are you in favor of giving contraceptive to teenagers?

Saturday, September 12, 2009

How to Talk With Your Kids About Sex

Talking with your kids about sex is never easy. It takes courage, a little bit of homework, and lots practice. But giving your child honest, straightforward information about sexual health is the best way to support them in having a healthy sexual life, including protecting them from unwanted pregnancies and STDs. Below are some tips that might help you navigate the murky waters of talking with your kids about sex.

If you’re looking for age-specific tips, you might want to also read:

Make talking with your kids about sex a lifelong conversation

When parents imagine talking with their kids about sex they often work themselves up about the "big sex talk." But talking with your kids about sex isn’t about a single moment -- it’s about the thousands of small moments of learning and teaching about sex that can happen throughout your child’s development. This means you get more than one chance to do it right, and if you screw up a talk, you’ll get another chance next week. The important thing is to keep the conversation open. Read more about making sex education a lifelong conversation with your kids.

Know your comfort level when it comes to talking about sex

Getting a sense of your own comfort is crucial. The well-meaning parent who is so uncomfortable talking with their kids about sex might inadvertently communicate a lot of negative messages about sexuality. Take some time to imagine conversations at different ages and stages in your child’s life. If you imagine these scenarios and shudder, don't put yourself down for it. There are lots of things you can do to increase your comfort talking with your kids about sex.

Clarify your own sexual values

Knowing how to talk to your kids about sex is often complicated by the fact that few of us spend time considering our own sexual values. Sexual values are the beliefs, priorities, prejudices, thoughts and feelings we have about sex, sexuality, and gender. Our sexual values will change over time and experience. But knowing how we feel about key issues of sexuality can go a long way to communicating clear and helpful information to our children. Read more about clarifying your own sexual values .

Make it okay for your kids to ask about sex

All children have questions about sex. When we don't give our children permission to ask questions or create appropriate time and space for them to ask their questions, the questions come anyway, and they can come at embarrassing or inconvenient times. If you are genuinely interested in raising sexually healthy children you need to create an environment where they feel comfortable asking you questions. This might mean having age-appropriate sex education books in the house, or it might mean telling your kids straight up that you’re open to questions about sex.

Use age-appropriate sex information

We all take in information differently at different times in our life, and too much good information is still too much. Present your child with information that is appropriate for their age, in a way that they can understand, and don't give them more information than they're ready to hear. If you’re not sure how to gauge this, you may want to look for resources on sex education in your local library or contact an organization like SIECUS, which supports comprehensive sex education and offers great bibliographies on their site.

Practice talking about sex

The only way to get comfortable talking about sex is to talk about sex. The more you talk about sex, the better you'll be at it. And this experience is transferable. If you get comfortable talking about sex with a friend, or your partner, often that comfort level and self-confidence can help you when talking to your kids. If you’re comfortable, it can go a long way to putting your kids at ease, too, and you are modeling a behavior you want to support them in.

Take the time you need to talk about sex

When we feel rushed to answer questions, our answers are often not as good as they could be. A way to convey that sexuality is important to your children is to make sure that "sex talks" happen at a time when they don't have to be rushed. This is also important as these talks can open up into unexpected other subjects. Because sexuality is part of who we are, sex talks can lead to amazing sharing on other topics that seem unrelated to sex. If you get a sex question at a time when you don’t feel comfortable talking about it, let your child know that you’re happy to talk about it later, and then follow up.

Don’t feel pressured to answer sex questions on the spot

If you are shocked by a question, or get a question you don't know how to answer, it’s okay to admit that, and let your child know you want to talk about it, but you want to do that later. Don't use this as a way to avoid answering the question altogether, but if you've had a long day at work and are rushing around trying to get the grocery shopping done, it's okay to tell you child that they need to wait until the end of the day, or when you're at home and will feel more comfortable talking about it.

Don’t try (or pretend) to have all the answers

Tips on talking with children about sex and sexuality


Sexuality involves our bodies, minds, spirits, society, and more. There is no way you will ever have answers to all your children's questions. Admitting this to your kids can teach them that no one has all the answers (and that you are human like the rest of us) may well turn into a chance to help them learn where to find their own answers (a trip to the library, or a previously checked-out, credible sexual health website might be in order).

Know your boundaries and model them for your kids

You are not your child’s best friend, and you shouldn’t feel like you have to answer every personal question your child might ask you. Establishing boundaries (the things we will and won’t talk about with strangers, family, friends, and eventually romantic partners) is an important developmental stage, and you can model for your child by having clear boundaries about what you will and will not discuss with them.

By Cory Silverberg, About.com

Updated: March 30, 2008

About.com Health's Disease and Condition content is reviewed by the Medical Review Board

Friday, September 4, 2009

Do I Have to Talk With My Kids About Sex?

The Importance of Providing Sex Education for Your Kids
By Cory Silverberg, About.com

Updated: March 30, 2008

About.com Health's Disease and Condition content is reviewed by the Medical Review Board


Many parents would rather not talk with their kids about sex. Of course many parents would rather not talk with anyone about sex. And while you can choose to avoid sexual communication in your adult life with romantic partners (but I wouldn’t recommend it) if you choose to never talk with your kids about sex you do so not only at your own peril, but theirs as well. There are lots of good reasons to talk with your kids about sex. Here are a few of my favorites.

Talking with your kids about sex can help keep them safer.

There is a lot of research that has shown that when parents talk with their kids about sex, their children are:
  • more likely to use contraception
  • more likely to delay intercourse
  • less likely to have a teenage pregnancy

To be clear, it’s not just any kind of sex talk that helps, and some of the survey research offers conflicting reports on the impact of talking with your kids about sex, which may reflect the fact that it is possible to talk with your kids about sex in ways that are not helpful. So while it’s a good idea to talk with your kids about sex, it’s equally important to know what makes for good sex education and what the best way is to do it.

Kids listen to their parents when they talk about sex.

It might surprise some people who think of teens as extremely disaffected and contradictory to find out that both adolescents and teens, when asked, say they listen to what their parents have to say about sex:
  • One study in 1995 found that adolescents rated parents higher in credibility than school and friends when it comes to getting sex information (although they rated them low in “accessibility”).
  • A more recent 2006 survey by the Canadian Association for Adolescent Health found that sixty three percent of teens considered their parents a major source of information, and forty three percent thought parents were the most useful and valuable source of information.

It may be true that when they reach a certain age your kids are less likely to listen to what you have to say about many things. Interestingly, sexuality doesn’t seem to be on that list.

You’ll learn things from talking with your kids about sex.

Having to talk with your kids about sex means having to re-think many aspects of sexuality you may now take for granted. Even answering a simple question like “why would anyone want to have sex?” (not an uncommon question among kids of a certain age) requires us to think carefully about what sex means for us. In another example, with an older child, you might have to do some research just to keep up with sexual options on line, and this means learning for yourself as well as your child.

The fact is that when it comes to sex we’re all life long students. Our sexuality never stops changing as we age and this means that as long as we don’t turn away from it, there is always something new to learn. Talking with your kids about sex is another way to keep your mind open to the meaning of sex in your own life.

Talking about sex with your kids can further develop your relationship.

Any relationship that’s based on communication is going to have its challenges, and often its in overcoming those challenges that the relationship grows. Your relationship with your kids is no different, particularly as they get older and become more independent adults. Talking with your kids about sex won’t always be easy, but it’s well worth the effort, and the payoff can be more than a healthy child, it can be a healthier relationship overall. Sources:
Eisenberg, M.E., Sieving, R.E., et. al. “Parents’ Communication with Adolescents About Sexual Behavior: A Missed Opportunity for Prevention?” Journal of Youth and Adolescence. Vol. 35, No. 6 (2006): 893-902.

Tuesday, September 1, 2009

When Should Sex Education Start?

What Age Do You Talk with Your Kids About Sex?


Many parents want to know at what age is it appropriate to start teaching their children about sex. What most of us don’t think about is that the question presumes that there is an age at which sexuality becomes important or “an issue”. This presumption is 100% wrong. Sexuality is an intrinsic part of who we are, from birth to death. And while our sexuality isn’t the same when we’re six as when we’re sixteen, or sixty, it is always there and always a part of us. So the question isn’t so much when to start talking with your children about sex, but how to do it at every age and stage of their lives.

Many, possibly most, parents are less than proactive in talking about sex with their children, and don’t deal with it until moments like these:

  • Your toddler begins exploring his or her body in public and you’re not sure how to deal with it.
  • You wonder at what point it’s “not okay” to let your child see you without clothes on.
  • Your child asks you where they came from or where other babies come from.
  • Your child begins to ask questions about their body and why it looks different from their brothers or sisters.

Each of these are important teaching moments, and if you want to avoid dealing with situations and questions at awkward or inconvenient times (say, in the middle of a holiday service, at a family dinner, or just as your rushing off to work) you’re best protection is to be proactive, and make space for sex talks on an ongoing basis.

Teaching your children about sex should begin as soon as you’re communicating with them. If they have questions they’ll let you know. And even if they don’t, you can let them know that you’re open to the questions by including sex education in all the things you teach them.

A good example is body parts. A common early learning experience between parents and children is teaching the names of body parts. We all learn about our ears and eyes and nose and mouth. In fact we usually cover all the major parts of the body but many parents don’t include names for parts of the body they consider sexual (e.g. penis, nipples, vagina, etc…). They’ll ignore those parts of the body even while young children are learning about them by touching themselves. Make no mistake, children learn as much by what parents don’t talk to them about, as they do from what parents do tell them.

Of course talking with your children about sex is extremely difficult when you have questions of your own, and no comfort level or practice. But waiting doesn’t make it easier, and the most important thing for you to do is be willing to listen to your child and help them find answers even when you don’t have them.

Sunday, August 16, 2009

Asthma and Pregnancy:

Does Asthma Get Worse During Pregnancy?

Asthma tends to follow a “rule of thirds” during pregnancy. This means that one-third of pregnant asthmatics get better, one-third get worse, and one-third remain the same as prior to pregnancy. Women who follow one pattern with one pregnancy tend to have a similar pattern with future pregnancies.

It is common for severe asthmatics to get worse during pregnancy, while those with mild asthma tend to improve. The majority of asthma exacerbations occur during 24 to 36 weeks of gestation; only rarely does the asthma worsen significantly during labor and delivery. Usually asthma returns to its pre-pregnancy state within 3 months of delivery.

What are the Risks of Asthma During Pregnancy?

Asthma is the most frequent chronic respiratory disease affecting pregnancy, occurring in approximately 4% of pregnant women. There are numerous complications that affect mother and baby if the asthma is uncontrolled. After all, the fetus is relying on the mother’s lungs for oxygen. If the mother’s oxygen level is low because she is having as asthma attack, then the fetus is not likely getting enough oxygen either.

Maternal complications of uncontrolled asthma include:

    • High blood pressure
    • Toxemia of pregnancy
    • Uterine hemorrhage
    • Need for caesarian section

Fetal complications of uncontrolled asthma in the mother include

    • Risk of stillbirth
    • Premature birth
    • Low birth weight
    • Growth Retardation

How Should a Pregnant Asthmatic Be Monitored?

It is recommended that all pregnant women with asthma are followed closely by an asthma specialist during their pregnancy. This may include monthly evaluations of asthma history and lung function testing. An obstetrician may plan to perform more frequent ultrasound examinations in women with under-controlled asthma. It is important to tell your obstetrician if you have asthma.

What Medication is Safe to Take During Pregnancy?

According to the Food and Drug Administration (FDA), no asthma drugs are considered completely safe in pregnancy. This is because no pregnant woman would want to sign-up for a medication safety study while she is pregnant. Therefore, the FDA has assigned risk categories to medications based on use in pregnancy.

Pregnancy category “A” medications are medications in which there are good studies in pregnant women showing the safety of the medication to the baby in the first trimester. There are very few medications in this category, and no asthma medications. Category “B” medications show good safety studies in pregnant animals but there are no human studies available. Pregnancy category “C” medications may result in adverse effects on the fetus when studied in pregnant animals, but the benefits of these drugs may out weight the potential risks in humans. Category “D” medications show clear risk to the fetus, but there may be instances in which the benefits outweigh the risks in humans. And finally, category “X” medications show clear evidence of birth defects in animals and/or human studies and should not be used in pregnancy.

Before any medication is taken during pregnancy, the doctor and patient must have a risk/benefit discussion. This means that the benefits of the medication should be weighed against the risks – and the medication should only be taken if the benefits outweigh the risks.

What Asthma Medication is Safe to Take During Pregnancy?

Again, safety of asthma medications during pregnancy is a determination of risks and benefits to be made by a physician. However, the professional organizations of obstetricians (ACOG) and allergists (ACAAI) have published guidelines on the management of asthma during pregnancy. In general, treatment of asthma during pregnancy is not different from guidelines for asthma in non-pregnancy. This is also true for recommended medications based on level of severity of asthma.

Rescue medications for acute asthma symptoms include inhaled beta-agonists such as albuterol. While these medications are all category “C”, the experience of these drugs in pregnant women is enormous and shows no evidence of adverse effects on the baby, either during pregnancy or breastfeeding.

Controller medications for persistent asthma include inhaled steroids, which are the preferred method to control the underlying inflammation in asthma. Other medications in this group include long-acting beta-agonists (used in combination with inhaled steroids such as in Advair®) theophylline, cromolyn, nedocromil, and leukotriene blocking medications (such as montelukast).

The preferred inhaled steroids include beclomethasone (category “C”) and budesonide (category “B”). However, ACOG/ACAAI considers it reasonable to continue another types of inhaled steroid during pregnancy if the mother was well-controlled with using that medication.

A combination product such as Advair® may be required in patients with more severe asthma. These medications combine inhaled steroids with a long-acting beta-agonist (albuterol-like medication), and is used as a controller therapy. Patients still require albuterol for “as needed” or rescue use. Long-acting beta-agonists, such as salmeterol, are considered to have safety comparable to albuterol.

Other controller medications such as theophylline (category “C”) and cromolyn, nedrocromil and the leukotriene blocking drugs (all category “B”) are reasonable to continue during pregnancy if the mother has had good benefit from the medications prior to pregnancy. However, none of these medications would be considered a “first choice” to start during pregnancy.

Friday, August 7, 2009

menopause


Some women continue to menstruate normally until the onset of menopause and then simply cease to have periods. But for most women, the transition is not so orderly. You can expect to see a variety of changes. What they are and why they happen is the subject of the discussion that follows. Under other headings, you'll find more on the symptoms and management of the most troubling of these problems.

Changing Hormonal Patterns
A woman's egg supply, as much as 2 million in the ovaries at birth, is programmed for depletion. When the supply is almost exhausted because of the aging process, or the ovaries are surgically removed, the menstrual cycle comes to an end. In fact, the reproductive cycle begins to change several years before menopause, a period referred to as perimenopause.

During this time, typically starting in the late 40's, the ovaries' response to the various stimulating hormones produced by the brain becomes unsynchronized, until eventually the aging ovaries fail to respond at all. They start to produce less progesterone, losing their ability to ovulate and develop the subsequent corpus luteum. When ovulation stops, estrogen levels decline and menstruation ceases.

As ovulatory cycles become more irregular throughout perimenopause, the body's sensitive hormonal rhythm is thrown off and menstruation may vary more from month to month. In addition, two hormones known as androgens begin to play a bigger role. Though referred to as male sex hormones, they are in fact produced in small amounts by the female body as well. As levels of the female hormones decline, the impact of these "male" hormones can increase.

The bottom line is that fluctuating blood levels of hormones during the transitional years can create a number of physiological changes. These may be less unsettling for women who have an understanding of what their bodies are going through.

Menopause at a Glance
The wide array of problems shown in this diagram may seem daunting; but fortunately, few women experience every one of them. Hot flashes are the most common complaint. However, these annoying sensations pass in due course, while other symptoms may pose a much greater long-term threat. Be particularly alert for lower back pain, which may signal the onset of osteoporosis, the bone-weakening disorder that leaves older women prey to fractures. Remember, too, that menopause robs you of estrogen's protective effect on the heart, and that heart disease is the Number One killer of women. (For more information, see "Heart Disease: The Greatest Threat of All.")

Changes in the Menstrual Cycle
Cyclical Changes occur for the vast majority of women whose periods do not just stop. The perimenopausal years may be marked by skipped menstrual periods, heavier or lighter than usual bleeding, and changes in the frequency of cycles. During some menstrual cycles, no egg may be produced; these are called anovulatory cycles.

Light, short, or skipped periods occur as the ovaries' hormonal response becomes unpredictable. Heavy and prolonged bleeding arise when a longer than normal release of estrogen overstimulates growth of the uterine lining. The lining may be irregular or thickened and may not slough off completely or evenly, causing menstruation to stop and start again. Clotting may be noticeable in menstrual bleeding.

The physical changes that accompany the menstrual cycle may also become less predictable and regular. Such signs as breast tenderness, fluid retention and headache may occur at unpredictable times.

Fertility declines as a woman enters her 40s, but it does not disappear entirely until menopause is complete. To avoid unplanned pregnancies, doctors recommend using birth control until a full year has passed since the last menstrual cycle.

Menopause: Myths and Realities

Myth: Menopausal women are unhappy and depressed.

Reality: Most women cope very well with the physical challenges of menopause. Serious mental health problems do not increase. While some women may experience emotional distress, this is often related to sleep disturbance and deprivation due to hot flashes.

Myth: All women going through menopause are plagued by hot flashes.
Reality: About 80 percent of American women experience only mild symptoms, or none at all, during menopause. When hot flashes do occur, in most cases they are mild and disappear after a few months, rarely persisting for more than 2 or 3 years.

Myth: Menopause is the end of your sex life.
Reality: Libido, or sexual desire, does decline with aging, but many women continue to enjoy a satisfying sex life deep into old age. Some women find sex more enjoyable after menopause when concerns about pregnancy are past.


Tuesday, July 14, 2009

genital herpes

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2). Most genital herpes is caused by HSV-2. Most individuals have no or only minimal signs or symptoms from HSV-1 or HSV-2 infection. When signs do occur, they typically appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it almost always is less severe and shorter than the first outbreak. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years.


HOW COMMON IS GENITAL HERPES?

Results of a nationally representative study show that genital herpes infection is common in the United States. Nationwide, at least 45 million people ages 12 and older, or one out of five adolescents and adults, have had genital HSV infection. Over the past decade, the percent of Americans with genital herpes infection in the U.S. has decreased.

Genital HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of eight). This may be due to male-to-female transmission being more likely than female-to-male transmission.


HOW DO PEOPLE GET HERPES?

HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause, but they also are released between outbreaks from skin that does not appear to have a sore. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected.

HSV-1 can cause genital herpes, but it more commonly causes infections of the mouth and lips, so-called “fever blisters.” HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV-1 infection. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks.


WHAT ARE THE SIGNS AND SYMPTOMS OF GENITAL HERPES?

Most people infected with HSV-2 are not aware of their infection. However, if signs and symptoms occur during the first outbreak, they can be quite pronounced. The first outbreak usually occurs within two weeks after the virus is transmitted, and the sores typically heal within two to four weeks. Other signs and symptoms during the primary episode may include a second crop of sores, and flu-like symptoms, including fever and swollen glands. However, most individuals with HSV-2 infection never have sores, or they have very mild signs that they do not even notice or that they mistake for insect bites or another skin condition.

People diagnosed with a first episode of genital herpes can expect to have several (typically four or five) outbreaks (symptomatic recurrences) within a year. Over time these recurrences usually decrease in frequency. It is possible that a person becomes aware of the “first episode” years after the infection is acquired.


WHAT ARE THE COMPLICATIONS OF GENITAL HERPES?

Genital herpes can cause recurrent painful genital sores in many adults, and herpes infection can be severe in people with suppressed immune systems. Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

In addition, genital HSV can lead to potentially fatal infections in babies. It is important that women avoid contracting herpes during pregnancy because a newly acquired infection during late pregnancy poses a greater risk of transmission to the baby. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed. Fortunately, infection of a baby from a woman with herpes infection is rare.

Herpes may play a role in the spread of HIV, the virus that causes AIDS. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.

HOW IS GENITAL HERPES DIAGNOSED?

The signs and symptoms associated with HSV-2 can vary greatly. Health care providers can diagnose genital herpes by visual inspection if the outbreak is typical, and by taking a sample from the sore(s) and testing it in a laboratory. HSV infections can be diagnosed between outbreaks by the use of a blood test. Blood tests, which detect antibodies to HSV-1 or HSV-2 infection, can be helpful, although the results are not always clear-cut.


IS THERE A TREATMENT FOR HERPES?

There is no treatment that can cure herpes, but antiviral medications can shorten and prevent outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy for symptomatic herpes can reduce transmission to partners.

HOW CAN HERPES BE PREVENTED?

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Genital ulcer diseases can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of genital herpes.

Persons with herpes should abstain from sexual activity with uninfected partners when lesions or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected and they should use condoms to reduce the risk. Sex partners can seek testing to determine if they are infected with HSV. A positive HSV-2 blood test most likely indicates a genital herpes infection.


WHERE CAN I GET MORE INFORMATION?

Division of STD Prevention (DSTDP)
Centers for Disease Control and Prevention

Personal health inquiries and information about STDs:

CDC-INFO Contact Center
1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

Tuesday, July 7, 2009

SYPHILIS

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It has often been called “the great imitator” because so many of the signs and symptoms are indistinguishable from those of other diseases.


HOW COMMON IS SYPHILIS?

In the United States, health officials reported over 36,000 cases of syphilis in 2006, including 9,756 cases of primary and secondary (P&S) syphilis. In 2006, half of all P&S syphilis cases were reported from 20 counties and 2 cities; and most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence of P&S syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Reported cases of congenital syphilis in newborns increased from 2005 to 2006, with 339 new cases reported in 2005 compared to 349 cases in 2006.

Between 2005 and 2006, the number of reported P&S syphilis cases increased 11.8 percent. P&S rates have increased in males each year between 2000 and 2006 from 2.6 to 5.7 and among females between 2004 and 2006. In 2006, 64% of the reported P&S syphilis cases were among men who have sex with men (MSM).


HOW DO PEOPLE GET SYPHILIS?

Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal, or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.

WHAT ARE THE SIGNS AND SYMPTOMS IN ADULTS?

Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission occurs from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, transmission may occur from persons who are unaware of their infection.

Primary Stage
The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is usually firm, round, small, and painless. It appears at the spot where syphilis entered the body. The chancre lasts 3 to 6 weeks, and it heals without treatment. However, if adequate treatment is not administered, the infection progresses to the secondary stage.

Secondary Stage
Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts with the development of a rash on one or more areas of the body. The rash usually does not cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing or several weeks after the chancre has healed. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The signs and symptoms of secondary syphilis will resolve with or without treatment, but without treatment, the infection will progress to the latent and possibly late stages of disease.

Late and Latent Stages
The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis even though there are no signs or symptoms; infection remains in the body. This latent stage can last for years. The late stages of syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear 10 – 20 years after infection was first acquired. In the late stages of syphilis, the disease may subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.

HOW DOES SYPHILIS AFFECT A PREGANANT WOMAN AND HER BABY?

The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth. An infected baby may be born without signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies may become developmentally delayed, have seizures, or die.


HOW IS SYPHILIS DIAGNOSED?

Some health care providers can diagnose syphilis by examining material from a chancre (infectious sore) using a special microscope called a dark-field microscope. If syphilis bacteria are present in the sore, they will show up when observed through the microscope.

A blood test is another way to determine whether someone has syphilis. Shortly after infection occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and inexpensive blood test. A low level of antibodies will likely stay in the blood for months or years even after the disease has been successfully treated. Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have a blood test for syphilis.


WHAT IS THE LINK BETWEEN SYPHILIS AND HIV?

Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV if exposed to that infection when syphilis is present.

Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex, increase the infectiousness of and susceptibility to HIV. Having other STDs is also an important predictor for becoming HIV infected because STDs are a marker for behaviors associated with HIV transmission.


WHAT IS THE TREATMENT FOR SYPHILIS?

Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year. For people who are allergic to penicillin, other antibiotics are available to treat syphilis. There are no home remedies or over-the-counter drugs that will cure syphilis. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

Because effective treatment is available, it is important that persons be screened for syphilis on an on-going basis if their sexual behaviors put them at risk for STDs.

Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.


WILL SYPHILIS RECUR?

Having syphilis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection. Only laboratory tests can confirm whether someone has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or mouth, it may not be obvious that a sex partner has syphilis. Talking with a health care provider will help to determine the need to be re-tested for syphilis after being treated.


HOW CAN SYPHILIS BE PREVENTED?

The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior. It is important that sex partners talk to each other about their HIV status and history of other STDs so that preventive action can be taken.

Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of syphilis, as well as genital herpes and chancroid, only when the infected area or site of potential exposure is protected.

Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective than other lubricated condoms in protecting against the transmission of STDs. Use of condoms lubricated with N-9 is not recommended for STD/HIV prevention. Transmission of an STD, including syphilis cannot be prevented by washing the genitals, urinating, and/or douching after sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex and to see a doctor immediately.


WHERE CAN I GET INFORMATION?

Sexually Transmitted Diseases - Home Page
Syphilis - Topic Page
Syphilis and MSM - Fact Sheet
STDs and Pregnancy - Fact Sheet
Order Publications Online

Sunday, June 14, 2009

First Trimester Prenatal Visit

Typically you will make an appointment with your doctor or midwife as soon as you have a positive pregnancy test. The typical prenatal care schedule in the first trimester is that you are seen every four (4) weeks or about once a month.

There are some practitioners who do not want you to schedule a prenatal visit until after you have missed two or more periods. This can make you nervous and worried, be sure to explain this to the practitioner or find a new doctor or midwife.

You will be allowed additional visits if you are having problems like bleeding or cramping. These are done on an as needed basis which can range from daily to weekly.

Common Tests in the First Trimester

Sunday, June 7, 2009

Anatomy of Prenatal Visit

While every practitioner is different, the basics of the prenatal visit are usually the same. Some of these will be done in different orders, some at every visit, while others not at every visit. You may even have things done that are not on this list. The thing to remember is always ask what the test is for, how are the results given, do you have an option for a different test, to skip the test, or wait for awhile.

Here is what will happen at a typical prenatal appointment with your midwife or doctor:

  • Give urine. This is done to check for many different things, usually protein and glucose. These may indicate a problem, or just give us history about what you had for breakfast!
  • Blood Pressure. Having this taken at every visit will give us a baseline. This will tell us what your normal blood pressure should be, and if it rises, what the rate of rise was. It is not absolute numbers as much as it is rate of rise when looking at blood pressure as a problem.
  • Fundal Height. This measures the size of your uterus. It is usually begun around 20 weeks. At this point the uterus usually measures 20 centimeters from the pubic bone, and will stay around the number of weeks you are. The numbers will be give or take about 2, and can change as the baby changes position and grows. They might indicate a problem or surprises (twins!) if the numbers change dramatically.
  • Fetal Heart Rate. If your practitioner uses a doppler this miraculous sound can be heard on average about 12 weeks. Maternal fat stores, positioning of the uterus might get in the way. Around 18 weeks a fetoscope or regular stethoscope will pick up the baby's glorious beats. (Hear a baby.)
  • Nutrition. What have you been eating? How are you feeling? Weight fluctuations... You might need some help in directing your diet.
  • Health. Are you tired? How is work? Do you have any swelling? Headaches, sinus problems, etc.
  • Mental Health. How are you adjusting to the pregnancy? How is your family reacting? Are you preparing for baby?
  • Social Behavior. Are you smoking, drinking, taking drugs? Are you around people who smoke?
  • Questions? What questions do you have about future visits, things that have come up, the future?

Thursday, May 14, 2009

H1N1 and Pregnancy

What if I get this new virus and I am pregnant?

We don’t know if this virus will cause pregnant women to have a greater chance of getting sick or have serious problems. We also do not know how this virus will affect the baby. Photo of pregnant mother

We do know that pregnant women are more likely to get sick than others and have more serious problems with seasonal flu. These problems may include early labor or severe pneumonia. We don’t know if this virus will do the same, but it should be taken very seriously.

What can I do to protect myself, my baby and my family?

Take these everyday steps to help prevent the spread of germs and protect your health:

  • Cover your nose and mouth with a tissue when you cough or sneeze, or sneeze into your sleeve. Throw the tissue in the trash after you use it.
  • Wash your hands often with soap and warm water, especially after you cough or sneeze. Alcohol-based gel hand cleaners are also good to use.
  • Avoid touching your eyes, nose or mouth. Germs spread this way.
  • Try to avoid close contact with sick people. (If you are pregnant and you live or have close contact with someone who has H1N1 flu, talk to your doctor about medicines to prevent flu.)
  • Have a plan to care for sick family members.
  • Stock up on household, health, and emergency supplies, such as water, Tylenol®, non-perishable foods.

What are the symptoms of H1N1?

Symptoms are like seasonal flu and include the following:

  • Fever
  • Cough
  • Sore throat
  • Body aches
  • Headaches
  • Chills and fatigue
  • Sometimes, diarrhea and vomiting

What should I do if I get sick?

  • If there is H1N1 flu in your community pay extra attention to your body and how you are feeling.
  • If you get sick with flu-like symptoms, stay home, limit contact with others, and call your doctor. Your doctor will decide if testing or treatment is needed. Tests may include a nasal swab which is best to do within the first 4-5 days of getting sick. Like regular flu, H1N1 flu may make other medical problems worse.
  • If you are alone at any time, have someone check in with you often if you are feeling ill. This is always a good idea.
  • If you have close contact with someone who has H1N1 flu or is being treated for exposure to H1N1 flu, contact your doctor to discuss whether you need treatment to reduce your chances of getting the flu.

How is H1N1 flu treated?

  • Treat any fever right away. Tylenol® (acetaminophen) is the best treatment of fever in pregnancy.
  • Drink plenty of fluids to replace those you lose when you are sick.
  • Your doctor will decide if you need antiviral drugs such as Tamiflu® (oseltamivir) or Relenza® (zanamivir). Antiviral drugs are prescription pills, liquids or inhalers that fight against the flu by keeping the germs from growing in your body. These medicines can make you feel better faster and make your symptoms milder.
  • These medicines work best when started soon after symptoms begin (within two [2] days), but they may also be given to very sick or high risk people (like pregnant women) even after 48 hours. Antiviral treatment is taken for 5 days.
  • Tamiflu® and Relenza® are also used to prevent H1N1 flu and are taken for 10 days.
  • There is little information about the effect of antiviral drugs in pregnant women or their babies, but no serious side effects have been reported. If you do think you have had a side effect to antiviral drugs, call your doctor right away.

When should I get emergency medical care?

Photo of hospital signIf you have any of these signs, seek emergency medical care right away:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting
  • Decreased or no movement of your baby
  • A high fever that is not responding to Tylenol®

How should I feed my baby?

Flu can be very serious in young babies. Babies who are breastfed do not get as sick and are sick less often from the flu, than do babies who are not breastfed.

Breastfeeding protects babies. Breast milk passes on antibodies from the mother to a baby. Antibodies help fight off infection.

Is it ok to breastfeed my baby if I am sick?

  • A mother’s milk is made to fight diseases in her baby. This is really important in young babies when their immune system is still growing.
  • Do not stop breastfeeding if you are ill. Breastfeed early and often. Limit formula feeds if you can. This will help protect your baby from infection.
  • Be careful not to cough or sneeze in the baby’s face, wash your hands often with soap and water.
  • Your doctor might ask you to wear a mask to keep from spreading this new virus to your baby.
  • If you are too sick to breastfeed, pump and have someone give the expressed milk to your baby.

Is it OK to take medicine to treat or prevent H1N1 flu while breastfeeding?

Yes. Mothers who are breastfeeding can continue to nurse their babies while being treated for the flu.

Thursday, May 7, 2009

H1N1 Virus (Swine FLu)

H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people. This new virus was first detected in people in the United States in April 2009. Other countries, including Mexico and Canada, have reported people sick with this new virus. This virus is spreading from person-to-person, probably in much the same way that regular seasonal influenza viruses spread.

What is H1N1 (swine flu)?

H1N1 Influenza virus imageWhy is this new H1N1 virus sometimes called “swine flu”?
This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and avian genes and human genes. Scientists call this a "quadruple reassortant" virus.


Novel H1N1 Flu in Humans


Are there human infections with this H1N1 virus in the U.S.?
Yes. Cases of human infection with this H1N1 influenza virus were first confirmed in the U.S. in Southern California and near Guadalupe County, Texas. The outbreak intensified rapidly from that time and more and more states have been reporting cases of illness from this virus. An updated case count of confirmed novel H1N1 flu infections in the United States is kept at http://www.cdc.gov/h1n1flu/investigation.htm. CDC and local and state health agencies are working together to investigate this situation.

Is this new H1N1 virus contagious?
CDC has determined that this new H1N1 virus is contagious and is spreading from human to human. However, at this time, it is not known how easily the virus spreads between people.

Photo of nurse and childWhat are the signs and symptoms of this virus in people?
The symptoms of this new H1N1 flu virus in people are similar to the symptoms of seasonal flu and include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. A significant number of people who have been infected with this virus also have reported diarrhea and vomiting. Also, like seasonal flu, severe illnesses and death has occurred as a result of illness associated with this virus.

How severe is illness associated with this novel H1N1 flu virus?
It’s not known at this time how severe this new H1N1 flu virus will be in the general population. In seasonal flu, there are certain people that are at higher risk of serious flu-related complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. Early indications are that pregnancy and other previously recognized medical conditions that increase the risk of influenza-related complications, like asthma and diabetes, also appear to be associated with increased risk of complications from this novel H1N1 virus infection as well.

One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far in the outbreak. CDC is conducting laboratory studies to see if certain people might have natural immunity to this virus, depending on their age. Early reports indicate that no children and few adults younger than 60 years old have existing antibody to the novel H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against the novel H1N1 flu by any existing antibody.

How does novel H1N1 flu compare to seasonal flu in terms of its severity and infection rates?
CDC is still learning about the severity of the novel H1N1 flu virus. At this time, there is not enough information to predict how severe this novel H1N1 flu outbreak will be in terms of illness and death or how it will compare with seasonal influenza.

With seasonal flu, we know that seasons vary in terms of timing, duration and severity. Seasonal influenza can cause mild to severe illness, and at times can lead to death. Each year, in the United States, on average 36,000 people die from flu-related complications and more than 200,000 people are hospitalized from flu-related causes. Of those hospitalized, 20,000 are children younger than 5 years old. Over 90% of deaths and about 60 percent of hospitalization occur in people older than 65.

So far, with novel H1N1 flu, the largest number of novel H1N1 flu confirmed and probable cases have occurred in people between the ages of 5 and 24-years-old. At this time, there are few cases and no deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu. However, pregnancy and other previously recognized high risk medical conditions from seasonal influenza appear to be associated with increased risk of complications from this novel H1N1.

How does this new H1N1 virus spread?
Spread of this H1N1 virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How long can an infected person spread this virus to others?
At the current time, CDC believes that this virus has the same properties in terms of spread as seasonal flu viruses. With seasonal flu, studies have shown that people may be contagious from one day before they develop symptoms to up to 7 days after they get sick. Children, especially younger children, might potentially be contagious for longer periods. CDC is studying the virus and its capabilities to try to learn more and will provide more information as it becomes available.

Can I get infected with this new H1N1 virus from eating or preparing pork?

No. H1N1 viruses are not spread by food. You cannot get this new HIN1 virus from eating pork or pork products. Eating properly handled and cooked pork products is safe.

Is there a risk from drinking water?
Tap water that has been treated by conventional disinfection processes does not likely pose a risk for transmission of influenza viruses. Current drinking water treatment regulations provide a high degree of protection from viruses. No research has been completed on the susceptibility of the novel H1N1 flu virus to conventional drinking water treatment processes. However, recent studies have demonstrated that free chlorine levels typically used in drinking water treatment are adequate to inactivate highly pathogenic H5N1 avian influenza. It is likely that other influenza viruses such as novel H1N1 would also be similarly inactivated by chlorination. To date, there have been no documented human cases of influenza caused by exposure to influenza-contaminated drinking water.

Can the new H1N1 flu virus be spread through water in swimming pools, spas, water parks, interactive fountains, and other treated recreational water venues?
Influenza viruses infect the human upper respiratory tract. There has never been a documented case of influenza virus infection associated with water exposure. Recreational water that has been treated at CDC recommended disinfectant levels does not likely pose a risk for transmission of influenza viruses. No research has been completed on the susceptibility of the H1N1 influenza virus to chlorine and other disinfectants used in swimming pools, spas, water parks, interactive fountains, and other treated recreational venues. However, recent studies have demonstrated that free chlorine levels recommended by CDC (1–3 parts per million [ppm or mg/L] for pools and 2–5 ppm for spas) are adequate to disinfect avian influenza A (H5N1) virus. It is likely that other influenza viruses such as novel H1N1 virus would also be similarly disinfected by chlorine.

Can H1N1 influenza virus be spread at recreational water venues outside of the water?
Yes, recreational water venues are no different than any other group setting. The spread of this novel H1N1 flu is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

Prevention & Treatment

What can I do to protect myself from getting sick?

There is no vaccine available right now to protect against this new H1N1 virus. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza.

Take these everyday steps to protect your health:

  • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
  • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
  • Avoid touching your eyes, nose or mouth. Germs spread this way.
  • Try to avoid close contact with sick people.
  • Stay home if you are sick for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. This is to keep from infecting others and spreading the virus further.

Other important actions that you can take are:

  • Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
  • Be prepared in case you get sick and need to stay home for a week or so; a supply of over-the-counter medicines, alcohol-based hand rubs, tissues and other related items might could be useful and help avoid the need to make trips out in public while you are sick and contagious.

Photo of man sneezingWhat is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. If you are sick, stay home for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. Cover your mouth and nose with a tissue when coughing or sneezing. Put your used tissue in the waste basket. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water or clean with alcohol-based hand cleaner. CDC recommends that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.

What should I do if I get sick?
If you live in areas where people have been identified with new H1N1 flu and become ill with influenza-like symptoms, including fever, body aches, runny or stuffy nose, sore throat, nausea, or vomiting or diarrhea, you should stay home and avoid contact with other people. Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings

If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed

If you become ill and experience any of the following warning signs, seek emergency medical care.

In children, emergency warning signs that need urgent medical attention include:

  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Severe or persistent vomiting
  • Not waking up or not interacting
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough

In adults, emergency warning signs that need urgent medical attention include:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting
  • Flu-like symptoms improve but then return with fever and worse cough

Are there medicines to treat infection with this new virus?
Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with the new H1N1 flu virus. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current outbreak, the priority use for influenza antiviral drugs during is to treat severe influenza illness.

What is CDC’s recommendation regarding "swine flu parties"?
"Swine flu parties" are gatherings during which people have close contact with a person who has novel H1N1 flu in order to become infected with the virus. The intent of these parties is to become infected with what for many people has been a mild disease, in the hope of having natural immunity to the novel H1N1 flu virus that might circulate later and cause more severe disease.

CDC does not recommend "swine flu parties" as a way to protect against novel H1N1 flu in the future. While the disease seen in the current novel H1N1 flu outbreak has been mild for many people, it has been severe and even fatal for others. There is no way to predict with certainty what the outcome will be for an individual or, equally important, for others to whom the intentionally infected person may spread the virus.

CDC recommends that people with novel H1N1 flu avoid contact with others as much as possible. They should stay home from work or school for 7 days after the onset of illness or until at least 24 hours after symptoms have resolved, whichever is longer.

Contamination & Cleaning

Photo of hands and soapHow long can influenza virus remain viable on objects (such as books and doorknobs)?

Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for up to 2-8 hours after being deposited on the surface.

What kills influenza virus?
Influenza virus is destroyed by heat (167-212°F [75-100°C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols are effective against human influenza viruses if used in proper concentration for a sufficient length of time. For example, wipes or gels with alcohol in them can be used to clean hands. The gels should be rubbed into hands until they are dry.

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk, for example, and then touches their own eyes, mouth or nose before washing their hands.

How should waste disposal be handled to prevent the spread of influenza virus?
To prevent the spread of influenza virus, it is recommended that tissues and other disposable items used by an infected person be thrown in the trash. Additionally, persons should wash their hands with soap and water after touching used tissues and similar waste.

Photo of cleaning suppliesWhat household cleaning should be done to prevent the spread of influenza virus?
To prevent the spread of influenza virus it is important to keep surfaces (especially bedside tables, surfaces in the bathroom, kitchen counters and toys for children) clean by wiping them down with a household disinfectant according to directions on the product label.

How should linens, eating utensils and dishes of persons infected with influenza virus be handled?
Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first.
Linens (such as bed sheets and towels) should be washed by using household laundry soap and tumbled dry on a hot setting. Individuals should avoid “hugging” laundry prior to washing it to prevent contaminating themselves. Individuals should wash their hands with soap and water or alcohol-based hand rub immediately after handling dirty laundry.

Eating utensils should be washed either in a dishwasher or by hand with water and soap.

Response & Investigation


What is CDC doing in response to the outbreak?
CDC has implemented its emergency response. The agency’s goals are to reduce transmission and illness severity, and provide information to help health care providers, public health officials and the public address the challenges posed by the new virus. CDC continues to issue new interim guidance for clinicians and public health professionals. In addition, CDC’s Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak.

What epidemiological investigations are taking place in response to the recent outbreak?
CDC works very closely with state and local officials in areas where human cases of new H1N1 flu infections have been identified. In California and Texas, where EpiAid teams have been deployed, many epidemiological activities are taking place or planned including:

  • Active surveillance in the counties where infections in humans have been identified;
  • Studies of health care workers who were exposed to patients infected with the virus to see if they became infected;
  • Studies of households and other contacts of people who were confirmed to have been infected to see if they became infected;
  • Study of a public high school where three confirmed human cases of H1N1 flu occurred to see if anyone became infected and how much contact they had with a confirmed case; and
  • Study to see how long a person with the virus infection sheds the virus.


*Note: Much of the information in this document is based on studies and past experience with seasonal (human) influenza. CDC believes the information applies to the new H1N1 (swine) viruses as well, but studies on this virus are ongoing to learn more about its characteristics. This document will be updated as new information becomes available.

For general information about swine influenza (not new H1N1 flu) see Background Information about Swine Influenza.

Tuesday, April 7, 2009

pap smear

What is a Pap smear?


A Pap smear (also known as the Pap test) is a medical procedure in which a sample of cells from a woman's cervix (the end of the uterus that extends into the vagina) is collected and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for pre-malignant (before-cancer) or malignant (cancer) changes.

A Pap smear is a simple, quick, and relatively painless screening test. Its specificity - which means its ability to avoid classifying a normal smear as abnormal (a "false positive" result) - while very good, is not perfect. The sensitivity of a Pap smear - which means its ability to detect every single abnormality -- while good, is also not perfect, and some "false negative" results (in which abnormalities are present but not detected by the test) will occur. Thus, a few women develop cervical cancer despite having regular Pap screening.

In the vast majority of cases, a Pap test does identify minor cellular abnormalities before they have had a chance to become malignant and at a point when the condition is most easily treatable. The Pap smear is not intended to detect other forms of cancer such as those of the ovary, vagina, or uterus. Cancer of these organs may be discovered during the course of the gynecologic (pelvic) exam, which usually is done at the same time as the Pap smear.


Who should have a Pap smear?

Pregnancy does not prevent a woman from having a Pap smear. Pap smears can be safely done during pregnancy. Pap smear testing is not indicated for women who have had a hysterectomy (with removal of the cervix) for benign conditions. Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy.

The screening guidelines of several key medical organizations are summarized below.

American Cancer Society 2004

When to start Pap smear testing

3 years after vaginal intercourse, no later than age 21

Frequency of Pap smear testing

Yearly with exceptions:

every 2 years if liquid-based kit

every 2-3 years if three normal tests in a row in women >30 years old

At what age to stop having Pap smears

Total hysterectomy for benign disease

> 70 years old with at least three normal Pap smear results and no abnormal Pap results in the last 10 year


American College of Obstetrics and Gynecology

When to start Pap smear testing

3 years after first sexual intercourse or age 21, whichever comes first.

Frequency of Pap smear testing

Yearly until age 30 years. Beginning at age 30, if three normal annual Pap results, can do a Pap alone every 2-3 years

At what age to stop having Pap smears

Difficult to set an upper age limit-postmenopausal women screened within the prior 2-3 years have a very low risk of developing abnormal Pap smears.

Which women are at increased risk for having an abnormal Pap smear?

A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.

HPV: The principal risk factor is infection with the genital wart virus, also called the human

papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. (See below for details). About 95%-100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women.

Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.

Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.

Medications: Women whose mothers took the drug diethylstilbestrol (DES) during preg

nancy also are at increased risk.

Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age.


How is a Pap smear done?

A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician). These agents may wash away or hide any abnormal cervical cells.


A Pap smear can be done in a doctor's office, a clinic, or a hospital by either a physician or other specially trained health care professional, such as a physician assistant, a nurse practitioner, or a nurse midwife.

With the woman positioned on her back, the clinician will often first examine the outside of the patient's genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal.

A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.)

A cotton swab is sometimes used to clear away mucus that might interfere with an optimal sample.

A small brush called a cervical brush is then inserted into the opening of the cervix (the cervical os) and twirled around to collect a sample of cells. Because this sample comes from inside the cervix, is called the endocervical sample ("endo" meaning inside).

A second sample is also collected as part of the Pap smear and is called the ectocervical sample ("ecto" meaning outside).These cells are collected from a scraping of the area surrounding, but not entering, the cervical os.

Both the endocervical and the ectocervical samples are gently smeared on a glass slide and a fixative (a preservative) is used to prepare the cells on the slide for laboratory evalua tion.


A bimanual (both hands) pelvic exam usually follows the collection of the two samples for the Pap smear. The bimanual examination involves the physician or health care practitioner inserting two fingers of one hand inside the vaginal canal while feeling the ovariesand uterus with the other hand on top of the abdomen (belly).


The results of the Pap smear are usually available within two to three weeks. At the end of Pap smear testing, each woman should ask how she should expect to be informed about the results of her Pap smear. If a woman has not learned of her results after a month, she should contact her health care practitioner's office.


What are the risks of having a Pap smear?

There are absolutely no known medical risks associated with Pap smear screening. (However, there are medical risks from not having a Pap smear.)


How is a Pap smear read (analyzed)?


Pap smear analysis and reports are all based on a medical terminology system called The Bethesda System. The system was developed (at the National Institutes of Health (

NIH) in Bethesda, Maryland) to encourage all medical professionals analyzing Pap smears to use the same reporting system. Standardization reduces the possibility that different laboratories might report different results for the same smear. Standardization and uniform terminology also make Pap smear reports less confusing for the clinicians who request the tests and for their women patients.

The Bethesda System was the outcome of a National Cancer Institute workshop that was held in 1988 in an effort to standardize Pap reports. The guidelines address many aspects of Pap smear testing and its results. In 2001, the guidelines were revised and improved. Acceptance of the Bethesda reporting system in the United States is virtually universal.


What information is included on a Pap smear report?

The first items on a Pap smear report are for purposes of identification. The report is expected to have the name of the woman, the name of the pathologist and/or the cytotechnologist who read the smear, the source of the specimen (in this case, the cervix), and the date of the last menstrual period of the woman.

The Pap smear report should also include the following:

A description of the woman's menstrual status (for example, "menopausal" (no longer menstruating) or "regular menstrual periods")

The woman's relevant medical history (example, "history of genital warts")

The number of slides (either one or two, depending on the health care practitioner's routine practice)

A description of the specimen adequacy (whether the sample is satisfactory for interpretation)

The final diagnosis (for example, "within normal limits")

The recommendation for follow-up (for example, "recommend routine follow-up" or "recommend repeat smear")


Why is a woman's menstrual status important for the Pap smear?


A woman who is menstruating sheds cells from the lining of her uterus called endometrial cells. If these cells are seen on the Pap smear of a menstruating woman, the report may note "endometrial cells, cytologically benign, in a menstruating woman. The comment that cells are "cytologically benign" means that they do appear not to be malignant (cancerous) cells. A comment of this nature is absolutely not worrisome since a menstruating woman may be expected to shed such cells.


However, if a woman is menopausal (no longer menstruating) she would not be expected to be shedding cells from the uterine lining. Therefore, endometrial cells on a Pap report might be indicative of an abnormal thickening of the endometrium, the lining of the uterus. The Pap smear is not specifically designed to detect such an abnormality. Nonetheless, if these cells are noted in a non-menstruating woman, her physician should attempt to determine the cause of the shedding of the endometrial cells.


Sometimes, the cause is endometrial hyperplasia, a precancerous condition of the uterine lining, which can be detected by a relatively simple office procedure called an endometrial biopsy. Sometimes, menopausal hormone therapy can cause shedding of endometrial cells that appear on a Pap smear. The pattern of bleeding, the exact type of hormone therapy, and the individual woman's health history are the three components that guide the physician to know whether and what type of further evaluation is necessary.


Why is a woman's past Pap smear history pertinent?


If a woman has had a history of a cellular abnormality on a previous Pap smear, it is important for her to inform the health care practitioner performing the current Pap smear. The patient should provide the details of any previous problems and treatments so that this information can be noted on the lab form. The past history of the woman helps the person who is reading (interpreting) the current Pap smear, because a particular abnormality on previous screening alerts the health care practitioner to look more carefully for specific findings on the current Pap smear.


When might a Pap smear not be adequate for interpretation?


It is a requirement that the report comment on the adequacy of the smear sample for Pap analysis. If the sample is inadequate, the report details the reason. Examples of problems that might be listed under "sample adequacy" include "drying artifact" or "excessive blood." These comments refer to factors that the person analyzing the smear feels may have interfered with his or her ability to interpret the sample.


Sometimes, a Pap smear report will read "unsatisfactory due to excessive inflammation." Inflammation that is present in the woman's cervical area may make it difficult to interpret the Pap smear. Examples of causes of inflammation might include infections or irritation. Inflammation is a common finding on pap smears. If it is severe, your doctor may want to try to determine the cause of the inflammation. In many cases, a repeat pap smear is recommended to determine if the inflammation has resolved and to obtain a sample that is adequate for interpretation.


How is the final Pap smear diagnosis made?

The final Pap smear diagnosis is based on three determining factors:

The patient's history: The reader (the person reading the smear) takes into account the woman's history as noted on the lab request by the clinician performing the smear.

Sample adequacy: The reader then decides whether the sample was adequate for interpretation.

The presence or absence of cellular abnormalities: The reader then notes whether cellular abnormalities were seen on the slides. If the appearance of the Pap smear does not seem to coincide with the woman's clinical history, a comment may also be made to that effect.


The final diagnosis is a short statement that summarizes what the reader has found. Examples of final diagnoses include:

Within normal limits;

Absence of endocervical cells on the Pap smear;

Unreliable Pap smear due to inflammation;

Atypical squamous cells of undetermined significance (ASCUS);

Low-grade squamous intraepithelial lesion (LSIL); or

High-grade squamous intraepithelial lesion (HSIL).

There may also be additional comments such as "low-grade squamous intraepithelial lesion (LSIL) with human papilloma virus."

What are the possible recommendations for follow-up after a Pap smear?

Once the final diagnosis has been made, the follow-up recommendation informs you what the appropriate next step(s) might be. For example, if the final diagnosis states that the smear was "within normal limits," the appropriate follow-up might be "recommend routine follow-up."


An abnormal Pap smear is one in which the laboratory interprets the cellular changes to be different from those normally seen on a healthy cervix. There are a number of possible follow-up scenarios for an abnormal Pap smear.


Absence of endocervical cells on the Pap smear: There is a particular area wherein the cells lining the vagina change to the endocervical cells that characterize the inside of the cervix. This is called the "transition zone" and is the target of the endocervical sample. However, it may be so far up inside the cervix that the Pap smear sampling instrument simply cannot reach that high. To further complicate the situation, the transition zone in a woman migrates (changes its position) at different times in her life and under different conditions. Sometimes, the transition zone may be less accessible to the Pap brush or the cervical os (opening to the cervix) cannot be seen well enough to obtain an adequate sample. Sometimes, the reason for the absence of endocervical cells on the Pap smear is simply not evident.


Regardless, if the cause of the absent endocervical cells is known or unknown, the situation must be evaluated by the physician. In everyday practice, an appropriate response to the absence of endocervical cells is to redo the Pap smear, but also to take the woman's prior history into account in determining the timing. If the woman has had regular Pap smears, has never had an abnormal one, and does not have an added risk factor for an abnormal Pap smear, then the clinician will often wait a year before repeating the smear. If the woman does have risk factors, the clinician will often elect to repeat the smear sooner.


Unreliable Pap smear due to inflammation: If severe inflammation is present, its cause(s) must be investigated. The physician's goals are to identify the cause of inflammation and to treat and resolve the condition, if possible. Untreated inflammation can have consequences for the woman as well as her sexual partner(s).

Sometimes, the woman's medical history will shed light on the cause of inflammation. For example, a woman may complain of irritation, dryness, or pain in her vaginal area. The inflammation can then be verified by the physician during a pelvic exam. The vaginal irritation may be caused by a lack of estrogen, such as occurs after menopause when the ovaries stop producing this hormone. This lack of estrogen tends to make the vaginal walls irritated and red. If a woman has this condition and it is related to an estrogen deficiency (called "atrophic vaginitis" and usually described on the Pap smear report as "atrophic changes"), her physician may recommend a trial of topical (locally- applied) vaginal estrogen (cream, vaginal estrogen tablets, vaginal estrogen ring) to hopefully heal the inflammation. The Pap smear is then repeated.


In summary, the physician will use clinical judgment in terms of the specific follow-up after a Pap smear that reports inflammation.


Atypical squamous cells of undetermined significance (ASCUS): Sometimes, atypical squamous cells of undetermined significance (also called "ASCUS"), is the determination written on the Pap report. This is the mildest form of cellular abnormality on the spectrum of cells ranging from normal to cancerous. ASCUS means that the cells appear abnormal but are not malignant.


"Of undetermined significance" means that the atypical-appearing cells may be the end res

ult of a number of different types of injuries to the cervix. For example, the human papilloma virus (HPV) could be the cause of ASCUS. Most instances of ASCUS (80%-90%) resolve spontaneously (by themselves without specific medical intervention or treatment). This is the reason why many women with ASCUS readings will be asked to simply have a repeat Pap smear in 4 to 6 months. The expectation is that regardless of the original cause of the ASCUS, it will be resolved by the time the Pap smear is repeated. If not, the cause of the ASCUS can still be identified and treated if ASCUS is again observed on the repeat Pap smear 4 to 6 months later. This standard recommendation of serial Pap smears - repeating the Pap smear in 4 to 6 months - is made unless the physician has a concern that the woman is not willing or able to return for a repeat Pap smear. In these cases, a colposcopy (see

below) may be done without waiting to repeat the Pap smear.

The third approach to ASCUS (besides serial Pap testing and immediate colposcopy) is called reflex HPV testing. Reflex HPV testing refers to a process in which the HPV test is only performed if the Pap smear result is abnormal. If the Pap smear result is normal, it is not performed. For reflex testing to be possible, a liquid-based Pap testing kit is required, which allows the lab to store the sample until the Pap smear result tells them whether the HPV test will be necessary or not. Not all facilities have access to liquid-based cytology kits. If repeat smears are to be done for monitoring, the testing needs to be done every 4 to 6 months for 2 years until there have been three consecutive normal smears, at which time routine screening can be resumed. The Pap smears, however, must not only be negative, but also satisfactory for interpretation, according to National Cancer Institute Workshop Guidelines.


The irritation of the genital area that accompanies menopause can trigger ASCUS by causing inflammation. If the physician suspects that this is the cause of ASCUS, he or she may prescribe intravaginal estrogen (local estrogen, such as a vaginal ring, vaginal cream, or vaginal estrogen tablets) and repeat the Pap smear in 4 to 6 months to confirm that the inflammation is resolved. If the inflammation persists, colposcopy will be necessary. Sometimes, the ASCUS reading is accompanied by a comment to the effect that the Pap smear reader thinks there may be a suggestion of dysplasia (abnormally dividing or abnormal appearing cells), often worded as "favor dysplasia." In this case, the ASCUS is generally not monitored over time but rather treated as if it is dysplasia (see discussion below). Similarly, a woman who has a suppressed immune system is not a good candidate for serial Pap smear tests because she is at higher risk of serious abnormalities. Therefore, she should undergo colposcopy instead of serial Pap smears. It is evident from this discussion that many factors go into a physician's decision regarding which of the three treatment options to recommend to an individual woman.


Low-grade squamous intraepithelial lesion (LSIL): A more serious cellular abnormality is low-grade squamous intraepithelial lesion (LSIL). A reading of LSIL is a reason for immediate further investigation because it is more abnormal than ASCUS. Fifteen to 30% of women who have this abnormality on Pap testing will have a more serious abnormality on biopsy of the cervix. Thus, all women with LSIL are recommended to undergo colposcopy. On the brighter side, even LSIL spontaneously returns to normal without therapy in many women within several months. For that reason, if the initial colposcopy and biopsy results are favorable, serial Pap smears every 4 to 6 months may be recommended, after which a return to normal screening is possible if there are three negative, consecutive, satisfactory Pap smears.

High-grade squamous intraepithelial lesion (HSIL): The most severe cellular abnormality that is not actually cancer is high-grade squamous intraepithelial lesion (HSIL). A finding of HSIL unquestionably requires prompt treatment.

Women with HSIL have a 70%-75% chance of having a more serious abnormality (CIN 2,3 see below) on biopsy of the cervix, and a 1%-2% chance of having actual cervical cancer on biopsy of the cervix. Therefore, colposcopy is undoubtedly the routine recommendation for all women with HSIL.

Cervical intraepithelial neoplasia (CIN): This is the most severe form of high-grade squamous intraepithelial lesion (HSIL). A neoplasia is within the realm of cancer. Type 1 CIN is "low grade," or less serious than Type 2, 3 CIN (high-grade). The diagnosis of a cervical intraepithelial neoplasia (CIN) on a woman's Pap smear means that she needs to be evaluated and treated as soon as possible by a qualified physician.

Carcinoma in situ: This diagnosis is also a form of high-grade squamous intraepithelial lesion (HSIL). A reading of "carcinoma in situ" on a Pap smear report means there is cervical cancer present. However, the cancer is "in situ," which means that it appears to be limited to the cervix and not to have invaded other tissues


What treatments are available if a Pap smear is abnormal?

If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, andlarge-loop excision of the transformation zone.


All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in a number of other respects and so will be discussed separately.


Colposcopy: Colposcopy is a procedure that allows the physician to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.


During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).


If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist and the biopsy results determine the next step in the treatment.


The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.


In unusual circumstances, colposcopy does not allow an adequate view of the cervix and another procedure called conization is necessary in order to obtain a tissue biopsy.


Conization: This is still the standard method to which all other methods are compared. Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch long and 3/4 inch wide) is taken from around the endocervical canal.


Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual intercourse.


Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.


With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis of cancer) already, or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.


Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments. It may also be appropriate for women with certain specific findings after conization.


Cryocauterization: Cryocauterization is a simple and safe procedure. A probe, called a cryoprobe, is first cooled by carbon dioxide and then touched to the abnormal cervical area. This freezes and kills the cells, resulting in the sloughing of the abnormal tissue.


A woman undergoing cryocauterization can expect a watery vaginal discharge for several weeks after the procedure.


Laser therapy: Laser therapy makes use of the principle that laser light can be produced by electricity running through gas. In the treatment of cervical lesions, the gas is usually carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells.


When a laser beam (using a tiny wand called a micromanipulator) is directed into the cervix at an area of abnormal cervical tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization. However, the laser apparatus is expensive, and its use requires more skill than other treatment options, such as cryocauterization. The procedure is also painful and generally requires general anesthesia.

The benefit of laser therapy is that it may cause less cervical scarring as compared to cryocauterization. This in turn may mean that, should the woman need colposcopy in the future, the chances of adequately viewing her cervix may be better after laser therapy.


Large-loop excision (LEEP) of the transformation zone: Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.


Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. When there is no more evidence of abnormal cervical tissue, it may be possible to resume annual screening Pap smears.


What is the follow-up after treatment for an abnormal Pap smear?

Follow-up is crucial after treatment for an abnormal Pap test. Women who have undergone any one of the above-described treatment procedures require special follow-up schedules. They must be evaluated and checked until the physician is fully convinced that routine Pap smears can be resumed.


What is the current status of human papilloma virus (HPV) typing?

HPV is a sexually transmitted virus that may be spread from one person to another even when the genital sores are not visible. Many sexually active people are carriers of HPV, very often without even knowing they are carriers. It is estimated that up to 60% of sexually active women harbor this virus on their cervix or in their vaginal area. It is not unusual for a woman to be unaware that she has HPV - only to find out that her Pap smear shows evidence of HPV.


HPV is not curable, although the cellular damage it causes is generally treatable and a vaccine against the four most commonly found HPV types is available. A woman with HPV needs careful and regular long-term medical follow-up to watch for any resulting HPV-associated pre-cancerous cellular changes.

There are over 70 different strains of HPV virus. Based on the observation that certain strains of HPV (for example, types 16 and 18) are more likely to be associated with cervical cancer, some people have advocated testing HPV infected women in order to identify their specific strain of HPV. Following an abnormal Pap smear, this information would then be used to help select the specific treatment strategy. In other words, a physician would more aggressively treat a woman with an abnormal Pap smear if she tests positive for an HPV type that is more likely to be associated with the development of cervical cancer.


However, even the so-called "low-risk" HPV strains can still be associated with cervical cancer at some time in the future and not all of the high-risk HPV strain abnormalities will necessarily result in cervical cancer. Furthermore, the HPV typing is expensive. The main use of HPV testing in screening for cervical cancer is for determination of treatment and follow-up recommendations for women with Pap smears interpreted as atypical squamous cells of undetermined significance (ASC-US) . Those with positive tests for high risk HPV types and an ASC-US smear are referred for further evaluation.


HPV testing along with Pap screening (a combined test) was approved for primary screening for cervical cancer by the U.S. Food and Drug Administration (FDA) in 2003. This combined testing has been used as an alternative screening test for low risk women aged 30 and over at intervals of three years or greater.


When should women start and stop having Pap smears, and how often should Pap smears be performed?

The table summarizes the consensus of all the major organizations regarding these important questions. The key points of the table are as follows:


All the guidelines agree that Pap smears should be started within 3 years of first sexual activity or age 21, whichever comes first.


There are minor differences in the recommendations for the frequency and age at which to stop Pap smears.

Older women who have had many normal Pap smears in a row and have been regularly screened are highly unlikely to have an abnormal Pap smear. These findings point to stopping Pap smears in older women, as reflected by several of the guidelines in the Table.


Women who have had a total hysterectomy for a benign condition no longer have a cervix, and thus do not derive any benefit from screening for cervical cancer.


In contrast, women who have had a subtotal hysterectomy still have a cervix, and thus should be screened according to the recommendations of women who have not had a hysterectomy.


Women who have had a hysterectomy for abnormal Pap smears have their own special recommendations.

Special situations may impact the frequency of screening. For example, women who have had cervical cancer, exposure to diethylstilbestrol, or a compromised immune system (as with HIV infection, for example) should continue annual screening as long as they are in reasonably good health. Women who have had a hysterectomy for CIN2 or CIN3 (a type of abnormal Pap smear) should be screened until they have had three normal Pap smears, (and if no abnormal Paps show up in 10 years, they can stop having Pap tests).


What is the current status of the newer Pap smear technologies?


New technologies have been developed to try to circumvent the problem of false-negative Pap smears. False-negative results occur when a disease or condition is present but the test does not detect it. False-negative Pap smears (slides with abnormal cells judged to be "normal") are estimated to be between 5% and 30%.

The new techniques consist of alternative ways to prepare and read Pap smears. In one new preparation method known as liquid-based cytology, cervical cells are obtained as usual but a new technique is used to prepare the slides for analysis. The physician puts the cell sample into a vial of liquid preservative. The cells are then sent to the laboratory where they are filtered and spread on glass slides. This method removes any contamination from blood or mucous.

Prepared slides are usually read by cytotechnologists who examine thousands of slides under a microscope every day. This exhausting process may be subject to human error. Computer systems are now being developed to assist by providing an automated analysis of slides. Slides containing abnormally appearing cervical cells can first be automatically identified and then subjected to a second, manual re-screening.

Recent guidelines are conflicting as to whether to recommend the new technologies because sound scientific research is not available on which to base a thoughtful recommendation. Besides being more expensive, the underlying problem is that the new technologies (such as liquid-based cytology) have never been proven to decrease mortality from cervical cancer as compared to conventional Pap testing. In addition, even if future research shows that more cases of cervical cancer are detected with the new technologies versus the conventional Pap testing, there may be too many "false positive" cases in which women are labeled to have abnormal Pap smears when they are perfectly normal. This last point is critical. The information must be gathered before rational recommendations can be widely instituted.


With Pap smears so available, why are women still dying of cervical cancer?

It is critically important to recognize that the women who are at highest risk for abnormal Pap smear testing are those who are not getting regular Pap testing. Therefore, it follows that in order to improve overall cervical cancer screening, women who are not getting regular Pap smears should be educated about and offered Pap testing. These under-served women should be the most heavily targeted for Pap screening.

Between 60% and 80% of American women who are newly diagnosed with invasive cervical cancer have not had a Pap smear in the past five years and may never have had one. Women who have not had Pap smear screening tend to be concentrated in certain population groups including:

Older women;

The uninsured;

Ethnic minorities, especially Latino, African American, and Asian American women;

Poor women; and

Women in rural areas.

Many physicians feel that the emphasis should be on universal access to proper Pap screening as opposed to the comparatively small benefit that would come from utilizing the newer technologies in women already undergoing screening. Cervical cancer is one of the most common causes of cancer worldwide. It is also one of the most preventable and treatable cancers.