Thus, it is current practice to treat all cervical disease as if it might develop into cancer. The colposcopy program is really a cancer prevention program, not a method of treatment that will rid the entire genital tract of infection of HPV.
Important!
If both partners are otherwise healthy individuals with normal immune systems, and both partners remain monogamous, they should eventually become free of HPV disease because of the formation of antibodies again the HPV by their own immune systems. If you choose not to remain sexually active, abstinence is another viable alternative that will eventually allow a cure to take place.The first follow-up Pap test should be done about four months or more after the therapy, and on or two more Pap tests should be done in the year following treatment (total of two or three). If your tests remain normal one year following treatment, you are considered to be cured. Almost all apparent treatment failures represent reinfection with another type of HPV. Immunity when it develops is type specific. Because of this, if one monogamous partner develops immune partner has long lasting protection against reinfection from the non-immune partner, but this protection is only against that one specific HPV type. More than 20 varieties can infect the genital tract.
Appropriate follow up care also includes a healthy life style to assist your immune system. Eat properly, get enough sleep and control stress as much as possible. Continue to encourage good body hygiene. Smoking seriously interferes with the body's ability to mount an adequate immune response. If you are looking for a reason to stop smoking this is certainly a good one. Stopping could save your life. Do not despair if your first Pap tests are not completely normal. In almost all cases they will revert to normal, and complete re-evaluation would ordinarily not be considered until one year after the initial treatment.
Cancer of the cervix does not develop in a few months, rather is usually takes years for HPV infection to progress to that point. Thus, it is important to stay in care, follow instructions and Pap tests done regularly as instructed. The incidence of cervical cancer has dramatically decrease in the is country due to the Pap test and proper longitudinal care.
Treatment Instructions
Though more than one form of treatment method is available if biopsies confirm that you do have an HPV infection of the cervix, the Health Service believes that cryosurgery and the application of certain chemicals such as trichloracetic acid and 5-fluorouracil cream can treat almost all conditions encountered in the health centers. Outside referrals will be made in those few cases best treated with other modes of therapy, such as laser or electrocauter.Topical Chemical Applications
When receiving a course of topical applications of one of the above chemicals it is very important that you continue in treatment until your health care provider indicates that regular applications are no longer necessary. Continue to practice good body hygiene and bring apparent new lesions to the attention of the clinician caring for you at the time of each visit.Treatment of Male Partners
It is important that, if you are currently sexually active with a male partner, your partner be examined, and treated if necessary. Male patients can be seen at any of the health centers but should not be referred to the colposcopy program. Those who are not students at Rutgers can be seen by any knowledgeable health care provider who is experienced in the diagnosis and treatment of males with this disease. The Health Service is willing to assist you in a referral for your partner. An adequate examination of male requires the use of magnification an vinegar. It is not sufficient for a clinician to simply look at the external genitalia without the utilization of the above aides. A simple hand held magnifier (3x and 5x) is sufficient for this type of examination. Just as with the treatment of females, removal of visible warts does not render the individual completely free of infection but does greatly reduce infectivity. Even if adequate examination fails to identify lesions, your partner should be considered to be infected with HPV. He may never develop visible lesions. The opposite is also true, some females with infected partners may never develop visible lesions or abnormal Pap tests, but they must also be considered to be infected.Please remember to keep your appointment
If you are referred for colposcopy and possible cryosurgery because of an abnormal Pap test, you may be seen by a clinician outside of the Student Health Service at your own expense or be referred to the Health Service colposcopy program. The only charges for the Rutgers Health Service program are for the biopsies which are sent to an outside laboratory. Up to $150 of the cost will be paid directly from the student insurance fund. It will be you responsibility to keep your appointment or to call and cancel and/or, reschedule another. If you do not do this and are a "no show," it is our policy to not provide you with another Health Service appointment, but rather to refer you to an outside clinician at your own expense. Please inform us if there are any extenuating circumstances.
Is Treatment Required?
Cervical biopsy specimens taken at the time of colposcopy are reported as either normal, or showing a lesion (cellular abnormality). These lesions are graded as either low grade (less severe changes), or high grade (more server changes). This is important, because research shows that there is a difference in the long term likelihood of progression to more serious disease (local cancer or invasive cancer of the cervix).It is estimated that approximately 50% of low grade lesions on the surface of the cervix will regress (heal themselves and become normal cells) without treatment. Other low grade lesions (about 30%) will remain stable, not becoming normal cells, but never progressing to a worse stage. About 20% of low grade lesions may progress to high grade lesions or eventually to cancer in some cases, if not treated.
In the case of high grade lesions, the progression to cervical cancer is more likely, with 30-50% progressing if not treated. There is a question whether low grade lesions should be left untreated, and instead be observed closely for a period of time with Pap smears, and possibly additionally colposcopies. There is no clear, definite answer to this question. Some reasons for following low grade lesions with careful observation instead of immediate treatment of the cervix are:
1) Treatment would be unnecessary in those cases where lesions heal themselves spontaneously.
2) Cervical treatments carry a small but definite risk of later problems such as cervical stenosis (narrowing of the cervical opening, producing painful menstruation and other problems), or cervical incompetence (weakening of the cervix which could lead to pregnancy problems and miscarriage).
3) There is some discomfort associated with cervical treatments. This is usually not a major problem, but it may be consideration for some women.
4) Cervical treatments could cause difficulty with future Pap smear interpretation and colposcopic evaluation. This occurs if, following treatment, the cells most susceptible to pre-cancerous changes recede further into the cervical canal, and sampling becomes more difficult.
Some reasons to favor treating low grade lesions instead of following with close observation are:
1) There is a chance for progression to a more severe lesion, which would then require the same treatment, or even more extensive treatment.
2) Choosing close monitoring instead of treating immediately requires time and effort for the patient. She must be willing to make more frequent office visits for Pap smears and /or colposcopy exams for the time period recommended to her. This could be more expensive, too, in the long run.
3) It is not clear whether treating areas affected with low grade lesions my help reduce the spread of HPV infection to sexual partners. If so, treatment may have additional benefits.
4) It is unlikely but possible that a serious lesion could develop and be missed, even with the most careful monitoring, resulting in a more serious disease (cervical cancer). We must also remember that there is a remote possibility of this occurring even if there has been treatment. Every woman's situation is unique. The patient and the provider should discuss the issues involved in treatment vs. observation before a decision is made regarding how to manage a low grade cervical lesion. If a high grade lesion is detected by biopsy, the decision is more clear curt. In these cases, prompt treatment is advised.
For more information, contact your health care provider.