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                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     [phone] ext 3305
                       September 23, 1994

                Women and HIV Infection (Part IX)

         Cervical Cancer Screening for Women Who Attend
            STD Clinics or Who Have a History of STDs

     Women who have a history of STDs are at increased risk for
cervical cancer, and women attending STD clinics may have
additional characteristics that place them at even higher risk.
Prevalence studies have found that precursor lesions for cervical
cancer occur approximately five times more often among women
attending STD clinics than among women attending family planning
clinics.
     The Pap smear (cervical smear) is an effective and relatively
low-cost screening test for invasive cervical cancer and squamous
intraepithelial lesions (SIL)*, the precursors of cervical cancer.
The screening guidelines of both the American college of
Obstetricians and Gynecologists and the American Cancer Society
recommend annual Pap smears for sexually active women.  Although
these guidelines take the position that Pap smears can be obtained
less frequently in some situations, women who attend STD clinics
or who have a history of STDs should be screened annually because
of their increased risk for cervical cancer.  Moreover, reports
from STD clinics indicate that many women do not understand the
purpose or importance of Pap smears, and many women who have had
a pelvic examination believe they have had a Pap smear when they
actually have not.

Recommendations

     Whenever a woman has a pelvic examination for STD screening,
the health-care provider should inquire about the result of her
last Pap smear and should discuss the following information with
the patient:

  o  Purpose and importance of the Pap smear,

  o  Whether a Pap smear was obtained during the clinic visit,

  o   Need for a Pap smear each year,

  o  Names of local providers or referral clinics that can obtain
     Pap smears and adequately follow up results (if a Pap smear
     was not obtained during this examination).

     If a woman has not had a Pap smear during the previous 12
months, a Pap smear should be obtained as part of the routine
pelvic examination in most situations.  Health-care providers
should be aware that, after a pelvic examination, many women may
believe they had a Pap smear when they actually have not, and
therefore may report they have had a recent Pap sear.
     In STD clinics, a Pap smear should be obtained during the
routine clinical evaluation of women who have not had a documented
normal smear within the past 12 months.
     A woman may benefit from receiving printed information about
Pap smears and a report containing a statement that a Pap smear
was obtained during her clinic visit.  Whenever possible, a copy
of the Pap smear result should be sent to the patient for her
records.

FOLLOW-UP

     If a Pap smear shows severe inflammation with reactive
cellular changes, the women should be advised to have another Pap
smear within 3 months.  If possible, underlying infection should
be treated before the repeat Pap smear is obtained.
     If a Pap smear shows either SIL (or equivalent) or atypical
squamous cells of undetermined significance (ASCUS), the woman
should be notified promptly and appropriate follow-up initiated.
     Appropriate follow-up of Pap smears showing a high-grade SIL
(or equivalent) on Pap smears should always include referral to a
health-care provider who has the capacity to provide a colposcopic
examination of the lower genital tract and, if indicated,
colposcopically directed biopsies.  Because clinical follow-up of
abnormal Pap smears with colposcopy and biopsy is beyond the scope
of many public clinics, including most STD clinics, in most
situations women with Pap smears demonstrating these abnormalities
will need to be referred to other local providers or clinics.
Women with either a low-grade SIL or ASCUS also need similar
follow-up, although some experts believe that, in some situations,
a repeat Pap smear may be a satisfactory alternative to referral
for colposcopy and biopsy.

OTHER MANAGEMENT CONSIDERATIONS

     Other considerations in performing Pap smears are the
following:

  o  The Pap smear is not an effective screening test for STDs;

  o  If a woman in menstruating, a Pap smear should be postponed
     and the woman should be advised to have a Pap smear at the
     earliest opportunity;

  o  If a woman has an obvious severe cervicitis, the Pap smear
     may be deferred until after antibiotic therapy has been
     completed to obtain an optimum smear;

  o  A woman with external genital warts does not require Pap
     smears more frequently than a woman without warts, unless
     otherwise indicated.

SPECIAL CONSIDERATIONS

PREGNANCY

     Women who are pregnant should have a Pap smear as part of
routine prenatal care.  A cytobrush may be used for obtaining Pap
smears from pregnant women, although care should be taken not to
disrupt the mucous plug.

HIV INFECTION

     Recent studies have documented an increased prevalence of SIL
among women infected with HIV.  Also, HIV may hasten the
progression of precursor lesions to invasive cervical cancer;
however, evidence supporting such a progression is limited.  The
following provisional recommendations for pap smear screening among
HIV-infected women are based partially on consultation with experts
in the care and management of cervical cancer and HIV infection
among women.
     These provisional recommendations may be altered in the future
as more information regarding cervical disease among HIV-infected
women becomes available:

  o  Women who are HIV-infected should be advised to have a
     comprehensive gynecologic examination, including a Pap smear,
     as part of their initial medical evaluation.

  o  If initial Pap smear results are within normal limits, at
     least one additional Pap smear should be obtained in
     approximately 6 months to rule out the possibility of false-
     negative results on the initial Pap smear.  If the repeat Pap
     smear is normal, HIV-infected women should be advised to have
     a Pap smear obtained annually.

  o  If the initial or follow-up Pap smear shows severe
     inflammation with reactive squamous cellular changes, another
     Pap smear should be collected within 3 months.

  o  If the initial or follow-up Pap smear shows SIL (or
     equivalent) or ASCUS, the woman should be referred for a
     colposcopic examination of the lower genital tract and, if
     indicated, colposcopically directed biopsies.

     HIV infection is not an indication for colposcopy among women
with normal Pap smears.

*The 1988 Bethesda System for Reporting Cervical/Vaginal Cytologic
Diagnoses introduced the new terms low-grade squamous
intraepithelial lesion (SIL) and high-grade SIL.  Low-grad SIL
encompasses cellular changes associated with HPV and mild
dysplasia/cervical intraepithelial neoplasia 1 (CIN 1).  High-
grade SIL includes moderate dysplasia/CIN 2, severe dysplasia/CIN
3, and carcinoma in situ (CIS)/CIN 3 (16).

(Centers for Disease Control and Prevention. 1993 Sexually
Transmitted Diseases Treatment Guidelines. 1993 Sept;42(No. RR-
14):[pages inclusive].)

       MEDICAL MATTERS: Treatment of an Abnormal Pap Smear

(From PWAC/NY Newsline: People with AIDS Coalition of New York -
January, 1994.)

     If a Pap smear shows any degree of abnormality, the woman can
be scheduled for a colposcopic examination. However, it is very
important for the clinician to treat any condition that can be
treated before making the referral for colposcopy. It is important
to treat Vaginal Thrush (also called candida, monilia, or fungal
vaginitis), Trichomonal, Bacterial Vaginosis (also called BV or
gardnerella), Atrophic Vaginitis (due to low estrogen levels, and
treated with estrogen creams), Herpes Simplex Infection, and any
other condition. If a condition is diagnosed and treated, it is
quite reasonable to reschedule the Pap test in 6-8 weeks. This is
because any of these conditions can give an inaccurate Pap result,
either falsely positive or falsely negative. If the Pap returns
with Aytpia or CIN 1, some clinicians will repeat it in two to
three months before making a referral. There is nothing wrong with
rhis practice in healthy women.
     The same is true for women with HIV who are healthy. There is
also nothing wrong with referring for colposcopy right away.  This
is an individual decision that should be based on the relationship
between the woman and her provider.  However for women with low CD4
counts, or who have signs of immune compromise, it is probably best
to go right to colposcopy. This is because not enough is really
known about the process of cervical disease in women with low CD4
cells.  Also, any Pap that shows moderate or severe dysplasia (CIN
2, CIN 3, or CIS) should be evaluated by colposcopy within six
weeks.  The appointment should not be scheduled when the woman is
menstruating.
     The Colposcope is a magnifying instrument (which looks
something like a microscope with a lens that can be focused on the
vulva, vagina, and cervix.  It rests on a stand, and the examiner
looks through it. The colposcope does not go inside the vagina. It
magnifies the surface of the cervix, so that the examiner can see
the transformation zone (T-Zone), where most abnormalities start.
The T-Zone occurs at the border between two different types of
cells;  Squamous Cells and Columnar Cells. It is a very active area
which undergoes frequent replication of new cells, and also reacts
in response to the hormonal signals of puberty, menstruation,
pregnancy and menopause. It is this intense activity that makes it
such a vulnerable area.
     In general, the examiner is looking for abnormalities in the
squamous cells that line the outside of the cervix (the ecocervix)
and which might extend into the vagina or even the vulva. There can
also be abnormalities of the inner lining of the cervical canal,
the columnar cells. This is a much more rare phenomenon, however,
and the examiner must be sure of the type of abnormality and in
what type of cells it is occurring. The exam must also make clear
the extent of the abnormality. Like with the Pap smear, the degree
of abnormality is graded, and in general, the same terms are used.
The difference is that, in colposcopy, the abnormalities are
evaluated in a tiny sample of cervical tissue called a biopsy.
     The purpose of using the colposcope is to find the most
abnormal looking areas, and to take samples of them with biopsies.
Two types of biopsies may be taken of the cervix: and Endocervical
Biopsy and a Cervical Biopsy. The endocervical biopsy samples
columnar cells and the cervix biopsy samples squamous cells.
Remember that the examiner needs to know which type of cells are
abnormal tissue. Biopsies hurt a little, like a sharp pinch; but
only for a few seconds. After having a biopsy, a woman may have
some spotting or bleeding for a day or two, and must not put
anything into the vagina during the first two or three days it
takes for the biopsy to heal.
     Before the colposcope was used widely, any abnormal Pap test
was followed with a Surgical or Cone Biopsy. In a cone biopsy a
wedge of tissue (about the size of the end of your thumb) is
removed under general anesthesia. I will discuss this diagnostic
test more later.
     However, in general, the use of colposcopy reduces the need
to place women under general anesthesia and remove a large sample
of tissue for diagnosis. But with colposcopy, an accurate diagnosis
depends on the clinician finding the most abnormal looking area to
take the biopsy sample. This takes training.
     The colposcopic exam and biopsies are for diagnosis, and do
not treat the problem. Therefore, the woman must be scheduled to
return to the clinic in two to three weeks for treatment and
consultation, depending on how long it takes to get the biopsy
report back. When the woman returns the diagnosis is shares with
her. If the biopsies agree with the Pap smear, and do not indicate
invasive cancer, a local treatment of the cervix can be planned.
The following treatments are all considered adequate for treating
dysplasia of the cervix:

     Cryotherapy

     This is most commonly used because it is an easy technique to
learn, it can be done in an office without anesthesia, and the
equipment is inexpensive. The "cryo unit" holds a gas tank attached
to a probe that can touch the cervix. The gas gets very cold under
pressure in the tank, and the cold probe is held against the
abnormal areas until the tissue is frozen. The frozen tissue dies,
sloughs off, and if all goes well, new healthy tissue replaces the
"bad" tissue. The healing process takes two to three weeks, and the
woman usually has heavy, watery discharge during this time. Shd
should not put anything into the vagina during healing.

     Cone Biopsy

     This procedure is done if the dysplasia is severe, if it may
extend up into the cervical canal, if the Pap report and the
biopsies do not agree on the degree of abnormality, or it may also
be used for minor dyxplasia. In a surgical cone, the woman must be
under anesthesia for the surgery, but can go home the same day.

     Electronic Therapy (also called LEEP)

     In this therapy a thin wire loop and electrical current are
used to remove and destroy abnormal tissue. In some cases this is
performed as surgery, and done under anesthesia; often this is done
when a cone biopsy is being done by LEEP to treat high grade
dysplasia. The technique may also be used in the clinic setting
without anesthesia, to obtain biopsy specimens. In these cases, the
diagnostic procedure may remove the entire area of abnormal tissue,
eliminating the need for further treatments. However the woman
should be scheduled to return for follow-up care and to learn the
results of her biopsy.

     Laser Treatment

     Laser therapy uses intense light energy which can destroy
abnormal tissue by creating sufficient heat to "vaporize" cells.
Laser treatment of dysplasia must be performed by an expert in the
technique. When done properly, cure rates are good, and
complications are rare. Laser of the cervix can be performed with
local or no anesthesia. When used to perform a cone biopsy, or to
treat the vulva, general anesthesia is used. Healing from laser
therapy usually occurs more rapidly than with cryotherapy.

     Naturopathic Remedies

     Naturopaths are doctors who use "natural," herbal and
traditional remedies, instead of conventional medicines and
treatments. There is literature which describes naturopathic
remedies for dysplasia. In all cases, the literature advises proper
diagnosis by colposcopy, close follow-up, and referral for more
conventional therapy if the problem does not improve or gets worse.
The scientific study of these treatments is extremely limited (that
is we don't know whether they work or not). The treatments include
local therapy called Escharotic Treatment, in which herbal packs
that cause tissue sloughing are applied to the cervix in the
doctor's office. This is done twice weekly for several weeks. In
addition, the woman is instructed as to certain nutritional
supplements, dietary changes, and use of suppositories and herbs.

     Treating Cervical Cancer

     In some cases, the biopsy report will confirm invasive cancer.
In these cases, another process, called Staging, must be performed.
Staging is a series of tests and evaluations that will determine
where the invasion has spread, and whether or not the organs are
involved.
     When the Centers for Disease Control and Prevention added
cervical cancer to the list of AIDS-defining illnesses, they
specified that the cancer must be invasive, and it must extend
beyond the cervix itself. Some AIDS activists and women's advocates
feel that this requirement is quite stringent; we hope to treat any
dysplasia or microinvasive cancer before it spreads beyond the
cervix. A cancer that does not extend beyond the cervix is
generally treated by total hysterectomy, or hysterectomy with
removal of lymph nodes (radical hysterectomy).
     Once the disease has spread beyond the cervix, radiation
therapy is generally used. Occasionally, microinvasive cancers are
treated by cone biopsy alone, with very close follow-up. The
treatment decision must take into account whether or not the woman
desires to carry a pregnancy in her future. Chemotherapy plays very
little in the treatment of cervical cancer.
     In women with immune compromise, surgery and radiation pose
greater risks than the risks to women with good immune function.
But, even in HIV infection, cervix cancer can be prevented by early
detection of dysplasia. This is a powerful reason to recommend
frequent gynecological check-ups and Pap tests every six months for
an HIV-positive woman.

     Who can perform colposcopy?

     Almost all Obstetrician/Gynecologists (OB/GYNs) are trained
in their residency to do the procedure. Some OB/GYNs even
specialize in cervical diseases. Other primary care doctors (such
as family practitioners or internists) can learn the technique on
their own, or by attending special training programs. Primary care
doctors may feel they see enough women with abnormal Pap tests to
justify getting the extra training. Also, some nurse-practitioners,
who specialize in women's health care, complete training programs
in colposcopy.
     However, most primary care providers consider colposcopy a
specialized procedure; so most women who need the exam have to be
referred to someone else, usually someone they have never met. Of
course, gynecologic surgeries are only performed by gynecologists,
and laser therapy should only be performed by a gynecologist who
has a special training in its use.
     Nurse practitioners and physician's assistants who perform
colposcopy usually learn to do so in order to follow their own
patients, and most work in close cooperation with a gynecologist.
In my own practice, I really appreciate being able to offer
colposcopy to women that I already know, instead of having to refer
them to a stranger. I am also fortunate to work with a
compassionate and skilled gynecologist. I mention this because, at
the present time, there are not enough clinicians trained in
colposcopy to provide the service in a timely way to all the women
who need it. Further, referrals often lack a personal touch,
frightening women unnecessarily, and then blaming these women for
"poor compliance."
     It seems clear that our present medical system is not meeting
basic gynecological needs for women, and that women with HIV may
be at the greatest risk of inadequate, insensitive and unsatisfying
gynecological care. It is important that those of us involved in
women's health look at these problems, and come up with solutions
that make the care more accessible, more comfortable and more user
friendly.

[Copyright (c) 1994 - PWAC/NY Newsline.  Non commercial
reproduction permitted provided no fees or dues are charged for the
material and proper credit to PWAC/NY Newsline in excerpts or
quotes.]