HPV virus and cervical cancer

HPV virus structureHPV virus is a topic of interest in public health sites, blogs, magazines and it particularly affects sexual health as it is related to our sex life, is very frequent indeed, and was up to recently virtually unheard of. Even now it is treated with prejudice and misconception. Let us follow a TRUE-FALSE topic review and hopefully cover all questions and related issues.

The HPV virus is a recently developed virus that did not exist in the past, exactly like the HIV virus.
FALSE. The virus has always been around, we were just not aware of its existence and its mechanism of action towards disease.

It has been incriminated as a predisposing factor for cervical cancer, but there are cases of cervical cancer not related to HPV infection, exactly like there is lung cancer not related to smoking.
FALSE. The natural history of cervical cancer is unique in its exclusivity. It is always related to a HPV infection that took place at some point. In other words, there cannot be cervical cancer without a pre-existing HPV infection. No other cancer is thus exclusively related to a single aetiologic factor. Indeed, smoking does not have such a strong association to lung cancer pathophysiology, as it seems to be the case with HPV and cervical cancer.

HPV infection almost always results from sexual intercourse.
TRUE. It seems that vaginal penetration is the main way of transmission, that is why condom use offers significant protection (by 70%). However, transmission has been reported to occur even upon simple external close contact of affected genitalia, even when no penetration takes place, as is the case in female homosexual intercourse.

The HPV infection is rather rare and most frequently related to multiple sexual partners.
FALSE. This is a very frequent infection. The life-time infection risk for an average woman is estimated to be up to 80% and it is obvious that the timing of infection most frequently coincides with the first decade following initiation of sexual activity. Multiple partners as well as multiple previous contacts of those partners apparently facilitates the viral spread.

There are several HPV viruses with different behaviour and varying oncogenic potential.
TRUE. More than 120 different HPV viruses have been identified. Some viruses ( namely, HPV 6 and HPV 11) are related to benign skin condylomata (warts), whereas other HPV strains will cause pre-cancerous lesion within the cervix, some (notably HPV 16 and HPV18) are aggressive, others have lower oncogenic potential and are deemed low-risk. However, multiple strains may infect simultaneously and a combined picture of external warts and internal cervical lesion frequently ensues.

External warts are also related to cancer.
FALSE  External skin warts, usually located on the skin of the genitalia and the perianal area, may grow bigger and expand in the nearby skin. They may provoke discomfort but they do not turn into cancer. This is why HPV infection in men is not related to malignancy. Having said that, an extreme rare penile HPV-related cancer is  described, warts therefore should always be treated.

The virus may be transmitted through simple direct physical contact.
FALSE The current literature is rather vague, yet it seems that transmission is not possible through everyday contact, hand-shaking, hugging, common use of kitchen utensils or toilet. Apparently, it requires intense contact and friction, most commonly in the sensitive genital area.

The literature reports cases of HPV wart lesions in children.
TRUE When not related to child abuse, it is reported to occur by careless direct contact from the hand of an infected parent to the child’s skin.

HPV infection in pregnancy puts the embryo at high risk.
FALSE The virus has no teratogenic action. It may however infect the baby during delivery through an infected birth canal and may cause wart lesions in the baby’s throat. When prominent warts are seen within the vagina, a caesarean section is advised, in order to prevent direct contact. A pregnant woman with an abnormal Pap smear does not need to have a caesarean, she may be at risk but not the fetus and a caesarean will not anyway offer total protection.

Oral sex is a safe sexual practice as far as HPV transmission is concerned.
FALSE Warts in the mouth and pharynx are directly related to oral sex practice and it appears to be a common and serious problem as they may commonly develop into cancer. Saliva may have a protective effect against HPV, yet oral sex is a well documented mode of HPV transmission and significant related pathology.

Homosexual men are not at risk from HPV.
FALSE In recent years, HPV-related anal cancer is becoming a huge public health issue in homosexual populations. It is as common and serious problem as cervical cancer and we have not yet developed a screening program, as is the case with Pap smears and cervical cancer. Anal cancer risk obviously also affects women who practice anal sexual intercourse.
When infected by HPV, one will “carry” the virus indefinitely.
TRUE AND FALSE  In most of the cases, the virus will attach itself on the surface of the cervical cells, will independently multiply its genetic material (DNA) without affecting the DNA of its host cell. At some point, at 1-2 years the latest, the human body will mobilize its natural defense mechanisms and eradicate the virus. In a small percentage (up to 10%) of women, the virus (usually a high-risk strain) may persist, incorporate its DNA to the cervical cell DNA, and damage the host DNA (pre-cancerous lesion) and cause it to mutate (cancer).
A 40 year old lady presents with a pre-cancerous lesion seen on her Pap smear. That implies that she or her partner were recently infected by HPV.
TRUE AND FALSE  This could well be a recent infection, particularly if external warts co-exist along with the cervical lesion. Yet, it could also be associated with an old infection which gradually led to cellular damage and now presenting through the abnormal smear test.

The infection may raise issues many years after its initial transmission.
TRUE The natural history of the infection is anyway long. The time interval between the initial infection and the pre-cancerous lesion development is estimated to range between 7 and 15 years. Having sai that, in a small percentage of women this could be surprisingly short, up to 2 years after initiation of sexual activity and HPV infection. This is why the first Pap smear should be taken 18 months after the sexual activity initiation.

Younger women are primarily affected and considered to be high risk.
TRUE AND FALSE Infection is indeed more likely to occur to a 20 year old but she would be more likely to eradicate the virus within 1-2 years. Women older than 30 are less likely to be infected in the first place, but more susceptible to viral persistence and eventual serious lesion.

HPV infection will always lead to cervical cancer, unless medical intervention occurs.
FALSE The virus will infect the majority of women (life-time risk up to 80%) but only a slim percentage of those will eventually develop cancer. HPV virus is usually eradicated, and when it persists it is even then unlikely to develop into a serious lesion, let alone cancer. It is true though that medical intervention as in Pap smear population screening, significantly reduces the risk. In developing countries, where this is not available, cancer is much more common, reaching up to 80% of all global cases.
Women who smoke and are infected by HPV are more likely to later develop a serious pre-cancerous lesion.
TRUE When the virus persists, smokers carry up to twice the risk of developing serious lesion, than non-smoking women.
Viral persistence and detection in consecutive pap smears and colposcopies for over 2 years raise the risk for cancer development.
TRUE When the infection persists, it is probably a strain with high carcinogenic potential which has already managed to incorporate itself within the cellular DNA and it is now capable to activate abnormal mutations.
The incubation period between initial infection and lesion appearance on the skin or the cervix is just a few days.
FALSE It is estimated to range between 6 weeks and 8 months. External skin warts have been reported to occur up to 3 weeks after infection. A 3 month period is typically reported in textbooks.
A woman who has been given a Pap smear positive for HPV should inform her past and/or present partner.
TRUE We should bear in mind though that this viral infection is extremely common. If we take a picture today of the global population, a 10% of women will be found to be currently infected and we have already mentioned that the life-time infection risk is up to 80%. We should therefore avoid to blame or have feeling of guilt and remorse. Current or previous partners should be informed. Men are not at risk to develop cancer but they may carry the virus and infect a new partner, and they may after all develop skin warts. Incubation periods are as we said vague and even the doctor cannot safely guess the timing of infection. Just inform partners and be cool about it.
A young woman with HPV infection and an abnormal PAP smear test must have a surgical procedure to remove the lesion from her  cervix, before cancer develops.
FALSE We tend to avoid surgical intervention in young women and try to be conservative as long as it is safe. At her age, the lesion is anyway more likely to disappear spontaneously. Furthermore, we wish to avoid an operation that will destroy or remove part of her functioning cervix, which could later lead to fertility problems and preterm labour risk.
Medical treatment, suppositories, vaginal douches can be used to eradicate the virus.
FALSE There is no available medical treatment. This is exactly like the flu virus, there is no direct antiviral treatment, one can only prevent through vaccination. All available treatment modalities are destructive (diathermy, LASER) and there are also some topical remedies which fortify the local skin natural defenses. We do give emphasis to natural defense mechanisms, we advise the woman not to smoke, we treat any concurrent disease. We frequently tend to postpone treatment in order to allow time for natural defenses to mobilize and correct the cellular abnormalities.
The available vaccination is effective but is still experimental and its safety profile is not documented.
FALSE Its safety is well documented, its main side-effects being local irritation at the injection site (20-90% of cases) and transient fever (10-13%). No serious adverse effect has been reported and this not a new vaccination- several million doses of both available vaccines have already been administered worldwide.
The HPV vaccination constitutes a total prevention modality against cervical cancer, in other words, it protects 100%.
FALSE The vaccine covers against strains No 16 and 18, the most frequent high-risk strains. They are incriminated for 70% of cases of cervical cancer, hence the vaccination protection would be exactly at 70%. There is reliable evidence that demonstrates that other strains with similar structure are also covered. This cross-cover as a bonus will further raise the protection rate. The Pap smear screening program should nevertheless keep going. Once 16 and 18 are eradicated, other strains may tend to proliferate and cover the gap, the population screening should therefore not be discontinued.
There are two vaccinations in the market, equally effective.
TRUE Both have sufficient supporting evidence regarding their efficiency. The quadrivalent vaccine includes cover against the non-cancerous skin wart strains No 6 and 11.
Young girls, not yet sexually active, are the ideal candidates for vaccination.
TRUE When sexually active, one may suggest that HPV infection may have already occurred. The vaccination should anyhow take place early in life (before the age of 15) regardless of sexual activity, because it is more effective then, stimulating better immune response.

Bartholin’s cyst – a cause for vulvar discomfort

Bartholin’s cyst – a cause for vulvar discomfort

Near the introitus (that is, the opening of the vagina, but we need to talk in proper medical terms, this is not a cosmopolitan blog…), there are two glands, one on each side, just behind the labia. They are called Bartholin glands, named after a Danish anatomist, Caspar Bartholin in the 17th century.

 

They are small, you cannot palpate them and they produce a thick secretion, in order to lubricate and protect the lining of the vagina. They were thought to be related to lubrication during sexual arousal but, alas, their contribution is minimal. The glandular fluid enters the vaginal epithelium through a narrow tube, the duct.

 

Occasionally, for unknown reasons, the duct will get blocked and the sticky fluid will accumulate within the gland and the gland will  become swollen. This is a bartholin cyst, and it affects 2% of women, mostly aged between 20 and 30. It may be asymptomatic, with just a local swelling and minor discomfort. If the cyst becomes infected, it then becomes an abscess, very tender indeed, the patient may find it difficult to walk and it needs urgent treatment.

 

It is not related to sexual intercourse and don’t blame your partner for transmitting the infection- there are many other reasons to blame your partner but not Bartholin issues.

It is equally not related to poor hygiene, tight underwear, sweating, swimming, the duct somehow decides to block itself and there is nothing you can do to prevent it from happening- frequent question when someone already suffered from one gland and wishes to avoid trouble from the other side in the future.

 

We tend to give a short course of antibiotic when a cyst appear, to prevent infection and this may delay the process but eventually things will get worse. The cyst will need to be drained and ideally a new duct should be surgically created. This procedure is called marsupialisation ( from Latinmarsūpium, from Ancient Greek μαρσίππιον (marsippion), diminutive of μάρσιπος (marsipos, pouch))– yes, blame the Greeks for everything…  This is a minor operation, it needs anaesthetic and it involves exteriorisation of the gland internal to the vaginal lining so that the fluid will readily be expelled in the future.

 

It is therefore a rather nasty situation but it is benign and will not affect your future sex life or fertility. Having said that, in older women (above the age of 40) we have the extremely rare bartholin gland cancer, so all labial swellings should be reviewed by a gynaecologist.

 

To summarise, when in pain, see your doctor and blame Caspar Bartholin …   

Polycystic ovaries- key points

Polycystic ovaries- key points

Key points

/ issued by the Royal College of Obstetricians & Gynaecologists, UK

  • Polycystic ovary syndrome (PCOS) is a condition where the ovaries contain more developing follicles than normal. It can affect the balance of your hormones.
  • Symptoms can include:
    • more body hair than is usual for you
    • irregular periods or no periods at all
    • being overweight
    • difficulty in getting pregnant
    • acne.
  • You may have a higher risk of long-term health problems such as heart problems or diabetes.
  • Diet and exercise can help reduce your risk of long-term health problems.

 

This information is intended for you if you have been told you have polycystic ovary syndrome.  It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Long-term consequences of polycystic ovary syndrome (published in May 2003).

It tells you:

  • about the long-term effects of PCOS on your health
  • about the recommendations the guideline makes on the best ways of reducing the risks of those long-term effects
  • how much we know about possible links between PCOS and certain health conditions.

It aims to help you and your healthcare team make the best decisions about your care. It is not meant to replace advice from a doctor or nurse about your own situation.

This information tells you about the recommendations the RCOG guideline makes. It does not tell you in detail about how PCOS is diagnosed or about treatments for the symptoms.

  • Some of the recommendations here may not apply to you. This could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor or with someone else in your healthcare team.

 What is polycystic ovary syndrome (PCOS)?

In a normal ovary, around five follicles (small sacs) develop each month, at the beginning of the menstrual cycle. These follicles contain eggs. Usually one follicle each month continues to develop until it releases an egg into the fallopian tube. This is known as ovulation.

If the egg is fertilised by sperm, it travels down to the womb, implants in the lining and a pregnancy begins. If the egg is not fertilised, the lining of the womb is shed at the end of the monthly cycle, when you have your period, and the egg is absorbed naturally back into your body.

Polycystic ovaries have at least twice as many developing follicles as normal ovaries.  However, many of these follicles do not mature to the point of releasing an egg (ovulation). Because they have more follicles than is usual, polycystic ovaries are slightly larger than normal ovaries.

The term polycystic is a bit misleading. Early researchers thought that they could see cysts (small fluid-filled sacs) on the ovaries. In fact, what they saw were enlarged follicles.

Around 20 out of every 100 women have polycystic ovaries. Most women with polycystic ovaries have no symptoms.

A syndrome is a collection of different signs and symptoms that are all part of the same underlying medical condition. Women with polycystic ovary syndrome (PCOS) rarely have all of the possible signs and symptoms. PCOS is therefore difficult to diagnose. The doctor will take account of your symptoms and will usually check your hormone levels (through a blood test) and your ovaries (through an ultrasound scan).

PCOS runs in families.

What could PCOS mean for me?

If you have polycystic ovary syndrome (PCOS), you may become aware of some or all of the following symptoms. You may:

  • have more body hair than is usual for you
  • have irregular periods or no periods at all
  • have difficulty in getting pregnant
  • be overweight
  • have acne.

These symptoms can vary from mild to severe. They can be caused by other conditions, too.

If you have PCOS symptoms, you have a greater risk of developing long-term health problems such as:

  • heart problems
  • diabetes
  • high blood pressure
  • cancer of the lining of the womb (known as endometrial cancer).

This information tells you about these long-term problems.

What can help reduce long-term health risks?

  • Following a balanced diet and taking regular, appropriate exercise are the main ways in which you can help yourself. They can help reduce the long-term health risks associated with PCOS.

 If you are overweight, losing weight will help you. If your periods are irregular or non-existent they may become more normal. Follow advice from your doctor or nurse on reducing your calorie intake and taking more exercise.

Even if you are not overweight, you should take care to keep your weight within the normal range for your height. Your doctor or nurse should give you more information on what you need to do.

To monitor your health, your doctor may offer you tests on the levels of cholesterol and certain fats (known as lipids) in your blood. These may be done regularly (usually once a year), especially if you are overweight and you have a family history of heart disease. They should be available either at your GP clinic or a hospital outpatient department. Your doctor or nurse can then advise you on what you can do to help reduce your cholesterol and lipid levels.

Women with PCOS are more likely than normal to develop a form of diabetes known as type 2 diabetes. One or two in every ten women with PCOS go on to develop this form of diabetes. It can be treated by diet and exercise, and sometimes also with tablets or insulin injections, depending on your circumstances.

If you are overweight and you have a family history of diabetes, you may be offered regular tests on the levels of sugar in your urine or the levels of glucose in your blood, to check for signs of type 2 diabetes. These tests may be done about once a year through your GP or at a hospital outpatient clinic.

If you have few periods or no periods at all, the lining (known as the endometrium) of your womb may be more likely to thicken. Having regular periods usually prevents this. If the endometrium thickens, it can sometimes lead to cancer. To reduce this risk, your doctor may offer you treatment with progestogen hormones to ensure that you have a period at least every three to four months.

How much do we know about the links between PCOS and other conditions?

 Insulin resistance and diabetes

Insulin is a hormone that regulates the amount of glucose (a form of sugar) in your blood. If the levels of glucose in your blood do not stay normal this leads to diabetes.

Some people need a lot of insulin in order to keep their blood glucose at the normal level. This is known as being insulin resistant. Some women with PCOS are insulin resistant and therefore more likely to develop diabetes.

Drugs known as ‘insulin sensitising agents’ (such as metformin) act by making the body more sensitive to insulin. These drugs can be used for short periods of time to help non-diabetic women who have PCOS (especially women who do not ovulate). There is not enough evidence to tell us how safe or effective they are for long-term use by people who do not have diabetes. More research is needed on this.

If you become pregnant when you have PCOS, and especially if you are very overweight, you may develop diabetes during your pregnancy. This is known as gestational diabetes. You should be tested for it early in your pregnancy. It usually goes away once your baby is born, but you may be more likely to develop type 2 diabetes later in life.

If you have diabetes while you are pregnant your doctor or midwife should refer you to a specialised obstetric diabetic service.

Heart disease

If you have diabetes and/or high blood pressure you may be more likely to develop heart disease in later life. However, there is no clear evidence that, just because you have PCOS, you are any more likely to die from heart disease than women who do not have PCOS.

Breast cancer

If you have PCOS and you have been through the menopause, evidence shows that your risk of developing breast cancer is the same as women who do not have PCOS.


Is there anything else I should know?

  • You have the right to be fully informed about your health care and to share in making decisions about it. Your healthcare team should respect and take your wishes into account.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Long-term consequences of polycystic ovary syndrome (published in May 2003). The guideline contains a full list of the sources of evidence we have used. You can find it online at: www.rcog.org.uk/guidelines.asp?PageID=106&GuidelineID=50

Clinical guidelines are intended to improve patient care. They are drawn up by teams of medical professionals and consumers’ representatives who look at the best research evidence there is about care for a particular condition or treatment. The guidelines make recommendations based on this evidence.

This information has been developed by the Patient Information Subgroup of the RCOG Guidelines and Audit Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It was reviewed before we published it by women from Leeds, Sheffield, London and elsewhere in the UK. The final version is the responsibility of the Guidelines and Audit Committee of the RCOG.

First period upon us…

Some delicate issues to address today, given that my 12 year old daughter recently had her menarche (all greek, men=menses, actually means month, arche=beginning), that is she began menstruating.

A period does not have to be heavy, nor painful. There is a myth, spread amongst older women that the uterus is a vile and dirty organ that needs to be thoroughly cleansed monthly, in order to remain functional. Heavy periods are therefore welcome, which is of course nonsense. The period blood consists of the lining of the uterus, the endometrium, along with blood originating from exposed vessels under the lining- whether you bleed more or less, the endometrium will anyway shed itself and a new cycle will commence, so women are better off when bleeding mildly.

The same applies for pain- it is true that ovulation (the egg production from the ovary) may make periods more painful (and contraceptive pills reduce the pain exactly by inhibiting ovulation). Painful periods may therefore suggest that ovulation takes place regularly. Still, pain may be dealt with without affecting ovulation and fertility.

Conclusion: when bleeding or suffering you may ask for help from the gynaecologist, you don’t have to go through puberty, studying and exams with those additional burdens.

Talking about ovulation: usually your initial periods may involve anovulatory cycles- meaning that you may have regular period, every month but your ovaries may not produce eggs. The same applies for a 49 year old woman: she may have monthly bleeds but she rarely ovulates- in her case because her ovaries are old and tired- in your case because they are still immature, not properly hormonally balanced yet.

This is why your first cycles may be irregular, heavy, with intermittent spotting, you name it. You get upset, mom gets worried, but the doctor yawns, yes it is absolutely normal.

And now, hot topics. Is it ok to have a relationship? Well, it’s not, and this is the doctor (not just the father speaking). You may be biologically mature to have sex but, come to that, you are also biologically mature to have children, raise them, get a job, pay taxes (well, it’s not funny, it happens in 3rd World countries). The obvious answer is you don’t want all that, you feel young and immature. Well the same applies to sex, it’s not just fun, it entails relationship, responsibilities, precautions and you have to share these with a boy of your age- and boys at 12-13-15 (trust me I ‘ve been there) mostly think about football.

Let’s get serious. Having talked to hundrends- probably thousands of girls, most of them told me that premature relationships were a disaster and things got much better after the age of 17. So, trust them, not medical textbooks- which by the way point out that teenage pregnancies are high risk situations and having an abortion at this age may affect your future fertility. There, I think that was scary enough.

Overall enjoy this milestone- boys do not have such a distinct and remarkable landmark to prove that they move towards manhood. Other than that, nothing much changes- friends and family are still the same, still there for you.

Alex. Kalogeropoulos

Summertime common complaints and issues to resolve

Admittedly boring issues from a strictly medical point of view, yet they can ruin your holidays if not taken care of.

1)   Thrush, yeast, that is candida albicans infection. For Latin speakers, candida means candid, benign, playful. It’s exactly that- you won’t get cancer or infertility because of it, but it may playfully and stubbornly give you itchiness, irritation, persistent discharge or even excruciating discomfort- a perfect combination for holidays, swimming and seasonal nocturnal activities.

What needs to be done- obviously prevention! Avoid tight nylon underware- traditional cotton please. Cover any antibiotic   treatment with a simultaneous prebiotic formulation – even one yogurt per day may do the trick. These formulations offer a load of healthy micro-organisms that normally inhabit the flora of the vagina, namely the lactobacillus, and that competes against candida.

Pre-empt: do not sit and wait to be visited by candida in a humid 3rd World country- Greece included…- and expect to understand the local Pharmacist’s instructions- keep a local cream in your luggage, as well as your Gynaecologist’s mobile number.

2)   Period within your holiday period. Yes, you may use tampons but you could easily manipulate your cycle ( approximately similar to husband manipulation). Seek advice from your doctor in advance, as last minute medication will not help.

3)   Urine infections- extremely common in summer for obvious reasons. Vital advice: do not take antibiotics the moment you get slight frequency- do not blindly take antibiotics fullstop. If you do take antibiotics please please take a full course of treatment- do not improvise and stop 24 hours later, when you feel slightly better. Incomplete treatment encourages the micro-organisms to develop resistance to the antibiotic and next time the same treatment will be useless. Drink plenty of fluids even though this will exacerbate you urinary frequency.

There’s apparently more, i.e. lost condoms, more serious infections, e.t.c. Do not despair and keep in mind that Gynaecologists, unlike most other professionals, are busy in summer too -delivering babies- and they will answer their mobile phone in August.

Dermoid cyst, or teratoma of the ovary

This is a rather common, benign cyst developing in the ovary. It is frequently seen in young women. It usually presents without any symptoms, as an incidental finding in routine ultrasoound. It is not uncommon to see two or three of them, frequently affecting both ovaries.

The picture may appear disturbing as the cyst contains sebum, hair, even teeth – actually the term teratoma originates from the greek word ‘teras’, that is monster, and our greek ladies are obviously alarmed when they hear that a monster develops within their reproductive organs. Different tissues are seen because the tumour originates from primordial embryonic cells, with the capacity to differentiate into various types of tissue.

Alarming though it may seem, these are benign in the vast majority of cases. We need to operate and remove when they grow bigger, thus affecting the blood supply and the function of the ovary, particularly if future fertility is an issue. Furthermore, sudden tumour enlargement or abnormal vascularity may point towards the extremely rare teratocarcinoma. It is therefore important to monitor regularly those cysts and remove them, if indicated.

Cancer of the ovary, aka the silent killer…

Ovarian cancer, aka the silent killer
Basic facts


  • It is truly a silent killer: the ovaries, deep inside the abdomen will not give you pain or vaginal bleeding, even when the cancer has spread.
  • When diagnosed, in 70% of cases the cancer has already spread  beyond the ovary.
  • Incidence peaks after menopause- exactly when many ladies strongly believe that they no longer need to visit a Gynaecologist.
  • Women have never heard of it. When I perform a vaginal scan and tell my patients that I want to look at the ovaries, many look slightly irritated- ok, doctor, get on with it, as if I am going to get pregnant and he looks at my ovaries to see if I ovulate… Women are alarmingly ignorant, as opposed to cervical or breast cancer.
  • Not very frequent: 1.5% life-time risk, but definitely lethal.
  • More common in ladies who have had many ovulatory cycles in the past- so, those who did not have as many (because they were pregnant, breastfeeding, or on the contraceptive pill) are protected. Yes, the use of contraceptive pill reduces the ovarian cancer risk by almost 50%.
  • Not really related to lifestyle, diet, sexual behaviour, smoking.
  • Family history of ovarian cancer and breast cancer increases your baseline risk.
  • Difficult to diagnose early- no pap smear for the ovaries! The most reliable method is frequent transvaginal ultrasound- to make sure that the postmenopausal ovaries look atrophic and inactive. We keep trying to develop blood tests, biochemical tumor markers that will become abnormal in the early course of the disease. One you have heard of, Ca-125, is quite useful, yet in many cases it becomes raised quite late. Furthermore, it may frequently be elevated due to benign causes, such as endometriosis.

HPV infection- a summary

HPV at a glance:

A very common STD- 1 in 2 women and men will be infected (life-time risk).

Most commonly transmitted through penetration, yet direct skin contact and oral sex may also transfer the virus.

May express itself as external skin lesions-genital warts.

In women it may cause internal- within the cervix- precancerous lesion- seen only through pap smear tests or colposcopy.

Internal lesions usually regress without intervention. If they persist and remain untreated, these  may develop into cervical cancer, but it usually takes 10 to 13 years for this to happen.

Genital warts may be the only visible sign of HPV infection, but they may not appear for weeks, months or even years after infection occurs.

Warts may be cauterised or treated with local applications.

If we have ‘HPV changes’ described in a smear report, don’t panic, one in three young women at some point will have the virus. In the vast majority of women, the virus will just linger for a few months, usually up to a year, and will then be eliminated, exactly like when we get rid of a flu virus.

We just do a colposcopy, to have a close look at the cervix under the microscope and confirm that the virus just ‘lingers’ but has not created a lesion deep in the cervix, and therefore is likely to persist.

There are no tablets or creams to kill the virus. We wait for it to go spontaneously and we stop smoking, as it is documented to help HPV survive long-term.

We don’t do contact tracing, blaming your ex, or warning him, the virus is far too common. It may be spread by non-sexual means, yet we don’t panic about our mother and sister and toilet seats. We just follow the basic hygiene rules at home.

If you have visible warts, we will cauterise them under local anaesthetic at the Practice, and, alas, they recur and we may need to repeat these treatments a few times.

Using a condom for 3 to 6 months following treatment for warts may help prevent reinfection.

If the virus persists in subsequent smear tests, it may eventually lead to pre-cancerous changes and cancer, this is usually a 10-12 year process. We will monitor with regular smear tests and colposcopies and when necessary, will remove the lesion with a cone biopsy, before it becomes cancerous.

The recently developed vaccine reduces the risk of cervical cancer up to 70%. It is important to vaccinate young girls aged 12-13.

Pregnancy & Childbirth- basic do’s and dont’s

Pregnancy and childbirth- vital do’s and dont’s

Pregnancy and childbirth is an amazing period of your life, with plenty of excitement and worries and eventually some unforgettable memories. We aim to provide careful monitoring and constant reassurance so that will be confident and relaxed to enjoy your pregnancy.

We count a total of 40 weeks, starting on the day that your last actual period began.
You obviously did not get pregnant on that day, but approximately 2 weeks later, upon ovulation, and the actual duration of the gestation is therefore 38 weeks. Still, we use your LMP (Last Menstrual Period) as a defining point, as cycle duration varies and it is frequently impossible for you to know exactly when you conceived.

Your first visit at the Practice is vital. Your period may be late and you are not certain what’s going on. We will confirm your pregnancy status and with pelvic ultrasound (which is absolutely safe) we will make certain that this is a healthy intrauterine pregnancy, thus ruling out a threatened miscarriage or an ectopic.
We will then sit down, take a deep breath and talk about the next 9 months, how your pregnancy will be monitored and exactly which investigations may be needed. We will discuss common pregnancy symptoms and worries, no matter how insignificant they may seem. You will leave the office relaxed, confident and jubilant.

We may need to repeat the scan to confirm that the pregnancy sac keeps growing and eventually the fetal heartbeat becomes obvious. I will also suggest some blood tests that will rule out infections such as rubella (german measles) and hepatitis. Some of those sound strange and offending, such as syphilis and HIV. Trust me, this is a universally accepted screening package in pregnancy and all those diseases, if promptly diagnosed and treated, can save your baby’s life.
An early visit to the Dentist will be advised. Your teeth and gums are sensitive in pregnancy and any kind of oral cavity infection can later be related to premature contractions and labour. Any dental work should therefore be carried out promptly, with the appropriate local anaesthetic. I would only wish to avoid a dental X-ray in pregnancy.

The first trimester, up to 12-13 weeks, can be rather difficult. Headaches, morning sickness and vomiting, swellings, mood swings, you name it. There is also a continuing risk of miscariage, gradually diminishing as your pregnancy progresses, and you might experience abdominal discomfort or even spotting. Your skin may well change while you’re pregnant. You might find that it becomes less dry or less oily, or that you get fewer spots, or the opposite could happen. Extra fluid in your face may smooth out any wrinkles, but it may also make you look a bit chubby. Quite early on, you will notice that the area around your nipples is darker and a brown line appears down the centre of your abdomen. You may get brown patches on your face too, especially if you’re in the sun. All these colour changes go away or fade after the baby is born. Stretch marks, may appear on your bump and your breasts from about three or four months. There’s no evidence that these can be prevented. They fade after the baby is born but never disappear.
We will discuss any complaints and exclude potential problems and complications.

The next milestone is the nuchal scan at 12-13 weeks. You will be gradually feeling better and this a good time to enjoy your baby on ultrasound, fully formed and playful and not that big yet. This is also an excellent opportunity to check the space behind the baby’s neck, the nuchal translucency. All babies have a small quantity of luis underneath the skin of the back of the neck. In Down syndrome babies this is found commonly increased. Unfortunately not all Down babies have increased fluid and, vice versa, not all babies with increased fluid have Down’s syndrome. We have therefore monitored several thousands of pregnancies in US and in the UK ten years ago. We checked the nuchal fluid, took into account the age of the mother and obviously the pregnancy outcome. These observations resulted in a screening test, an equation with all the above parameters. This test can pick up more than 90% of Down babies. We will check the nuchal translucency, ask for your age and your last period, and enter all the parameters in a computer software. The computer will alter your basic, age-related risk for Down syndrome, and give you an adjusted risk. If the final risk sounds good, (and we’ll have a long chat about acceptable risks), we may decide to avoid an amniocentesis, even when you are older than 35. An additional, independent parameter that will increase the sensitivity of the test is a hormone blood test (free BHCG and PAPP-A). When your blood result is ready, we shall modify the risk and give you the final result.

The next important scan is the anomaly scan, or b-level scan. This will take place at 22-23 weeks of gestation. It is a thorough scan, checking number of fingers, heart valves and other important details of the baby’s anatomy. A normal result is reassuring but bear in mind that some minor abnormalities may still be missed, even in expert hands.

From 14 weeks onwards, you will also probably feel much better, with plenty of energy to do things and appetite. Take it easy and keep an eye on your scales. You will be free to have a holiday as long as you do not stress yourself too much and avoid exposure to the sun. You will be able to swim and take sport activities. Sex will also be part of the agenda, unless advised otherwise.

We will have regular visits in our Practice, every four weeks, and more frequently should any problem arise. We will be checking the blood pressure, the urine and your weight and we will do regular scans to check the baby’s growth. I will be checking on you overall welll-being, including the psyhological aspect and see that your pregnancy progresses smoothly. Our midwife will be advising on breast preparation for lactation and nipple care.

At 28 weeks I will ask you to have a glucose tolerance test, in order to exclude gestational diabetes.

At 32 weeks a Doppler scan will reassure us that the placenta remains healthy and that the blood flow and the oxygen supply to the baby is adequate.

At 37-38 weeks, in addition to ultrasound, we will do a cardiotocogram (CTG), checking the baby’s heart rate variation in relation to uterine contractions. This is an additional reassuring test to check fetal well-being.

From 36 weeks onwards, we will be prepared for labour. Early labour signs include regular contractions and the rupture of membranes. If your waters go, it will be easy to tell, there is usually plenty of it and you will get soaked. You must immediately get going for the hospital. If you start having painful contractions, check how frequently they come and whether they are regular or not. Genuine labour pain, as opposed to Braxton-Hicks contractions, comes and goes at regular intervals, initially every 20-30 minutes, gradually getting more frequent. When not certain, you ring me or my midwife and we tell you what to do. Another early sign is the ‘show’, a mucous, thick, vaginal discharge, occasionally mixed with small amount of blood. This is the cervical ‘plug’ that kept the cervix tightly sealed throughout pregnancy and prevented micro-organisms from ascending into the cavity of the womb. A couple of days prior to onset of labour, this, having served its purpose, will pop out. It is a fairly accurate sign that labour is imminent, so don’t panic, don’t rush to the hospital, just have your things ready.

When the time comes, be it regular pain or the waters, you ring me or the midwife and we all meet in Labour Ward. We will remain with you throughout the whole labour and keep you informed and so that you remain confident and reassured.

Epidural anaesthesia is strongly recommended, but obviously you are the one to decide. An epidural will completely stop any painful sensation without making you drowsy. You will be alert, yet relaxed. You will not be stressed and you will be breathing better and that helps the oxygen supply to the baby. There are no significant recognised side-effects apart from a transient headache.
An epidural will not affect the labour outcome and will not increase the possibility for caesarean section.

I will guide through the stages of labour, aiming towards a straightforward vaginal delivery, and I am keen to persist and wait, as long as it is safe, in order to get there. However if any complication arises, or if the baby simply gets ‘stuck’ within the pelvis, we will be ready to proceed, with your consent, to a safe instrumental delivery or caesarean section. The Labour Ward at Iaso is perfectly organised and the staff are trained to assist in any kind of emergency. In the end of the day what we must have is a healthy mother and a healthy baby and I am keen to pre-empt problems and advocate safe, standard practice.

Once the baby is born, we will give you to hold and hug for as long as you like, early bonding between the two of you is essential. In the meantime, I will remove the placenta and may need to put a couple of stitches in the vagina. You will then be able to rest for a couple of hours in Labour Ward Recovery before you are transfered to your bed in the Ward.


Basic guidelines and do’s and dont’s for your pregnancy

Any medication use should be discussed with us, particularly during the 1st trimester. You may take paracetamol tablets (Depon, Panadol), up to 3 a day, if you have a headache or a flu, and Buscopan tablets for the occasional tummy ache, but other than that talk to us and double-check.

The only strict prohibition in pregnancy is smoking and if you do smoke we will advise to give it up promptly. Smoking has been related to high risk of miscarriage, prematurity, placental abruption, high blood pressure. Maternal smoking has also been incriminated for cot death in infancy.

You may have sexual intercourse throughout pregnacny, unless otherwise indicated. Always make certain that this is not painful or uncomfortable and you may want to try different, more comfortable positions We obstetricians tend to advise against it during the last 4 weeks of gestation, but even then there is no harm you can do, apart from initiating labour.

Try to keep away from stray cats and if you have a cat yourself, have someone else to collect its faeces. Avoid fresh salads if the greenery has not been thorougly cleaned.

Dring plenty of milk – at least two full glasses a day. You may opt for semi-skimmed milk, with less fat but same amount of calcium and vitamins. Make sure that your milk is pasteurised- avoid fresh goat milk from your village! Avoid evaporated milk – most of its vitamins have been affected.

Avoid nuts during pregnancy. Recent studies relate maternal consumption in pregnancy with subsequent allergy to nuts of the offspring.

You may use hair dye and nail polish, as this has not been found to have any detrimental effect whatsoever to your pregnancy.

You may drive your car up to the end of gestation, as long as there are no pregnancy complications. Always wear your seatbelt, with the the horizontal part underneath your belly and the transverse part crossing above it.

It is safe to work long hours in front of a computer screen, as it is established to be absolutely safe.

Recent evidence shows that consuming hot beverages or food from a plastic cup or container is harmful, as plastic, when hot, releases toxic chemicals within the cup. These toxins seem to significantly increase the miscarriage risk, as they are found in large concentrations in blood samples of women who had a miscarriage.

FOODS TO AVOID

• Soft cheese, such as Brie, Camembert, however, cottage, gruyere and feta cheeses are fine. Blue-veined cheeses, such as Danish Blue or Stilton should also be avoided.
• Unpasteurised goat’s, cow’s, or sheep milk. • Ready-prepared coleslaw. •Raw shellfish. •Raw eggs (in mayonnaise, mousses, cake-icing or cheesecake). •Paté (any type) •Raw or undercooked meat. •Liver (unacceptably high levels of vitamin A). •Peanuts or peanut butter (if there’s a family tendency to allergies).

 

Breastfeeding

Your own breastmilk is exactly the right food for your baby. There’s strong evidence that babies do best if they have nothing but breastmilk for about the first six months of life. This may be important if you have any diabetes or allergies in your family as the use of formula milk increases the risk of diabetes, asthma or eczema. Breastfeeding protects your baby from infections, including sickness and diarrhoea, ear infections and chest infections. For some infections this protection continues even after you stop breastfeeding. Exclusive breastfeeding – giving nothing except breastmilk – is more likely to reduce the risk or severity of allergies and provides the best protection. However, combining breastmilk with some formula still helps to reduce the risk of infections. Women who breastfeed have less risk of pre-menopausal breast cancer, ovarian cancer and broken bones due to osteoporosis in later life. If you choose to combine formula feeding alongside breastfeeding, you can increase your chances of maintaining a good milk supply if you only introduce formula once breastfeeding is well established. Your midwife can help you work out when – and how – to do this. But if you start to bottle feed from the beginning it can be very hard to change to breastfeeding. If you are undecided, it’s therefore best to start breastfeeding. Your baby will benefit from even a few feeds of colostrum – which is the first milk that your breasts produce, rich in antibodies and other substances that protect against illness and infections.

Paediatric concerns

If you worry about the ‘day-after’, when you go home with your baby, have a chat with our Paediatrician, Dr Amalia Michaelidou. She is a Consultant Neonatologist at Iaso Neonatal Unit and a Member of the Royal College of Paediatrics in London. She will guide you through the basic do’s and dont’s and reassure you.

Above all, don’t worry. Pregnancy is a normal process and all problems and complications are very rare. Enjoy your pregnancy and don’t listen to horror stories and scenarios. We will be monitoring your pregnancy closely and keep you well informed and reassured.

 

Dr Alexandros Kalogeropoulos
Member of the Royal College of Obstetricians & Gynaecologists, London

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