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

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For women living with 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 care from a health care provider. Gynecologic (GYN) care means 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 women living with HIV to have regular GYN visits and tests for cervical cancer. The US Centers for Disease Control and Prevention (CDC) recommends that:

  • Women living with HIV should have a complete gynecological examination, including a cervical screening test (e.g., Pap test) and a pelvic exam, when they are first diagnosed with HIV, and then another test six months later
  • If both tests are normal, they should have another cervical screening test (e.g., Pap test) every year
  • Women living with HIV who have had dysplasia (abnormal cells) in the past should have a cervical screening test every six months
  • Pregnant women living with HIV should have a cervical cancer screening test when they first seek prenatal care
  • Women who were born with HIV (acquired HIV at birth) are more likely to have high-risk types of HPV (human papillomavirus); therefore, they should have cervical cancer screenings before they are 21 years old if they are sexually active

You should be tested for gonorrhea and chlamydia at your first gynecological visit. It is important to repeat these tests if you have a new partner or if you have sex without condoms or other barriers.

What to Expect in the Office

Usually, your health care 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 infections or 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 check different parts of your body. Not all providers perform all the exams listed below in the same order. The provider often asks a member of their 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 bottom 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 metal 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 the provider can see your cervix (the opening to the uterus, or womb).

Then the provider will use a small brush, spatula, or swab to collect some cells from your cervix for the cervical cancer screening test. The cells will be sent to a laboratory, where they will be examined under a microscope to see if there are any abnormal cells (dysplasia). This is called a Pap test. 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 check 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 (vinegar) on the cervix and look directly at it to see if any areas need treatment. Other countries use HPV human papilloma virus (HPV) tests, which test samples taken from your cervix to see whether they contain HPV's DNA (its genetic material).

Bimanual Exam

No speculum is used for the bimanual exam. 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 their 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 ("butt") to feel for any unusual bumps or sores. She or he may collect a small amount of stool ("poop") 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 women living with HIV to have abnormal cells (dysplasia) in their anus (butt-hole), which can lead to anal cancer. A rectal examination (checking your "butt") with an anal Pap smear is the best way to find anal dysplasia. There are currently no official recommendations for anal Pap smear screenings among women living with HIV. Some providers perform this exam because of the higher risk for anal cancer among people living with HIV. Similar to a cervical Pap smear, the provider inserts a small swab into the anus to collect cells. The cells are then sent to a laboratory, where they are 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 better throughout the exam.

Common GYN Problems

Certain gynecologic conditions are more common, more serious, and/or more difficult to treat in women living with HIV 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 known 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 our fact sheet on STIs:

  • Chlamydia
  • Gonorrhea
  • Genital warts/human papillomavirus (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 the yeast overgrows, you get candidiasis. Symptoms may include itching, burning, and pain around your vagina, vaginal lips, or anal area. You may also have a thick, white, cottage cheese-like vaginal discharge. Women living with HIV often have repeated yeast infections that are difficult to treat. You are more likely to experience yeast-related problems if you:

  • Have a low CD4 cell count
  • Take antibiotics, steroids, or birth control pills
  • Douche, wear tight underwear, or use scented soaps on your vagina
  • Do not finish the full course of yeast infection treatments, whether these treatments are prescribed or over-the-counter medicine

Treatments include:

  • Over-the-counter or prescription anti-fungal creams made specifically for use on the vagina (women living with HIV often need longer courses of treatment). Make sure you choose something that says it is for curing vaginal yeast infections and does not only help against vaginal itching.
  • Prescription oral antifungal drugs such as ketoconazole, fluconazole, or 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.

Preventing yeast infections   

If you douche, you may want to consider limiting how often you douche or stop 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 lets air through better than underwear made of polyester or nylon. Underwear that "breathes" can help stop yeast from growing too much.

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 common infections, including the sexually transmitted infections gonorrhea and chlamydia. PID starts after these infections move from the vagina to other organs in the body. There they can cause serious damage and lead to infertility (difficulty getting pregnant).

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 ("peeing"). Women living with HIV who develop PID should be carefully followed by their health care providers. They may need to be treated with antibiotics in a hospital.

Menstrual (Period) Problems

Many women living with HIV experience menstrual changes or problems. 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 these changes and the effects of HIV and HIV drugs on women's periods, see our fact sheet on Menstrual Changes.

Menopause

Menopause usually occurs in women from 38 to 58 years of age because of natural changes in the body. The ovaries make less estrogen (a female hormone), which leads to symptoms of menopause, including irregular periods (different in how much you bleed, how often or for how long), hot flashes (suddenly feeling very hot without a good reason), night sweats (sweating a lot at night), and vaginal dryness (the vagina is drier than usual, even during sex).

Some studies have suggested that women living with HIV may experience menopause earlier than HIV-negative women. This may be due to anemia, lower 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 our fact sheet 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
  • Wash your vaginal and rectal areas (your bottom) with water and soap or body wash 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 to 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 cervical screening (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 (how much, how often, or how long)?
  • 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, amount you take (number of pills or drops, amount of liquid), 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 down a list of questions you want to ask your health care provider. Many women find it difficult to remember to ask their questions because so much 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 problems (how much, how often, how long)
  • Urinary incontinence (leaking) or frequency (feeling that you need to pee 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 have good 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
  • Asking the provider to send you a copy of your results

If you have just had your GYN exam, congratulations! You have just done one of the most important things a woman living with HIV can do to keep herself healthy. Regular GYN exams and cervical cancer screenings are very important to your health. 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 knows the results from your cervical screening tests, 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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