Female Body Parts 101: The cervix – Soon to be #1 Cancer Threat to Women Worldwide


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.




Obtaining cells for a pap smear

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.



Henrietta Lacks in Haiti – Tackling the epidemic of cervical cancer


For those of you who may not have heard of Henrietta Lacks, allow me to provide a short tutorial of her immortal importance after her death. Ms Lacks died of an aggressive form of cervical cancer in 1951 at the age of 31. During this same time, researchers at Johns Hopkins Hospital in Baltimore were attempting to grow tissue cultures from human cells. Most of these cell lines died within a few days, but the tissue obtained from Ms Lacks tumor reproduced at a high rate and could be kept alive to allow for further study. The cell line became known as HeLa and was instrumental in developing the polio vaccine 3 years later as well as other breakthroughs in medical science. We now understand that the reason that her cells reproduced so rapidly, and also why she suffered from such an aggressive form of cervical cancer at a young age, is that her cells were infected with a high risk strand of HPV (human papilloma virus) which caused uncontrolled growth of infected cells. This understanding has led to the Gardasil vaccine as well as more sophisticated HPV testing, both of which have the ability to eradicate cervical cancer from the globe.

Cervical cancer is becoming strikingly more important from a global health perspective for two reasons:  Maternal mortality has been reduced by almost 50% and HIV infected woman are living longer on retroviral medication. Unlike Henrietta Lacks, most women don’t die of cervical cancer until their 40’s to 50’s. Keeping more women alive in childbirth means that there will be a larger contingent of women susceptible to the effects of HPV. Women living with HIV, although appearing healthy when taking daily retroviral medication, have a depressed immune system and are more likely to develop cervical cancer when exposed to HPV.  Currently, 85% of world-wide deaths due to cervical cancer occur in the low and middle income countries.

During my 25 years of practice in the US I have encountered 4 cases of cervical cancer. Each of those cases occurred in a woman who had not had a pap smear or pelvic exam in more than 10 years. More than 50% of cases of cervical cancer in the US are not due to the inadequacy of screening but rather to the lack of screening. With the recent addition of HPV testing to pap smears, the accuracy of this test has improved even further. My   work in Haiti has revealed a much different picture. In 15 trips over the past 10 years, I have diagnosed 12 cases of cervical cancer, all of which were well advanced. By some accounts, Haiti has the highest incidence of cervical cancer in the world with 94 cases per 100,000 women. Cervical cancer is the leading cause of cancer death in Haitian women, with 1500 Haitians succumbing every year. It kills nearly as many women as all other cancers combined. This is in comparison to the US, where cervical cancer accounts for only 3% of female cancer deaths. Keep in mind that cervical cancer is one of the few cancers that we currently have the ability to not only prevent but also to treat pre-cancerous lesions before they progress to cancer. Cervical cancer can become a forgotten disease in 25 years.


On the same evening that Henrietta Lacks premiered as an Oprah movie on HBO, I boarded a flight to Port au Prince, Haiti to participate in a conference addressing the need for a cervical cancer screening program in a country with low resources. Members of the Ministry of Health, Haitian ob/gyns and American aide groups came together to discuss and formulate a future plan. We discussed what works and what doesn’t work, the need for education in the community and how best to use limited resources to benefit the majority of women. Haiti sans Cervical Cancer has a tremendous amount of work to accomplish, but is stronger when everyone is pulling in the same direction.


Partners in Health, known as Zamni Lasante in Haiti, is part of our coalition of Haitian organizations that has approached seemingly insurmountable world-wide public health challenges in the past. They were pioneers in improving tuberculosis treatment when multi-drug resistance to the disease became problematic and were instrumental in bringing HIV medications to poor people suffering from the disease. In both of those cases, the “experts” said it couldn’t be done but PIH proved them wrong. Cervical cancer is an equally deadly disease, killing mothers in the prime of their lives. The solution, however, is much less expensive – receiving 2 doses of the Gardasil vaccine as a young teenager and then a $10 HPV test every 5 years starting in your mid 20s until mid 50’s. By reducing the rate of maternal mortality by 50%, we have been successful keeping many more women alive during childbirth – now we need to tackle the disease that can kill these women later in life.

The Paradoxes of Haiti


My first week back after a medical mission trip to Haiti presents many difficulties – some physical (I won’t expand on the topic of GI issues after eating rice, beans and potatoes every day for a week) but most psychological. At 10 am on Sunday I was enjoying the feel of sand between my toes and salt water on my ankles as I walked down the beach, knowing that 12 hours later I would be arriving to Minnesota and freezing temps. That is the uncomplicated part of the transition. The psychological transition is still a part that I struggle with and sometimes do better than other times. Following are just a few of the thoughts that have created a wrestling match in my head this week.

  1. We were able to prevent a woman from dying due to a bad infection in her foot by amputating her lower leg. She has very poorly controlled diabetes due to poverty, low IQ, and lack of resources for adequate administration of insulin. One of the last patients  I saw before I left for Haiti also has poorly controlled diabetes – due to lack of motivation to check her blood sugars and take medication, both of which are provided thru her insurance.
  2. Maternity was very busy the week we were in Haiti and our nursing volunteers spent many hours working with Haitian staff to improve breast-feeding and care of patients in labor. It is much easier to teach the mechanics of nursing care than it is to teach respectful care. Slapping and yelling at patients during labor is all too commonplace.
  3. Cervical cancer continues to be a preventable disease that kills all to many mothers, disrupting their families. We screened 67 patients for cervical cancer, treated 10 pre-cancerous lesions and diagnosed 1 locally advanced cancer that is untreatable and will be the cause of death in this woman within the next year. A combination of low-cost screening and vaccination with Gardasil has the potential to completely eliminate this cancer throughout the world. Due to unfounded fears of vaccines in this country, only 40% of young girls and boys are vaccinated with Gardasil.
  4. Motorcycles are the primary mode of transportation in Haiti. We treated 3 victims of moto accidents, one a  16-year-old girl who will have permanent scarring on her leg that impedes her ability to walk in the future. Once their wounds were cleaned, stitched and dressed, we sent them home on a motorcycle
  5. Most of the hysterectomies that we perform are due to fibroids (benign tumors of the uterus) and heavy menses. One of the patients that we saw was 41 years old and had not been able to conceive a pregnancy. She was severely anemic but her husband decided that they would pray to God for a miracle child rather than allowing her to have surgery. Another woman looked 8 months pregnant due to her enlarged uterus and her hemoglobin was 3 (normal is 12-15). She was in danger of bleeding to death with her next period. In the US, she would have received 4 units of blood before surgery. She received one unit of blood that was donated by a relative and infused during her surgery. She was also unhappy as she has only one child.
  6. A young man presented to clinic with a large abscess on his arm. His HIV test was positive, as was his syphilis test. He did not believe the results and declined government-funded HIV meds or antibiotics. We could not operate on him as he was at high risk of complications with active HIV.

When co-workers see me this week they often ask, “How was Haiti?”. Trying to find the words to describe the above and more can be difficult, if not impossible,  in a few minute passing conversation.  Do others really want to hear the confusion in my head or do they want to hear that we performed 49 surgeries, 67 cervical cancer screenings and 104 dental exams?  To say “Great job and thank you for what you do” and then move on. But what we do in one week is not enough. And that is the Paradox of Haiti.

Cervical Cancer – Women’s Next Biggest Killer


Roseline had delivered her baby during the chaos of our first day at Mama Baby Haiti, a birthing center for women near CapHaitian, Haiti. Mondays are the busiest day at the center, located on a dirt road just off Highway 1, as it is the intake day for expectant mothers that are new to the program. Three of us had arrived the night before from the early spring of Minnesota weather to be greeted by unseasonable warm Haitian weather – 95 degrees and high humidity. While we were teaching 10 Haitian nurses and physicians about cervical cancer screening in a low resource setting, Roseline was laboring with the aide of a Haitian trained nurse midwife to deliver her healthy baby girl. She graciously agreed to be interviewed only hours after the birth of her child and shortly before she was to depart for her home (patients stay at the center for only 4 hours after an uncomplicated birth).

As is true for many of the 30-40 women who deliver at Mama Baby Haiti each month, she had heard of the program thru a friend. She lived 20 minutes away and had been seen for 5 prenatal visits. She was appreciative of the nurse midwives that seemed to listen to her concerns and the cleanliness of the birthing center. This was Roseline’s first child, the father of her baby was sick and unable to work and she supported herself with side jobs and help from her family. The cost of her care at the center was much reduced from what her care would have cost at the local hospital. Without the services of Mama Baby Haiti, she would have had to deliver at home, either by herself or with an unskilled birth attendant.
Mama Baby Haiti, along with other such organizations in the developing world, is partly responsible for reducing the maternal mortality by 50% since 1990. That is the good news for mothers like Roseline. The bad news is that because mothers are not dying in childbirth and are living longer lives, they are now more at risk of dying of cervical cancer in their 40’s and 50’s. Cervical cancer deaths have increased by 40% over the same time period that has seen a reduction in maternal deaths. Within the next 5 years, a woman in the developing world is more likely to die of cervical cancer than in childbirth. 90% of the deaths due to cervical cancer occur in the developing world. We have great opportunity and much work to be done.
IMG_1177  IMG_1156

Using the simple tools of dilute vinegar and a bright light, local providers are able to screen women for pre-cancerous cervical lesions and treat them by freezing the cervix at the same visit. Given the wonders of the digital age, we were able to load pictures of normal and abnormal appearing crevices onto an ipad and review them with the participants, in addition to screening 55 women who agreed to be teaching models. We also were able to educate Haitian women about what cervical cancer is and the risk factors. Just as knowledge about HIV has empowered women to reduce their risks of AIDS, knowledge about a similar virus that causes cervical cancer (Human Papilloma Virus or HPV) can help women reduce their risk by making better choices.

My Mother’s Day wish for women in the developing world is that a new report will be issued in 5 years. Childbirth will be even safer and deaths from cervical cancer will be falling due to improved screening efforts and access to an inexpensive version of the HPV vaccine. Our work has only just begun.


Upcoming Trip to Haiti


Three of us will be traveling to Haiti next week to work at Mama Baby Haiti, a birthing center in Cap Haitian that employs Haitian trained nurse midwives. They have received a grant from Dining for Women which allows them to expand their program to include well woman care. A community health worker will be trained to educate area women about sexually transmitted disease, contraception and cervical cancer screening. The goal of our trip is to train midwives, physicians and nurses in the technique of cervical cancer screening with VIA(visual inspection with acetic acid). 285,000 women die each year of cervical cancer, 85% of them in the developing world. During my last trip to Haiti in November 2014 we diagnosed 5 cases of advanced cervical cancer. Screening via VIA is very inexpensive (the cost of vinegar and a cotton swab) and treatment for pre-cancerous lesions by freezing the cervix can be performed the same day. This treatment is 75-90% effective at preventing the development of cervical cancer. There is no facility in Haiti available for treating a patient with locally advanced cervical cancer, so screening and treatment is of even more importance than a similar service in America.

Haitian women are the backbone of the family. When they become sick or die, not only is their children’s health affected but also their child’s ability to attend school. Talking to Haitian women about their daily lives and what they wanted for their children’s future was the impetus for creating the microfinance organization, Helping Haiti Work. A recent facebook post by Nadene Brunk, the founder of Midwives for Haiti, which is the program that trained the midwives that are employed at Mama Baby Haiti, sums up much of what I have learned from Haitian women.

Please continue to check in here or at Helping Haiti Work over the next few weeks, as I will continue to report on our work in Haiti with both photos and video.