Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Cervical Cancer: Screening and Prevention
Listen to this replay of "Cervical Cancer Awareness" from Season 2 with guest Dr. Sharon Sutherland from the Cleveland Clinic. Speaking of Women's Health Podcast host Holly Thacker, MD focuses her questions on raising awareness about cervical cancer and the importance of regular screenings to prevent it.
January is Cervical Cancer Awareness month, so there's no better time to hear about how you can prevent cervical cancer with regular screenings.
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Welcome to the Speaking of Women's Health podcast. I'm your guest host for this episode, leigh Klecker. I'm the producer of the Speaking of Women's Health podcast and I'm back in the Sunflower House for a somewhat new episode. In season two, our wonderful executive director and host, dr Holly Thacker, interviewed Dr Sharon Sutherland all about cervical cancer. As January is Cervical Cancer Awareness Month, dr Sutherland is the director of the Center for Prevention of Cervical Cancer at the Cleveland Clinic, of the Center for Prevention of Cervical Cancer at the Cleveland Clinic, and cervical cancer prevention is so important and a message that we want to continue sharing this January in season three. But before we replay that episode, I want to share a few pieces of information on cervical cancer, some new and some just some friendly reminders. So Dr Thacker again, our brilliant Speaking of Women's Health podcast host and executive director of Speaking of Women's Health. She recommends that women, even if they are told they can go five years between their PAPs, that many times insurance covers it three years and people are busy and five years can turn into a longer time period and even if you're not getting a PAP smear of the cervix, one still needs to get regular gynecologic exams because too many women can fall through the cracks, and this is a, by and large, preventable cancer death. And the latest statistic on cervical cancer is about 13,820 new cases of invasive cervical cancer will be diagnosed this year and about 4,360 women will die from cervical cancer. It is the most frequently diagnosed cancer in women between the ages of 35 and 44, with the average age being 50. And many older women. They don't realize that they are still at risk of developing cervical cancer as they age, and more than 20% of cervical cancers are found in women over age 65. However, these cancers rarely occur in women who have been getting regular tests to screen for cervical cancer before they were 65, which is why cervical cancer screening is so important and the message that we want to relay in this episode.
Speaker 1:So back in May of 2024, the Food and Drug Administration expanded the approvals of two tests that detect cancer-causing types of the human papillomavirus, or HPV, in the cervix, and both tests they're used as part of screening for cervical cancer. So under these expanded approvals, people can now be offered the option to collect a vaginal sample themselves for HPV testing if they cannot have or do not want to have a pelvic exam. However, the collection, which involves a swab or a brush. It must be done in a healthcare setting. That would be a primary care office, urgent care, pharmacy, mobile clinic. And it starts for women beginning at age 30. And it starts for women beginning at age 30. So the tests included in the approvals are OnClarity HPV and that's made by Becton, dickinson and Company and Cobuz HPV.
Speaker 1:So until now, screening for cervical cancer in the US has required a sample of cells collected from the cervix during a pelvic exam performed by a healthcare professional.
Speaker 1:So that would be your physician, your nurse practitioner, a physician assistant. But the availability of the self-collection option in healthcare settings should help widen access to cervical cancer screening. So increased access to HPV testing is a particular need for certain populations among which rates of cervical cancer screening continue to be low, like healthcare deserts across the country, where people still don't have access to a regular healthcare clinician. And access isn't the only barrier to cervical cancer screening. People may have personal preferences, be it religious or cultural beliefs, maybe a history of trauma or disabilities or medical conditions that would prevent them from getting a pelvic exam performed by a healthcare clinician, and many clinicians they believe that making this home-based sample collection an option will hopefully widen access to screening even further in the future.
Speaker 1:The gold standard for cervical cancer screening is CO testing, with both a HPV and a pap test by a doctor or advanced practice provider, but the self-HPV testing which is still being studied is better than not doing any screening at all, so this is a really good new option for those who would qualify. I want to thank you for listening to this quick update on cervical cancer screening, and up next is the cervical cancer awareness podcast episode with Dr Sutherland and Dr Thacker from season two, and I hope you enjoy listening to it, either for the first time or again. And thanks for joining me in the Sunflower House and I'll see you next time.
Speaker 2:Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I'm back in the Sunflower House for a brand new episode of our Speaking of Women's Health. And I'm back in the Sunflower House for a brand new episode of our Speaking of Women's Health podcast. And this is our second season and it's January, which is Cervical Cancer Awareness Month, and I started off the New Year's season talking about staying healthy and sticking to health goals and lots of fun natural beauty hacks, and I promised the audience I would tell you if I used any of the beauty hacks. And I did use that apple cider vinegar on my nails. It did help dehydrate them for a good manicure. So go back and listen to that first one of the year if you missed it. But even though we like fun things as women and we care about how we look and how we feel and I do have an upcoming podcast more on skincare and hair because I know those are popular topics we're not going to be around to enjoy those fun feminine things if we don't take care of ourselves. And we're going to talk about something very serious, as serious as cancer and one of the most exciting preventive tests that came down in the field of medicine is the pap smear, and cervical cancer screening has been around so long and some of the guidelines have changed. It's kind of gotten complicated for physicians so you can imagine what it's like for the average woman. Guidelines have changed. It's kind of gotten complicated for physicians so you can imagine what it's like for the average woman and I think that that's kind of fallen off a lot of patients and women's important concerns Very much different than it was 20 or 30 years ago when I started in the field. And women specifically they wanted their yearly exam and their PAP and their pelvic. And women specifically they wanted their yearly exam and their pap and their pelvic.
Speaker 2:So it is my great pleasure to invite our guest, dr Sharon Sutherland, a partner, a friend, a colleague. She's a staff physician at the Cleveland Clinic for over 20 years, even though she only looks 20. And she was trained in OBGYN and she's a surgeon. She has a very calm, measured, unflappable, focused approach and that's a wonderful constellation of characteristics that you want in a physician and surgeon. And she's focused her career, most recently after delivering, you know, I'm sure, thousands of babies, she's now really focused on patient care quality cervical cancer screening and ultrasound pelvic ultrasound and we hope to get into some of these topics. She does see patients at the main campus, and she also spends some time in the Center for Specialized Women's Health, where we love to see her, and she trains some of our Specialized Women's Health fellows.
Speaker 2:Her main clinical focus right now, though, is on diagnosis and treatment of pre-cancers of the cervix as well as abnormal bleeding, and those are two areas that, in midlife women's health even though they're important before and after really are big focuses, and she has been named the director for the Center for the Prevention of Cervical Cancer, which is a group of 14 specialists who are driving excellence in care and treatment of patients with precancerous cervical lesions, because you certainly want to deal with those before they turn into cancer. She's also taken on another big role. You know she's the typical multitasking, high-energy woman. She is now in charge of gynecologic ultrasound, and she is the director of gynecologic imaging for OBGYN Institute, and I feel kind of a kinship because neither one of us are radiologists, but just like I read bone densities I'm not a radiologist, but that's a radiology reading imaging test I really feel like the clinical background helps me be a better radiologist with bone health, and I imagine she may have some comments about that in terms of being a gynecologist and a radiologist in terms of ultrasound in the pelvis.
Speaker 2:She completed medical school and residency at Ohio State and a master's of public health at Columbia University, and she and her husband are big Cleveland fans, cleveland Browns fans, osu fans and we won't talk about the recent football championship. And there's one. Oh my goodness, her lecture that she gave to our entire Institute on cervical cancer was so good and I was so embarrassed because I was getting out of the shower and I had a towel on my head and accidentally turned on the Zoom camera. Oh my goodness, all you could see was my towel and, oh, I was like so embarrassed. So sometimes it's good to keep the camera off, but it's great that we have the camera on. So welcome, dr Sutherland.
Speaker 3:Thank you so much, Dr Thacker.
Speaker 2:This is a pleasure and this is such an important topic, tell us about cervical cancer. It seems like we've made so many strides but now it feels like to me that we're backtracking and we are still seeing women in 2024 with cervical cancer invasive, that they may die from.
Speaker 3:Well, people don't realize, but 100 years ago cervical cancer was one of the number one causes of death of women, especially in their early life, between the ages of 20 and 40. In fact, my own great-grandmother died of cervical cancer in her 40s, so it was a very, very common disease. We did have development of the PAP test, as you mentioned, and then more recently testing for high-risk HPV. So now it's down as far as the list of cervical, you know, as far as cancers for women, it's not at the head of the pack anymore.
Speaker 2:but we definitely have opportunity. My mother's mother died of a gynecologic cancer which they said was cervical. So it was either cervical potentially I mean, I don't have the pathology and she was in her 40s and it was devastating. And I just think that a lot of younger women and just busy women, if they don't have that personal experience, they're just thinking about breast cancer, maybe they're thinking about ovarian cancer. If they have abnormal bleeding, they worry about uterine cancer. But cervical cancer really we should be ahead of and there really shouldn't be hardly anyone, any woman, dying of cervical cancer, right? Because what's the cure rate if you find it really early?
Speaker 3:Yeah, that's absolutely true. As far as our current rates, we have about 14,000 new cases of cervical cancer every year in the US. When we think about the average age, average age is 50. We see some people as young as in the early 20s to mid-20s, and then we're seeing an increase in women as they get older, and part of it has to do with the reduction in cervical cancer screening in women over 65.
Speaker 2:And you know that the alert on our medical record goes away at 65, and we can turn that back on. But I have a lot of women who say, oh well, I was told I'm over 65. I don't need that anymore. Oh, I don't have a cervix so I don't need exams. The gynecologist told me not to come back and I can understand why. Maybe you don't need to see a busy surgical cancer doctor or a gynecologist that's specializing in things. But we have a whole cadre of very well-trained women's health nurse practitioners for annual exams or at least every two-year exams. So tell us why are you more than just a cervix and what's involved and what's the difference between exams and PAPs and HPVs, et cetera. We'll be back after a quick break.
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Speaker 3:So, just in general, when we talk about cure rate, like you mentioned, it's probably one of the only cancers that we can truly prevent. So if all of our women were getting the proper screening with the PAP and the HPV, based on their risk factors, at the right time, we would really potentially see zero cervical cancers. If we do diagnose them early, the cure rate is very high greater than 90%. So it's the kind of thing that we don't want to be fearful of. For some people, they fear getting a pap because they're worried what if it's abnormal? What if I have to do something to follow up? But it's exactly the reverse we should be fearful of what happens if I don't get a pap.
Speaker 2:Absolutely, absolutely. And the other trend I've seen is busy physicians and busy APPs have so much on their plate and that's one reason I encourage women to make more appointments rather than less. It's easier to cancel appointments and to come focused with things and not expect, you know, 10 problems and a preventive visit to all be done at once. But if they have a normal PAP and a negative HPV, a lot of women are told not to come back for five years and women aren't putting that in their calendars necessarily, and some women, five years is not appropriate. We have a lot of transplant patients, people who are immunocompromised HIV. Do you want to talk about some of those special categories? I think, minority women, women that maybe are disadvantaged and haven't had regular health screenings? If you can, comment on those special groups?
Speaker 3:Yeah, so one of the areas that we're looking at is, just like you mentioned, trying to look at that patient's individual risk. Women who are HIV positive, I think, have about four times the risk of developing cervical cancer. Same with transplant, whether it's a bone marrow transplant or a solid organ transplant. So those patients go through screening prior to getting transplant, but then it's very important every single year, as long as they're healthy enough, to have a Pap and HPV test. The other evolving area are a lot of these immunosuppressive drugs. They're really improving quality of life for people with colitis, maybe with severe psoriasis, things like arthritis. However, they carry with them a major risk of immunosuppression and, in this case, risk of cervical cancer. So we recommend that our physicians look through that list in our APPs of their meds, because sometimes they're relatively healthy but they're on this medication that flags that, hey, this gal should have a pap every year and when cervical cancer is not diagnosed early.
Speaker 2:tell us about what some of the symptoms and some of the problems that women can deal with. I've seen some young women really suffering with horrible complications.
Speaker 3:So when we think about the cancer, it typically develops at the tip of the cervix, and so that's where, in the very early stages, it can be prevented or cured with a minor surgery to the cervix In the first stage. If we catch it early enough, sometimes we can do a hysterectomy and completely remove the tumor. This is the type of tumor that spreads locally, so rather than the cells going all through your body, usually the first thing that'll happen is it'll invade into the upper vagina, into the bladder, into the rectum, into the pelvic bones. So it's a very destructive tumor. Women will present with pelvic pain, they'll present with abnormal bleeding, and the treatments at that point require chemotherapy and radiation. Sadly, only two out of three who are diagnosed with cervical cancer will survive five years, and the main reason is that more than half of our cervical cancers are diagnosed when they're already beyond the cervix.
Speaker 2:Yeah, and that really just shouldn't be the case. My niece, who's in college? She's 18. She's at the University of Alabama, roll Tide. When I saw her at the holidays she asked me Aunt Holly, when should I get my first pap smear? I went to the health center and they said I don't need one. But I just want to know. I want to stay healthy.
Speaker 3:So when we think about screening there are different guidelines. In some places they recommend starting at 25, but unfortunately we know that's too late for some patients. So in general at the Cleveland Clinic we recommend starting at the age of 21, doing a PAP every two to three years up until the age of 30. And then at the age of 30, adding HPV screening along with the pap. And for most women that can be in that four to five year range. But for those higher risk women we need to be doing those tests more often.
Speaker 2:Well, I know our nurse practitioner, dana Leslie, who I've had on this podcast and I plan to have again this season who I personally see for my gynecologic exams and PAPs. She many times will do it every three to three and a half years because if she's seeing the person and then they don't come back and so too many people just get lost to follow up and you know it's hard to completely know if between now and the next time you see a person, if they're going to be put on rheumatoid arthritis medicines or their nutritional status is going to go down or you know something else is going on. And a lot of women I find don't always even keep records of their last pap and HPV and so or they don't know what they had done to their cervix, like oh, it was abnormal, but then it's okay. Can you talk a little bit about colposcopy, that paps are really not diagnostic and you need to do colposcopy if you're not sure? And then what some of the surgical procedures are if the PAP is abnormal?
Speaker 3:So the colposcopy is one of the early advances in cervical cancer screening. First we had the PAP and at that time the PAP was really just to diagnose the actual cancers. But then they started to realize maybe there are some changes in the cells that can diagnose it early. So we have protocols that we follow and, based on the PAP profile and the rate of high-risk HPV for that particular patient, we all do a colposcopy. That is like a PAP. We look at the cervix with a microscope, we apply different medicines to the cervix. We look at the cervix with a microscope, we apply different medicines to the cervix and then any areas that look like they could be precancerous we take tiny pinch biopsies.
Speaker 3:A lot of women are fearful of pain but often feel very little. I relate it to somebody tugging your hair. All of us have had a little hair pull at the beautician and we're good with that. So you know it's the type of thing that the colposcopy for most women is not severely painful. We will see an upgrade of results. So, for example, some patients will present with a low-grade pap but then have about a 15 to 20 percent chance that they actually have a higher-grade lesion that the pap missed. So that's why the colposcopy is so important. Abnormal paps don't hurt us, and being positive for high-risk HPV doesn't hurt us. What we're really looking for is that high-grade pre-cancer, because that is the trigger to treat.
Speaker 2:And there's no special preparation that a woman needs to do for colposcopy. If she's having a heavy period, does she have to reschedule? Can she just come into the office like for a pap smear that takes just a little bit longer and then plan to go back to work? We'll be back after a quick break.
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Speaker 3:For most women they don't need any preparation. In general, if you're having light bleeding, like at the beginning or the end of the period, it doesn't interfere. But if you are on one of those heavy flow days where you're changing protection every couple hours, we would recommend that you reschedule, Although sometimes cervix cancers present with abnormal bleeding. So if we have patients that are having abnormal bleeding, it's very important that we actually examine the cervix, because sometimes we find that the cervix is actually the problem From the standpoint of other preparation. As we get older and our hormone levels drop, sometimes the cervix will become stenotic. What that means is I relate it to like a flower that is going in reverse. So if we think of our cervix like a flower that blooms, it blooms when we have hormones and then it goes back into the bud stage and closes up very tightly in menopause. So sometimes we'll give medicines to soften the cervix and make it more likely that we can get adequate samples.
Speaker 2:Yeah, that is so important. I usually will give vaginal DHEA because it's not estrogen. So even if there is something wrong inside the uterus that's estrogen sensitive, it's not going to hurt. And then the cytotec or misoprostol, which we use to prevent stomach acids, helps to dilate the cervix. I always joke you could drive a truck through my cervix. I had three big boys, which made it very easy when I've had to have hysteroscopies or procedures to look up inside of the uterus, which I will want you to talk about the procedure of office hysteroscopy, which a lot of gynecologists don't necessarily do, but you do and you have that expertise.
Speaker 2:And you have been listening to the Speaking of Women's Health podcast. I'm your host, Dr Holly Thacker, and we are talking to gynecologist surgeon and cervical cancer expert, Dr Sharon Sutherland. So you were talking about how bleeding can be a sign of cervical cancer, and that's one thing I talk to all of our trainees about. A lot of times they'll just order a pelvic ultrasound, which is very important and may be helpful for other reasons, but I'm like you need to repeat the pap. I don't care that their pap was normal three years ago. If they're having abnormal bleeding, it's a diagnostic pap. So talk to us about screening paps, about this trend of some doctors only going with HPV, which I'm certainly not for. I think you want the cells as well as that, Because I've seen women that don't have HPV-related cervical cancer, some with like gastric mucosa types, and I don't know if there's some genetic predispositions, potentially, even though most of it is HPV.
Speaker 3:So you're absolutely right. When we look at the totality of cancers, 5% will actually test negative for HPV. In fact, sometimes I have found exactly that I've diagnosed the cancer. The pap will show invasive cervical cancer, but the HPV test would be negative. This is the concern about actually moving to 100% HPV testing. In other words, that would require all women to do an HPV test first and then to return for a PAP if the HPV was abnormal. I think the biggest concern is that it's hard enough for women just to come for the PAP, let alone two visits.
Speaker 3:Yes, hpv is also very, very common. We think about 80% of women are exposed by the time they're 50. So you know who knows what the future holds. There are some exciting research areas now. For example, women doing a home swab for HPV. So when we have groups of women who sometimes find it very difficult to get into medical care sometimes it's in a rural area, sometimes they may have a hard time with their work schedules, that type of thing that would unleash that ability to maybe improve screening for those women. But they would still have to be activated to come in and get the follow-up testing.
Speaker 2:And certainly we want to take away any kind of stigma about having HPV, because if you're sexually active, which most people have been in their life, that's how we have to reproduce our species. You can have one sexual partner and have HPV, so it's sexually associated, but it's not necessarily like we consider a sexually transmitted infection per se. We just assume that most everyone has it, and I do think, though, that women need to understand that. Having multiple sexual partners, smoking cigarettes, bad nutrition, not eating enough fruits and vegetables and some of the anti-cancer DIM substances having low vitamin Ds which you know, like almost all my patients in Northeast Ohio have I wonder if you have comments, other comments in that regard comments.
Speaker 3:Other comments in that regard. I think you're very on spot there that HPV in a healthy patient will sometimes just cause a temporary infection. That patient may have a temporary slight change in their pap, but the natural history for most women is that their body will overcome it, the HPV will go dormant and their PAPs will go back to normal. Now we have to remember that sometimes later in life some new insult comes. So, for example, now we have breast cancer, we're getting chemotherapy for breast cancer that sometimes can wake up that HPV virus that went dormant years ago. From the standpoint of what we can do, the best thing, like you mentioned, is good nutrition. I think the other thing that a lot of women cheat on is sleep. Women do not get enough sleep and that's so important, you know, to our healing. So all those things you mentioned, I think are also, you know, very important.
Speaker 2:And HPV is everywhere. There's all different types. Some types 16 and 18 are worse than others. I have had women who have normal PAPs but they have persistent positive HPV and I really like your service that you have that we can put in an abnormal PAP consult to see if that patient should go on for colposcopy, Because I know I would want the next step to take a look at the cervix with colposcopy if I had persistent HPV, since we know that is such a significant risk for cervical cancer, even though you can have it and not have cancer.
Speaker 3:And that's where we're very lucky in GYN that we do have PAPs, so that's very helpful when we think about the prevention of cervical cancer. Also, for some women they need vaginal PAPs. So they've had a hysterectomy but perhaps they had a high-grade precancerous lesion or they have a history transplant or some other risk factor. So colposcopy and biopsying of the vagina can help us prevent vaginal cancer. It's treated with laser vaporization, so to treat vaginal cancer we kind of burn away just a superficial layer of the vaginal wall versus the cervix, where we do a surgery to remove part of the cervix.
Speaker 3:Hpv, though, is implicated in many other cancers, and the research is not nearly as mature as it is in gynecology. The next rising area is an anal cancer. We're seeing a rise in anal cancer, especially in women who have had a high-grade dysplasia of the cervix. So if you've had that situation, you might talk to your doctor about it. We can actually do anal PAPs and anoscopy, where we look at the anal area with a microscope and do biopsies, and then, sadly, the most common HPVV related cancer now is oropharyngeal, so it's now overtaken the GYN cancers.
Speaker 3:We don't have a pap test for the throat, we don't have an HPV test for the throat and unfortunately they aren't mature enough to be able to diagnose this as a precancerous lesion. So more to come. You know there's a lot of research happening in those areas.
Speaker 2:That's fascinating, I certainly. It's one reason I ask all my patients have you seen the dentist? You needed a good oral exam, teeth exam and oral exam twice a year. And I encourage everyone to not use alcohol mouthwash, because HPV and alcohol, even if you're not swallowing it or drinking it, if you're just exposing your mucosa to it every day sometimes there's lots of different cofactors with cancer and there may be some breast cancers too that could be potentially HPV related. My son Stetson, who's been mentioned lots of times on this podcast and is in season two as well, lots of times on this podcast and it's going to be a is in season two as well.
Speaker 2:The geneticist.
Speaker 2:He developed terrible plantar warts, which is from a different, you know type of HPV virus and you know most people have warts on their fingers or their feet, and he needed extensive scraping of his feet and I would do that every night like I'd be in, like my pajamas, and then I ended up developing a breast papilloma that needed surgery and I said, oh, it's benign, why do I need surgery?
Speaker 2:Well, one in four times it can turn to cancer. And the breast surgeon said this could be HPV related and I thought, oh my God, I spent so much time scraping, scraping and probably being exposed to that strain of HPV every night trying to fix his feet. Luckily, he improved his nutrition and sleep. Sleep was really bad for him in high school and he cleared it up, thank goodness. But I thought that was really fascinating and there's so many things in the environment that we're naturally exposed to, as well as nutritional factors and genetic factors, that can all coalesce. So tell us a little bit about hysteroscopy, preparing for that, why that's been such a huge, huge advance, at least in terms of taking care of midlife women's health.
Speaker 3:So abnormal bleeding at midlife is very, very common. For most women it is probably hormone related and there's not any kind of pathology. Back 30 years ago if a woman had abnormal bleeding and went to the gynecologist, the doctor would say well, you're done having children, let's do a hysterectomy. So if you look at your own family tree, a lot of women will have gone through hysterectomy. But now rate of hysterectomy is far lower. The reason is because we have ways to do minimally invasive procedures to diagnose problems and treat them.
Speaker 3:So when we think about hysteroscopy, what that is is where we put a camera through the cervix, we instill saline and then what that'll do is expand the cavity. We look on the video screen and we can literally look directly at the lining of the uterus. For some women it's very cool because you can see where your fallopian tubes come out, where you're. When you got pregnant, that little embryo floated right down that tube and and stuck you know before your, your baby, before you even knew that you were pregnant. But sometimes we'll find that there are polyps, Sometimes there can be scar tissue, there can be a regular thickening, sometimes due to hormonal imbalance. That could be precancerous, and sometimes not very often, but sometimes we'll find a woman has an endometrial cancer.
Speaker 2:Yeah, and so anytime someone is over 40 and they have abnormal bleeding we have to evaluate it. If you haven't been, I mean, what my general rule of thumb is unless they're like super high risk or previously had cancer or Lynch syndrome or some genetic predisposition is that if you've been evaluated in the last year we'll maybe readjust your hormones and check. But if it's been more than a year and a lot of clinicians are just ordering ultrasounds and if the lining is thin, they're not necessarily pursuing tissue diagnosis. But I think sometimes you can miss some cases.
Speaker 3:I think that's true especially in older women. There are certain subtypes of endometrial cancer that are less common. Unfortunately, they have a worse prognosis. In other words they're more aggressive. So clear cell, serous type of cancer. So in general I recommend biopsy for everybody 45 and over who has either bleeding in between periods, very heavy periods, or in general any woman with postmenopausal bleeding. It's not normal.
Speaker 3:Once we're in menopause, we're not supposed to bleed, so something is going on and the biopsy can be a way to sample that lining, either reassure us that there isn't a cancer or, if it's there, to find it early so we can treat it.
Speaker 2:And some women who have bleeding in their late fifties and they say, oh, it's my regular period. We do a biopsy and it's secretory and they're still ovulating. But you don't necessarily know that. And there are some postmenopausal women, of course, that I prescribe and we prescribe hormone therapy to that we cycle so that we know when they bleed, because unfortunately the uterus is made to bleed.
Speaker 2:But I think if the ultrasound and the biopsy aren't revealing, I think the next step of looking in the office with that lighted camera three millimeters, you know doesn't take too much time for most women, unless women to be strong and be healthy and be in charge. I did want to touch a bit about trying to reach out, because you've done so much for the community, for rural women, for inner cities, for disadvantaged women, and rates of cervical cancer in certain groups, including black women, is increasing and I know one of our fellows who we've also had on this podcast, Dr Madeline Cohn, is very interested in doing some quality improvement and population research and looking at different characteristics. So I wondered if you could comment about some of your outreach activities and why that's important and different populations that might not be getting good gynecologic medical care regularly that they need.
Speaker 3:So that really brings up a good point. Sometimes it is around access, Sometimes it's really around patient activation. So one example is HPV vaccination. Many people know that that can cut children's rates of developing cervical cancer by 90%. So if you have young people in your life, either male or female, to recommend, you know, talk maybe with their parents to say you know, this is a vaccine that's really proven to help reduce these rates of severe dysplasia of the cervix.
Speaker 2:And venereal warts too, depending on which of the vaccines that you get.
Speaker 3:Oh, that's so true. And these other cancers, for example, anal dysplasia and the oropharyngeal cancers. There's probably going to be information that says you know that the HPV vaccinations are very effective. However, when we look at rates, it's very interesting. Urban women have higher rates of HPV vaccination, and most likely because they are more likely to have a clinic within walking distance. Sometimes they may have more reliable insurance, even if it is a government program. They're in that loop where they're getting their regular care.
Speaker 3:Women in rural areas are less likely to get HPV vaccination and in fact, what we're seeing is that urban versus rural, we're seeing higher rates of cervical cancer, probably not only because of HPV vaccination but also access to providers for PAPs. However, on the racial side, if we should look at men and women, you probably know in general that for a lot of our African American women, they have worse health outcomes. Cervical cancer is no different. When we diagnose cervical cancer in a black woman, more likely that it's advanced and more difficult to treat. So it's one of those things where just because care is there doesn't mean that people will always come in and get the care they need.
Speaker 2:Certainly, especially if there's, you know, being suspicious of the medical profession, especially, you know, based on past historical events. How much of that do you think is lack of screening or genetic predispositions? I also am always one interested about vitamin d, because we see maybe less breast cancer in black women but more aggressive breast cancer and we certainly see lower vitamin d levels the farther north you go and the darker the skin is. And I wonder, has anyone looked at vitamin d in cervical cancer? I know they have in prostate cancer and breast cancer.
Speaker 3:I'm not aware of any studies around vitamin D, but from the standpoint of the risk, I think it is the lack of screening. And when we think about coordination of care, there are those three big areas vaccination, screening and then following up for women who've been known to be abnormal in their PAP or their HPV. So we're so excited with the center that we have a coordinator now. Her name is Nicole Jackson.
Speaker 3:And what we do is every single week we look through the list of every patient in the clinic system who's either had an abnormal PAP or a high-risk HPV, and then Nicole will do that one-to-one outreach. So if that patient hasn't followed up, they haven't scheduled a colposcopy. If it's indicated, she'll reach out and say hey, you know, we're here. How can I explain to you what this test is? Why is this important? Because you know it's just a shame if we have somebody who could prevent a cervical cancer if she just came in and she chooses not to.
Speaker 2:Now this is just so wonderful. Do you know if there's other, because we have listeners from 81 countries all over the place? Are there other medical centers who are doing this to be a lot more proactive with the results and the screening we have?
Speaker 3:Well, I think as a medical center, a lot of times we aren't really in the best position to do that outreach to the community. So I have looked at some of the centers around the country and what they're doing, but when we think about our biggest opportunity is for medical centers to partner with community health agencies. So we have federally qualified health centers. We sometimes don't have a county health department, and so that's a point of care for a lot of people, and so how can we actually travel out into those communities, because it's difficult for patients sometimes to come into a medical center. So, you know, I think there's more to come. I think that idea of home HPV testing, for example, that could be a game changer. But then there has to be that follow-up care, if we're able to make it, you know, to that point so that patients know like, hey, this is nothing to be scared of, I'm positive, I just have to go and get checked.
Speaker 2:Exactly, exactly. Well, this has just been so wonderful. January is cervical cancer prevention month, but every month of the year is important to think about your health, to be strong and be healthy and be in charge and take control. Keep copies of your records, bring them in. If you think that you need an exam or a PAP and your clinician is not interested, then you can potentially find another one. I think it's so important to get that sleep, get that good nutrition, eat cruciferous vegetables that are rich in DIM, which seem to have anti-HPV effects, and any new gynecologic symptom or abnormal bleeding or abnormal discharge certainly needs to be evaluated. So any other final parting comments, dr Sutherland?
Speaker 3:Well, I am so grateful for all that you do in your facility and in this group to really activate women. I think sometimes you know we have so many priorities and it's so easy for women to put their health, you know, at the end of the list. I'll do it someday. And that's where we have to realize that we don't want anybody taking care of us. So if we're going to take care of everybody else, just like the oxygen mask in the plane, you got to put yours on first.
Speaker 3:So women have to be able to start putting themselves first and say you know what? I have to make time for this. So I appreciate what you're doing to encourage people to do that.
Speaker 2:Oh, and there was one other point that I wanted to make that I learned in your lecture the lecture that I was so embarrassed by, and thankfully the audio recording, but not the visual recording of me zooming in wasn't there that you talked about that if you're not pregnant and you have an abnormal pap and you're going for colposcopy, that the ordering physician should order an ECC. And why is that important? Because I thought that was a very important pearl that I was not aware of.
Speaker 2:And we have a lot of physicians who listen to this podcast as well.
Speaker 3:Yeah, so when we think about the cervix, there's the ectocervix. In other words, when we look at the cervix with a speculum, we can look directly at it. However, it's the lining between the opening of the cervix and the lining of the uterus, what we call the endocervical canal. 10% of the high-grade precancers are exclusively found in that area. Those are more difficult to diagnose and they're also more difficult to treat because it's an ascending tumor. So, in other words, sometimes, if you think of it like taking a scoop for an ice cream scooper, you have to go deeper to be able to get all of those high-grade precancer cells to prevent it from turning into cancer. So yeah, the ECC is a very important part of colposcopy.
Speaker 2:So women out there who've had abnormal PAPs and had colposcopies, ask your women's health clinician did you get the ECC and when should you get your next pap and HPV? So thank you so much for our listeners. If you've enjoyed this episode and you want to help support the podcast, share it with others. It's free. You can give us a five-star rating. If you don't get our regular all of our podcasts you can subscribe. Anywhere you listen to podcasts Apple Podcasts, spotify, tune in. And thanks again and I look forward to seeing you next time in the Sunflower House.
