I have previously written about the uterus and menstruation, but have been lax in finishing the reproductive system. Two patient stories reminded me of how neglected the cervix can be. As I was interviewing a new patient, age 24, I noted that she had not received a Gardasil vaccination in her teen years. I informed her of the benefits of the vaccine, preventing Human Papilloma Virus (HPV) infection of the cervix, thus markedly reducing her long term risk of cervical cancer. The vast majority of cervical cancer is caused by HPV, with strains 16 and 18 accounting for 70% of cervical cancer. The vaccine can be administered from ages 12-26 in both boys and girls and is covered by insurance. Following our discussion, she declined the vaccine stating “My family doesn’t believe in vaccines”.
Later in the week, I was called to the ER to see a 65 year old woman who presented with vaginal bleeding after menopause. She had not seen a physician since her last child was born in her late 30’s. A large tumor had completely replaced her cervix and was extending into her uterus. Her survival chances are around 60% – after radiation, chemo and extensive surgery. Due to age this woman did not have the option of a Gardasil vaccine, but the cancer could have been detected in a pre-cancerous state by a pap smear and easily removed via an office procedure.
The cervix is a muscular structure that is located at the top of the vagina and encompasses the lower third of the uterus. It is the gateway that allows blood to leave the uterus during a period and remains closed to keep the developing fetus inside the uterus until labor ensues. It responds to uterine contractions by slowly dilating to allow for passage of the infant.
Pap smears were developed to screen for pre-cancerous changes on the cervix that could be treated before they developed into cervical cancer. We have only recently discovered that HPV is the virus that causes cervical cancer and now screen for HPV when we do pap smears. HPV is a virus that is passed back and forth between men and women during intercourse. It is a silent infection in men – no symptoms, no testing available, no treatment and no long term health consequences. Completely sexist but so are many health problems – ie breast cancer, pregnancy, uterine and ovarian cancer. So it only follows that vaccinating young men to prevent them from transmitting the virus will help to reduce the burden on women.
Pap smears should be performed every 3-5 years, depending on age, and don’t need to be performed after age 65 if you have not had an abnormal pap in the past 10 years. A common misconception is that pap smears are performed whenever a speculum is placed in the vagina – NOT! Pap smears are never done in the ER or urgent care, even if a speculum is placed or pelvic exam done. You just need to believe me on this fact.
By 2020, cervical cancer is expected to exceed deaths during childbirth as the number one killer of women during their reproductive years. Currently, 70% of cervical cancer is diagnosed in the developing world due to lack of screening for pre-cancerous abnormalities. In 2011 Rwanda initiated a school based vaccination program for both boys and girls and thus far has a 93% coverage of eligible youth. The current rate in the US is 60%, with many states less than 50%. Rwanda, still recovering from a horrific genocide and 70% of it’s population rural, beats the US in vaccination rates by a great distance. We are the richest country in the world with the most expensive health care system. Treatment for the 65 year old patient described above will cost hundreds of thousands of dollars. Where are we willing to spend our dollars?
Cervical cancer is one of the few cancers that is well understood and has a single cause; HPV. We have the ability to eradicate this cancer in the near future via robust vaccination programs and regular screening. Former president Jimmy Carter had a vision to rid the world of Guinea Worm, a parasitic infection in tropical countries. It will soon be the second disease eradicated in the world, after smallpox. Cervical cancer can be #3 and the first cancer.