2.  DNA tumor virus  Associated with premalignant/malignant cervical disease and other cancers  Over 100 virus types with various manifestations (common warts, plantar warts, skin cancers, anal/genital warts)  Most common STD in the U.S.

3.  Squamous epithelium  Columnar epithelium  Meet at the squamocolumnar junction  Squamous metaplasia: process of change from columnar to squamous cellls  Transformation zone: area between old and new SCJ

4.  Papanicolaou (Pap) test - 1940s ◦ Cytological study for detecting cancer ◦ Worldwide, most widely used cancer screening method ◦ Can detect 95% of all cervical cancers and precancerous abnormalities ◦ Dramatically reduces cervical cancer death rates

5.  Begin at age 21  Every 2 years ages 21–29  Age 30+: if three consecutive negative results, screen every 3 years unless special risk factors ◦ HIV+ or DES or previous cervical cancer ◦ Immunosuppressed

6.  Collect cytology sample at mid-cycle  Teach patients: for 24–48 hours prior to testing ◦ Avoid intercourse ◦ Avoid vaginal medications ◦ Avoid douching  Document all communication re: Pap testing

7.  May discontinue after age 65–70 if three consecutive negative tests and no abnormal test findings in previous 10 years (ACS,USPSTF, ACOG)

8.  Cryosurgery  Laser ablation  Conization ◦ Cold knife ◦ Laser ◦ Loop electrosurgical excision procedure

9.  Produces no symptoms  Detected by DNA testing  Primary cause of cervical neoplasia  Persistent infection associated with cervical cancer

10.  Performed on vaginal/cervical cell sample collected for a Pap test  Assesses for one or more potentially cancer- causing HPV types  Recommended for women 30+ years old

11.  Abnormal Pap test results  External genital warts (1%) ◦ Condyloma acuminata, smooth papular warts, keratotic genital warts, flat warts  Cervical lesions (10%) ◦ Majority heal through natural immune response ◦ Some persist and progress to cervical cancer

12.  Cigarette smoking  Greater than three lifetime sex partners  New sex partner within past 12 months  Drug use within past 12 months  Intercourse while alcohol-impaired  Never married

13.  Healthy lifestyle ◦ Diet ◦ Avoid chemical/environmental hazards ◦ Sexual health awareness (e.g., condoms, monogamous relationship) ◦ Prophylactic HPV vaccination

14.  Gardasil – HPV types 6, 11, 16, 18 ◦ Also approved for use in males  Cervarix – HPV types 16, 18  Three intramuscular injections  Ideally administered before initiation of sexual activity  Avoid during pregnancy

15.  Squamous cell carcinoma (80%–90%)  Adenocarcinoma  Typically slow growing, begins as dysplasia (pre-cancerous condition) ◦ Detected by Pap test ◦ 100% curable

16.  HPV infection, immunosuppression  Cigarette smoking, alcoholism, poor nutrition  Co-infection with other STDs  Early onset of sexual activity, multiple sexual partners, early age first full-term pregnancy  Inadequate cervical screening  In utero DES exposure  Family history of cervical cancer

17.  When present, may include ◦ Continuous vaginal discharge ◦ Abnormal vaginal bleeding ◦ Heavier, longer menstrual periods ◦ Loss of appetite, weight loss ◦ Fatigue ◦ Pelvic pain, back pain, leg pain

18.  To determine spread, testing may include ◦ X-ray computed tomography ◦ Magnetic resonance imaging ◦ Positron emission tomography ◦ Cystoscopy ◦ Chest x-ray ◦ Intravenous pyelogram

19.  Dependent upon cancer stage  May include ◦ Surgery ◦ Radiation therapy ◦ Chemotherapy ◦ Biological therapy

20.  Used for metastatic or recurrent cancer  May be oral or intravenous  May be used in combination with other chemotherapeutic agents  May be combined with RT or surgery

21.  Common side effects ◦ Nausea and vomiting ◦ Change in appetite, oral lesions ◦ Vaginal sores ◦ Temporary hair loss ◦ Fatigue ◦ Anemia, bruising, skin rash, infection susceptibility ◦ Menstrual cycle changes, infertility ◦ Pain, swelling in legs and feet

22.  Used for metastatic cancer  Interferon most common therapy  Sometimes combined with chemotherapy  Usually administered on outpatient basis  Counsel about side effects: flu-like symptoms, rash, anorexia, bruising

23.  Education – all ages ◦ Cervical cancer screening ◦ Cervical cancer symptoms ◦ Relationship between HPV and cervical cancer ◦ Strategies to reduce HPV risk  Support for state, federal funding