The Ins and Outs of Pap Smears

A Pap smear is a sampling and microscopic examination of the cells nornially shed by the cervix. It is only a screening technique and can only determine if an abnormality is present. It cannot determine where the abnormality is located on the cervix, nor can it accurately determine how serious an abnormality is present.

What does onę do when she is notified of an ab normal Pap smeår? At Women's Health Services in Santa Fe, New Mexico, we use the standard numerical system:

I: All cells are behaving as they should with no or minimal inflammation.

II: All cells were completely normal, but moderate to severe inflammation is present. Inflammation may be caused by a number of agents: yeast, herpes, trichomoniasis, or bacteria. Ordinarily the infection is treated and the woman repeats the Pap test in two or three months. I usually means the presence of a cervical infection, and not cellular changes.

II+ There is the beginning of some unusual cell behavior. This disturbance of cells is called dysplasia. Class 11+ means mild dysplasia.

III: Moderate to severe dysplasia.

IV: Highly suspicious of malignant cells. V: Frank malignant cells.

Dysplasia means a precancerous change in the cervical cells and is very valuable as a warning. With annual Pap tests, early dysplasia can be picked up and treated.

The next step after an abnormal Pap varies according to the degree of abnormality of the smear. If the abnormality is very mild, usually a repeat Pap is done in three months, and if the abnormality is still present on the repeat Pap, colposcopy is recommended. 11 there is infection, first that is treated, and then a

repeat Pap is done, and if abnormality is still present and significant, a colposcopy is done.

If there is a significant abnormality, usually Class 11+ or greater, then a colposcopy is indicated to identify the abnormal areas and to do a biopsy.

Colposcopy is an examination done by a gynecologist with an instrument called a colposcope. A colposcope is a dissecting microscope, rather binocular-like, mounted on a swivel. It is a light and magnifying system used to identify and pinpoint abnormal cells so they can be biopsied.

Usually the whole colposcopy/biopsy procedure takes about one-half hour-about 10-15 minutes to look, and to explain to the woman what is happening; and 10-15 minutes to do the biopsy. The first part involves a pelvic exam, with a speculum, and looking through the colposcope at the cervix and vaginal area, identifying the abnormal cell area by applying acetic acid (diluted white vinegar, basically) which makes landmarks show up-variations of white are observable in the abnormal area.

After identifying the abnormal cell area, a punch biopsy is taken with biopsy forceps-the area taken is about 3mm x 3mm (or half the size of a fingernail). Sometimes a woman feels some pain or cramping, and some bleeding is possible, although complications are rare. If there is much bleeding, a chemical agent like silver nitrate inay be used to stop bleeding. Necessity for a stitch is extremely rare.

Depending on the results of the biopsy, different treatments may be used. If the abnormality is mild, cryocautery is usually recommended. (Cryocautery is freezing--using cold to destroy cells with a probe molded to the surface of the cervix.)

With a moderate abnormality, cryocautery is usually done. With severe abnormalities or car-

Hysterectomy Malpractice: A Costly Error

New York (LNS)—In the largest medical malprac tice judgment in Maryland's history, 29-year-old Belinda Chambers was awarded $1.5 million in early June after receiving an unnecessary total hysterectomy.

Chambers had received an incomplete abortion in late December, 1975. After examining her, her doctor failed to discover that she was still pregnant. A few weeks later, Chambers was rushed to the hospital in extreme pain. According to the evidence presented at trial, Chambers' left fallopian tube had ruptured during a night of internal bleeding. While waiting for her doctor to arrive (at 1 a.m. he told her to go to the hospital although he didn't arrive until 9 a.m.), she signed a surgical consent form permitting an exploratory operation and any other necessary procedures.

Chambers' doctor then performed a complete hysterectomy. After the operation the pathologist's report showed that Chambers' right fallopian tube, right ovary and uterus were all normal. At the trial the pathologist admitted an error in his original finding and stated that all the organs needed to removed. In her depression after the operation, Chambers aĺ tempted suicide,

The surgery also left Chambers dependent on Infant Formula in the House?

(Her Say)-Reps. Ron Dellums and George Miller have introduced into the House of Representatives a measure which seeks to control the promotion and marketing of infant formula in areas of the world where low incomes, poor water, widespread illiteracy and lack of refrigeration make its use hazardous. The bill is in response to criticism of major baby food companies for peddling formula in Third World countries where breast-feeding is often the safest and least expensive way to feed an infant.

regular doses of estrogen to maintain her hormonal balance. Medical studies have shown that high dosages of estrogen increase the user's chances of developing breast cancer and blood clots.

Depo-Provera Registry

(Her Say) The National Women's Health Network, Inc., in Washington, D.C., has announced the establishment of a national registry for women who have received or are receiving the injectable contraceptive, Depo-Provera.

Depo-Provera is a birth control drug whose side effects include infertility, menstrual disorders, hair loss, weight gain and depression. Studies have also shown that monkeys injected with the drug developed uterine cancer, and dogs administered the contraceptive developed malignant breast tumors and reproductive ailments.

National Women's Health Network Executive Director Belita Cowan says the Network is cstablishing the registry in order to identify and assist women who may have been injured by the drug.

The Food and Drug Administration has so far taken no action to alert physicians and the public to the dangers of Depo-Provera. Last August, witnesses at congressional hearings before the House Select Committee on Population testified that DepoProvera was especially useful for "women of low socio-economic status," for "the illiterate or semiliterate woman," and for "the unmotivated.”

Depo-Provera is currently being injected into 3 to 5 million women in 70 countries.

The Network is urging women who have ever received birth control injections to contact them. The address of the Network is Parklane Building, Suite 105, 2025 "1" Street NW, Washington, D.C. 20006, or call Belita Cowan al (202) 223-6886.

HEALTH

cinoma in situ (cancer limited to the surface of the cervix, non-invasive), cryocautery is sometimes done. However, often a hysterectomy is recommended. This is because other forms of treatment are only 75 percent curative.

Sometimes a colposcopic exam is attempted, but the doctor may feel it is inadequate for various reasons. If no abnormalities are seen with the colposcope, a scraping of the cervical canal is done (usually painless, it sometimes causes mild cramps). If the area where the abnormal cells came from is still not located, a cone biopsy is usually recommended. The cone biopsy is a larger procedure compared to the 3mm x 3mm punch biopsy discussed above. The cone biopsy is the procedure which was always done before the implementation of the colposcope as an aid in examination and biopsy.

The cone biopsy consists of taking a much larger cone-shaped piece of tissue with the base of the cone at the vaginal opening and the point of the cone al the opening of the cervix. This is the area where cancer is most likely to develop. This procedure must be done in a hospital, with anesthesia. There is more bleeding, stitches are usually necessary, and the area heals in six to eight weeks. Rarely, a transfusion may be necessary.

Biopsy results are usually available within a week. It is not usually possible to tell a malignancy by just looking at the abnormal tissue with a colposcope; a biopsy must be done.

The aim of identifying and treating abnormalities of the cervix, as mentioned above, is to prevent the progression of these abnormalities to invasive cervical cancer (which kills 40 percent of the women alflicted with it).

The cost of a colposcopy ranges from $40 to $75. plus an additional $20 to $40 for the biopsy.

-Barbara Clutter, M.D. The Hot Flash, a Newsletter from Women's Health Services, Santa Fe, New Mexico 87501

The Rebirth of Midwifery

(Her Say)-A midwifery renaissance is being seen in the United States. Interviews with expectant parents and health officials across the nation reveal that an increasing number of women are turning to

JAMA WOMAN GIVINGBIRTH TO MYSELF.

Marcia Salo Rizzi

midwives for care traditionally provided by obstetricians. According to the New York Times, midwives are doing everything from counseling pregnant women about their diet to helping them select a form of contraception following the delivery.

Dr. Lewis Mehl, of the Center for Research on Birth and Human Development in Berkeley, California, feels that midwifery is in the midst of a renaissance throughout the U.S., although it is growing faster in California and the West. Why this renaissance? Dr. Mehl feels that increased demand for women practitioners as a result of the women's movement, along with the demand for natural childbirth and the changes in the laws that license midwives, all contribute to growing acceptance of midwives in the United States.

July, 1979/What She Wants/Page 11