Our Bodies, Ourselves (132 page)

The results of the Pap test are classified according to what kinds and degrees of cell changes you have, if any. Many systems have been used over the years. At one end of all the scales is normal, and at the other end is cancer. In between are grades of dysplasia. Sometimes it can be difficult to distinguish one stage or grade of dysplasia from the next, and different laboratories or practitioners may interpret a given cell sample differently. Since the addition of the HPV DNA test in 2003, many clinicians interpret results of the Pap test in conjunction with this newer test.

As many as 40 percent of all tested women will have an abnormal Pap test at some time during their life. We often feel anxious when we hear our results are “abnormal,” because we fear cancer, but there is no need to panic. Most cervical cell changes are very slow. Dysplasia is not cancer, and in about 80 percent of cases, dysplasia does not develop into cancer. The cells of most women diagnosed with mild dysplasia will return to normal. But all cases of diagnosed dysplasia should be watched closely—with repeated Pap tests and other recommended procedures. If abnormal cells are found, many women get tested again after six months to see if the abnormalities are still present. Dysplasia should be treated if it is severe or if it progresses.

Clinicians sometimes recommend a colposcopy after an abnormal Pap test. This is an office procedure during which the cervix is swabbed with an acetic acid (dilute vinegar) solution to make the abnormal areas stand out. Selected biopsies of the most abnormal areas are then examined under a microscope by a pathologist to better define the extent and severity of the abnormalities.

Treatments for cervical dysplasia are based on age, severity of the dysplasia, and each woman's personal history.

Treatments for dysplasia (precancer) of the cervix vary widely. Different practitioners may have varying preferred treatments for each diagnosis, making it difficult sometimes to get appropriate treatment for your condition and avoid unnecessary or pointless diagnostic tests, treatments, and surgery. That's why second and even third opinions may be important. Procedures such as colposcopy, punch biopsy, and cone biopsy should be done only by medical practitioners who have special training, skills, and sufficient experience.

Minimal abnormalities often require no treatment. Mild (low-grade) abnormalities are usually managed with watchful waiting. Moderate or severe (high-grade) abnormalities require treatment or further evaluation. Treatments include:

Cryotherapy
, which destroys abnormal tissue by freezing, can be done in the clinician's office.
Laser
, which uses a high-intensity light beam to evaporate abnormal tissue, is most often performed in an outpatient procedure center or occasionally in a hospital on an outpatient basis. Often, local anesthesia is given to numb the cervix.

Loop electrical excision procedure
(LEEP),
which uses a wire loop charged with a small electrical current, is usually performed in an office or outpatient procedure center with local anesthesia. Clinicians use LEEP to remove abnormal tissue. The sample can also be sent to a pathology lab for evaluation. Sometimes this procedure is also called a LLETZ (large loop excision of the transformation zone).

Cone biopsy
, which removes a cone-shaped portion of the cervix, can be done in an outpatient procedure center, or in the hospital on an outpatient basis, with local or general anesthesia. Clinicians may use a scalpel, laser, or electrical loop as used in LEEP to remove the tissue. Because cone biopsy does not destroy tissue, the sample will be sent to the pathologist for evaluation.

Hysterectomy is not appropriate for cervical dysplasia, but it is recommended as the appropriate treatment for invasive cancer (see
“Uterine Cancer,”
). This is major surgery, with serious risks and other health consequences.

Long-term negative effects of laser and LEEP on the cervix are uncommon. Tissue damage may, on rare occasions, weaken the cervix, so it can be harder to carry a pregnancy to term. (This is more common with a cone biopsy, which also can produce scarring that might later interfere with dilation of the cervix during labor and birth, sometimes leading to a cesarean section.)

Since the 1940s, the U.S. cervical cancer mortality has decreased by 75 percent. Currently, between 10,000 and 11,000 cervical cancer cases occur yearly, resulting in 3,000 to 4,000 deaths. (In comparison, about 40,000 women die yearly from breast cancer.)

In its early stages, cervical cancer is almost always curable, depending on the severity of the lesions and the treatment used.

If severely abnormal cells have spread beyond the upper tissue layer (surface epithelium) of your cervix into the underlying connective tissues, you have invasive cervical cancer. A Pap test followed by a biopsy can determine whether that has happened. At first the spread is very shallow and may not involve the lymph or blood circulation systems.

For invasive cervical cancer, most physicians recommend a hysterectomy with removal of lymph nodes in the pelvis. If the cancer has spread into the lymph or blood vessels, doctors usually suggest radiation or hysterectomy plus removal of the ovaries. Sometimes a combination of the two is used (chemotherapy is not as effective as local radiation). Recently, there have been efforts to find fertility-sparing surgeries for cervical cancer.

You should be involved in your treatment and have the final say in all decisions. If you have any doubts about treatments recommended by your health care provider, try to get second and third opinions.

Ovarian cysts are relatively common and may result from normal ovulation. They develop when a follicle (the fluid-filled sac that nurtures a developing egg) has grown large but has failed to rupture and release an egg. Often, cysts don't cause any symptoms or discomfort, but you may experience a disturbance in the normal menstrual cycle, an unfamiliar pain, or discomfort on one side in the lower abdomen. Pain during intercourse is another symptom. Cysts are sometimes found by a routine bimanual pelvic exam, then diagnosed with ultrasound. Often
they disappear by themselves, though some types may have to be removed.

To determine whether a cyst requires treatment, wait a cycle or two for it to disappear. If it persists, a medical practitioner may use ultrasound to monitor it. Practitioners disagree about whether removing benign cysts is necessary, but small ones do not usually cause problems and may be left alone.

A large cyst is more of a health risk because it can rupture, causing severe abdominal pain and sometimes bleeding. A large cyst may also twist and damage the blood supply to the ovary. These two uncommon situations require prompt surgery. Pathological cysts, such as a dermoid cyst or a cyst of endometriosis, should usually be removed.

If your physician advises removal of the ovary along with a benign cyst, get a second opinion. Removing the ovary, though a conventional practice in the past, is unnecessary in many cases. Ovaries perform many functions, even after menopause.

Recurrent cysts may indicate a hormonal imbalance and/or life stresses. Changing your diet, learning how to reduce stress, and using acupuncture may also help to get your system back in balance.

Cancer of the ovaries accounts for only 3 percent of all cancers in women in the United States. About 22,000 cases were estimated for the year 2010 (with about 14,000 deaths expected). It is the ninth most common cancer among women in this country, but it is the deadliest among gynecologic cancers. Most ovarian cancer occurs among midlife and older women; more than half of all women diagnosed with ovarian cancer are over age sixty.

The exact causes of ovarian cancer are still unknown. Possible risk factors include a family history of ovarian cancer; few or no pregnancies; the use of fertility-stimulating drugs; a history of breast, colorectal, or endometrial cancer; exposure to industrial products, including asbestos, or to high levels of radiation; a diet high in fat; and the use of estrogens other than the birth control pill. (In one large study, the risk of developing ovarian cancer was higher in women who used menopausal hormone therapy than in women who never used such therapy, but the increased risks varied by type of hormone and regimen, as well as by whether a woman had had a hysterectomy).
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Using talcum powder in the genital area has long been suspected as a risk factor, but so far evidence points to an elevated risk for only one type of relatively rare ovarian cancer. Oral contraceptive use is protective against ovarian cancer, as is having multiple pregnancies. Having a tubal ligation also appears to reduce risk.

One reason the death rate is so high is that most ovarian cancer is found in the later stages, when it is harder to treat effectively. When it is found early, about 90 percent of the women treated survive at least five years.

Ovarian cancer does not always have clear symptoms. Its warning signs—which may be vague and are frequently dismissed as stress or nerves—include indigestion, gas, bowel disturbances, loss of appetite or weight, a feeling of fullness, enlargement or bloating of the abdomen, lower abdominal discomfort or pain, unexplained weight gain, frequent urination, fatigue, backache, nausea, vomiting, nonmenstrual vaginal bleeding, or pain during intercourse. Most of these are relatively common complaints in midlife women.

If you have persistent symptoms or a family history of ovarian cancer, your gynecologist
should do a thorough evaluation. In some cases, you may need to be referred to a gynecological oncologist, who specializes in cancer diagnosis and treatment. The screening tests now available for ovarian cancer are not very accurate, so there is still no good routine testing method for women with no symptoms and no risk factors. A blood test for a protein called CA-125 is not enough to diagnose ovarian cancer, because many other conditions can also raise the level of CA-125 in the blood; therefore, it needs to be used in combination with other tests.

Diagnostic tests for cancer of the ovaries include pelvic ultrasound, computerized tomography (CT or CAT scan), magnetic resonance imaging (MRI), and surgery, the only conclusive diagnostic tool. Exploratory surgery (laparotomy) is used for diagnosis, staging, and, frequently, tumor reduction. (For more information on stages and different types of ovarian cancer, including borderline tumors not likely to become malignant, see Recommended Resources.)

About 5 to 7 percent of ovarian cancer cases are associated with an inherited risk factor, and removal of an ovary or ovaries (
oophorectomy
) has been shown to be an effective way to avoid breast cancer in women who carry a BRCA1 or BRCA2 gene mutation. Discuss all the benefits and harms of a prophylactic oophorectomy with your health care provider.

Early detection, prompt diagnosis, and accurate staging are necessary for the successful treatment of ovarian cancer. Treatment depends on the stage of the disease at the time of diagnosis, the type of cells that make up the tumor, and how fast the cancer is growing. The current standard medical options for treating ovarian cancer include surgery, chemotherapy, and/ or radiation. Immunotherapies, including interferon, interleukin, bone marrow or stem cell transplants, and monoclonal antibodies, are also available in clinical and/or research settings.

New cancer therapies often become available to patients through clinical trials. Information about some of these investigational treatments is registered with the National Cancer Institute (cancer.gov). Many women also explore supplemental or alternative treatments, alone or in conjunction with mainstream treatments. More research is still needed to better understand the causes of ovarian cancer and to find more effective diagnostic tests and treatments.

I had been complaining of the same problem—pain in my lower right abdomen—for a couple of years. I had severe menstrual irregularities, fevers, bleeding between periods, bleeding after intercourse, pains, and general malaise. Several times I was treated with antibiotics, which brought only some temporary relief. Never was the issue resolved as to what was causing this. Never were my sexual partners or practices mentioned
.

Pelvic inflammatory disease (PID) is a general term for an infection that affects the lining of the uterus (endometritus), the fallopian tubes (salpingitis), and/or the ovaries (oophoritis). It is caused primarily by sexually transmitted infections that spread up from the opening of the uterus to these organs (see
Chapter 11
, “Sexually Transmitted Infections”). Nearly 1 million women in the United States develop PID every year, and 300,000 women are hospitalized for it.
This may be a low estimate, because PID is underdiagnosed.

The primary symptom is pain in the lower abdomen. It may be so mild that you hardly notice it, or so strong that you may not even be able to stand. You may feel tightness or pressure in the reproductive organs, or an occasional dull ache. Part of the reason PID is so underdiagnosed is that women may also have some, most, or none of these other symptoms: abnormal or foul discharge from the vagina or urethra, pain or bleeding during or after intercourse, irregular bleeding or spotting, increased menstrual cramps, increased pain during ovulation, frequent or burning urination, inability to empty the bladder, swollen abdomen, sudden high fever or low-grade fever that comes and goes, chills, swollen lymph nodes, lack of appetite, nausea or vomiting, pain around the kidneys or liver, lower back or leg pain, feelings of weakness, tiredness, depression, and diminished desire to have sex.

The intensity and extent of the symptoms depend on which microorganisms are causing the problem, where they are located (uterus, tubes, lining of the abdomen, etc.), how long you have had PID, what if any antibiotics you have taken, and your general health. Doctors characterize PID as acute, chronic, or silent (when symptoms are not noticeable).