Caring for a Woman's Body: Care and Prevention of GYN Problems

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For women living with HIV (HIV+), there are many aspects to staying healthy. You are off to a good start if you take your medications on schedule, eat well, and get regular physical activity. But to take care of your whole body, you need to get regular gynecologic (GYN) care from a health care provider. Gynecologic care refers to the diagnosis and treatment of issues affecting the female reproductive organs (also called the female genital tract).

How Often Should You Go?

It is very important for HIV+ women to have regular GYN visits and tests for cervical cancer. The US Centers for Disease Control and Prevention (CDC) recommends that:

  • HIV+ women have a complete gynecological examination, including a Pap smear, when they are first diagnosed and when they first seek prenatal care
  • HIV+ women have another Pap smear six months after diagnosis
  • If both tests are normal, a repeat Pap smear should be done every year
  • HIV+ women with symptoms or who have had dysplasia (abnormal cells in the cervix, or entrance to the womb) in the past should receive a Pap smear every six months until they have two normal tests in a row; then they can go back to having tests every year

You should be tested for gonorrhea and chlamydia at the first visit. It is important to repeat these tests if you have a new partner or if you have unprotected sex.

What to Expect in the Office

Usually, your provider will begin by asking you about your sexual history. You will be asked about:

  • Your current sex life
  • The number and sex (male/female) of sexual partners in your past
  • Whether you have ever been pregnant or had an abortion
  • What kind of birth control you use, if any
  • How you protect yourself and your partner(s) from sexually transmitted diseases
  • How you protect yourself (and possibly your partner(s)) from a different strain of HIV

These questions can feel uncomfortable for both the provider and the patient. Even if it is hard for you, do the best you can to answer honestly. Your provider needs complete information to take good care of you.

After the interview, the provider will examine different parts of your body. Not all providers perform all the exams listed below in the same order. It is common for the provider to ask a member of the health care staff (usually a medical assistant or nurse) to join her/him in your room for the physical exams. This is for everyone's protection and to make sure the exams are performed in a professional manner.

Breast exam

For the breast exam, the provider will ask you to lie back and raise one arm over your head as she or he feels with her/his hands for any lumps or masses in the breast on the side with your raised arm. The provider will then repeat this on the other side of your body, asking that you raise your other arm and feeling your other breast.

Pelvic Exam

For the pelvic exam, the provider will ask you to lie down and scoot your butt to the end of the exam table. Then you will be asked to open your legs, bend your knees, and place your feet in the stirrups. Often, at this point, the provider will use her or his gloved fingers to examine the outside of your genitalia for any bumps, sores, or other problems. Next, your provider will insert an instrument called a speculum into your vagina. This instrument opens the walls of the vagina so that your cervix (the opening to the uterus) can be seen by the provider.

Then the provider will use a small brush to collect some cells from your cervix for the Pap smear. The cells will be sent to a laboratory to be examined under a microscope to see if there are any abnormal cells (dysplasia). Additional tests will be done if abnormal cells are found. While the speculum is still inserted, the provider may also collect fluid to check for infections.

Because Pap tests require laboratories and people skilled in reading them, resource-limited countries offer different tests to screen for dysplasia and cervical cancer.  One method is called visual inspection with acetic acid, or VIA.  When using VIA, health care providers swab acetic acid (also known as vinegar) on the cervix and look directly at it to see if any areas need treatment. Other countries use human papilloma virus (HPV) tests, which test samples taken from your cervix for the presence of HPV's DNA (its genetic material).

Bimanual Exam

The bimanual exam is performed without a speculum. In this exam, the provider places two gloved fingers inside your vagina and places the other hand on your belly. He or she feels your ovaries and uterus between the hands and checks for any pain. The provider may also perform a rectal exam. During the rectal exam, the provider gently puts a lubricated, gloved finger into your rectum to feel for any unusual bumps or sores. She or he may collect a small amount of stool to check for blood.

Many women find the pelvic and bimanual exam slightly uncomfortable and embarrassing. One reassuring thought is that the speculum is used for only two or three minutes, and the whole thing is usually over in less than five. And the more often you go, the easier it gets.

Anal Pap Smear

It is possible for HIV+ women to have anal dysplasia, which can lead to anal cancer. A rectal examination with an anal Pap smear is the best way to detect anal dysplasia. There are currently no official recommendations for anal pap smear screening among HIV+ women; however, some providers perform this exam due to the higher risk for anal cancer among HIV+ people. Similar to a cervical Pap smear, an anal Pap smear includes the insertion of a small swab into the anus to collect cells that are then sent to a lab to be examined under a microscope to see if there are any abnormal cells.

It is important to remember that at any point during the breast, pelvic, bimanual, or anal exams, you can ask your provider to tell you what she or he is doing as it is happening. Some women find this helps them relax more throughout the exam.

Common GYN Problems

Certain gynecologic conditions are more common, more serious, and/or more difficult to treat in HIV+ women than in HIV-negative women. If left untreated, some GYN infections can develop into more serious conditions such as pelvic inflammatory disease (PID) or cervical cancer.

Sexually Transmitted Diseases (STDs)

STDs, also know as STIs (sexually transmitted infections) are infections and diseases that are passed from person to person through oral, vaginal, or anal sex. While there are over 25 STDs, the most common ones are listed here and described in more detail in The Well Project's article on STDs:

  • Chlamydia
  • Gonorrhea
  • Genital warts/human papillomavirus (HPV; for more information specifically on HPV, see our article on HPV)
  • Hepatitis (Hepatitis A, or HAV; Hepatitis B, or HBV; Hepatitis C, or HCV)
  • Herpes simplex virus (HSV; genital herpes)
  • Human immunodeficiency virus (HIV)
  • Syphilis
  • Trichomoniasis

Fungal Infections (yeast infections, vaginal candidiasis, vaginitis)

Candidiasis is a very common vaginal infection caused by yeast (fungus). This fungus normally exists in the human body (including in the vagina) and lives in balance with helpful bacteria. When an imbalance occurs and the yeast overgrows, candidiasis occurs. Symptoms may include itching, burning, and pain around your vagina, vaginal lips, or anal area. You may also have a thick, cottage cheese-like vaginal discharge. HIV+ women often have repeated yeast infections that are difficult to treat. You are more likely to experience yeast-related problems if you:

  • Have low CD4 cell counts
  • Take antibiotics, steroids, or birth control pills
  • Douche, wear tight underwear, or use scented soaps
  • Do not finish the full course of yeast infection treatments, whether those treatments are prescription or over-the-counter

Treatments include:

  • Over-the-counter creams like Monistat or Gyne-Lotrimin or prescription anti-fungal creams (HIV+ women often need longer courses of treatment). Make sure you choose something that says it is for curing vaginal yeast infections and is not only for helping with vaginal itching.
  • Prescription oral antifungal drugs such as Nizoral (ketoconazole), Diflucan (fluconazole), or Sporanox (itraconazole) for difficult-to-treat infections. Many antifungal drugs interact with HIV drugs. Some of them are also not recommended for pregnant women. Make sure your health care provider knows what HIV drugs you are taking and whether you are pregnant or are trying to become pregnant.

Prevention of yeast infections   
If you think you may be likely to get vaginal fungal infections, there are some things you can do to help prevent them. First, you can drink milk that contains acidophilus or eat yogurt with active bacterial cultures. There are also over-the-counter acidophilus supplements you can take, but it is important to make sure you take one that has a high level of active cultures. Also, some foods or food ingredients can promote the growth of yeast. Nutritionists recommend that you avoid foods containing yeast, sugar, wheat, and caffeine. If you smoke or drink alcohol, you should be aware that alcohol and nicotine can also promote the growth of yeast. If you douche, you may consider limiting the frequency of douching or eliminating douching altogether. Douching reduces levels of helpful bacteria in the vagina and is not recommended. Lastly, because yeast grows best in moist areas, wearing looser-fitting pants or underwear can help prevent yeast infections. Cotton underwear breathes better than underwear made of polyester or nylon, and can also help minimize yeast growth.

Pelvic Inflammatory Disease (PID)

PID refers to inflammation in the upper genital, or female reproductive tract (which includes your ovaries, uterus, and fallopian tubes.) PID is often caused by a number of common infections, including the sexually transmitted diseases (STDs) gonorrhea and chlamydia. PID starts after these infections travel up from the vagina to other organs in the body, where they can cause serious damage and lead to infertility.

The most common symptoms of PID are lower belly pain, irregular menstrual cycles, vaginal bleeding when you are not having your period, vaginal discharge, and painful or frequent urinating. HIV+ women who develop PID should be carefully followed by their health care providers since they may need to be hospitalized and treated with antibiotics.

Menstrual (Period) Problems

Many HIV+ women experience menstrual changes or irregularities. These changes to your menstrual cycle (or period) are less common if you have a high CD4 count and are taking HIV drugs. For more information on the types of menstrual changes HIV+ women experience and the effects of HIV and HIV drugs on women's periods, see The Well Project's article on Menstrual Changes.

Menopause

Menopause usually occurs in women from 38 to 58 years of age because of natural changes in the body, including the ovaries making less estrogen. Symptoms of menopause include irregular periods (different in amount, frequency, or duration), hot flashes, night sweats, and vaginal dryness.

Some studies have suggested that women with HIV may experience menopause earlier than HIV-negative women. This may be due to one or more of many factors including anemia, decreased hormone production, illness, weight loss, effects of HIV drugs, effects of street drugs, or smoking.

For more information about menopause, its symptoms, and options for relieving those symptoms, see The Well Project's article on Menopause.

How to Prepare for Your GYN Care Appointment: A Checklist and Questions for Your Provider

There are many things you can do to make your appointment with your GYN provider a smoother, easier, and more helpful visit.

Preparing your body
To get the best results from the physical exam part of your visit, it is important to do the following:

  • Make sure you will not have your period during your visit; it is best to schedule your exam for one to two weeks after your period
  • Do not douche or use other vaginal preparations for two to three days before your exam
  • Do not have vaginal sex or sexual intercourse for 24 hours before your exam

Preparing for your provider's questions
Your GYN care provider will ask you several questions about your sexual and medical history. These questions are not meant to invade your privacy or criticize, but to gather important information to make good decisions about your health. It may be helpful to think about your answers before your appointment. Be prepared to answer the following questions:

  • When did your last period begin?
  • How long do your periods last?
  • How often do they occur or how many days between periods?
  • When did you have your last GYN exam (if you are seeing a new GYN provider)?
  • Have you ever had any abnormal Pap smears or Pap test results in the past? If you have, your provider will likely ask you when you had those abnormal test results, what those results were, and what treatments you received. You may find it easiest to bring copies of the reports. If you do not have copies of the reports, bring your previous GYN provider's contact information so that your new provider can get your past medical records from your previous provider. You will likely be asked to sign a medical release form that gives your new provider permission to ask your previous provider for your medical records.
  • Have you noticed any changes in your menstrual cycle or periods (in amount, frequency, or duration)?
  • Have you noticed any vaginal discharge?
  • Have you had any lower belly or pelvic pain?
  • Have you noticed any blood after sex or between periods?
  • What other drugs and medications are you taking (including your HIV drugs)? For each drug, be sure to write down the name, dose, number you take, and when you take it. If you are not sure about your list or you are running late, put all your medications in a bag and bring them to your appointment so your provider can see exactly what you are taking. Make sure you also tell your provider about any other treatments or remedies you are taking – over-the-counter medications, herbal supplements, vitamins, teas, etc.

Preparing your questions
Whether or not you feel comfortable going to your GYN appointment, it is important that you write out a list of questions you want to ask your health care provider. Many women find it difficult to remember to ask their questions given all that goes on during the visit: the exam room, the change of clothes, the physical exam itself, and all the questions the provider asks! This is your opportunity to raise concerns and ask questions about the health of your body, so be ready with your list.

Things you may wish to talk about with your GYN provider:

  • Getting vaccinated against Hepatitis A, Hepatitis B, or HPV
  • Questions about birth control and contraceptive use
  • How to improve the safety and satisfaction of your sex life
  • Menstrual irregularities (amount, frequency, duration)
  • Urinary incontinence or frequency (leaking urine or feeling that you need to urinate often)
  • How having been abused or assaulted (sexually or otherwise) in the past might affect your health now; while it may be a very uncomfortable thing to talk about, mentioning past trauma may help your provider better understand your symptoms and history and make a more accurate diagnosis
  • Things you can do to maximize your GYN and overall health
  • How you will communicate with your provider after your visit, including if and how your provider will let you know the results of your exam

If you have just had your GYN exam, congratulations! You have just done one of the most important things an HIV+ woman can do to keep herself healthy. Regular GYN exams and Pap smears are crucial to your health since many GYN conditions do not have obvious symptoms and can get worse without your realizing it. Finding and treating GYN conditions in the early stages can prevent them from becoming more serious conditions later.

If your health care provider is not skilled in GYN care, or you would rather see a specialist, ask for a referral to a GYN care provider who is experienced in treating women with HIV. If you receive GYN care from someone who is not your HIV provider, be sure that your HIV provider is aware of results from your Pap smear, other GYN tests, and any treatments you might be taking for GYN conditions.

Additional Resources

Select the links below for additional material related to gynecological care.

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