Treatment Issues for Women
HPV and Cervical Dysplasia
HPV (human papilloma virus) is the most common sexually transmitted infection. Most women have at least one type of HPV during their lifetime, but only a few of us know we have it. There are over 100 strains, and it's possible to have more than one strain at the same time. Some HPV strains cause warts to develop on your skin and genital area. Others infect cells inside our cervix, vagina, or anal canal, where we can't see them, but they can cause lesions to develop. Lesions are areas of abnormal tissue. If untreated, lesions can lead to invasive cervical, anal and genital abnormalities (called dysplasia) and cancer in some women.
In addition to higher rates of HPV infection, HIV-positive women with HPV are more likely to have:
Chronic HPV infection
Infection with the HPV strains more likely to cause cancer
HPV in both the cervix and anus
Several strains of HPV at once
Reactivated HPV infections that were previously under control
Any of these factors alone can make us more likely to develop cervical and anal abnormalities. Immune suppression from HIV also plays a role. It seems that with lower CD4 counts and higher viral loads, we're at increasing risk for developing HPV-related lesions -- including high-grade lesions -- in the cervix and anus.
Smoking and untreated sexually transmitted infections, especially chlamydia, can make your cervix more vulnerable to damage from HPV and other infections. So can low levels of certain nutrients including beta-carotene, folic acid, and vitamins A and C. It's not clear yet if supplementation helps, but if you have HPV, it's at least a good idea to maintain normal levels of these nutrients, either through food sources or a multivitamin.
Pap smears are the first step in screening for abnormal cell changes in the cervix and in the anus. Pap smears collect cells -- called squamous cells -- from the transition zone of your cervix or anus, the area most likely to be infected by HPV. Pap smears can detect inflammation and, in most cases, predict cervical or anal abnormalities.
In HIV-negative women, annual Paps are frequent enough to detect any changes that may have occurred since the last exam. This isn't the case in HIV. As a positive woman, it's important to evaluate your individual risk for cervical and anal dysplasia and consider more frequent screening. How frequently depends on a lot of individual factors, including your previous Pap result and whether you've been treated for warts or abnormalities. If your CD4 count is below 300 or has been dropping, have Pap smears at least once every six months. In HIV, any Pap smear result showing abnormal cells needs to be further evaluated by colposcopy.
Colposcopy is an exam of your cervix using a low-powered microscope to look at the tissue more closely. This procedure allows your doctor to see your cervix (or anus) and identify any areas of abnormal tissue. Lesions, warts, and inflammation are usually visible during colposcopy. But it's still hard to tell the difference between low and high-grade lesions. This is why a biopsy is often taken if any lesions are seen during colposcopy.
Biopsy is a procedure that takes a small tissue sample from an area of your cervix. Biopsy is the most reliable way to tell the difference between mild lesions and those that are more likely to progress to cancer. Be prepared -- biopsy can be uncomfortable, even painful, and some women have mild bleeding afterwards. Ask your provider about your pain management options before the procedure begins.
Many positive women have more than one biopsy, either during diagnosis or as part of follow-up care. Understandably, this can make it hard to go back. But it's important to stay involved in our care and give input to treatment decisions that affect us. If you're feeling resentful, angry, or scared, tell your gynecologist. Remember, your GYN wants to keep you healthy. The more she or he knows about what's going on with you, the better they'll be able to work with you.
What Do Results Mean?
If you've had an abnormal Pap smear, you may recognize the terms CIN, LSIL, or dysplasia. These words are from the many different systems used to classify cervical and anal abnormalities. Most U.S. labs use what's called the Bethesda system to report Pap smear results. The Bethesda system includes information about how adequate your Pap smear specimen is and divides abnormalities into the following categories:
Negative for Squamous Intraepithelial Lesions (SILs) or dysplasia
No changes in size and shape of cells were seen.
ASCUS -- Atypical Squamous Cells of Undetermined Significance; or
ASC-H -- Atypical Squamous Cells, can't rule out High-Grade Lesions (HSILs)
ASCUS and ASC-H are cells that can't be classified as completely normal or abnormal. ASCUS may indicate you have inflammation in your cervix. ASC-H is a new category that was added in May of 2002. If you get either of these results, you should have a colposcopy to rule out the possibility of any high-grade abnormalities.
LSIL -- Low-Grade Squamous Intraepithelial Lesion
Intraepithelial means abnormal cells are only present in the surface layer of your cervix. LSIL is considered a mild abnormality, but one that needs to be watched carefully. So far, treatment is not considered standard for positive women with LSIL.
HSIL -- High-Grade Squamous Intraepithelial Lesion
HSIL is a more severe abnormality, with a higher likelihood of progressing to cancer. Any high-grade lesion in your cervix, vagina, or anus requires treatment.
Dysplasia is just another way of describing HPV-related cervical and anal abnormalities. Dysplasia is when cells are different in size, shape, or appearance from normal. Low-grade refers to early changes in size or shape, while high-grade indicates more severe (sometimes pre-cancerous) abnormalities.
Screening and Treatment Guidelines for HIV+ Women
Standards of preventive screening for positive women differ slightly than those for HIV-negative women. Several sets of screening recommendations exist for positive women and standard of care is controversial. The recommendations for women with HIV are generally more aggressive, urging Pap smears more often, and colposcopy (with possible biopsy) anytime ASCUS or other abnormalities are found. The following chart was adapted from the Bethesda system and averages some of the different screening recommendations for positive women.
|If Pap Smear Shows:||Then:|
|Negative||Pap smear in 6 months to a year.|
|ASCUS or ASC-H||Colposcopy to investigate;|
Treat any source of inflammation;
Follow-up Pap smear in 3-8 months.
|LSIL||Colposcopy plus biopsy;|
Repeat Pap smear in 3-8 months.
|HSIL||Colposcopy plus biopsy to determine degree of lesions, followed by treatment;|
Repeat Pap smear in 4-6 months.
|Carcinoma in Situ (precancerous condition) or invasive cancer||Immediate treatment, plus frequent follow-up through Pap smear and colposcopy to prevent recurrences.|
Treatment Options for Dysplasia
For those of us with HPV, there's no simple pill or treatment to prevent us from getting warts or developing cervical and anal abnormalities. So it's important to screen carefully and regularly for changes in the cervix and anus and deal with any high-grade abnormalities, so that they don't progress to cancer.
Treatments for HPV can remove genital warts, destroy HPV lesions, and get rid of abnormal tissue. Genital warts can be treated with topical solutions or by laser, freezing or burning. Most treatments for dysplasia focus on destroying the abnormal tissue so that it doesn't progress to cancer. Treatment options include:
LEEP: removes abnormal tissue with a wire loop
Cone biopsy: removes a cone-shaped piece of tissue from the cervix by surgery or laser. This is done under anesthesia. It's frequently used to treat high-grade dysplasia in positive women.
There are additional challenges to treating cervical and anal abnormalities in positive women:
Many women respond poorly to standard therapies used to treat HSIL.
Some of us need multiple treatments using different methods.
Treatment of HSIL can only try to manage HPV -- it won't prevent a recurrence.
There is low success treating LSIL.
Anal/cervical dysplasia and cancer are more common in positive women.
Both cervical and anal dysplasia can return after treatment. Recurrences may be more likely if you have a higher viral load, but it's not clear that antiretroviral therapy slows the progression of cervical disease. Even when the immune system is partially restored by anti-HIV treatment, anal and cervical dysplasia may progress to cancer. So careful, regular monitoring is the best way for us to ensure that any problems are detected and treated as soon as possible.