What's Going On Down There?
Three years ago, a sexually transmitted infection was the last thing Jodi McKinney, a 39-year-old mother of five young kids in suburban New Jersey, was worried about. (Diaper rash, yes. Herpes, not so much.) So when her ob-gyn suggested she pair her annual Pap smear with a new HPV screening to test for the human papillomavirus strains most responsible for cervical cancer, it was the first time she'd heard of the test — or the virus. Still, she was game. "It was just another safeguard to verify that everything was okay," she says.
The Pap result was negative. But the HPV test was positive. McKinney was stunned. After a biopsy revealed atypical cells, she had a procedure called LEEP, which uses a low-voltage electrical wire to remove abnormal tissue. "If not for the HPV test, I wouldn't have gone back to the doctor for another year — and by that point I might have had full-blown cervical cancer," she says now. "The more I talk to friends, the more I hear, 'I wasn't offered that.' Women are not educated about this."
If you count yourself in that camp — or if skipping your annual is an annual ritual — it's time to get serious about your sexual health. Why? In case you haven't heard, sexually transmitted diseases and infections are on the rise; studies estimate up to 80 percent of us will have HPV at some point. Meanwhile, new vaccines, screenings and, in some cases, hormone therapy make it easier than ever to treat conditions early. With so many sexual health issues in the news, "we're fielding thousands of questions every month — more than ever before," says Elizabeth Battaglino Cahill, executive director of the National Women's Health Resource Center. Consider this your primer, through your childbearing years and beyond.
A Newer, Better Pap Screen
Introduced in the 1940s as a screening test for cervical cancer, the second most common cancer in women, the Pap test has successfully cut death rates from the disease in half in the past 35 years. But it's hardly perfect: In one study, the Pap correctly detected precancerous lesions just 55 percent of the time. Only annual testing increases the potential hit rate; with three successive annual Paps, about 90 percent of cervical cancer cases are detected.
Enter the HPV test. Approved by the FDA in 2003, the test has an accuracy rate of 95 percent. When paired with the Pap, the rate jumps to 100 percent. Right now, the HPV test is approved only as a co-test with the Pap or as a follow-up test when a Pap is inconclusive; but within the next two to five years, it might become the main screening tool, says Eduardo Franco, PhD, director of the division of cancer epidemiology at McGill University in Montreal.
Currently, the HPV test isn't recommended for primary cervical cancer screening in anyone under 30. That's because about 90 percent of younger women with HPV clear the virus with their own immune system before it causes problems, says Mark Einstein, MD, director of clinical research in the division of gynecologic oncology at the Albert Einstein College of Medicine in New York City. Once you're sexually active, your best line of defense is an annual Pap, which helps a doctor keep track of cervical-cell abnormalities.
But around age 30, the odds of HPV turning into cervical cancer increase, so request combining your Pap with an HPV test, which insurance should cover.
The Cervical Cancer Vaccine
The health community cheered in June 2006 when the FDA approved a vaccine that could eliminate HPV altogether. But there's a catch: Gardasil, which protects against the four HPV types that cause at least 70 percent of cervical cancer cases and 90 percent of genital warts cases, was approved for women under age 27 only. The theory was that older women were likely to have been exposed to the virus, rendering the vaccine less effective, says Eva Chalas, MD, chief of gynecologic oncology at Winthrop-University Hospital in Smithtown, New York. Then last year, Gardasil's maker, Merck, submitted new research to the FDA showing that the vaccine -- which can also ward off some vaginal, vulvar, and oral cancers — provides protection for 91 percent of women up to age 45. Revised FDA approval is pending. (GlaxoSmithKline's similar vaccine, Cervarix, which at press time was awaiting approval for use in the U.S., is already widely available in 49 countries.)
Should you get the vaccine? If you're under 27, definitely, according to the Centers for Disease Control and Prevention. (Your insurance will likely pay for it.) Women 27 and older should talk to their doctors about whether their sexual history makes them good candidates for the series of three shots, which costs $500 to $800. For each sexual partner she's had, a woman has a 5 to 10 percent increased chance that she's been exposed to one of the four HPV types covered by the vaccine. Previous exposure leading to an infection means Gardasil "won't do anything but give her a pain in the arm," says Dr. Einstein.
Because researchers are still studying the vaccine, no one knows how long immunity lasts, so don't think of it as a license to slack off on using protection or to skip your ob-gyn visits.
New STD Scares
More than one million cases of chlamydia, which can cause pelvic inflammatory disease (PID) and infertility, were reported in the U.S. last year — the most ever for an STD. Rates for gonorrhea — another PID trigger — increased for the second year in a row in 2006. Syphilis, though still uncommon, became more widespread among women last year, while genital herpes is expected to affect half of all women by 2025; both conditions can harm fetal health if left untreated in pregnancy. Newly discovered STDs (such as M. genitalium, a bacterium that can lead to PID and inflammation of the cervix and urethra) now affect an estimated 70,000 women ages 20 and 24. How to explain the spread of so many STDs? While it's hard to pinpoint a single cause, the expansion of sophisticated screening tests along with an underfunding of prevention programs could play a role.
Because most STDs have no noticeable signs, and fewer than one in three physicians routinely screens patients for STDs, you could have one of these conditions and not know it. "We hear about a lot of asymptomatic young women who don't find out they're infected until they're 35 and can't get pregnant," says Lynn Barclay, president and CEO of the nonprofit American Social Health Association.
If you've never been tested for an STD or you've had a new partner since your last tests, talk to your doctor about the smartest screenings for you (most are covered by insurance). The CDC now recommends that all sexually active women under age 26 — and any woman who's had sex with multiple or new people in the last year — get an annual urine test for chlamydia. If you're pregnant or thinking about getting pregnant, you should also request a blood test to screen for HIV, hepatitis B, and syphilis. Some experts say that screening for herpes simplex virus 2 is a good idea as well. Finally, keep up with your annual pelvic exams. They allow your doctor to look for signs of an infection, such as inflammation that could indicate M. genitalium.
Hormone Therapy: Help Is on the Way
Sometime in your 40s, your hormones begin to fluctuate, often resulting in hot flashes, night sweats, vaginal dryness, and wacky menstrual cycles (not to mention moods). One of the most effective treatments to relieve these symptoms: hormone therapy (HT). Most doctors stopped prescribing it in 2000 when a highly publicized study showed it raised a woman's risk for breast cancer, heart disease, and stroke, but it's now being widely used again. That's because a reanalysis of the study's data found that HT doesn't increase your risk if it's been less than 10 years since the onset of menopause or if you're in your 50s or younger.
Some alternative therapies, such as acupuncture, and off-label treatments, including use of the anticonvulsant drug gabapentin, may help too, new research suggests. But "the gold standard for women with moderate to severe menopause symptoms is still hormone therapy, because it can reduce hot flashes up to 90 percent of the time," says JoAnn Pinkerton, MD, medical director of the Midlife Center for the University of Virginia Health System in Charlottesville.
If you have more than seven hot flashes a day, interrupted sleep, fatigue, or irritability, consider HT. Your doctor can assess your risk for breast cancer and other health issues and "prescribe the lowest dose for the shortest period of time," says Dr. Pinkerton. It's also smart to request blood tests and ultrasounds to ensure that what you assume to be your natural "change of life" (such as a belly bulge) isn't something else entirely. Thyroid disease, fibroids, certain cancers — even pregnancy — can be misdiagnosed as menopause.