Endometriosis is a condition which usually affects women in their childbearing years and can lead to pelvic pain and infertility. Endometriosis consists of clusters of endometrial cells (the cells which form the lining of the uterus and are shed each month with menstruation) growing outside the uterus. These clusters of endometrial cells, or implants, can be found most commonly in the pelvis including the ovaries, fallopian tubes, and the surface of the uterus. They can also be found on the intestine, upper abdomen or in other parts of the body such as the lung. Because endometriosis cells are subject to the same monthly hormonal changes that normal endometrial cells are, but cannot be shed, this can lead to scar tissue, cysts, and pain. Women who have endometriosis may have a higher risk of developing ovarian cancer. This risk has been difficult to quantify and the mechanism of this elevated risk is unknown.
It is estimated that endometriosis affects over one million women in the United States, and most cases are diagnosed in women between 25 and 35 years of age. However, because many women have no symptoms, the exact prevalence is unknown. The condition is uncommon in postmenopausal women. Other risk factors for endometriosis include being Caucasian (compared to African American and Asian), being tall and thin with a low body mass index, being infertile and delaying pregnancy until older ages.
We do not know the exact causes of endometriosis, but there are several theories. It is thought that estrogens contribute to the formation of endometriosis. Other possible causes of endometriosis include: retrograde menstruation – when endometrial tissue is deposited in strange locations because of menstrual flow that backs up into the fallopian tubes and abdominal cavity, immune system problems – causing the body to not recognize and destroy cells or tissue that is growing where it should not be, and cellular metaplasia – the cells of the areas lining the pelvic organs have certain cells that can grow into other forms of tissue such as endometrial cells.
Many women will have no symptoms of endometriosis, and the amount of the endometriosis does not correlate with the degree of symptoms. The predominant symptom of endometriosis is pain. Endometriosis associated pain may be located in the pelvis, lower abdomen, rectum, vagina, or lower back. It may vary with different points in the menstrual cycle. It may also occur during sex, bowel movements, ovulation, or all the time. Abnormal bleeding is also a symptom of endometriosis. Heavy periods, spotting or bleeding between periods, bleeding after sex, or blood in the urine or stool can occur as a result of the condition. Infertility can also be caused by endometriosis. Disrupted bowel habits such as constipation or diarrhea can also occur.
In order to diagnose endometriosis, a thorough medical history and physical examination will be taken in order to ascertain for the symptoms of the condition. Some health care practitioners will prescribe medical treatments for endometriosis; an improvement in symptoms after medication usually indicates that the problem was endometriosis. Imaging tests, such as ultrasounds, magnetic resonance image (MRI) tests, and CT scans also may be employed However, endometrial implants will many times not show up on even the most sensitive of imaging tests. The only way to truly diagnose endometriosis is through directly evaluating the abdominal and pelvic cavity. This most commonly accomplished through the use of laparoscopy, which is minimally invasive or “belly button” surgery. Biopsies are usually taken in order to rule out other conditions such as ovarian cancer.
Treatment options consist of medical treatments and surgical treatments. The route of treatment will depend on the goal of the woman and can differ if the woman wants to get pregnant or is focused on treating pain. Medical treatments include pain medicines such as NSAIDs (non steroidal anti inflammatory), birth control pills, hormone therapy such as GNRH (gonadotropin-releasing hormone analogs) such as Lupron, Danazol and progestins, and aromatase inhibitors. Many of the medical treatments provide only temporary relief while they are being utilized and can have side effects. Some, like Lupron, can only be used for a limited period of time due to their side effects of bone loss. Surgery may be an option chosen for some women who are attempting to get pregnant or in which medical management has failed. This may consist of ablation techniques or accomplished by excision techniques. This form of surgery, when conducted properly, is quite complex and a gynecologic surgical sub-specialist is encouraged to be consulted. The ovaries and uterus may also be recommended to be removed for some women. This type of surgery, while may be successful in the short run for relieving the symptoms of endometriosis, may not provide long-term pain control for all women,
Take home message:
Endometriosis may be a cause of unexplained pelvic pain, abnormal bleeding, or infertility.
Endometriosis is not an uncommon problem in women.
Diagnosis is usually made on the basis of symptoms and laparoscopy may be used.
Treatments may be either medical or surgical.
If surgery is being entertained as a treatment option, in order to assure that you have the best outcome, consult and expert gynecologic surgeon.
Posted: August 8th, 2010 | Author: drpoynor | Filed under: endometriosis, general health, gynecology | Tags: reviews | No Comments »
First, take a deep breath and realize that if your Pap smear is abnormal it does not mean that you have cancer and that you are not alone. About 55 million Pap tests are performed each year in the United States. Of these, approximately 3.5 million (6 percent) are abnormal and require medical follow-up.. The Pap smear samples cells which are on the surface of the cervix and these cells are looked at underneath the microscope. The procedure is named after the doctor who first discovered that cervical cells changed before cancer of the cervix develops, Dr. George Papanicolaou. Cells on the surface of the cervix sometimes appear abnormal but are very rarely cancerous. The Pap smear was designed to pick up abnormal cells before they have a chance to become cancerous and having regular Pap smear tests and appropriate treatment and follow-up of abnormal results, significantly reduces the chance that cervical cancer will ever develop. Prior to the introduction of the Pap test, cervical cancer was a leading cause of cancer death in women, and still is in some parts of the world. Since the introduction of the Pap test, deaths caused by carcinoma of the cervix have been reduced by up to 99% in some populations where women are screened regularly. A healthcare provider may simply describe Pap test results to a patient as “abnormal.” It is important to remember that abnormal conditions do not always become cancerous, and some conditions are more likely to lead to cancer than others.
The cells of the cervix may be abnormal due to infection, lack of estrogen in older women, or precancerous changes. Although the Pap smear is not designed to reliably pick up abnormal cells from sources other than the cervix, some abnormal Pap smears may be due to vaginal, endometrial, fallopian tube, ovarian, or rectal abnormalities. Breast cancer cells have even been found in Pap smears, although quite rarely. The vast majority of precancerous changes in the cervix are due changes in the cells that cover the outer surface of the cervix, the squamous cells. Some precancerous changes will be due to the cells lining the inner portion of the cervix, called glandular cells. If any unusual cells are detected, further tests are done to determine if treatment is needed. This is the best way to find out if cancerous or precancerous cells are present.
Precancerous changes in the squamous cells of the cervix are referred to as cervical dysplasia or cervical intraepithelial neoplasia (CIN). If these type of changes are detected on your Pap test, they will be graded as mild (CIN 1), moderate (CIN 2), or severe (CIN 3). CIN 1 is also referred to as a low-grade squamous intraepithelial lesion (LGSIL) and CIN 2 and CIN 3 are referred to as a high-grade squamous intraepithelial lesions (HGSIL). Any of these changes require further discussion and evaluation with your health care professional.
We know understand that virtually all precancerous and cancerous changes in the cervix are due to the human papilloma virus (HPV), a very common, sexually transmitted virus. HPV infection is the primary risk factor for cervical cancer, however only a very small percentage of women with untreated HPV infections develop cervical cancer. Approximately 80% of women will become infected with the HPV virus in their lifetime and many times there are no associated signs or symptoms other than an abnormal Pap smear. About 6 million new genital HPV infections occur each year in the United States. HPV may also cause vulvar, vaginal and rectal cancers. In most cases of HPV infection, the immune system quickly attacks the virus, and it is cleared from a woman’s system. For other women, the immune system does not rid the body of the virus, and a small number of these women will develop CIN. The development of CIN is more likely to occur in older women who have had HPV for a long time. Women who smoke and have HPV face twice the risk of developing CIN than women who do not smoke. The good news is that if you have regular Pap smear tests and appropriate, regular follow-up, it’s unlikely that cervical cancer will develop.
The most common system for describing Pap smear test results is the Bethesda System. The Bethesda System uses a number of terms to relate the results. Squamous intraepithelial lesion (SIL) describes precancerous changes in cervical cells. Using this system, your Pap smear test results may be:
- Normal
- Atypical squamous cells of undetermined significance (ASCUS) This is the most common abnormal Pap smear test result indicating the presence of cervical cell changes. This term simply means that the squamous cells of the cervix appear unusual and cannot be further categorized. These changes may be due to infections, thinning of the cervix and vagina in women who have low estrogen levels, or precancerous or cancerous changes.
- Squamous intraepithelial lesion (SIL) This term describes abnormal cervical cell changes that may be a sign of precancer. SIL is either low grade (LGSIL) or high grade (HGSIL). LGSIL or HGSIL refers to the grade of dysplasia and CIN. LGSIL is indicative of either the presence of HPV or mild precancerous changes; this is a common type of abnormal Pap smear result. HGSIL, on the other hand, indicates more serious cervical cell changes.
- Atypical squamous cells, cannot exclude HGSIL (ASCH) This Pap smear test result means there is uncertainty about whether HSIL is present.
- Atypical glandular cells (AGC) This term implies precancerous changes to the upper cervix or uterus.
- Cancer Hopefully, you will never get this result from your Pap smear. Having regular Pap smear tests can almost guarantee that you will never get a result of cancer
- Endocervical and endometrial abnormalities can also be detected, as well as a number of infectious processes, including yeast, herpes simplex virus, and trichomonas.
What next?
Make sure that you review results with your health care professional. Many times, this will mean a trip to the office to review the meaning of an abnormal Pap smear and review recommendations for treatment.
Not all abnormal Pap smear test results require other tests and sometimes observation and closer surveillance will be recommended. The important thing is that you follow recommendations after having any type of abnormal Pap smear test result. In some instances, further investigation of the cervix with colposcopy will be recommended.
If the Pap test shows an ambiguous or minor abnormality, the healthcare provider may repeat the test to determine whether further follow-up is needed. Many times, cell changes in the cervix go away without treatment. In some cases, healthcare providers may prescribe estrogen cream for women who have ASC–US and are near or past menopause as these cell changes are often caused by low hormone levels. Applying an estrogen cream to the cervix for a few weeks can usually help to clarify the cause of the cell changes.
If the Pap test shows a finding of ASCUS, ASC–H, LGSIL, or HGSIL, the healthcare provider may perform a colpsocopy. A colposcope is a microscope that provides a closer view of the cervix. The colposcopic exam is similar to a regular pelvic exam and should only take a few minutes to perform. Anesthesia is not required.
Dilute acetic acid (vinegar solution) is placed in the vagina to help determine of there are any abnormal areas, they turn white and may be refereed to as aceto-white lesions. The colposcopy itself is painless, however if abnormal areas are seen, then very small (2-3mm) pieces of tissue may be removed in the form of a colposcopically directed biopsy. This may lead to a small about of pain, cramping and bleeding which usually rapidly resolves. This cervical tissue is then sent for laboratory evaluation. These biopsies cause no long-term damage to your cervix. Endocervical sampling may also be performed, which is a scraping from the inside of the cervix. This may also lead to cramping and spotting.
If the testing shows abnormal cells that have a high chance of becoming cancer, further treatment is needed. Treatment options include the following: LEEP (loop electrosurgical excision procedure) is surgery that uses an electrical current which is passed through a thin wire loop to act as a knife and is a larger cervical biopsy, CO2 laser which uses a narrow beam of intense light to destroy or remove abnormal cells, or conization which removes a cone-shaped piece of tissue using a knife, a laser, or the LEEP technique.
Summary:
Take a deep breath, the vast majority of abnormal Pap smears do not indicate the presence of cancer.
Follow your healthcare providers recommendations for treatment and follow-up.
Treatment of abnormal Pap smear test results depend on the type of cervical changes seen, the age of the women, and other individual circumstances.
With appropriate treatment, cervical cancer can be prevented in the vast majority of the time.
Resources:
http://www.cancer.gov/cancertopics/factsheet/Detection/Pap-tes
http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
http://www.cancer.gov/cancertopics/understandingcervicalchanges
Posted: June 19th, 2010 | Author: drpoynor | Filed under: cancer diagnosis & treatment, cancer prevention, general health, gynecology | Tags: abnormal Pap smear, cancer prevention, cervical cancer, Pap smear | 3 Comments »
Why should I care about this? The FDA does not currently require health studies or pre-market testing for cosmetic products before they are sold. We live in a world where most of us enhance beauty and daily living through the cosmetics and pharmaceutical industries, and many women use a lot of these products. The typical person uses up to an average of 9 personal care products with as many as 126 unique chemical ingredients, applied to the skin daily. I am a child of this more is more world. Until recently, I routinely used all the latest fragrances, hair dyes, skin care products and cosmetics. This began to change when I had a child. I necessarily made myself aware that environmental exposures early in life can have potential devastating consequences. One example is lead exposure in young children, which can lead to lifelong developmental and behavioral deficiencies. I was also made aware of the dangers of heating plastic bottles and containers. I immediately switched to glass for all of my storage needs for my son. I began to read the bottles of the cleansers and shampoos that I used for my young child. Until recently, however, I did not read the bottles and review the contents of the products that I use. Over the past few months, I simply have not had time to color my hair or get to the department store to buy the latest facial cleanser or moisturizer and I resigned myself to having a few gray hairs as natural highlights. I began to use the natural soap that my son uses, along with his natural and largely organic shampoo and body cleanser. Surprising to me I felt healthier, my hair looked much better and my skin did not have a chronic film of “gunk” on it.
All of this lead me to look more closely into the daily products that not only I am using, but my patients are using. I am a physician and surgeon that specializes in cancer. All of this will, I hope, ultimately lead to better care of my patients. The first group of products, being a gynecologist, that I began to look at more closely are the vaginal lubricants that women use.
Women begin to have a decline in estrogen sometime in their forties and the resulting vaginal dryness can casue discomfort on its own, or lead to painful intercourse. Younger women may also have this problem, especially if they are on a low dose birth control pill. Vaginal dryness can be treated with vaginal estrogen (not the topic of this post – check back in the future) or by non hormonal lubricants. Until recently, there were virtually no natural lubricants on the market and I would recommend Vitamin E oil or the generally available “drugstore” preparations.
It is important to look at the components of the topical agents that we apply to our skin and scalp, as well as those used vaginally. Some of the more popular vaginal lubricants which are mass marketed and generally available in a drugstore may contain gylcerins, propylene glycol and parabens. Glycerin may lead to increased problems with yeast infections. The safety of propylene glycol has been questioned by some groups. Propylene glycol is widely used in food and cosmetic manufacturing. It is a liquid substance that absorbs water and helps to maintain moisture in the product to which it has been added. Some have noted that this agent may be a possible carcinogen and skin irritant. The FDA lists propylene glycol as generally recognized as safe “GRAS”. Parabens are also widely used in the personal care industry as a preservative. Researchers from the Department of Biology and Biochemistry of Brunel University in the UK conducted a study that found that the alkyl hydroxy benzoate preservatives (that is, methyl-, ethyl-, propyl-, and butylparaben) are weakly estrogenic. Allergic reactions and dermatitis may also be caused by parabens. Preservatives are a key component to personal use products, otherwise they can become overgrown with bacteria which has its own set of risks. The following ingredients—can also be used as preservatives and seem to cause the least irritation and fewest allergic reactions: grapefruit seed extract, tocopherol (vitamin E) · vitamin A (retinyl) · vitamin C (ascorbic acid).
While we cannot over analyze each product and its content, there are practical maneuvers that a woman can use in order to cut down on risks from environmental exposures. The effect of any ingredient is dependent on the level of the exposure, including the amount that is contained in a particular product and the frequency of use of the product. Our modern society is moving in the less is more direction with more and more large commercial manufacturer’s marketing and promoting “green” and “organic” products. The trick is to make sure that their claims are true.
The take home message:
- Be aware of the products that you use on a daily basis and what they contain
- Try to avoid vaginal lubricants with parabens
- If possible try to use lubricants based on natural ingredients with organic certified production.
- For more information on your personal lubricant its contents and safety profile go to Skin Deep: Cosmetic Safety Reviews
Posted: February 13th, 2010 | Author: drpoynor | Filed under: general health, skincare & cosmetic surgery | Tags: cosmetics, home, lubricant, safety, vagina | 3 Comments »
