Women's Sexual Health
The Pap smear is a simple procedure that is used primarily to detect pre-cancerous cells being shed from the cervix. It is also helpful in the detection of abnormal cells from other causes.
If you are sexually active, regardless of age, you should have a Pap smear at least once a year. If you are not sexually active, you should have your first pap by age 20 and then yearly.
The Pap Smear Examination
Having a pap smear is a relatively simple procedure. The cervix is visually examined by your physician or clinician, using an instrument called a speculum. The surface of the cervix is gently skimmed with a spatula and a tiny brush. The cells are then smeared on a glass slide and sent to a laboratory for analysis.
It is important not to use douches, vaginal creams, medication or have intercourse within 48 hours prior to your pelvic exam. These can distort the appearance of the cells to be studied in the pap.
Most Pap smears are normal. This means that all the cells appear healthy.
An abnormal Pap smear means that the cells appear different, but are not necessarily harmful. An abnormal Pap may result from infection by bacteria, viruses, or from unknown causes. Sometimes abnormal Pap smears are associated with STDs (sexually transmitted diseases).
If your Pap smear was not normal, it could indicate a premalignant condition. Further investigation would be needed to determine the appropriate course of action. This could require a repeat pap smear or the use of a colposcope.
A colposcope is merely a binocular microscope designed to assist in locating abnormal cells on the cervix.
If an abnormal area is discovered, a pinch of tissue must be taken and examined. This is called a "pinch biopsy." The result of the pinch biopsy will help your doctor determine whether treatment is necessary.
Treating Abnormal Pap Smears
The usual treatment for an abnormal Pap smear is called "cryotherapy," which simply means to freeze.
The area from which the unhealthy cells were found is frozen. The frozen tissue is sloughed off by the body and new, healthy tissue will then grow in its place. During this process, a heavy, watery discharge may occur for approximately two weeks.
Your clinician will probably recommend increasing your intake of water and potassium rich foods during this time. Have a follow-up pap smear 4-6 months after cryotherapy.
Even in these modern times, some women feel embarrassed by the exposure involved in a pelvic exam. Others view the pelvic exam as an indignity to their bodies.
Actually, these feelings, although understandable, must be overcome. Few examinations are as important to your health and well-being. Just as periodic examinations of your breasts can detect early lumps or thickening, the pelvic exam is essential for the early detection of genital cancer, infection or other abnormalities.
As with breast cancer, genital cancer is best managed if found early, and early detection and treatment of other problems can often head them off before they become serious.
As a patient, the best way to approach the pelvic exam is as a routine examination that happens to take place in the gynecologic area. It should be no more embarrassing than your annual overall physical checkup, and the steps involved are no more difficult than having your blood pressure recorded.
Before beginning the pelvic exam, you and your physician will discuss your particular requirements as a patient: Are you planning to be married? About to start on a birth control pill? Do you have a history of vaginal infection? All of these factors will be taken into consideration.
The examination usually involves two steps:
- vaginal examination with a speculum
- vaginal examination with the hands and fingers (digital exam). Your doctor may also want to perform a rectal checkup during the digital phase of the examination
Preparation: Usually with the aid of the nurse, your body is draped with a sheet and your feet are placed in stirrups. After routinely examining the breasts, abdomen and groin, your physician inspects the outer genitals. Because good light is important, a lamp may be used during this inspection. Generally, the examiner will place an arm or elbow on your leg or thigh before touching the outer genitals. This is to avoid startling you--in which case your genital muscles might involuntarily contract and interfere with the examination.
Inserting the Speculum: A speculum is an instrument which enlarges the vaginal opening and spreads the vaginal walls so that your physician can "see what is going on" inside the vagina. Your doctor will carefully insert the speculum into the vaginal entrance with one hand, while using the other hand to gently spread the labia. The type or size of the speculum depends on whether the patient is a virgin, has had children or is post-menopausal. To avoid discomfort, the speculum is inserted slowly and at an angle. But if you feel any distress--which is extremely rare--your doctor will adjust the speculum to make you feel more comfortable.
Inspecting the Cervix: As it is gradually rotated, the speculum can be opened to expose the cervix--the "neck" of the lower uterus that connects it with the vagina. Again, this is done with very little discomfort to the patient. By manipulating the speculum, the doctor obtains a clear view of the cervix and can examine it for cysts, tears or other abnormalities.
The Pap Smear: Named for its developer, Dr. George N. Papanicolau, the Pap test is a simple procedure which detects precancerous cells. In other words, the Pap test can warn of cancer even before clinical signs of disease are apparent.
You've probably been instructed not to use douches, vaginal creams or medications for at least 48 hours prior to your pelvic exam. This is important because these substances can distort the appearance of the cells to be studied in the Pap smear.
While the cervix is still exposed by the speculum, cells are taken from the cervix and vagina with a scraper or cotton-tipped applicator. The cells are then smeared on a glass slide and sent to a laboratory for analysis.
With the speculum still in place, your physician may also take appropriate smears to determine the presence or absence of vaginal infection.
After gradually withdrawing the speculum, the examiner will carry out the digital examination. This is just what it sounds like: an examination with the fingers or "digits." It is also a "bimanual" examination because both hands are used--one internally and one externally on the abdomen. Wearing a glove, your physician inserts the index and/or middle finger of one hand into the vagina. In this way, the cervix can be palpated or "felt" for consistency, shape and position. The cervix may be moved from side to side to determine if it is tender to the touch. And the upper vagina is explored for masses, tenderness, or distortion.
During the digital exam, your physician will also examine the uterus and ovaries. While the finger (or fingers) within the vagina elevate the cervix and uterus, the other hand is gently placed on the abdomen. By "grasping" the upper portion of the uterus between the vaginal fingers and the abdominal hand, the examiner can determine its size, its mobility and the presence or absence of tenderness. The ovaries also can often be located and felt.
In order to completely rule out abnormality, your physician may include a rectal checkup as part of the digital examination. Just stay relaxed, and you'll feel nothing more than perhaps a brief sensation of a full bowel.
The rectal examination follows naturally from the digital exam. Still wearing a glove, your doctor again inserts the index finger into the vagina. The middle finger--which has been well lubricated--is gently and slowly inserted into the anal canal. This is done to determine whether there is any mass in the anal canal or lower rectum. By reaching further into the rectal canal, the examiner can also palpate the cervix and uterus.
After the pelvic exam, you'll be asked to return to the consulting room, where you and your doctor will discuss the findings of the examination. You'll be told when to expect the results of your Pap smear. If birth control is your primary concern, a contraceptive program will be tailored to your individual needs.
Your physician will also tell you when to come in for your next pelvic exam and Pap smear, generally within one to two years. You may get a reminder in the mail--but don't wait to be reminded! Now that you know about this all-important method of detecting genital cancer and infection, you'll probably want to have a pelvic exam and Pap smear at least once every one to two years.
Vaginitis is an inflammation of the vagina. The most common symptoms are itching burning and abnormal vaginal discharge.
Most women will experience some form of vaginitis during their life times. The most effective way to prevent vaginitis is to understand its causes and follow advice to reduce your risk.
Normal vs. Abnormal
Every woman has some vaginal discharge, and every woman's vagina contains organisms necessary to keep bacteria in normal balance. When the normal balance is upset, the vagina may be susceptible to organisms which ordinarily would be killed or controlled. The result may be an abnormal discharge which may irritate tissues, causing swelling, itching and burning of the vulva, and/or unpleasant odor.
Pelvic examinations are usually required to determine the kind of infection you may have and the proper treatment for it. There are three major types of vaginal infections, including monilia, trichomonas, and bacteria.
Monilia, sometimes called "candida" or "yeast" is probably the most common form of vaginitis. It is caused by a fungus which does not pose any serious health hazard, but can be very annoying.
The main symptom is itching of the vagina and surrounding area, accompanied by a thick white, discharge usually having a strong odor. Although monilia is not considered to be a sexually transmitted disease, it is possible to catch monilia from your sexual partner. Uncircumcised males may harbor the fungus under the foreskin, which would look red and scaly.
If you are experiencing symptoms of monilia, see a clinician or doctor as soon as possible.
Monilia is treated with an anti-fungal medication. This may be in the form of vaginal suppositories, creams or tablets and should always be used as prescribed.
Often simply called "trich" (trick), this form of vaginitis is caused by single-celled organisms (protozoa), which may be found in both men and women. Trich is considered a sexually transmitted disease, but it may also be passed from person to person on washcloths, towels or bathing suits.
Trich is not as common as monilia, but the symptoms are just as annoying. Symptoms include a greenish-yellow discharge accompanied by an unpleasant odor and sometimes itching. Men usually have no symptoms.
Treatment for trich is usually a tablet called Metronidazole or Flagyl taken orally or Metrogel applied vaginally.. Both sexual partners should be treated simultaneously. To prevent re-infection, a condom should be used during sexual intercourse until treatment is complete. Re-examination after treatment is essential.
Bacterial vaginosis is caused by bacteria which normally inhabit the vagina, but under certain conditions, begin to overgrow.
Symptoms of bacterial vaginosis include a heavy, vaginal discharge having an unpleasant odor. The discharge is usually very liquid and can be irritating.
Bacterial vaginosis is treated with antibiotic vaginal creams or suppositories and oral antibiotics.
Males may harbor these bacteria with no obvious symptoms. Check with your clinician to find out if your partner should also be treated. Condoms are recommended during intercourse to prevent reinfection and both partners should be reexamined after treatment.
Use all the medication as prescribed. Disappearance of the symptoms may not mean disappearance of the infection.
Check with your clinician about any other medication you may be taking. Some kinds may make your vagina more susceptible to infection. Infection spreads in moisture and heat. Keep the vulva as dry as possible.
Poor diet, lack of sleep or the presence of other disease or infection can lower your body's resistance to vaginitis. Medications such as antibiotics, hormones and excessive douching also can increase susceptibility. Other contributing factors may include psychological factors, childbirth, cuts or abrasions, intercourse without enough lubrication and even tight-fitting clothing
If you are unsure of your sexual partner's contacts outside your relationship, insist that a condom be used during sex.
Using a condom will help prevent sexually transmitted illnesses (STI) and vaginitis. There is evidence that lamb skin condoms do not protect against STIs because the membrane is too porous. Use latex condoms instead.
If you notice any genital sores or penile discharge, do not have intercourse until you and your partner have been treated.
Do not use bubble baths, feminine hygiene preparations, deodorant tampons or colored and scented bathroom tissue.
Wear white cotton underwear and change at least every 24 hours.
Always wipe from front to back after a bowel movement. Bacteria from the anal area can cause vaginitis.
Douching is usually not necessary for feminine hygiene. If you feel the need to douche, use a solution of water and vinegar.
Information for patients receiving a colposcopy
What is a colposcopy? If you have had an abnormal pap smear or abnormal cervigram, you may be scheduled for a colposcopy. Specially trained physicians use an instrument called a "colposcope" to examine your cervix carefully. The colposcope is similar to a microscope. It is attached to a floor stand and magnifies the cervix under a powerful beam of light. By using this instrument the doctor can locate any suspicious areas on the surface of the cervix not visible to the naked eye.
Is a colposcopy painful? No. There is no pain associated with the colposcopic exam.
Information for patients receiving a biopsy
What is a biopsy? Should an abnormal area appear on your cervix, a tiny pinch of tissue, or a biopsy, will be removed from that area. The specimen will then be sent to a pathology laboratory for processing and evaluation. The final results are returned to your physician within one week.
Will the biopsy be painful? This pinch biopsy will hurt as would a pinch anywhere on your body. The cervix has fewer pain fibers than your skin so this will not be severely painful. Anesthesia is not required.
You may also have a scraping of your endocervical canal (the passageway from the opening of the cervix to the uterine cavity). This will be uncomfortable, usually crampy, but should not be painful.
You may experience some pain and cramps during and following the biopsy. You may wish to take some pain medicine (Motrin-800mg or Advil-4 tablets) with food about an hour before your appointment.
Are there any complications after a cervical biopsy? Generally, complications are rare. Following the biopsy, you will have a very dark, thick discharge from your vagina. This is due to the medicine applied to the pinched area of your cervix. This discharge should last only a few days. You may have a bloody discharge. if the discharge becomes heavier than normal menstrual flow, contact the SHS Clinic (721-3448).
Will I be restricted in my activities after a biopsy? No. You can carry on your normal activities, although you should abstain from vaginal intercourse for two to three days after the biopsy.
When will I receive my biopsy results? The report should be back within one week. Please call the SHS Clinic (721-3448) and ask for your biopsy results. The nurse or doctor will explain the results to you as well as any additional treatment that is recommended. If the nurse or doctor is unavailable at the time of your call, s/he will return the call as soon as possible.
If you would prefer, you may schedule an appointment with your doctor to discuss your results. Please schedule a consultation for one week after your biopsy.
One of the safest and most effective ways to prevent pregnancy is "the pill." This method of contraception involves swallowing a tiny pill daily on either the 21, 28, 91 or 365 day programs.
Birth control pills are prescribed medicine and must be used correctly to be effective.
How Does the Pill Work?
Many birth control pills contain synthetic forms of two hormones, estrogen and progesterone. These synthetic hormones mimic the effects of naturally produced hormones, producing a steady synthetic hormone level in the body to suppress ovulation. Since no egg is released, pregnancy does not occur.
The Diaphram vs. The Pill
College women who have chosen the diaphragm over the pill should know that diaphragms have a very high failure rate among younger women, according to studies by the Center for Disease Control's Reproductive Health Unit.
Of 100 typical users under age 22 who begin the year using diaphragms, an average of 33 are pregnant by the end of the year. The corresponding number of pregnancies in pill users under age 22 is only 4.7 (This failure rate is attributed to incorrect and inconsistent use.)
How Safe is the Pill?
The health risks involved in taking the pill during the '60s and '70s have been greatly reduced today. The pills in use today typically contain only 1/3 the estrogen and 1/10 to 1/25 the progesterone of earlier pills. Also, pills are not prescribed for women of all age groups and health conditions.
The most serious risk to pill users is the increased possibility of stroke or heart attack. However, among all women less than 35 years and among nonsmoking women less than 45 years, there are no significant differences in death rates from circulatory diseases between those who take the pill and those who don't. The number of such deaths in women in their early 20s is so small that accurate conclusions cannot be drawn.
Other side effects of pill use, such as weight gain, may bother some women, but do not cause serious health problems. Women who use the pill may experience slight weight gain as a result of cyclical fluid retention or increased appetite. A clinician can monitor any weight fluctuations and may change your pill prescription as needed to modify any hormonal effects.
Nausea can be a problem on the pill but usually lessens after the first few months. Pills should be taken with meals if nausea occurs. Some pill users experience depression, while others have increased feelings of well-being. Depression on the pill may often be related to a deficiency of vitamin B6 and can be treated with a diet supplement.
In general, numerous medical studies over the past 25 years, involving hundreds of thousands of women, show that for most healthy young women, the benefits of using the pill outweigh the risks.
When used consistently and correctly, birth control pills provide the most effective form of contraception, aside from abstinence and sterilization. Pills do not interrupt lovemaking and provide protection every day of the month. Other benefits of birth control pills may include:
- Reduced risk of Pelvic Inflammatory Disease (PID)
- Protection against endometrial cancer and ovarian cancer
- Reduced chance of tubal pregnancy
- Protection against fibrocystic breast disease
- Relief from menstrual problems such as cramps, tension and heavy bleeding
- Reduced chance of iron deficiency anemia
- Possible improvements in acne
Using Pills Correctly
Start taking the pill the first Sunday after your period begins. If your period starts on a Sunday, start the pill that day. If your period begins on Wednesday, start the pill the following Sunday.
For 21-day packs Swallow one pill a day for three weeks. Wait one full week during which menstruation will occur.
For 28-day packs Swallow one pill a day, every day, in the correct order. Bleeding normally begins about 48 hours after the last active pill.
For 91-day packs
Swallow one pill a day for 91 days. Bleeding normally comes during the last 7 days of the pill pack.
For 365-day packs
Swallow one pill a day for 365 days. You will not evperience withdrawal bleeding, but may have occasional break through bleeding or spotting.
Before you begin taking the pill, study the literature that is enclosed in your pill pack. This provides detailed information about the specific type of pill prescribed for you. If you have any questions consult SHS.
It is important to have a follow-up examination three months after beginning pill usage.
- Take the pill at the same time daily, preferably with food to decrease the possibility of nausea.
- Use another method of birth control during the first month when taking the pill.
- If you miss a pill, take the missed pill as soon as possible, then take another when normally scheduled.
- If you miss two pills in a row, take two each day for two days; use a back-up method of birth control until you begin your next pill package. If you miss three pills, begin using a back-up method of birth control immediately. Contact SHS (1-3448) for advice.
- Spotting or bleeding may occur during the first 2 or 3 cycles of the pill. Continue taking the pill and contact SHS if the bleeding is heavy or prolonged.
- Scanty or short periods, or lack of periods are common side effects. If you have taken the pill correctly and do not bleed after finishing the pack of pills, start the next pack on schedule and contact SHS for advice.
- The effectiveness of the pill may be affected by prescription drugs. If you seek medical treatment, make your clinician aware that you are taking the pill.
Problems & Risks
Pills must not be taken if the following conditions are present:
- A history of impaired liver function, including active hepatitis, alcohol liver damage, or liver tumor
- Known or suspected cancer of the breast, cervix, vagina, ovaries, or uterus, or malignant melanoma, at present or in the past
- Pregnancy or suspected pregnancy
- Severe migraine headache
- Serious heart or kidney disease
Oral contraceptives do increase the risk of developing four circulatory diseases:
- Blood clots in the veins
- Ischemic heart disease (including heart attack)
- High blood pressure
Remember . . .
Serious complications associated with using the pill are rare; however, there are warning signals of which you should be aware. If you experience any of the following symptoms, contact SHS immediately:
- Severe abdominal pain
- Chest pain or shortness of breath
- Blurred vision or loss of vision
- Severe leg pain
Putting the Risk of Using the Pill in Perspective
|Activity||Chance of Death in a Year|
|Smoking (one pack a day)||1 in 200|
|Motorcycling||1 in 1000|
|Automobile driving||1 in 6000|
|Pregnancy||1 in 10,000|
|Using the pill (smoker)||1 in 16,000|
|Playing football||1 in 25,000|
|Risking Pelvic Inflammatory Disease through intercourse||1 in 50,000|
|Using the pill (nonsmoker)||1 in 63,000|
|Canoeing||1 in 100,000|
|Legal abortion between 9-12 weeks||1 in 100,000|
Adapted from Sexuality: Contraceptive and Reproductive Health Issues, 1986, B.C. Sloane, Charles E. Merrill Publishing Co., Columbus, OH., pp. 31-34.
Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here's what you should look for:
- breasts that are their usual size, shape, and color
- breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor's attention:
- dimpling, puckering, or bulging of the skin
- a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)
- redness, soreness, rash, or swelling
Step 2: Now, raise your arms and look for the same changes.
Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).
Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.
Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage.
Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch. Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage.
Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.