Hello, SOGC

Hello.  It’s Me.  I am ranting once again about HPV

Well, not about HPV, just the vaccines.  Actually, not just the vaccines: pretty much everything I heard at a day-long SOGC workshop with the long-winded title, “Women and their Reproductive Health Across the Continuum: Setting Priorities for Women’s Reproductive Health Research”.  Attending were both health professionals and interested individuals.  And me: women’s health advocate and HPV vaccine skeptic.

Regarding the latter, I waited till the very end of the day to finally screw up my courage.

“I am about to state a very unfavorable opinion.  There are reputable health professionals who are opposed to mass HPV vaccination; in part, because some of the research has been tainted by conflict of interest; and also because of the way public messaging has stigmatized parents who have decided not to vaccinate their children.”

I added that equating infection prevention and cancer prevention is what has made public health and Big Pharma messaging so compelling to the general public.

There was absolutely no response.

The Sunnybrook Hospital meeting space was set up like a dinner party, with long lines of tables, labelled with discussion topics for the afternoon.  Speakers’ topics were preceded by the title, “State of the Evidence”: Human Papillomavirus, Fertility, Contraception, Menopause and The Environment.  Three out of five talks set my teeth on edge.

First up, Dr. Nancy Durand.

After giving some basics about HPV types and statistics (10 – 30% of adults are infected at any given time – good one) and the risks for persistence (being over age 30, smoking, having multiple sub-types and immunosuppression) she launched into straight into HPV vaccines as public health strategy.

Dr. Durand assumed, correctly, that she had the room in terms of the evidence she presented on the three available HPV vaccines regarding efficacy and safety.  She said that doctors should treat these vaccines like flu shots and encouraged doctors to say, “Have you had your HPV shot yet?”  She suggested it could be administered to babies with their childhood vaccines.  She quoted research that indicated there should be no upper limit in vaccinating; and that even if one had already been infected, vaccination was still effective (first time I’d heard that).  And yet…

Hello from the other side

My electronic files are full of evidence of conflict of interest (COI) between researchers and pharmaceutical companies and the attempts to expose them.

Moreover, the accepted medical evidence also insists that the only adverse side effects are irritation at the site of injection and increased fainting.

Japan has changed direction on HPV vaccination.  France, Spain  and Denmark have also reconsidered their position.

Fertility

Dr. Heather Shapiro did not mention potential environmental causes of infertility.  When I asked her about this, she said that was a whole other talk.  She leapt into Assisted Reproductive Technologies starting at IVF without passing through less invasive techniques like IUI.  I did find out that 90% of IVF babies are healthy; and the rates of success decline with age; and that there are now fewer multiple births.  Her talk was less about fertility and infertility that assisted reproductive technologies.  One presumes the research is directed towards treatment rather than prevention.  No mention of Pelvic Inflammatory Disease.

Contraception

I was glad to hear Dr. Dustin Costescu discuss unintended births in the context of the social determinants of health.  He said they occurred more often in younger, racialized, poor and Indigenous women; and that the greatest risk was due to systemic factors.  Among the contributors to non-use were being a sexual or gender minority, funding, and failure to initiate contraception.  He also blamed health care providers who sometimes recommended a “washout”; i.e., stopping a method to see if side effects subsided without offering a replacement method.

He pointed out changing trends.  With women having their first child around age 30, they require about 11 years of contraceptive use.

I was glad to hear him say that researchers needed to understand women’s experience through qualitative research regarding access, counselling, decision making and understanding side effects.  In our discussion session in the afternoon, he acknowledged that front-line workers have a lot to contribute to research.  Here are some of my contributions in WordPress:

 

Menopause

Any of the women attending who had not already gone through menopause and were listening to Dr. Jennifer Blake were probably bug-eyed looking at the list of what sounded like inevitable symptoms.  Early on in her talk, she said that perimenopause, the 2 – 3 years preceding the cessation of menses, was the “best time to get help”.  Now if that isn’t a clear medicalization of menopause, I don’t know what is.

Dr. Blake was quite definitive.  The “pleats” that make women’s vaginas stretch more easily smooth out.  You’re going to shrink, was the message.  Not to mention the loss of bone mineral density, the release of lead stored in the bones, changes in blood vessels, changes in abdominal fat metabolism, decreased carbohydrate tolerance, loss of lean muscle mass, vasomotor symptoms (hot flashes that could last up to 20 years), mood changes, reduced stress tolerance and memory changes (or as comedian Sandra Shamas tells us, loss of nouns.

And, oh, yes, loss of libido.  I’ve had a few thoughts on that one as well.

Dr. Blake gave a nod to the importance of exercise and good nutrition before moving ahead with hormone therapy (HT), “the single most effective treatment”.  She spent a good deal of time discussing the history of research on the effects of estrogen, in particular, how the Nurses’ Health Study was written and interpreted.  One telling statement at the end of her remarks on HT: “there is a higher risk of breast cancer with later pregnancy than with hormone therapy”.  In other words, you don’t need to worry about using HT.

Not all women experience menopause the same way – and that also applies to women around the world, their diets and lifestyles.  Women who suffer greatly from menopausal symptoms who consider HT are well advised to limit the duration of its use.

Environment

I’ve saved the best for the last. Dr. Eric Crighton laid it all out.  There are currently 80,000 registered chemicals currently in use.  7,000 new industrial chemicals are introduced annually.  Pregnant women have 43 different chemicals in their bodies.

He pointed out that some people are at higher risk than others, most notably those Indigenous people who are living with contaminated water and mercury poisoning.  Of course, we are all exposed to environmental toxins.  According to Health Canada’s 2010 statistics, they caused 13% of disease burden, an increased risk of prenatal and early childhood effects.  He talked about pesticide exposure and its effects on the brain development of four year olds…in short, he scared the *&*^% out of his audience.  I was sadly familiar with some of these issues, in particular through the Canadian Women’s Health Network.

There is good work being done by CPCHE which has published a number of useful brochures, but he pointed out that individual actions are not enough.  Moreover, he said when someone is struggling, for example, to feed their family, environmental toxins are low down on their list.  If you can barely afford formula, the plastic in the bottle becomes a non-issue.

I spoke with him afterwards, thanking him for mentioning the struggle of nail salon workers to limit their exposure to workplace toxins.  He was aware of the work of the Toronto Healthy Nail Salon Network.

Hello from the outside.  At least I can say that I’ve tried

I’m not sorry I went.  I did learn a few things and have checked out a dozen links to the studies quoted.  But there was little opportunity to challenge the experts or change the tone of the discourse.  It does make me wonder why the SOGC invited us in the first place.

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Do it Yourself Swabs

I was approached by a med-tech start-up company regarding their self-collection device for at-home screening “to prevent cervical cancer and Pelvic Inflammatory Disease (PID)”.  The Eve Kit’s promo video and Indiegogo funding campaign explains the device and their motivation for designing it.

Violeta Cobo, Territory Manager, said that “HerSwab™ (the device that collects the sample) has been approved for self-collection of cervico-vaginal samples” by Health Canada.  The device is to be launched in late 2016.

The promo video raised a number of questions for me.

The device was registered with Health Canada for “safety, efficacy and intended use”, but as I explained to Jessica Ching, co-founder and CEO, the term “approved” is open to interpretation.

But that was only a quibble.

How exactly did they intend to test for cancer, HPV and “STIs which could cause PID”?  Was the device a Pap test?  An HPV DNA test?  A swab for chlamydia and gonorrhea?

Ms. Ching explained that the device is not a Pap test.  It can sample for either HPV or gonorrhea and chlamydia depending on which test the woman prefers.  To detect HPV, the device collects the sample from the upper vaginal canal.  The lab uses PCR amplification to test for high-risk strains of HPV.

However, because Pap tests use cytology when they sample from the cervix, I expressed some concern in case the self-sample result was inaccurate.  A meta-analysis concluded that self-sampling and physician sampling were equivalent; but studies are ongoing.

Regarding the self-sample for chlamydia and gonorrhea a small study (189 women) found their swab for “easy, comfortable” and “suitable for diagnosis”.

As to what happens after diagnosis, Ms. Cobo responded:

“When a patient gets a positive result, she gets referred to one of the doctors we are going to work with. The doctor will follow up with her and prescribe treatment or refer to a screening visit (in case of HPV) if needed.  She could also grant us permission to share the results with her family doctor if she has one.”

However, when I asked about the availability of those doctors, Ms. Ching admitted that to date there were very few with whom they have been able to partner.  The ideal, she added, would be to eventually offer follow-up across the country; however, one of the rationales for the product is precisely the dearth of health care providers.

Do women want to do it for themselves?

The promotional material for the $85.00 kit argues that women find testing “awkward” and that they may not have time to see a health professional.  They also see at-home privacy as a plus.

I asked Ms. Ching about research they had done into whether and why women would prefer at-home testing.  They did focus groups with 20 women and spoke with 50 others from whom they gathered anecdotal information.  She also mentioned focus groups conducted by the Dalla Lana School of Public Health and St. Michael’s hospital and commented, “Our informal findings did mirror the findings of other published studies”.  A CMAJ commentary asks whether the time for self-testing in Canada has come.

The CMAJ commentary poses the question from a public health point of view about women at risk in Canada who might truly benefit.

In Australia, self-testing will be available in 2017 – to targeted women.  For me, this is the real public health issue.  In Australia,

“Women who don’t normally get pap smears – including indigenous women, victims of sexual abuse and those who avoid the test for cultural or religious reasons – have the highest rates of cervical cancer.  These are the women who, from 2017, will be able to collect their own tissue samples in world-first changes to the country’s screening program”.

Targeted self-testing strikes me as an improvement on the selling points of awkwardness, privacy and time constraints.

In Canada as in Australia, the women who get cervical cancer are not screened regularly and/or do not have follow-up and treatment for abnormal Pap tests.  They are poor, marginalized and Indigenous.  The Canadian government’s response has been expensive vaccinations for girls (and in some provinces, boys) against HPV.  Women’s health advocates would prefer to see better access to screening and follow-up through Pap registries; and improved access to health care, especially in remote areas.  According to the CMAJ commentary, some pilot testing of self-sampling has already taken place for these high-risk women.

The value of health professionals

 As someone who worked in a sexual health clinic as a counsellor for three decades, I have one more issue.

When a woman came in for testing, I explained the Pap test, what it was for and how it was done.  In fact, I often accompanied her to the examining room to translate (Spanish, French and occasionally very inadequate Portuguese) and in some cases, to hold her hand, especially when there had been past sexual trauma.

Counsellors use an intake sheet which covers not just medical, but also sexual history.  We find out if the woman has a history of sexual abuse, if she has been having unprotected sexual activity, if it was vaginal, anal or oral, if she understands the difference between the Pap test and STI testing.  We find out which STI she should be tested for depending on her risk factors.  We tell her about contact tracing in case we find a reportable STI.  We explain that HPV is very common and that only certain types may lead to cervical cancer unless the abnormal cells are treated.

These conversations are critical in helping a woman take control of her health in a way that DIY testing cannot.

Given the cost and limitations, it remains to be seen what role self-testing might play in this country.

 

 

 

Yikes. An STI Spike.

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it.  The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters.  While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

After discussing the increase on CBC’s “The Current” , I decided to expand my thoughts.

Unprotected sexual activity

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app.  Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking.  Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication.  Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated.  Should.

And yet, communication and negotiation are not always straightforward.  The result is risky behaviour.

The social determinants of health influence risk-taking.  Poverty, for example, is associated with increased risk-taking.  In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods.  Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Of course, comprehensive sexual health education and the availability of sexual health clinics also play a crucial role.  Awareness and testing go hand in hand.

One, two, three testing

Why get tested?  Here are the basics.

Most STIs show no symptoms.  To be blunt, if you have had unprotected sexual activity, you need to be tested.  But you will not necessarily get an HIV test for example, unless you specifically ask for it.  That means you have to actually disclose your unsafe sexual practices.  Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body.  The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests.  But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for  (HPV) or a screening test for herpes.  You have to show your bump or sore to a doctor.  You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex.  One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection.  If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex.  (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com .  “Plenty of syph” received a lot of attention, much of it negative.  The site has since been revised.  But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities.  Moreover, the assumption is that “sex” means penis in vagina intercourse.  Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic.  Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

  • no unprotected sex
  • abstinence
  • mutual monogamy
  • condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals.  In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers.  So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured.  This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion  touched on seniors and safer sex.  The statistics for seniors are becoming alarming.  Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64.  Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults.  Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs.  They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship.  They may also be learning the dating game the “hard” way.  A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV.  Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria.  Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

 True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

Here is my short wish list to prevent STIs:

  • ensure comprehensive sexual health education across the country
  • eliminate poverty, sexism, sexual abuse, homophobia and transphobia
  • adopt harm reduction as a national strategy
  • establish sexual health clinics from sea to sea to sea

That’s not a lot to ask, is it?

 

Chickens coming home to roost

If you have a cervix, read this.

In 2013, I wrote a blog on new provincial and federal cervical screening guidelines (https://springtalkssex.wordpress.com/2015/01/08/confused-about-pap-tests-july-2-2013/) partly because women’s health advocates were worried that these updated policies were putting women at risk in order to save money.  There was no risk, in my opinion, in delaying the initial Pap or from the longer interlude between screening tests.  But there certainly was a risk: not informing women of the difference between cervical screening and Sexually Transmitted Infection (STI) testing.

Because most Human Papilloma Virus (HPV) infections resolve on their own, research indicated that earlier and annual testing did not decrease sickness or death from cervical cancer.  Even high-risk HPV infections that cause cellular changes on the cervix tend to resolve on their own without treatment.  Cervical cancer develops when there is persistent infection with a high-risk type of HPV in the presence of co-factors like a suppressed immune system.  Pap testing (and/or HPV testing) indicate when treatment is necessary to prevent its development.

When Cancer Care Ontario (CCO) published fact sheets to inform the public about the new guidelines, I contacted them to point out that they also needed to provide information about the importance of STI testing.  It was obvious to me at the time that there would be repercussions.

I had been selling the annual Pap as part of sexual health education classes for years.  Suddenly, young women (including trans men with a cervix) were being told they didn’t have to start till they were 21 (Ontario) or 25 (federally); and they didn’t need to have a Pap every year.  So, of course, many stopped having internal exams until they were told they had to.

Young women, in my experience, especially those whose annual Pap test coincided with – and in some cases were dependent on – their birth control pill renewal, had no idea what was going on during their internal exam.  Despite the efforts of sexual health educators in the classroom to distinguish between the Pap test (checking for abnormal cells on the cervix) and STI screening (swabbing the cervix and inside of the vagina) when they arrived at clinic for their exam, counsellors had to take the time to explain it again. It is not clear if Physical Education teachers and family physicians today consider it important to educate about this important difference.

So what’s the big deal?

The importance of the distinction becomes clear when we look at the statistics.  According to the lead researcher of a recently published article on this issue (see below), over the past 10 years, chlamydia and gonorrhea rates in Canadians rose by 72 and 53 per cent, respectively, especially for chlamydia.  The highest number of cases of chlamydia are diagnosed in young people between the ages of 15 – 24.  The increase in diagnoses was in part due to Public Health Units encouraging an increase in testing in the early 2000s.  The urine (NAAT) test (v-e-e-ry appealing to men) also brought in more young people for testing.  One of the suspected behavioural reasons for the increased number of cases was less condom use among older adolescents and young adults who made the switch from condoms to hormonal contraception without being tested first.

Untreated chlamydia, which is commonly asymptomatic, can do serious damage to the Fallopian tubes.  Moreover, untreated STIs which provoke an increase in white blood cells at the site of the infection, make it easier for HIV to enter the bloodstream.

Here come the chickens

St. Michael’s Hospital in Toronto raised the alarm about a decrease in testing in their recent study (http://www.sciencedaily.com/releases/2015/10/151015144701.htm).  The lead researcher said, “…we found that women weren’t visiting family physicians as often for Pap tests, causing a drop in STI screening as well.  Female patients were also less likely to be screened for syphilis, hepatitis C and HIV under the new guidelines…”

When I contacted Cancer Care Ontario to complain about the lack of information on the importance of ongoing STI testing, the woman I spoke to thought it would be confusing to try to explain the difference between the various types of testing.  Prior to writing this blog, I re-visited the CCO web-site looking for what I hoped would be updated literature.  There is still no mention at all of STI testing.

The takeaway for readers with a cervix is this: if you have had unprotected sexual activity, whether you have symptoms or not, see your health care provider even though it is not time for your Pap test.  They will look at your genitals; they will test you for chlamydia and gonorrhea and any blood-borne infections you may have been exposed to.

As for me, I guess it’s time to contact CCO medical directors encouraging them to read the St. Michael’s study.  I wonder if they still think it’s too much for women’s brains to handle.

Read more here:

Cancer Care Ontario information on screening: https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9550

Pap registries: Do it right – December 1, 2013

Well, it turns out I don’t have cervical cancer. At least, that’s what Cancer Care Ontario (CCO) has told me in an unsolicited letter. Like many women, I usually expect to hear from my doctor if there are abnormal results. No news has been good news in the past. Getting my Pap test results from CCO in the mail was a bit of a shock.

I had heard about these letters from Ayesha Adhami, who runs a women’s sexual health centre in Toronto. She was concerned for her teenage clients, some of whom have little privacy. Lots of moms would find it difficult to resist opening a letter with the word “cancer” in the return address. So a young woman may find that her Pap test results have already been read by a snoopy parent or guardian—and that’s not good.

I called the number provided to ask some questions and to give them feedback about the letter and its accompanying pamphlet. The woman I spoke to was pleasant and took notes.

I first expressed surprise at receiving a letter from the provincial government about my Pap test results.

She said women were supposed to receive an initial letter to advise them of follow-up letters. I didn’t. Like cable companies who operate on an “opt out” system, if you don’t call when you receive the first letter, you will continue to receive them.

I shared my above concerns about confidentiality. She commiserated.

Then I painstakingly reviewed the letter and pamphlet while she listened patiently.

  • The letter includes the following: “See your health care provider if you have unusual bleeding or discharge from your vagina” [my emphasis]. All women have discharge from their vagina. Even if they had said “unusual discharge” this would hardly be considered a sign of cervical cancer.
  • The opening statement in the accompanying pamphlet, “Cervical cancer is caused by an HPV…infection” is also concerning. The overwhelming majority of sexually active people will get HPV at some point in their lives and 90% of them will clear the virus without medical intervention within two years. There is a difference between brevity and clarity. In this case, brevity is just plain scary.
  • Nowhere in the pamphlet do they make the distinction between low-risk and high-risk HPV. The word “wart” does not appear anywhere. When a woman is told she has an HPV wart, she may  worry she is at risk for cervical cancer, which is not the case.
  • On the back page, they give the number to call to opt out. Too little, too late.

The CCO representative told me that within a year, a letter will be sent to Ontario women who haven’t been screened in the past three years. That’s a good start, but it hardly deals with the full scope of the issue.

Women who are at most at risk for cervical cancer are poor, marginalized or Indigenous. These are the most important women to reach. With the advent of a three-year interval between Pap tests, even women who have been regularly screened in the past may not remember to go unless they get a call from their family doctor—if they have a family doctor. If a reminder letter goes out from the province, it will not reach women with no fixed address who are living in shelters, living rough or couch surfing.

There is an additional risk for women over 30, who have had serious abnormal results but don’t get a follow-up examination or treatment.

And that brings me to the big issue: who should run Pap registries across the country, how should they function and how can they inform women in a simple, but not simplistic, manner?

Ayesha checked out the system in Manitoba and discovered the following:

  • Women have to opt out there too.
  • Cancer Care Manitoba (CCM) keeps a copy of your Pap results.
  • CCM allows you to obtain your own test results.
  • They send a letter to your health care provider if you don’t show up for a post-abnormal Pap follow-up.
  • They send you a letter if you are overdue for your Pap or haven’t followed up on an abnormal Pap. (Read more on CCM website)

Although there are some positive innovations here, Ayesha is not entirely sold. She suggests that “to be truly client-oriented and confidential,” a Pap registry should not put the onus on women to opt out. She adds that “all notifications should be restricted to logging into a registry website. The only thing that should come to your home or email or phone via text,” she says, “is a notification to log in to the website for a notification about your healthcare…”

Of course, the problem remains for women who do not have regular access to the Internet. Remote (Indigenous) communities with inadequate Internet access are amongst the women most at risk.

One wonders whether women’s health advocates and consumer groups were consulted at an earlier stage for these systems. Ayesha says she first she heard of the letter when clients came in to her centre, waving it and demanding to know what it was all about. Clearly no advance warning was given to front-line health facilities. Another local sexual health clinic has posted a disclaimer on their website: “Please be advised that Cancer Care Ontario (CCO) has started sending correspondence without patient permission…They are initiating a Cervical Screening Program where they will be mailing your test results and other correspondence to the address associated with your Ontario Health Card. This will happen automatically unless you ‘opt-out’.” (Read the disclaimer).

Hundreds of millions of dollars are spent on the HPV vaccination program. Those of us who have been advocating spending this money elsewhere—on a well researched registry system and coverage for HPV testing as follow-up to abnormal Pap results—are still waiting. In the meantime, I prefer to get the results of my Pap test from my doctor.

Confused about Pap tests? July 2, 2013

When the Canadian Medical Association recommendations on new guidelines for screening for cervical cancer came out recently several of my sexual health colleagues were aghast. They asked me if it was part of an austerity program—cutbacks on screening programs. In my opinion, not this time.

Women and health-care providers are well aware that regular Pap testing is essential to women’s health. Pap screening has reduced deaths from cervical cancer by 70 per cent. The reason it has been so effective is that when irregular cells are detected, a woman can be followed and treated when necessary to prevent these cells from becoming cancer. Cervical cancer is very slow growing (10 to 20 years).

Until recently, most women were told they needed an annual Pap test. It was often done at the annual health exam. Some clinics tied it to birth control pill renewal to ensure that women were screened.

The most notable changes from the CMA are the recommended age to begin testing and the interval between tests.

According to the CMA, testing should begin at age 25. Regular screening should take place at three-year intervals until age 70. There are, of course, exceptions, in particular for women with symptoms of cervical cancer or previous abnormal test results on cervical screening; and for immunosuppressed women (e.g., women with HIV/AIDS).

The CMA’s reasoning is that while there is strong evidence for screening women 30 to 69, the value of screening and the balance of benefits and harms for women outside this age group is unclear. That is why the recommendation for routine screening for women 25 to 29 is weaker; and the recommendation for women 20 to 24 is for not routinely screening for cervical cancer; the CMA also recommends ending screening at the age of 70.

Two fundamental developments motivated the new guidelines.

We have known for more than a decade that cervical cancer is caused by persistent Human Papillomavirus (HPV) infection, combined with other factors such as smoking. What we have learned since then is how the body deals with the virus. Not only do most people clear HPV from their bodies without medical intervention, but the majority of women under the age of 30 (especially if they do not smoke) will have a normal result after a finding of Atypical Squamous Cells of Undetermined Significance (ASCUS), a Low-Grade Intraepithelial Lesion (LSIL) and even, in some cases, after a high-grade lesion is found. Current management of irregular results (recalls for Pap testing and repeated colposcopy) was deemed to cause more harm than good. Like breast self-examination, what appeared to be abnormalities, resulted in over-testing and anxiety for the women being tested, without reducing sickness and death.

The second change was the advent of HPV testing. Because there are certain strains associated with cervical cancer, it began to make sense to limit further testing like colposcopy to the women who had these strains. For over a decade, panels of researchers have been trying to decide how to integrate HPV testing into Pap screening. In some provinces, women over 30 are offered HPV testing following a specific abnormal result.

As the research evolved, the management of abnormal results in the sexual health clinic where I worked also evolved. Sending women for colposcopy became more selective depending on the result, as did the frequency of recall for abnormal Pap tests.

While I consider the new recommended guidelines to be a step in the right direction, my only disappointment is the lack of discussion about risky sexual activity and sexually transmitted infections (STIs). In my experience, women often think they are being tested for STIs when they have a Pap test; and think that when they have a Pap test, they are also being tested for STIs. This is not necessarily the case.

Women under 25 may or may not be having sexual activity. For that reason the CMA acknowledges that a woman who has not had had oral, vaginal, or digital sexual activity before age 25 need not start Pap screening.

However, women who have had unprotected sexual activity need to be tested for Chlamydia, gonorrhea and HIV. Women who share needles or crack pipes need to be tested for Hepatitis C. Women who notice unusual symptoms (or whose partner has unusual symptoms) need to see their health-care provider. While a Pap test may uncover HPV or herpes on the cervix, it is not an STI test.

So here are the take home messages:

Anyone with a cervix needs Pap testing. If you have sex with women or if you are a trans man with a cervix, this includes you.

Get tested for STIs as necessary—new partner, unusual symptoms, broken condom…

Information changes practice. Rightly so.

Oral sex – is the getting still good? September 10, 2013

Besides Human Papillomavirus (HPV), there are other issues that should be raised following Michael Douglas’ oral sex and throat cancer theory.

Who’s giving, who’s getting, who’s at risk and who cares?

Let’s start with cunnilingus (a very good place to start, some would say). There have always been negative attitudes about oral sex on women because of repugnance towards female genitals. Apparently, we smell, we’re dirty; and we don’t look the way we should. Feminine hygiene products included Lysol in the early days of making women feel bad about their genital scent. Female genital cosmetic cutting and anal bleaching are the contemporary equivalents. However, it would appear that some people have gotten over that prejudice, because in films and on TV, men are going down on women in droves, not to mention woman on woman action as well. However, I’ve met many young men who gave their female partners oral sex, but didn’t want their male friends to know; it was considered unmanly.

Interestingly, there are also prejudices against oral sex on a man. I worked with young women who said they could never kiss their baby after they had put their mouth on a man’s penis.

Oral sex has been on the menu for a long time, soon to be replaced in popularity, at least according to the media, by anal sex, even though statistics do not bear this out. We have some statistics regarding oral sex for adolescents. They mirror age-related statistics on vaginal intercourse—about half of the teen population are having vaginal and oral sex by age 17. The “epidemic” of teen oral sex never did materialize since the first hysterical media stories more than 15 years ago. Unfortunately, we can only guess at who’s giving and who’s getting. As sexualityandu.ca suggests, “It is sometimes assumed that with respect to teen oral sex there is a gender discrepancy in which females are more likely to be giving (fellatio) rather than receiving (cunnilingus) oral sex from their male partners.”

It is a fair assumption that for young women, oral sex on a young male partner is one way of preventing pregnancy and postponing vaginal intercourse. A lot of ink has been spilled over whether young women find it enjoyable and/or empowering to give oral sex to a male partner. I’d like to see a good study on that.

These days, adults are seeing oral sex in a different light: will it give me cancer?

Oddly, there has not been much discussion about a risk that is much more common: genital herpes. A person with a history of cold sores (even when no sore is present) can pass herpes simplex virus 1 (HSV-1) to a partner’s genitals. Part of my health promotion message has been that is it a courtesy to tell a person you have a history of cold sores, offering to cover your partner’s genitals before oral sex. Part of someone’s decision might include the fact that HSV-1 tends to recur less frequently than HSV- 2 on the genitals and tends to be less painful. I was recently called “sexist” for suggesting that men would tend to dismiss such protection in a nanosecond. A propos, I have never met a woman, no matter with whom she had sex, who used an oral latex barrier to receive oral sex.

Men having unprotected oral sex with multiple male partners are at risk for syphilis. My clinic experience tells me that, like heterosexuals and women who have sex with women, they are not likely to use protection for oral sex. They need to be tested more frequently, since untreated syphilis puts them at higher risk for HIV.

But Iet’s get back to Michael Douglas and throat cancer.

I have been following the HPV and oral sex story for several years. Although there has been speculation that the increase in HPV-related mouth and throat cancers (which is on the rise) may be related to the increase in oral sex in earlier decades, there has been no definitive proof. The non-HPV-related head and neck cancers are related to alcohol and tobacco abuse.

HPV is only a problem when it is persistent. Most people clear the virus in the first or second year after infection.

This information leaves people with some decisions to make.

The Public Health message, which I consider unrealistic, has always been to use a latex barrier for oral sex. People don’t, and then they feel guilty.

Unfortunately, there are no screening tests for HPV in Canada; i.e., although a Pap test may indicate the presence of HPV, it does not test for it. Genital warts are generally diagnosed on visual examination. The overwhelming majority of adults will have been infected with some strain or other of HPV in their lifetime. Most of them will have gotten rid of it.

So here are your homework questions:

If you always use condoms with a male partner for intercourse (or at least, until you’ve both been tested), does that also apply for oral sex?

If someone tells you they have a history of cold sores, are you going to politely decline oral sex, use a latex barrier or say, just do it?

Will fear of cancer mean you’re going to cover your next lover’s genitals with latex before you give them oral sex, even though the numbers of these cancers are still relatively low?

If you’ve ever had a bout of genital warts, do you need to tell a partner before they put their lips on yours (the other ones) even though genital warts are more a nuisance than a danger?

Bottom line, we need to decide on the level of risk we are willing to take.