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Female doctor in Durban

Dr H Ganesen( MBCHB, MMed Fam Med) 

Cervical cancer and pap smears

I find that most women have never had a pap smear.  It is most alarming to hear that most young women do not know what a pap smear is.  Reasons for not doing a pap smear commonly encountered include:

  1. I cannot afford to see gynaecologist
  2. I have no time to see my gynaecologist
  3. I am afraid it will be too painful.
  4. I have only one partner currently so why should I do it?
  5. I am in a same sex relationship so I do not need to do pap smears.
  6. I am not sexually active currently so why do I need a pap?
  7. I will start doing pap smears when I have children.

 

Financial limitations

You do not have to see a gynaecologist to do a pap smear.  Most primary health care doctors do this simple procedure in their rooms.  It takes me less than 3 minutes to collect the pap smear sample.  The cost of collecting the sample in included in our consultation fee of R490 for 2017.  However you need to pay an additional R155.00 ( in cash and not via card payments, to be sent to the lab directly as of 2017 rates) for the laboratory fees.  Most medical aids including Discovery, Medihelp Necesse, Momentum Ingwe, will pay for an annual pap smear for every female member older than 18.  This is not from your day to day savings.

 

The procedure

It is a simple procedure.  It is ideally done mid cycle.  Do not come book for a pap if you are menstruating.  Do not douche ( i.e. wash the inside of the vagina with water or other female hygiene products) on the day of the pap.  Ideally do not have sexual intercourse the night before the pap smear.

You will be expected to undress.  A speculum is inserted into the vaginal.  I special brush is used to brush the cervix.  The brush with sample tissue is sent to the lab for analysis.  It is not a painful process.  However it is uncomfortable having the speculum inserted.

 

It takes 3 working days to receive the result of the smear.  Results will be emailed to patients.

The following video outlines the actual procedure.  Please note, all pap smears are performed by Dr Ganesen herself, and not by an assistant.

 

Frequently asked questions related to Pap smears, HPV and Cervical cancer.

What is Cervical cancer?
 

Cervical cancer affects the mouth or the part of the womb that opens to the vagina ( called the Cervix).

 

When should I do a pap smear?

The 2017 South African guideline recommend that screening for cervical cancer should begin by age 25 or at the time of HIV positive diagnosis.

 

 

HIV negative female

HIV positive female

Initiate screening

Start at age 25* or within 3 years of onset of sexual activity

At the diagnosis of HIV

When to stop screening ( only if the last test was negative)

Age 65 or after a hysterectomy

Not to stop screening

Interval if HPV screening done

5 yearly

3 yearly

Interval if pap smears done

3 yearly

1 yearly

*Some guidelines recommend age 21.

Source: South Afr J Gynaecol Oncol 2017;9(1):8-12

What is a CIN lesion?

A CIN lesion means “cervical intraepithelial neoplasia”. This means that the skin of the cervix has become abnormal and that if this condition is left untreated over time this abnormality will become worse and develop into cervical cancer. CIN is an early warning lesion of cancer. It can be detected on Pap smears and can be treated effectively. This will prevent the development of cervical cancer in most instances.

What is HPV infection?

HPV stands for “human papillomavirus”. HPV infection is common in sexually active persons. It is usually harmless and disappears on its own as the body eliminates the virus.

More than 100 HPV genotypes are known. More than 40 infect the anogenital tractThere are many types of HPV but only a few types can lead to cervical cancer. These are called “high-risk types” and spread through sexual contact. Types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82 have been linked to cervical cancer. Some genotypes have been identified as of intermediate risk namely 23, 53 and 66. The low risk HPV types cause genital warts but not cancer.  If a high risk HPV type does not disappear on its own it can lead to the formation of abnormal cells in the skin of the cervix leading to a CIN lesion or later to the development of cervical cancer. In such cases treatment must be offered. It is known that HPV type 16 alone causes about two-thirds of all cervical cancers worldwide.

HPV can be found in the genitalia of the large majority of sexually active persons at some stage in their lives. As the infection is mostly temporary most women will not have any HPV by the age of 30 to 35 years.

Who is at risk and can get HPV and CIN?

All persons, male and female, who have been sexually active can get HPV infection. About three out of every four persons are estimated to have HPV infection at some stage in their lives, usually when quite young (late teens and twenties). Women who start with sexual activity at a young age, who have several sex partners or whose partners have or had several partners are at increased risk for having HPV infection.

It is now known that almost all cervical cancers are caused by HPV. Women who are at risk for HPV infection are therefore also at risk for cervical cancer if the HPV infection is of a high-risk type. The cervical cancer risk is increased by other factors such as smoking and HIV infection. As Pap smear and other screening tests for CIN and cervical cancer are very important in the early detection of abnormality. Women who have had no such screening tests are at the highest risk of all.

How is HPV diagnosed?

HPV infection rarely causes symptoms. Infection with a high-risk HPV type will lead to abnormalities in the cells covering the cervix that can be detected on special HPV tests and on Pap smear testing. Only a small number of women with HPV will develop cell changes. We order an additional HPV test on the same pap smear sample sent to the lab.  The cost of HPV testing from Lancet Laboratories in 2017 is R490.00.

 

What are the symptoms of HPV infection?

Initially there are no symptoms associated with the HPV infection that causes cervical cancer.  However once the infection causes cancerous changes in the cervix a persistent vaginal discharge may develop.

 

Can HPV infection be treated?

There is no treatment against the HPV itself. However there is a vaccine available for young girls to prevent them from contracting HPV. Currently the vaccine can be taken by women aged 26 and younger.  If the cervical cells have undergone changes and have become abnormal those areas on the cervix can be treated.

Who should be tested for HPV infection?

The HPV tests are used to detect high-risk types of HPV. It can be used with most success in women over the age of 30 in many cases together with Pap smears. In women younger than 30 years HPV is quite commonly present and in the large majority it will be eliminated. To do HPV testing on young women does not contribute much to her gynaecologic management.

Where did I get this HPV infection?

HPV is spread through sexual activity. The HPV can be dormant or resting for a short to very long period before causing cellular abnormalities. It is not possible to link HPV infection to a specific episode or time.

Can HPV infection go away on its own?

In the majority of women HPV infection is transient and will be eliminated by the immune system of the body. HPV infection may persist especially after age 30 years or older.

Can I do other things to help HPV disappear?

Yes: stop smoking as this can increase the risk for development of cellular abnormalities on the cervix. Maintain good sexual health and take care of your relationships.

What is the difference or relationship between HPV and HIV?

HIV is also a virus: the human immune deficiency virus. This is currently a massive health care problem especially in developing countries but also worldwide. It is linked to the development of AIDS. It is very different from HPV. Persons who get HPV infected and who are also HIV infected may have a more serious outcome of the HPV infection. Like HPV, HIV is transmitted sexually.

Does my partner need to be tested for HPV?

If you have a positive HPV test showing that you have infection with HPV it is absolutely likely that your partner will also have HPV infection. As most HPV infections are transient and tend to disappear it will not always be the case that both partners test positive. As there is no treatment against HPV testing the partner does not contribute to management. As condom use offers incomplete protection partner HPV testing will not influence this practice either.

Do we have to use condoms now, and for how long?

As HPV infection is common condom use will not be total prevention. If you had treatment it is not certain (but possible) that condom use may decrease the risk of recurrent infection.

After treatment can I be re-infected by my partner?

If a couple only has sexual relations with each other HPV will not be passed back and forth. Further contact with the same virus will not make it more difficult for either the HPV infection to go away or for cellular changes to be treated. Once a person has formed immune reaction to a specific HPV type a next exposure may be eliminated. There are however many HPV types and a person can get re-infected with another HPV type.

Can I still get pregnant if I am infected with HPV?

HPV does not cause infertility. There are many reasons for infertility and this may include other sexually transmitted infections.

How will it affect my baby and my pregnancy if I am infected with HPV?

HPV infection does not influence the course of the pregnancy. If a person has genital warts (low-risk HPV infection) these may increase in size during pregnancy. If a baby is born from a mother with extensive genital warts there is a possibility of infection of the newborn.

Does it affect other organs and can it spread?

HPV infection can also affect the vulva and the vagina and it is possible that HPV infection can spread from the cervix to these organs. It can be detected during clinical examination.

Source: https://www.sasog.co.za/Guidelines/HPVAdvisory