Birth Control: is it in you?

At a recent meeting of the Sexual Health Network of Ontario, health care providers came together to examine and extol the virtues of the Intra Uterine Device (IUD).  The IUD is a plastic device wrapped with copper that is inserted into the uterus.  I have always been a proponent of this method of birth control, especially for women looking for an alternative to hormonal methods.

The IUD had to overcome a terrible reputation from the bad old days of the Dalkon Shield.

I remember the Shield well.  I was a very young married woman when I had one inserted.  I complained to my gynecologist that I had ongoing pain on one side which lasted several days a month.  It felt like there was a plumb line attached to my ovary.  It wasn’t until returning from overseas that I had it taken out – or rather dug out – because that’s what it felt like.  The little claws were embedded in my uterus.

It was a deadly device.  The Dalkon Shield’s strings acted like a wick, drawing bacteria into the uterus, causing infections – and in nearly two dozen cases in the US – death.  The deaths in developing countries continued as “developed” countries offloaded their products abroad.

However, in the early 1980s, long after the discredited Shield had tarnished the reputation of all IUDs, new research indicated that the newer copper IUDs were both safe and effective and, in particular, did not cause ectopic pregnancies.  It also became clear that they functioned as a true contraceptive by creating an unfriendly environment in the uterus which repelled sperm.  This opened the door to women who had worried it was an abortifacient.

Copper IUDs

Dr. Sarah Warden from the Bay Centre for Birth Control updated our information on IUDs.  Copper IUDs are 99 – 99.8% effective.  In those rare cases where pregnancy occurs with an IUD in place, the pregnancy can continue as long as it is not ectopic.  Statistically, pregnancy outside the uterus is more likely with an IUD; but given its high effectiveness rate, the risk is very low.  A copper IUD can usually be removed if there is a pregnancy; but that would increase the risk of miscarriage.

A woman with average or no cramps and average bleeding is a good candidate.  She can expect a 10 -20% increase in cramping and bleeding with a copper IUD.  Counselling has changed over the years with regard to multiple partners.  Health care providers were concerned about untreated Sexually Transmitted Infections (STIs) causing Pelvic Inflammatory Disease (PID) with an IUD in place.  However, now STIs can be treated without removing the IUD; although, clearly, a woman with more than one partner is encouraged to use condoms.

Adolescents and women who have not been pregnant can also use the IUD.

Copper IUDs can also be used as emergency contraception up to seven days after unprotected intercourse.

There were a number of questions asked during the presentation; for example, the reason why some IUDs can stay inside the uterus longer than others.  Copper IUDs vary in the number of years they can stay in place: 3, 5 or 10 years.  The main difference between one copper IUD and another is the quantity of copper used.  Although Nova-T is a five year IUD, one practitioner said that they do not use it beyond 30 months because, after that point, they have found an increased risk of pregnancy.  10 year IUDs are larger and more difficult to insert and may cause more cramping on insertion.

The only contraindications to the use of a copper IUD include allergy to copper or other components of the IUD, pregnancy, endometriosis, an abnormally shaped uterus, very heavy bleeding or cramping; or active Pelvic Inflammatory Disease. There are a few risk factors, like perforation of the uterus with insertion, but perforation is rare and the uterus often repairs itself.

Intra Uterine System (IUS)

This progestin-releasing device can assist women with severely heavy bleeding as well as women with endometriosis .  By three to six months, most women who use Mirena (the first IUS on the market) experience dramatically reduced bleeding.  About one third of women will stop having periods after 12 months.

Because it uses the synthetic progestin levonorgestrel, it causes similar effects to Depo Provera which also uses a synthetic progestin; i.e., changes in the cervical mucus and uterine lining, making it harder for sperm to reach the uterus.  And similar to Depo Provera, there may be side effects, including:

  • bleeding and spotting between periods
  • heavier bleeding during the first few weeks after device insertion
  • headache/migraine
  • nausea
  • bloating
  • breast tenderness or pain
  • weight gain
  • changes in hair growth
  • acne
  • depression
  • changes in mood

As always, it is important that health care providers explain fully what a woman may expect.

I learned about some newer IUS devices aside from the more commonly known Mirena: Jaydess, a smaller, low-dose version, good for three years; and Kyleena, which releases the lowest dose of hormones for the longest amount of time.  Mirena has the highest dose of progestin of the three and is approved for five years, although data indicate it is effective up to seven.

The IUS can cause spotting for two to six months.  During the presentation, I had noticed two Orthodox Jewish women and a Muslim woman in attendance.  I made a comment about my birth control counselling at clinic regarding spotting.  Because there may be religious strictures about having intercourse in the presence of blood, I always made sure that women for whom this was an issue were well informed.

Speaking of blood, there was an interesting discussion around using a menstrual cup with the IUD.  Because of the suction on the vaginal walls with a cup, to avoid expulsion it is best to gently break the suction before removing the cup.  Another precaution would be not to use a menstrual cup for two months after an IUD insertion because the risk of expulsion is highest in those first two months.

The copper IUD is an excellent choice for women who want long-term, safe and effective contraception, but prefer not to use hormones.  Make sure that your health care provider has plenty of experience with insertion.

 

 

 

 

 

Advertisements

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

Reducing pregnancies for teens and poor women = reduction in poverty: reductio ad absurdum?

This New York Times article http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html?partner=rss&emc=rss&_r=2  asks the following question: “If teenagers and poor women were offered free intrauterine devices and implants that prevent pregnancy for years… would those women choose them?” The answer?  A “resounding yes”, which they deem a “startling success”.

Pregnancies to teenagers and “unmarried women who had not finished high school” plunged, especially in the poorest areas of the state, allowing them time, according to the article, to “gain a foothold in an increasingly competitive job market”.  It was seen as a poverty reduction strategy.

I wish I had been a fly on the wall during the counselling sessions that led these young and poor Colorado women to choose long-acting contraceptives.  Were they fully briefed on the side effects and potential risks?  Did they discuss Sexually Transmitted Infection (STI) prevention?  What was the overall vision of poverty reduction in Colorado?

During my sexual health clinic days, there were women who chose – and continued to use – Depo Provera, a contraceptive injection that lasts for three months.  They did so after I had fully informed them of potential side effects and risks of the progesterone-only method.  Some adolescents who came to the clinic were good candidates for the copper IUD and it worked very well for them.  After a clinic counselling session, when young teens or disadvantaged women opted for a method of birth control that worked for them; or they chose to end a pregnancy realizing that their circumstances would not allow them to raise a child at that time, they were making informed choices.  I recognized then as I do now, that reproductive control and poverty, while linked, are not the only elements in the equation.  After reading the article, I wondered about other measures proposed to reduce poverty in Colorado; and what will happen when the private grant to fund this experiment runs out.

Teenage pregnancy and pregnancy for low income women are complex issues.  Factors that result in unplanned pregnancies to teenagers include lower economic status, sexism, racism, prior sexual abuse and ongoing abusive relationships.  The absence of the social determinants of health can result in risk-taking behaviours, like smoking and unprotected sexual activity.  With regard to sexual abuse, for example, without the benefit of comprehensive counselling, young women run the risk of future sexual assault and abusive, controlling partners.  Some exploitative male partners will refuse to “allow” them to use contraception; or they may refuse to use condoms.  When one has little control in one’s life, reproductive control is not even on the table.

For younger and poor women, while it may not be prudent financially, emotionally or even physically to continue a pregnancy, if poverty itself were eradicated, part of the burden to the state would be eliminated, while still allowing funding to provide parenting support.

I imagine some ideological detractors of the Colorado experiment might accuse them of eugenics, deliberately limiting births to racialized and poor women.  I do not subscribe to this point of view.  However, one must acknowledge the history of eugenics practices in North America and abroad that will inevitably make some people skeptical of the motivation behind this poverty reduction experiment.

And yet, research is conflicting on the relationship between teen pregnancy and poverty.  According to Statistics Canada, “women from disadvantaged backgrounds are more likely to end up disadvantaged even if they delay childbearing. And while teenage childbearing continues to be a significant indicator of lower socioeconomic outcomes, the effect is smaller than originally believed” (http://www.statcan.gc.ca/pub/75-001-x/2008105/article/10577-eng.htm).

While I agree that delaying pregnancy is a tool towards poverty reduction, let’s be frank: only the redistribution of wealth will eradicate poverty.

The second issue in terms of the counselling process is STI prevention and treatment.  Like women who use oral contraceptives, women who use IUDs, injections (and implants in the US) may not see the need for condom use.  I would like to know if they discussed and offered testing and treatment for STIs like chlamydia, the rate of which is especially high in older adolescents and young women.  Because there are no symptoms of chlamydia in the majority of cases, without testing, women may contract Pelvic Inflammatory Disease which, if undetected over time, may lead to infertility – not a recommended form of birth control.

A Public Health map of Toronto that plots adolescent pregnancies follows the same geographical trajectory as STIs in the city, which, in turn, follows the curve representing its poorest neighbourhoods.

And who is at higher risk for poverty in Toronto?  Recent immigrants, Aboriginal people, those who are disabled, elderly and alone, racialized or children (http://www1.toronto.ca/City%20Of%20Toronto/Social%20Development,%20Finance%20&%20Administration/Strategies/Poverty%20Reduction%20Strategy/PDF/povertyinTO.pdf).

Poverty reduction, like unplanned pregnancy to young and poor women, is also complex.  There are no magic wands, but there are proven tools.  If we take the lead from developed countries where there is more economic equity, we see that a higher minimum wage and/or guaranteed income, a fair tax system where the wealthy and corporations paid their fair share and increased services, results in a profound reduction in poverty.

In the meantime, contraception and birth control, including post-coital options and abortion, should be freely available to all as a public health service.

Additional reading

The hidden epidemic: A Report on child and Family poverty in Toronto, November 2014

http://www.torontocas.ca/app/Uploads/documents/cast-report2014-final-web71.pdf

Poverty causes Teen Parenting, Not the other way around

http://rhrealitycheck.org/article/2013/04/29/poverty-causes-teen-parenting-not-the-other-way-around

Good Practices in Anti-poverty Family-focused Policies and Programmes in Developed Countries

http://www.un.org/esa/socdev/family/docs/egm12/PAPER-RICHARDSON.pdf

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.

Adolescent sexuality: Out of hand? – April 25, 2013

Actually, it seems to be in their hands. Handheld devices give teenagers access to sexual images—including unsolicited images of their peers—as well as anything they could possibly want to know about sex, both positive and negative. The unsolicited photos are an obvious negative, but some of the positives are that they can find a clinic, text a health agency for information, even let a partner know anonymously that they have an STI and need to get tested. With the increase in information from all sources, there have been some real advances in sexual health for adolescents and young adults; but there are still serious problems. So what are they really up to? Media messages mislead adults about adolescent sexual activity, giving the impression that they are having sex at increasingly younger ages. Federal and provincial health surveys seem to tell a different story. In 1996, 32 per cent of 15- to 17-year-olds reported that they had had (vaginal) intercourse; in 2003 and 2009, it was 30 per cent. Moreover, for 18- to 19-year-olds, fewer are reporting having had intercourse than previously. In 1996, it was 70 per cent; in 2009, it dropped to 68 per cent. Condom use is also increasing. Sixty-eight per cent of sexually active Canadians aged 15 to 24 reported using condoms in 2009-2010, compared to 62 per cent in 2003. However, older teenagers are less consistent in their condom use: for 18- to 19-year-olds (with one partner), 72.7 per cent used condoms the last time they had sex as compared to 81.2 per cent of 15- to 17-year-olds. The likely reason for the heterosexual teenagers is that the young women are on the Pill. Like deciding to postpone sex, condom use requires negotiation. In certain social groups, condoms are de rigueur. When I worked in a sexual health clinic, I noticed that there were some young people who were more sophisticated than many adults I know in terms of their ability to make sexual decisions. For example, young men were coming in with their female partners for testing, a great new twist on a date. The rates for adolescent pregnancy have plunged dramatically since the 1970s, with the increase in comprehensive sexual health education and access to birth control and safe abortion as back-up. The remaining pockets of adolescent pregnancy are still to be addressed by increased access to the basics: adequate food, shelter and safety, including sexual safety. Another positive: adolescents are coming out to themselves at younger and younger ages about their sexual orientation and/or gender issues. So we’re getting some things right by changing the discourse at home and school to ensure that they hear lesbian/gay/bisexual/trans (LGBT) positive messages. But we still need to up our game. The older adolescents who are no longer using condoms may not be getting pregnant, but they are getting STIs in record numbers. The number of cases of Chlamydia for 15- to 24-year-olds, for example, continues to rise. This is in part due to more, and better, testing.  (Urine tests for males as opposed to swabs make it a lot easier to convince them to go.) As mentioned, heterosexual teenage girls and young women in longer term relationships (three weeks or more!) are starting to use hormonal contraception, such as the Pill, as their method of birth control. But they tend to start the Pill before they get tested for STIs. As soon as they go on the Pill, they stop using condoms. They may be unaware that they were already infected with an STI from a previous partner, or they may get infected by their steady, loving partner, who was himself unaware that he was infected. To my mind, the most dramatic barrier to adolescent sexual health, as I reported in an earlier blog is the persistence of acquaintance rape and the apparent lack of empathy for its victims. Right alongside this phenomenon is intimate partner violence—emotional, physical and sexual abuse—that often starts in adolescence and persists into young adulthood, with the overwhelming majority of victims of intimate partner violence being female. While I fully acknowledge that each one of these problems has many factors, including high-risk behaviors linked to economic and social disadvantages, education remains a key factor. With increased education and access to services, we will be able to keep pushing down the stats on STIs and teenage pregnancy; but it will take some phone smarts to turn those handheld devices to our advantage. Agents for change will have to learn to blast positive messages to each and every one of them. I propose a new Twitter tag: #goodteensex.