July 21, 2014
Table of Contents
For women living with HIV (HIV+), there are many aspects to staying healthy. You are off to a good start if you take your medications on schedule, eat well, and get regular physical activity. But to take care of your whole body, you need to get regular gynecologic (GYN) care from a health care provider. Gynecologic care refers to the diagnosis and treatment of issues affecting the female reproductive organs (also called the female genital tract).
It is very important for HIV+ women to have regular GYN visits and tests for cervical cancer. The US Centers for Disease Control and Prevention (CDC) recommends that:
You should be tested for gonorrhea and chlamydia at the first visit. It is important to repeat these tests if you have a new partner or if you have unprotected sex.
Usually, your provider will begin by asking you about your sexual history. You will be asked about:
These questions can feel uncomfortable for both the provider and the patient. Even if it is hard for you, do the best you can to answer honestly. Your provider needs complete information to take good care of you.
After the interview, the provider will examine different parts of your body. Not all providers perform all the exams listed below in the same order. It is common for the provider to ask a member of the health care staff (usually a medical assistant or nurse) to join her/him in your room for the physical exams. This is for everyone's protection and to make sure the exams are performed in a professional manner.
For the breast exam, the provider will ask you to lie back and raise one arm over your head as she or he feels with her/his hands for any lumps or masses in the breast on the side with your raised arm. The provider will then repeat this on the other side of your body, asking that you raise your other arm and feeling your other breast.
For the pelvic exam, the provider will ask you to lie down and scoot your butt to the end of the exam table. Then you will be asked to open your legs, bend your knees, and place your feet in the stirrups. Often, at this point, the provider will use her or his gloved fingers to examine the outside of your genitalia for any bumps, sores, or other problems. Next, your provider will insert an instrument called a speculum into your vagina. This instrument opens the walls of the vagina so that your cervix (the opening to the uterus) can be seen by the provider.
Then the provider will use a small brush to collect some cells from your cervix for the Pap smear. The cells will be sent to a laboratory to be examined under a microscope to see if there are any abnormal cells (dysplasia). Additional tests will be done if abnormal cells are found. While the speculum is still inserted, the provider may also collect fluid to check for infections.
Because Pap tests require laboratories and people skilled in reading them, resource-limited countries offer different tests to screen for dysplasia and cervical cancer. One method is called visual inspection with acetic acid, or VIA. When using VIA, health care providers swab acetic acid (also known as vinegar) on the cervix and look directly at it to see if any areas need treatment. Other countries use human papilloma virus (HPV) tests, which test samples taken from your cervix for the presence of HPV's DNA (its genetic material).
The bimanual exam is performed without a speculum. In this exam, the provider places two gloved fingers inside your vagina and places the other hand on your belly. He or she feels your ovaries and uterus between the hands and checks for any pain. The provider may also perform a rectal exam. During the rectal exam, the provider gently puts a lubricated, gloved finger into your rectum to feel for any unusual bumps or sores. She or he may collect a small amount of stool to check for blood.
Many women find the pelvic and bimanual exam slightly uncomfortable and embarrassing. One reassuring thought is that the speculum is used for only two or three minutes, and the whole thing is usually over in less than five. And the more often you go, the easier it gets.
It is possible for HIV+ women to have anal dysplasia, which can lead to anal cancer. A rectal examination with an anal Pap smear is the best way to detect anal dysplasia. There are currently no official recommendations for anal pap smear screening among HIV+ women; however, some providers perform this exam due to the higher risk for anal cancer among HIV+ people. Similar to a cervical Pap smear, an anal Pap smear includes the insertion of a small swab into the anus to collect cells that are then sent to a lab to be examined under a microscope to see if there are any abnormal cells.
It is important to remember that at any point during the breast, pelvic, bimanual, or anal exams, you can ask your provider to tell you what she or he is doing as it is happening. Some women find this helps them relax more throughout the exam.
Certain gynecologic conditions are more common, more serious, and/or more difficult to treat in HIV+ women than in HIV-negative women. If left untreated, some GYN infections can develop into more serious conditions such as pelvic inflammatory disease (PID) or cervical cancer.
STDs, also know as STIs (sexually transmitted infections) are infections and diseases that are passed from person to person through oral, vaginal, or anal sex. While there are over 25 STDs, the most common ones are listed here and described in more detail in The Well Project's article on STDs:
Candidiasis is a very common vaginal infection caused by yeast (fungus). This fungus normally exists in the human body (including in the vagina) and lives in balance with helpful bacteria. When an imbalance occurs and the yeast overgrows, candidiasis occurs. Symptoms may include itching, burning, and pain around your vagina, vaginal lips, or anal area. You may also have a thick, cottage cheese-like vaginal discharge. HIV+ women often have repeated yeast infections that are difficult to treat. You are more likely to experience yeast-related problems if you:
Prevention of Yeast Infections
If you think you may be likely to get vaginal fungal infections, there are some things you can do to help prevent them. First, you can drink milk that contains acidophilus or eat yogurt with active bacterial cultures. There are also over-the-counter acidophilus supplements you can take, but it is important to make sure you take one that has a high level of active cultures. Also, some foods or food ingredients can promote the growth of yeast. Nutritionists recommend that you avoid foods containing yeast, sugar, wheat, and caffeine. If you smoke or drink alcohol, you should be aware that alcohol and nicotine can also promote the growth of yeast. If you douche, you may consider limiting the frequency of douching or eliminating douching altogether. Douching reduces levels of helpful bacteria in the vagina and is not recommended. Lastly, because yeast grows best in moist areas, wearing looser-fitting pants or underwear can help prevent yeast infections. Cotton underwear breathes better than underwear made of polyester or nylon, and can also help minimize yeast growth.
PID refers to inflammation in the upper genital, or female reproductive tract (which includes your ovaries, uterus, and fallopian tubes.) PID is often caused by a number of common infections, including the sexually transmitted diseases (STDs) gonorrhea and chlamydia. PID starts after these infections travel up from the vagina to other organs in the body, where they can cause serious damage and lead to infertility.
The most common symptoms of PID are lower belly pain, irregular menstrual cycles, vaginal bleeding when you are not having your period, vaginal discharge, and painful or frequent urinating. HIV+ women who develop PID should be carefully followed by their health care providers since they may need to be hospitalized and treated with antibiotics.
Many HIV+ women experience menstrual changes or irregularities. These changes to your menstrual cycle (or period) are less common if you have a high CD4 count and are taking HIV drugs. For more information on the types of menstrual changes HIV+ women experience and the effects of HIV and HIV drugs on women's periods, see The Well Project's article on Menstrual Changes.
Menopause usually occurs in women from 38 to 58 years of age because of natural changes in the body, including the ovaries making less estrogen. Symptoms of menopause include irregular periods (different in amount, frequency, or duration), hot flashes, night sweats, and vaginal dryness.
Some studies have suggested that women with HIV may experience menopause earlier than HIV-negative women. This may be due to one or more of many factors including anemia, decreased hormone production, illness, weight loss, effects of HIV drugs, effects of street drugs, or smoking.
For more information about menopause, its symptoms, and options for relieving those symptoms, see The Well Project's article on Menopause.
There are many things you can do to make your appointment with your GYN provider a smoother, easier, and more helpful visit.
Preparing Your Body
To get the best results from the physical exam part of your visit, it is important to do the following:
Preparing for Your Provider's Questions
Your GYN care provider will ask you several questions about your sexual and medical history. These questions are not meant to invade your privacy or criticize, but to gather important information to make good decisions about your health. It may be helpful to think about your answers before your appointment. Be prepared to answer the following questions:
Preparing Your Questions
Whether or not you feel comfortable going to your GYN appointment, it is important that you write out a list of questions you want to ask your health care provider. Many women find it difficult to remember to ask their questions given all that goes on during the visit: the exam room, the change of clothes, the physical exam itself, and all the questions the provider asks! This is your opportunity to raise concerns and ask questions about the health of your body, so be ready with your list.
Things you may wish to talk about with your GYN provider:
If you have just had your GYN exam, congratulations! You have just done one of the most important things an HIV+ woman can do to keep herself healthy. Regular GYN exams and Pap smears are crucial to your health since many GYN conditions do not have obvious symptoms and can get worse without your realizing it. Finding and treating GYN conditions in the early stages can prevent them from becoming more serious conditions later.
If your health care provider is not skilled in GYN care, or you would rather see a specialist, ask for a referral to a GYN care provider who is experienced in treating women with HIV. If you receive GYN care from someone who is not your HIV provider, be sure that your HIV provider is aware of results from your Pap smear, other GYN tests, and any treatments you might be taking for GYN conditions.