Women's Bodies, Women's Wisdom (59 page)

The Pap smear, a screening test for abnormal cervical cells, is taken from the opening in the center of the cervix, where the squamous cell covering of the outer cervix meets the inside of the cervical canal. (
Squamous
refers to a flattened type of epithelial cell that covers mucous membranes of the body— for example, inside the vulva, vagina, and mouth.) This area is known as the
squamocolumnar junction
(SCJ), a very dynamic location in which the mucus-producing endocervical gland cells are constantly changing into the tougher squamous cells. As a result, the normal secretions from the endo-cervix sometimes get trapped, causing mucus-filled cysts (nabothian cysts). These feel like little bumps on the cervix and can sometimes grow to one or two centimeters in diameter. Though many women who feel these bumps think they have an abnormality, they are completely normal and don’t require treatment.

In some women and most teenagers the SCJ is located way out on the outer part of the cervix, with the inner, redder-appearing cells of the endocervix extending outward onto the cervix. In the past many physicians have confused this normal anatomy with pathology, referring to this red glandular area out on the cervix as “cervical erosion” or “chronic cervicitis.” Many women have had normal cervical tissue cau terized because of this misunderstanding.

At this time in our history, chronic vaginitis, sexually transmitted diseases such as venereal warts and herpes, and abnormal Pap smears (also considered a sexually transmitted disorder) are virtually epidemic. These disorders can affect the vulva, vagina, and cervix all at the same time. And because the urethra and bladder are contiguous to this area, they are often affected as well. Though these disorders are often blamed on certain viruses, countless women who do not develop symptoms also have these same viruses present in their bodies.

Gynecologists work right in the middle of women’s most secret and painful issues. To be healers, they must recognize that a woman’s sexual vulnerability often hovers around her gynecological exam. When a woman is diagnosed with a sexually transmitted disease or has an ab normal Pap smear, all her fears, beliefs, and misconceptions about her sexuality and body may well come up. It’s vital for healers to be sensitive to these emotions and help their patients articulate their dis tress and grief, as well as their questions. If you do not think that your feelings about an exam or diagnosis are being treated with concern, tell your practitioner that your feelings are important to you and that you’ve learned to respect them as a necessary key to eventually under standing yourself better. Ask her or him for help and compassion during the pelvic exam. Though strong emotions may occur during a pelvic exam, don’t expect your practitioner or yourself to know exactly why at the moment they first arise. Simply stay with what you are feeling, with the intent to heal the situation. Then relax and allow the healing to come, by turning the situation over to your inner guidance. Eventually, when you are ready, you will get the insight you need about the situation.

A Healing Pelvic Exam

A pelvic examination is an ideal time to become acquainted with your lower genital tract in a positive and healthy way. Here’s how: Ask your health care provider to push the back of the exam table into an upright position so that you can watch the entire exam. Ask him or her to explain to you exactly what they are examining and why. If you are nervous about the exam, request that your health care provider tell you what he or she is about to do—and get your permission before proceeding with each subsequent step of the exam.

A pelvic exam begins with close examination of the labia majora (the large outer lips) and then the labia minora (the small inner lips) of the vulva. The urethral opening and clitoris are also examined and so is the perineum— the area between the vagina and the anus. It’s a good idea to ask for a mirror so that you can see these parts of your body and recognize exactly what “normal” looks like. After that, a warmed speculum is inserted into the vagina and opened so that the vaginal side walls and the cervix can be seen. (It should be routine for the doctor to use a warmed speculum. But we have a ways to go—when my daughters had their first pelvic exams by a female gynecologist in New York City several years ago, both the speculums and the doctor were very cold!) Many different speculum shapes and sizes are available, so this part of the exam should be comfortable. Your doctor can also show you what your cervix looks like and where the Pap smear is taken.

The part of the exam before the speculum is the perfect time to learn where your PC muscle is and how to contract it. Your health care provider can point out the muscle and then teach you exactly how to contract it. He or she will usually put one gloved finger in the vagina so you can tighten around it. Contracting and releasing the muscle several times before the speculum is inserted makes this part of the exam much more comfortable. After the speculum exam is completed and the Pap smear is taken from the cervix, the speculum will be removed and your doctor will do what’s called a “bimanual” exam, meaning that he or she will insert one or two fingers in your vagina and, with the other hand, palpate your lower abdomen above the pubic bone in order to feel the uterus and ovaries. This will be followed by a rectovaginal exam with one finger in the vagina and one in the rectum to feel the area behind the uterus. This part of the exam is simply not comfortable, though it doesn’t cause pain.

It’s perfectly acceptable for you to ask that the exam be stopped be fore it is complete. Some women with a history of trauma or adverse childhood programming about their genitals may find that going through a complete exam is too much for them until they get to know their practitioner better and feel more comfortable. This is fine. Many women feel uncomfortable during pelvic exams. But as you learn to accept and appreciate your lower genital tract, and also to contract and relax your PC muscle at will, you will be well on your way toward better gyn health and also sail through your pelvic exam!

HUMAN PAPILLOMA VIRUS (HPV)

Human papilloma virus (HPV) is a very common virus with more than a hundred different DNA subtypes that can cause venereal warts and cervical dysplasia. It is associated with abnormal Pap smears. The Centers for Disease Control and Prevention estimates that 20 million Americans are currently infected with this virus, with an additional 6.2 million people becoming newly infected each year. At least half of all sexually active Americans will become infected with HPV at some point in their lives. For the vast majority of women, this viral infection will spontaneously clear from the immune system within one to two years without any symptoms at all. Others will develop warts or cervical dysplasia. And some who have been exposed to certain high-risk subtypes of HPV will be at risk of developing cervical cancer.
¹⁰

The DNA of HPV has been found in the cells of virtually all abnormal Pap smears and cervical cancers. In March 2009, the FDA announced approval for the use of two new HPV DNA diagnostic tests. The first test is designed to identify thirteen types of HPV that have been associated with cervical dysplasia. It’s called Cervista HPV HR. The other detects only HPV 16 and 18 and is called Cervista HPV 16/18. These tests are available through the manufacturer of the ThinPrep Pap test.
¹¹
Though these tests have their place (see below), here’s what all women should know: The majority of women who have been exposed to even the most viru lent strains of HPV do
not
get cervical dysplasia. HPV should be thought of as an important risk factor for cervical dysplasia but shouldn’t be seen as the single cause of it.

We don’t really know, in a conventional sense, who will develop abnormalities from the virus and who won’t, unless we look at the factors that can contribute to decreased immunity. Abnormalities start to grow and cause damage only when the immune system has already been weakened in that area of the body and is unable to maintain the health of the tissue. The good news is that even though HPV is quite common in women under thirty, it usually clears up by itself in six to eight months. Because of this, the American College of Obstetricians and Gynecologists recommends HPV-DNA screening only in women age thirty and over. And this doesn’t need to be done regularly. (See Pap smear recommendations on pages 284–288.)

Chronic stress and specific attitudes about sex actually change the blood flow to cervical tissue and affect its secretions. Studies suggest a link between stress and the subsequent development of disease in this area of the body.
¹²
Suppression of the immune system as a result of chronic emotional or other stress can lead to changes in immunity that allow increased virus production in the first place. The link between ab normal Pap smears and deficient immune system functioning is well known: Women who have organ transplants and are on drugs that suppress the immune system (such as prednisone) have a much greater chance than normal of developing abnormal Pap smears. They also frequently have recurrent wart and herpes outbreaks. (Emotional reactions to the diagnosis of venereal warts can be similar to those that accompany a diagnosis of herpes. If you have concerns about either condition, please read through both sections.)

If our bodies are a hologram in which each part contains the whole (see
chapter 2
), then the HPV virus and the abnormal cells associated with the virus are two interrelated aspects of a greater whole that is not as yet entirely understood. For a variety of reasons, depressed immunity makes it much more likely that any HPV present on the cervix or in the vagina will attack already weakened cells. I think of the HPV virus as an opportunist at the scene. The virus doesn’t “cause” cervical dysplasia, and it doesn’t “cause” cervical cancer, either. Most women who have the HPV virus don’t go on to develop cervical cancer, because most viral activity and infections are halted by good immune functioning. But in about 10 percent of women with high-risk HPV on their cervix, the HPV infections will be long-lasting and will put them at risk for cancer.

Symptoms

Most women with HPV have
no
symptoms. In those who do, the most common symptom is warty growths (condylomata acuminata) on the outside of the vulva that are painless but can be seen and felt. These can grow and multiply during pregnancy, when the hormones associated with pregnancy stimulate their growth. They often disappear on their own following delivery, when the hormones once again change. Warts can vary in appearance from plaque-like growths to pointy, spiky lesions. Some women have only a few, while others have many all over the vulva. The virus can also cause warty growths on the tongue, the lips, and in the throat, though these sites are rare. Sometimes a woman has no obvious warts on the vulva but has them in the vagina or on the cervix. She may not be aware of these.

HPV infection is sometimes associated with chronic vulvar pain, chronic vaginitis, and chronic inflammation of the cervix (cervicitis). A vaginal discharge is usually not present, although it can be. Because some women have HPV infection in association with vaginal infections from yeast or from an imbalance in the vaginal flora known as bacterial vaginosis, it is not always possible to tell exactly what virus or bacteria is causing what symptom. Unless a woman has actual warty growths on her vulva or has chronic vulvar or vaginal irritation associ ated with HPV, she won’t know that she has it.

Diagnosis

Warty growths on the vulva, vagina, or cervix and abnormal cells on a Pap smear or cervical biopsy are usually associated with HPV. If these appearances are a first occurrence, a biopsy is taken and sent to the lab to confirm the diagnosis. Sometimes HPV is diagnosed by a colposcopy, an examination of the cervix and vagina through a magnifying lens, or a cervigram, a screening test in which a photograph of the cervix is made after applying dilute acetic acid (vinegar) to the tissue. When vinegar is applied to the vulva, cervix, or vagina and HPV is present in the tissue, the tissue often turns white. (This tissue is then called acetowhite epithelium, or white skin cells.) Biopsies of the white area often reveal HPV.

Common Concerns About HPV

Why Do So Many Women Have It?

HPV has probably always been present in the human genitals. You can certainly find it on old slides of Pap smears from more than forty years ago. Back then, HPV simply wasn’t recognized or studied as much as it is today. Several factors have contributed to its more frequent diagnosis now. One is the advent of colposcopy, a diag nostic technique developed in the 1970s as a follow-up to abnormal Pap smears. If any abnormal areas show up under examination by colposcopy, biopsies of those areas of the vagina or cervix will be done for further evaluation in the lab. (See page 289 for more details.) Because colposcopy and follow-up biopsies have allowed us to diagnose cervical ab normalities in their earlier stages, pathologists are now more likely to make the connection between cellular changes and HPV.

The sexual revolution and multiple sexual partners have increased the number of women who have been exposed to the HPV virus. Condoms don’t always prevent the transmission of HPV because the virus can exist in areas other than the pe nis, such as the scrotum; they do help, however. And monogamy is no guarantee against HPV if your partner is not monogamous, too. Of course, even if you are both monogamous, you could have been exposed to HPV by past sexual partners. Factors implicated in HPV leading to abnormal growths include a depressed immune system from suboptimal nutrition, emotionally unhealthy relationships, excess alcohol, and cigarette smoking. Therefore, it’s not simply the viruses from our past sexual partners that we bring to our current sexual partners. We also bring our current state of emotional health, which in part determines whether those viruses will become active.

How Did I Get This? Who Gave It to Me?