By the time I got to the consultation room with the information from the clinic, the tears had stopped flowing (see yesterday's post). Her mother was with her and the first thing I asked was if she wanted her boyfriend there as well. Again, she shook her head no, so I asked her to “Look me in my eyes and hear me loud and clear – You do NOT have cervical cancer.” Then I went on to explain that she did indeed have genital warts and that they are caused by viruses called human papillomaviruses (HPV). Some HPV types can eventually lead to cancer, but the common types that are the most likely to cause the kind of warts that she has, do not.
The ‘abnormal’ cells found on her Pap test are the lowest grade of abnormality and are very typical of what is seen with genital warts alone and they are a NOT ‘cancer’ cells. I told her that these viruses are very common in young sexually active women and many of them do not even know they have the infection. Unfortunately, she probably contracted the virus from her boyfriend right around the time she got pregnant and her immune system was not as effective at controlling the infection because of the pregnancy. I told her that many women, if left untreated during the pregnancy, will often go on to clear their warts spontaneously within a few months after delivery, although they may never completely clear the virus that causes them.
I also explained to her that the presence of ‘warts’ reflects an active virus infection in which new viruses are being produced and can be passed along to other individuals and, sometimes, even to babies at delivery. But, in the same breath, I told her that the presence of genital warts is rarely an indication for a cesarean delivery unless they are so extensive that they might interfere with repair of lacerations that need to be fixed at the time. I did suggest that because she was still very early in the pregnancy, and had very severe involvement of the vagina, vulva, and perineal areas, that it was probably worth trying to reduce the amount of disease she had before the delivery to minimize any risks of complications. Then I outlined a possible treatment plan that would be ‘safe’ for her and the baby.
She seemed satisfied with what she had been told, but was still concerned about the ‘cancer’ issue. “They told me I would have to have the cancer cells treated” she said, and her mother shook her head in agreement and told me she “was right there when they told her that.” I wasn’t about to argue with either of them about what they had been or thought they were told. There have been too many instances I have been aware of in the past when physicians, trying to insure that follow-up appointments for monitoring cervical dysplasia are kept, have used the “C” word to strike fear into the heart of the unwary rather than spending time on a more prolonged explanation. But, I did use this as an opportunity to provide some more information.
With the low-grade abnormalities she had on the Pap test, if these were only caused by one of the noncancer-causing types, 9 out of 10 women with one of these types will have a normal Pap test within 3 years without any treatment. Indeed, sometimes the treatment is worse than the disease under these circumstances. However, I also told her that some people will be infected by more than one HPV type and if she was, it would increase the chance she also had a type that might some day lead to cancer. “After you deliver, we will check you out on all that, but even then, you should have annual examinations until we recommend otherwise. It usually takes many years to develop cervical cancer and, if we follow you carefully, there is no reason you should ever get to that point.”
As she was getting ready to leave, I saw one other notation in her record that was worthy of comment under this situation. “By the way, I see you are a smoker. Smoking is not only associated with more difficulty getting rid of warts, it probably also increases your risk of cervical cancer from HPV. That’s something you could quit right now that will help both you and your baby. Why don’t you put the money you would spend on cigarettes into a college fund for your daughter, after all, you’ll probably be around now to see her finish high school.” She laughed nervously, but I think she got the message!