Our Bodies, Ourselves (131 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
Vaginal bleeding is abnormal in any woman who is postmenopausal (has gone a full year without any menstrual periods), unless she is taking hormones.
Clinicians will review a woman's medical history. For premenopausal women who are missing periods, the bleeding pattern may suggest pregnancy or ovulation (producing an egg). A pregnancy test can find out whether an abnormal pregnancy is causing AUB. Blood tests can check for anemia, thyroid function, and female hormone levels. Other symptoms, such as pelvic pain or hair growth, can suggest other particular causes of AUB.
A clinician may be able to detect uterine abnormalities such as fibroids through a pelvic exam. Women with AUB should get a Pap test if one has not been performed recently.
Adenomyosis (endometriosis in the wall of the uterus, a condition affecting about 10 percent of women) is another cause of heavy and painful periods. It can be diagnosed only with an expensive MRI or a surgical specimen during a hysterectomy.
Four special tests are often used to evaluate AUB, as follows.
Endometrial biopsy:
This is a quick office procedure involving the removal of tissue from the uterine lining (endometrium) to check for precancerous and cancerous cells. A thin tube, which is a suction device, is inserted into the uterus through the vagina and the cervical opening. It withdraws samples of uterine tissue for analysis. This may cause cramping, and some women will need pain medication, including anesthesia.
Transvaginal ultrasound:
In this test, a wand placed in the vagina produces sound waves that create an image of the pelvic organs. The test can identify uterine fibroids. It measures the endometrial lining and may indicate abnormalities in the endometrium.
Sonohysterogram, or saline infusion sonography:
This special kind of transvaginal ultrasound involves putting saline (salt water) into the uterus through a thin tube, to improve the image and detection of abnormalities.
Hysteroscopy:
Diagnostic hysteroscopy involves threading a thin flexible scope into the uterus to view the contents of the uterine cavity. It can be done in the office or at a surgical procedure unit. Operative hysteroscopy is done at the hospital with anesthesia. A slightly larger scope is used to look at the uterine cavity and remove abnormal tissue such as fibroids or polyps.
The treatment for abnormal bleeding depends on what is thought to be its cause. A woman's age and plans for childbearing, as well as her preference, are important in planning the treatment. Treatments range from observation (and taking iron, if a woman is anemic) to hysterectomy, or removing the uterus.
Various medications can reduce or regulate abnormal bleeding and relieve pain. Nonsteroidal anti-inflammatory drugs (such as ibuprofen) taken for pain may also reduce bleeding. Tranexamic acid is a medication that significantly decreases menstrual bleeding. Only recently introduced in the United States, it has been available in other countries for many years. Birth control pills make the cycle more regular and reduce bleeding, but there is some controversy about using them during perimenopause (See the Centre for Menstrual Cycle and Ovulation Research for more information: cemcor.org).
An IUD (intrauterine device) treated with a progestin, such as the levonorgestrel-releasing Mirena, can be a nonestrogen hormonal option for controlling bleeding. Some other drugs, such as danazol and Lupron, reduce bleeding even more but also have serious negative side effects (see above); they are typically used for only a short time, to postpone or prepare you for surgery.
Noninvasive outpatient surgery (endometrial ablation) may be done with several techniques that cauterize, freeze, or remove the lining of the uterus to reduce bleeding. These include operative hysteroscopy (where the uterine lining is surgically removed) or the use of specially designed instruments such as the thermal balloon (ThermaChoice) or NovaSure to cauterize or even freeze the uterine lining. Endometrial ablation is an option after more serious causes of abnormal bleeding are ruled out. It may be less effective in the presence of fibroids. Hysterectomy is the only known effective treatment for adenomyosis.
Always discuss the particulars of your situation and your choices with your clinician. If you are uncomfortable with the options offered, try to get a second opinion.
If you are premenopausal, you may be able to stabilize your menstrual flow by reducing stress and changing your diet. Cutting down on animal fat and adding fiber helps to restore normal hormonal balance by lowering cholesterol, which is converted to estrogen in your body.
There is controversy about whether soy productsâand which typesâare beneficial for AUB or may help to regulate periods. Supplements of vitamins A, E, and C with bioflavonoids may help if your diet does not include enough of these vitamins. (Take no more than 10,000 IU of a vitamin A supplement twice a day, since larger doses can be toxic. One carrot contains 8,000 IU, and dark green leafy vegetables contain a lot, too, so you can get enough vitamin A from food.) If you are bleeding heavily, increase your iron intake to prevent anemia.
Some women find that Chinese medicine, including acupuncture and Chinese herbs, helps to restore hormonal balance. If you are approaching menopause, the bleeding may stop by itself as your hormone levels get lower.
The underlying cause of very heavy periods may be von Willebrand disease (VWD), the world's most common inherited bleeding disorder. It's a deficiency in the amount or quality of a protein that is required for blood to clot. VWD affects about 1 percent of people of all racial and ethnic backgrounds. Both men and women can inherit it from either parent. Because of our monthly periods, VWD affects females more frequently than males, but health care providers don't always realize that is what's wrong. The bleeding can range from being simply annoying to interfering with school, work, sleep, and mood.
VWD bleeding can be described as “oozing and bruising.” Bleeding typically occurs in the mucous membranes (for example, in the mouth after dental work, or in the rest of the gastrointestinal system). The most common symptoms are heavy or prolonged periods, easy bruising, prolonged nosebleeds, and prolonged bleeding following surgery, injury, dentistry, and childbirth. Other signs can be bleeding into the joints and urine. VWD may result in miscarriage and unnecessary surgery, including D&C, uterine ablations, and hysterectomy at a young age. Affected family members can have different bleeding patterns, as can people with the same type of VWD. Absence of bleeding does not rule out the disease. People with severe VWD have the same
level of joint damage as do those with moderate hemophilia.
The American Congress of Obstetricians and Gynecologists (ACOG) recommends screening all women with severe uterine bleeding for VWD. A federally supported U.S. hemophilia treatment center, if near you, may be a good place to seek help.
There is no cure for VWD, but there are effective treatments. Treatment varies according to how severe your condition is, and may include hormones, a synthetic nasal spray, or medication that is injected under the skin or infused into a vein. You may need to see a hematologist (blood specialist) familiar with VWD for accurate diagnosis and appropriate treatment.
Cervicitis is a general term for inflammation of the cervix. A Pap test report or cervical biopsy may mention it, but it's not always a real disease or disorder. Cervicitis may accompany vaginal infections, pelvic inflammatory disease, and sexually transmitted infections.
Cervical eversion (also called ectropion) occurs when the kind of tissue that lines the cervical canal grows on the outer vaginal part of the cervix, making it red, with a bumpy-looking texture that is smooth to the touch. If the inside (columnar epithelium) puckers out, that is referred to as eversion. This is a common physical variation. Most women do not have any symptoms, although eversion can cause bleeding during a Pap test. Eversion requires no treatment unless it is accompanied by infection. Those of us whose mothers took diethylstilbestrol (DES) during pregnancy are more likely to have this condition.
Cervical erosion is a pinkish-red sore on the cervix, next to the cervical opening. This rare condition causes little discomfort. Most cases referred to as erosion in the past were really eversion.
Cervical polyps consist of excess cervical cells that “pile up” within the cervical canal. They appear as bright red tubelike protrusions from the cervical opening, either alone or in clusters. Polyps are very common and usually benign. Most polyps contain many blood vessels with a fragile outer wall, so bleeding may occur after intercourse or other vaginal penetration, douching, or self-exam. Polyps may also bleed during pregnancy, when hormonal changes stimulate growth of blood vessels in all cervical, vaginal, and uterine tissue.
Cells from the polyps will be collected as part of a Pap test. Cervical polyps are almost never cancerous.
Polyps do not necessarily require treatment. When they are small and there is little or no contact bleeding, you or your clinician can usually just keep track of them with regular exams. Removing cervical polyps is often recommended as a preventive measure but is not required. You may want to have them removed if the polyps begin to grow. This is a simple office procedure where your practitioner twists the polyp off and scrapes or cauterizes the base. If your polyp is very large (this is rare), or if you have several of them, you may have to go to the hospital for removal. Sometimes polyps grow back after removal.
RISK OF DYSPLASIA (PRECANCER) AND CERVICAL CANCER
The following factors may increase a woman's risk of cervical cancer:
⢠Never having a Pap test or not having had one for five or more years. Over half of new Cervical cancer diagnoses every year are in women who have been exposed to HPV and who don't get this screening test. Therefore, they do not get early intervention to prevent cancer from developing.
⢠History of sexually transmitted infections, since HPV is often transmitted along with other STIs
⢠Smoking, which has been linked to cervical cancer in large population studies
⢠Synthetic hormones such as those in birth control pills or exposure to DES in your mother's uterus
⢠Unprotected sex at an early age. Young cells in the vagina are more vulnerable to whatever may cause cervical abnormalities; these cells are gradually replaced during the teen years with more resilient cells.
⢠Exposure to infection. It takes only one sex partner with HPV to get an infection, but having more sex partners increases the chances of infection. If you or your partner have (or have had) multiple sex partners, your risks of developing abnormal cervical cells are greater. Barrier contraceptives (especially condoms) reduce such risks.
⢠Contact with cancer-causing substances (in mining, textiles, metalwork, or chemical industries) or sexual contact with a partner who has worked with these substances
⢠A compromised or weakened immune system, which can result from being HIV-positive or using immune-suppressing medications such as chemotherapy. Yearly Pap tests are recommended for these women.
⢠Unhealthy living and working conditions and environmental hazards, often the result of having limited income. Women without access to a safe, clean environment are more likely to develop dysplasia and cancersâand at earlier agesâthan other women.
Cancer of the cervix is responsible for the deaths of half a million women around the world every year. In some countries, it is the leading cause of cancer death in women. Cervical cancer deaths are on the decline in the United States, probably as a result of Pap tests (which can catch cervical cancer early) and the treatment of precancerous cervical problems called dysplasia. Most cervical cancer results from human papillomavirus (HPV) infections that are transmitted through
sexual contact
(In
Chapter 11
, “Sexually Transmitted Infections). The Pap test, often done as part of a routine gynecologic exam (see
“Pap Tests”
), is a screening test for precancerous or cancerous changes in cervical cells. Most of the cellular abnormalities we call dysplasia are now thought to be caused by HPV, but only some types of HPV are associated with cervical cancer. Tests that can identify the presence of these “high-risk” HPV
types are now available
.
HPV VACCINES
In 2006, the FDA approved the use of Gardasil, the first vaccine designed to prevent cervical cancer. FDA approval of Cervarix followed four years later. Both vaccines are highly effective against two types of HPV known to be associated with cervical cancer. Gardasil also protects against two other HPV types associated with
genital warts
. Newer HPV vaccines are being designed to protect against more HPV types.
Gardasil's introduction was highly controversial, because its manufacturer (Merck) initially lobbied some states for school mandates, which would require vaccine distribution in certain grades. Because the vaccine is so much less effective if administered after exposure to HPV, and because so many girls have their first sexual experience in their early teen years (when exposure to HPV is highly likely), these mandates were proposed for girls eleven to twelve years old.
Some parents objected strongly to these proposed mandates. Media coverage portrayed the objections as coming mostly from socially conservative groups and individuals, yet many parents who actively support school-based comprehensive sex education also objected primarily because the vaccine was tested mostly in older girls and women (age fifteen to twenty-five) instead of the group to which the vaccine is marketed. Only a few hundred girls in the eleven- to twelve-year-old range were included in the clinical trials that led to approval of the vaccine. Parents understandably wanted more evidence of safety before seeking the vaccine for their daughters. As of 2011 millions of young girls have been vaccinated with Gardasil and Cervarix, so five-year safety profiles for the vaccine will soon be available.
Even the chair of the CDC Advisory Committee on Immunization Practices pointed out that a school mandate for this vaccine was not appropriate when it was initially introduced. First, although genital HPV infections cause nearly all cervical cancer, they are not transmitted by person-to-person contact normally encountered in typical school or classroom settings. Simply sitting next to a student with an HPV infection will
not
transmit the HPV virus. Intimate contact is required. Second, new vaccines are generally introduced more slowlyânot with universal school mandatesâto determine what kinds of problems may emerge that need to be considered before rolling out a new vaccine campaign for a very large population.
Disparities in Access
Most women who die of cervical cancer never had regular Pap tests, had false-negative results, or did not receive proper follow-up.
In the United States, socioeconomic and racial disparities are evident in statistics for cervical cancer. Vietnamese immigrants are five times more likely to be diagnosed with cervical cancer than white women. African-American and Native American women are twice as likely to die of the disease as are white women.
In one study, Hispanic women had about twice the cervical cancer incidence of non-Hispanic women in border counties near Mexico.
16
Disparities are due, at least in part, to women of color having less access to Pap screening. It is quite possible that those women with the highest rates of cervical cancer will also have less access not only to Pap screening but also to the HPV vaccine. Until our health care system addresses such disparities in access, girls and women likely to benefit the most from this vaccine may well not be able to choose it.
To ensure more equal access to any adolescent vaccine, adequate infrastructure and resources must be made available. Some recommend implementation of school-based adolescent immunization programs similar to those formerly in place for delivery of hepatitis B vaccines. The United Kingdom and Australia have volunteer, nationally supported school-based campaigns that have resulted in high HPV vaccine coverage for about 70 percent of teenage girls.
Currently, school-based health programs and routine preventive care visits for adolescents are limited in the United States, making it highly difficult to provide good access to HPV vaccines, especially the type of access needed to ensure all three required vaccine doses are administered. Available data suggest HPV vaccine coverage in the United States is low (less than 50 percent) and the proportion of girls receiving all three doses of HPV vaccine is even lower (less than 25 percent).
Pap Tests Essential for Prevention and Treatment
HPV vaccines do not protect against all types of HPV associated with cervical cancer. Thus, regular Pap tests among sexually active women remain essential for cervical cancer prevention. Resources should not be diverted away from Pap screening programs to pay for the unusually expensive cervical cancer vaccine. Because Merck marketed Gardasil with a campaign that unnecessarily frightened girls, young women, and parents, many people now have a distorted view of this disease, the vaccine, and the continued importance of Pap screening.
There is no question that HPV vaccines represent an important scientific advance in the field of vaccine research, but exaggerating their potential benefit in places such as North America will not serve us well. In countries where there is little or no access to Pap screening, current HPV vaccines might have much more potential for saving lives if their costs were reduced considerably and if adequate infrastructure to provide them responsibly were securely in place.
Important questions will be answered over time as use of the HPV vaccine expands and improved vaccines are developed. For example, will successful prevention of infections and disease caused by the types of HPV targeted by this vaccine be replaced by disease caused by other HPV types, which now account for a smaller percentage of cervical precancer and cancer? Are three
doses of vaccine required for long-term protection? Will booster shots be needed to maintain protection throughout adulthood? If so, how many? What rare complications associated with these vaccines might be identified as more young women use the vaccine over time?
As with all drugs and vaccines, long-term surveillance supported by the FDA and drug companies is essential.