Millions of women are treated each year for illnesses and conditions which affect their reproductive system and/or genital tract.  Some situations are caused by sexually transmitted diseases (chlamydia, gonorrhea), some are related to personal hygiene or birth control methods (extended tampon use or intra-uterine devices (IUD)), and still others are mysterious acts of nature whose origins have escaped medical definition for centuries (endometriosis).  In America women’s health care has been greatly improved by Papanicolauou (PAP) tests, laparoscope examinations and laparoscopic surgery, and an increased awareness of the importance of nutritional elements such as specific vitamins and supplements.  However, conditions and illnesses which are specific to women and their reproductive/genital tracts can be embarrassing for many women to discuss, difficult for doctors to diagnose, and challenging to treat, both for the doctor and the patient, even with the medical advances available.  Many illnesses have similar symptoms, though necessary treatments are slightly different for each situation.  An absence of early symptoms, and the difficulty in differential diagnosis due to overlapping symptoms, make it is essential that women be aware of changes in their bodies.   The importance of being efficiently and properly diagnosed and treated when problems arise is necessary to maintain fertility, hormone balance, and overall physical and mental vitality.

It is understood that a woman’s reproductive system is complicated, made not only of organs, but also hormones and chemicals which affect the entire body, both physiologically and psychologically.  The following examples of the most commonly diagnosed and treated conditions/illnesses which affect the female reproductive system and genital tract are: Acute Pelvic Inflammatory Disease, Endometriosis, Cervicitis, Cervical Cancer, Endometriosis, Ovarian Cysts, Ovarian Cancer, and a section on Toxic Shock Syndrome.  Toxic Shock Syndrome, though not all that common now, can be deadly if not treated immediately. If not properly diagnosed, all of these conditions may create long term health concerns for afflicted individuals, especially when they are combined, as often seems to happen (example: Acute PID, cervicitis, cyst, and endometriosis).  Once one area of the reproductive system is ill, it is very easy for bacteria, virus, scar tissue, or cancer to spread throughout the reproductive system and genital tract, creating multiple strains and much confusion.

To bring clarity to a subject that many never discuss until it is problematic, and also to hopefully create interest in better gynecologic communication and care, the next section discusses each condition in terms of possible symptoms, diagnosis, research, prevention, and offers definitions for common tests and procedures for these conditions.

Acute Pelvic Inflammatory Disease (PID)
Overview

Pelvic Inflammatory Disease (PID) is an infection, or series of infections, of the upper genital tract.  It is primarily caused by Chlamydia or Gonorrhea, though PID may also be acquired through an IUD, endometrial biopsy, miscarriage, abortion, and/or child birth (Carlson, 1996).  Some organizations view it purely as a very problematic STD, “Next to Acquired Immune Deficiency Syndrome (AIDS) it is considered the most dangerous complication of sexually transmitted disease” (National Institute of Allergies and Infectious Diseases (NIAID), 1998).  PID starts in the vagina, spreads through the fallopian tubes, and into the ovaries.  In severe cases it can also spread into the abdomen (Micromedex, Inc., 2000). In the United States 500,000 - 1,000,000 women per year are diagnosed with PID.  A high percentage of those diagnosed cases are adolescents (Indiana School of Medicine, 1999).  The cost of treatment is an estimated expense of two to seven billion dollars annually (NIAID 98; Physicians Desk Reference, PDR, 2001). One of four women who contract the disease will be left infertile, or may suffer from ectopic pregnancy, a condition where the fetus develops inside the fallopian tubes as opposed to the uterus.   

Etiology

PID is most commonly caused by one of two sexually transmitted diseases, Chlamydia trachomatis or Gonorrhea, though recent studies have added the Human Papilloma Virus (HPV) as one of the causative agents.  In some cases, PID may be caused by “medical procedures performed on reproductive organs” (ObGynCenterOnline, 2005).  Normal vaginal or cervical bacteria can sometimes move upwards into the upper genital tract.  These bacteria include Garnerella vaginalis and Bacteriodes.  Other known bacteria which can causes disturbances are Mycoplasma and trichomonos.  Three ways that bacteria travel further into the reproductive system are menstruation, douching, and sexual intercourse.

Symptoms & Diagnosis

PID often shows no immediate symptoms.  The first sign of the disease is often a dull, continuous abdominal pain and bloating.  Sexual intercourse, exercise, or manual labor may worsen the pain.  As the disease progresses there are numerous, varied symptoms, such as worsening of abdominal pain, discolored  and pungent vaginal discharge with a “cheese” like quality about it, constant low running fever, hot flashes, and fatigue.  All accessible resource material stresses that the danger of PID is the difficulty in recognizing it until it is most advanced.  Many women do not show apparent signs of the disease, especially when caused by Chlamydia. Chlamydia now affects “approximately 2.2% of all U.S. adults ages 14-39 / with the highest prevalence rates among young women” (Kaiser Foundation, 2005).  “Young women ages 14 to 19 had the highest chlamydia prevalence of any group in the U.S. ...” (Reuters, 2005). Men in their early to late 20s followed close behind.  African-Americans have a higher rate than do Caucasians, and low income, adolescent workers and pregnant women seem to have more rates of infection that moderate income workers or women who delay pregnancy.

It is recommended that women receive regular PAP smears.  Annual PAP smears may detect problems before they are apparent.  However, it is important to note that PAP smears do not always show HPV, which often requires a separate test.

PID is often confused with numerous other conditions, which may create problems as it spreads into the upper genital tract.  When a patient complaining of abdominal pain, bloating, and discharge is suspected of having PID, a physician may begin with the patient’s medical history and a basic gynecologic examination.  After the initial examination, one or more of the following tests may be requested: blood tests, cultures to test for STD infection, cervical/birth canal swab, ultrasound, sonogram (deep body imaging through high frequency sound waves), endometrial biopsy (removal of living tissue for examination), or a laparoscopy (illuminated optical tube which probes through an abdominal incision).  A laparoscopy is considered the only completely conclusive method of diagnosis (PDR, 2001).         

Treatment

If a doctor suspects PID, antibiotics may be prescribed prior to positive test results.  However, it is best to have a secured diagnosis.  PID necessitates two or more separate antibiotics, which will be effective against multiple infectious agents. Incorrect antibiotics may exacerbate the irritations, and also make certain strains of bacteria resistant to effective treatment.

An example of antibiotic treatments utilized in the treatment of PID are:  Ofloxacin (Floxin) 400 mg orally twice a day for 14 days, plus metronidazole (Flagyl) 500 mg orally twice a day for 14 days; or one intramuscular injection of 250 mg of ceftriaxone (or a single injection of 2 grams of ceftriaxone together with an oral dose of 1 gram probednecid) plus doxycycline (Doryx or Vibramycin) 100 mg orally twice a day for 14 days (Sifton (ed), PDR, 2001; The Boston Women’s Health Book Collective, 1998).  It is very important that a doctor know about a patient’s mental, as well as physical, history.  Antibiotics can sometimes have a very negative effect beyond the commonly known side-effect of yeast infections.  A recent article which appeared in the International Journal of STD & AIDS stated results from a clinical study which showed that Ofloxin can cause psychiatric side effects when used for the treatment of PID on patients with a history of mental duress or illness (Hall, 2003). 

If antibiotics do not show a physical effect in three days, the infected patient may need to be hospitalized so that intravenous (IV) antibiotics may be administered.  If the prescribed antibiotics are not completed, recurrence is likely, along with the added effects of chronic pelvic pain, and tissue scarring.  A surgical procedure called tuboplasty is sometimes required to open scarred tissue or blocked tubes.  When adhesions or scar tissue bind to internal organs, laparotomy is required to laser them out.  Surgery, though, can sometimes add to adhesions or scar tissue.  It is also important to note that if PID is acquired through an STD, it is necessary for the sexual partner to also be treated for the specific cause of transference, such as chlamydia or gonorrhea.   This will prevent recurrence.   Numerous sources recommend that women have one sex partner, use condoms, or refrain from sexual activity altogether.  Safe, responsible sex, and open communication also seems worthy of mention. 

In severe or recurring cases, conservative or radical surgery is often necessary.  Conservative surgery entails removing adhesions, while radical surgery is a hysterectomy (Carlson, 1996). Though hysterectomy was very common from the 1950s through the 1980s, it is now considered an extreme measure.  Advances in women’s health care have allowed more consideration to be given to the effect hysterectomy has on a women’s mind and body.

The Boston Women’s Health Book Collective (1998) listed similar information for traditional treatment, though added information on complimentary methods of “self-healing” were also provided.  Included are some seemingly simple suggestions, such as hot baths and heating pads, and specific herbal remedies.  It is recommended that women experiencing discomfort from PID apply heat to the lower abdomen, along with taking extremely hot baths (less any fragrances or bubbles).  Heat can greatly reduce pain.  It is recommended to avoid any vaginal insertion device, from a tampon to a douche.  The amount of time it is advised to stay away from these kinds of items depends on the severity of the condition.  Acupuncture is recommended to alleviate pain, bloating, and to free toxins from the system.  Some of the suggested herbal remedies such as hot cloths with castor oil, poultices (generally a wad of bruised or chopped plant material applied topically to an area of the body. They become plasters when used with ground herbs or by adding ingredients to assist their cohesiveness such as corn meal or wheat flour, or teas of ginger root, taro root, or raspberry leaves (Kight, 2004). These relieve pain, eliminate accumulated toxins from adhesions, soften adhesions, and strengthen the reproductive system.  Taking high doses of vitamins C, A, D, B, and zinc in affiliation with eating whole foods is considered helpful.  Extra rest and a decrease of stress are also recommended, along with eliminating alcohol, tobacco, and lessening caffeine intake.

Research & Prevention

In response to the difficulty in diagnosing PID, NIAID is one organization which has actively been researching the effects of antibiotics, hormones, and other substances that enhance the immune system.  They are also involved with developing more efficient diagnostic tests to determine early stages of chlamydia and gonorrhea.  The early treatment of sexually transmitted disease greatly assists in preventing PID.

A 1994 study entitled, “Factors associated with the geographic variation of reported Chlamydia infection in Minnesota” evaluated screening process, reported cases, and care methods throughout the state of Minnesota in 1990 and 1991.  Research of the effects of reporting cases and evaluation of care came after a mandatory law put into effect in 1985 requiring all clinics and doctors to report to the state their Chlamydia cases in an effort to lessen its proportions.  A much more in-depth Swedish study completed in 1996  after twenty years of research found that episodes of PID were dramatically reduced by controlling the related STD’s.  Use of intrauterine devices, along with high infection rates of gonorrhea and Chlamydia contributed to the percentage of women with acute PID in the 1970s.  By the end of the study, increased understanding of the detection and treatment of STD’s greatly reduced the number of new PID cases, though there was no long-term documentation provided regarding statistics on recurrence.

Most studies on PID have taken place in the United States or Europe, and have focused on sexually transmitted diseases as the causative etiology.  In an interesting study for the Population Council, Inc., Bhatia and Cleland discuss self reported symptoms “suggestive” of PID as a result of “obstetric morbidity” in women located in Karnataka State, India. “Women who delivered their last child in a private institution were significantly less likely to report symptoms than those who delivered at home or a government hospital.” (Studies in Family Planning 1995; 26, 4:203-216). Is Acute PID the result of a combination of factors including environment and hygienic methods, and not only a sexually transmitted disease?

In a rare community-based study in India (Bang et al, 1989) it was found that 92 percent of the Gond tribe women had one venereal disease that was not being treated, with basic infections of the genital tract being half of that finding.  These untreated common bacterial infections spread throughout the reproductive system, and mixed with pregnancy and childbirth, create multiple cross infections, including PID. In an effort to provide better health care throughout financial classes, the state is setting up care centers, and funding of the study being referenced here was supported by the Ford Foundation.  Though there is much interesting information in the Indian report, the point of purpose is to show that PID is caused by bacteria and infection migrating untreated through the vaginal tract, into the upper genital tract, and into the reproductive system.  Though it is imperative to recognize STD’s as causative agents, it is also necessary to realize that bacteria and infection need not be sexually transmitted if PID is to be treated in the United States and abroad with complete effectiveness.  PID can cause infertility, and also chronic pain and illness which devastates the individual, and from a broader perspective, an entire community or society.

Cervical Conditions
Cervicitis
Overview

Cervicitis is an inflammation of the cervix, which is the entrance to the uterus.  Cervicitis may be caused by one or more of the following:  Sexually transmitted diseases (STD’s) such as Chlamydia, Gonorrhea, or Trichomonos; more severe STD’s such as Herpes Simplex and  Streptococcus; Enterococcus which may cause a secondary infection ;  birth control devices such as the cervical cap or diaphragm; multiple sexual partners; and difficult child birth.  In post-menopausal women, a lack of estrogen is often a cause of inflammation which can lead to irritation, and also cervicitis (Gale, 2001).  This may be described as an effect of urogenital aging, along with vaginal discomfort, atrophy and urinary tract infections. (Nachtigall, 1998).  Chemical exposure (in this situation defined as fragrance tampons or douches) may also cause irritation or infection in some women (PDR, 2001).  In some cases, it is not determined what causes the inflammation, it is simply treated.  When not treated, cervicitis may cause infertility because it rots away the cervix, and infects the surrounding area with the bacteria or virus that has created the condition.

When working properly, the cervix acts as an important part of fertility awareness.  Through changes in fluid and temperature, a woman may determine the best time of her cycle to become impregnated.  Many women are unaware of the important role their cervix plays in reproduction.
 The cervix is the muscular opening of the uterus. With the approach of ovulation it becomes softer, opens, and raises its position relative to the uterus. At infertile times it is low, firm and closed. The opening of the uterus is a thick muscle known as the cervix. As ovulation approaches, the same hormones that cause cervical fluid to be secreted also cause changes in the position, texture, and opening of the cervix. During infertile periods (Phase 1 and 3), the cervix is low, firm and closed (during Phase 3, it is closed tightly). It is so low that it is fairly easy to reach for observation purposes. As fertility increases, the cervix rises in position, becomes softer, and starts to open. At peak fertility, the opening of the cervix is about 15 mm wide. These changes make it easier for sperm to reach the ovum - conception wouldn't take place if the cervix is not open. If the Cervix didn't close tightly after ovulation, the uterus and fertilized egg could become infected” (YinYang, 2004).

Etiology, Diagnosis & Symptoms

When a woman has cervicitis, symptoms are not always present, and the condition may be well advanced by the time that there is notice of vaginal discharge, bleeding, vaginal itching, frequent and difficult urination, painful intercourse, odor, and lower back pain.  If the infection passes into the rest of the body, fever and nausea are possible.  The infection, if not treated, may also severely damage the fallopian tubes or the uterus.  Cervicitis is often confused with other less serious conditions, such as vaginitis.  This makes it very important to efficiently and properly detect.  Realizing subtle changes in the body is essential in order to get efficiently and effectively tested.

Laboratory tests must be done to determine the specific cause of the infection.  A biopsy may be recommended to rule out cervical cancer.  A colposcopy may also be done.  This is a simple procedure that involves looking into the pelvic region through the vagina with a device similar to a pair of binoculars.

Treatment

Treatment consists of antibiotics such as doxycycline (Doryx or Vibramycin), azithromyacin (Zithromax), ofloxacin (Floxin), Erythromyacin.  Sexual partners of the infected person should also be tested to rule out STD.  If nonspecific bacteria are found to be responsible, vaginal cream or medicated douches may be prescribed (PDR, 2001).

If the infection, or cross infection, is too severe to treat with antibiotics alone the following methods are utilized in treatment:  electro coagulation, or cautery; cryosurgery, or freezing; laser treatment; or Loop Electrosurgical Excision Procedure (LEEP).  These methods not only assist in stopping the infection, but also in securing other damage caused by infection, such as adhesions or open, rotting areas.  In extreme cases, a trachelectomy, or removal of the cervix, may be performed. Cervicitis is usually cured with the completion of a given treatment. 

Numerous sources cited that if Cervicitis is not STD in origin that no treatment need be considered.  It will probably fix itself.  Goldenseal and Vitamin C douches may provide some comfort.  Orally, high doses of vitamin C (up to 1500 mg for two weeks), zinc, and vitamin E are suggested, along with well rounded nutrition, and rest.

Research & Prevention

Most preventive measures stress controlled sexual behavior.  Though the idea of routine screening for both men and women to find the causative pathogen(s) is valid, it would be very expensive and, in many environments, considered controversial.   

Cervical Cancer (Dysplasia and Carcinoma)
Overview

The American Cancer Society recently released Cancer Facts & Figures, 2005 revealing,“An estimated 10,370 women in the USA will be diagnosed with cervical cancer in 2005, and 3,710 are expected to die” (USA Today, 2005). Overseas, an estimated 300,000 women die annually from the disease. (AP, 2005).Cervical dysplasia is a precancerous condition indicated by growth of abnormal cells on the cervix. Cervical dysplasia quickly leads to cervical carcinoma; carcinoma is cancer. Cervical cancer is the second most common malignancy in women worldwide.  In developing countries, it is one of the leading causes of death.  It is considered such an epidemic throughout the developing world in countries such as Ghana, India, Peru, South Africa, and Thailand that over a five year period Bill and Melinda Gates have granted over $50 million to assist in establishing screening and treatment facilities, to improve delivery systems; integrate community needs into medical programs, add palliative programs in areas where women have been living with advanced stages of the disease without any pain management when the disease is  terminal, and also to heighten awareness of cervical cancer and prevention strategies all over the world (ACCP, 2005).      

Annual PAP tests for the diagnosis of cervical cancer has lowered the amount of cases reported in the United States, though a report released by the National Cancer Institute over the summer of 2005 concluded that, “the nation’s public health system must improve its delivery of cervical cancer education, screening, and treatment and related health care to women at risk” (NCI, 2005).  Disparities amongst class and race, along with a lack of clear multi-lingual sexual health education and affordable screening are considered key elemental factors to be resolved.  “Black women in the south, women living along the Texas-Mexico border, white women in Appalachia, American Indians in the Northern Plains, Vietnamese-American women and Alaska Natives are among the U.S. women most likely to die of cervical cancer” (Kaiser Foundation, 2005).  These women are also likely to have breast cancer, colorectal cancer, and heart disease.  The authors of the NIH report entitled, Excess cervical cancer morbidity:  a marker for low access to health care in poor communities hope to inspire a collective  promotion of access, information and communication, collaborations (amongst health care workers), partnerships, advocacy, and research (NIH, 2005). The Office of Research on Women’s Health (ORWH) in Washington, D.C. had already  implemented “Health Disparities/Differences and Diversity” into their 2005 “overarching themes” as important to women’s health needs after reports concluded that not all women receive the same, or satisfactory, gynecologic care.  Their goal is to begin to bridge the divide “among different populations or sub-populations of women, including cultural diversity, racial/ethnic minorities, sexual orientation, rural/inner city residency status, effects of poverty, and disabilities” (ORWH, 2005).  Research is understood as necessary to understand U.S. cervical cancer morbidity rates.  Factors to be considered are “insurance status, transportation, lack of medical home, human papillomavirus (HPV) prevalence, smoking, sexual practices, and condom use” (NIH, 2005).  There was no mention of diet, lifestyle, mental and emotional health or domestic violence listed as part of the agenda.  Discussing the same problem from a different perspective, the Kaiser Network ran an article on August 17th, 2005 stating that women in Idaho were 22% “less likely than other American women” to develop cervical cancer, but “the state also has the second-lowest screening rate in the country, which health officials worry could lead to a surge in the number of cervical cancer cases because the disease takes between 10 and 20 years to develop. A bipartisan committee of the state Legislature is scheduled to meet this fall to discuss ways to increase screening for cervical cancer, which is done using PAP tests, after the defeat of a 2005 state bill that would have provided federal funding for the tests. "We need greater public awareness that says, 'Hey, we are sitting on a time bomb, and we need to start addressing it before we have a huge epidemic of cervical cancer,'" state Rep. Bob Ring” (Kaiser Foundation, 2005).  As long as women cannot afford to get annual PAP tests done, or do not understand the implications of not having them done, the United States is at risk for an epidemic believed possible only in third world nations.  Sadly, not only does cervical cancer affect fertility, but it is also terminal, and - if caused by the HPV virus - contagious.

Etiology & Diagnosis

A PAP test involves lightly scraping cells from the cervix in order to test for abnormalities in those cells. It is important to note that PAP tests do not always give correct answers.  In the mid 1990s, the Food and Drug Administration (FDA) approved “automated reinspection” of results (The Boston Women’s Health Book Collective, 1998).  This is due to the fact that false test results were not uncommon with the original PAP.  Also, testing should be continuous throughout a problem, meaning once a month for the duration of the illness, so that any changes in results can be noted. If the condition does not respond to initial treatment, it is imperative to know that the condition is still present and needs a different route of care.  Early detection is paramount in being able to treat this disorder.

Cervical dysplasia and cervical carcinoma are now considered to be the direct result of sexually transmitted diseases. When people think of cancer, few think of a sexually transmitted disease.  Most available literature on the subject does not clarify the difference, which can make the subject a bit confusing.  Cervical cancer is considered to be the only carcinoma caused by a sexually transmitted disease or virus.

The evolution of cervical cancer takes place in three stages, which also have varied stages within them.  First is ‘metaplasia’ which is considered the “transformation” zone, then ‘dysplasia’ (CIN I, II, III), and finally ‘carcinoma’, or cancer (Medfax-Sentinel; 1993).

Cervical intraepithelial neoplasis (CIN) and squamous intraepithelial lesions (SIL) are dysplasia, or an abnormal growth of cells which creates a precancerous condition. CIN is not a sexually transmitted disease, nor is it cancer, but if it is not treated, in a relatively short period of time it will most probably become cancer.  SIL is the combination of CIN and genital warts.

Dysplasia in women is most common in the reproductive tract.  Cervical dysplasia is the most prevalent of the possible reproductive variations of dysplasia, though vulva and vaginal dysplasia are also documented, as ovarian dysplasia is one possible precursor to ovarian cancer. 

Cervical dysplasia, and cervical cancer, is often discussed in affiliation with HPV.  HPV is most easily defined as genital warts. Some times these warts can spread inside of the body, where they lead to lesions which become cancerous.  There are over 100 types of HPV that can cause warts, and over 20 different types of HPV that can infect that genital tract, leading to complications with cervical dysplasia, and in some cases, cancer (New Zealand HPV Project, 1999). One of the primary problems that arise from HPV infection is that a person may have multiple strains of the virus at the same time, leading to complications in diagnosis, and cross infection potential.  “Multiple HPV infections may be concerned with pathogenicity in cervical dysplasia; however the single infection with only a few HPV types, such as type 16 in SCC and type 18 in adenocarcinoma, may play a role in cervical carcinogenesis” (Nakagawa, 2002).  Another problem with the HPV virus is that, often, women will not have any symptoms until it is in the advanced stages. “Although 20 million Americans are infected with HPV, many women aren’t aware that they have the virus, since many cases have no symptoms and resolve on their own.  It is essential, though, that every woman knows her risk of HPV” (Women’s Health Today, 2005, P. 13).

Over recent years HPV has become a standard explanation for cervical problems, but there are still many factors that need to be further researched and understood.  An article published last year in Reviews in medical virology (Bekkers, 2004) explains, “Many studies have indicated a causal relation between genital human papillomavirus (HPV) infections and cervical cancer.  High-risk HPV genotypes have been detected in almost 100% of all cervical cancers, and the process of HPV mediated carcinogenesis has been partially clarified.”  Though all of the cases reviewed in this particular study had HPV, not all of the cases of HPV developed cancer.  “Epidemiologic studies indicate that 50% of women becoming sexually active contract a genital HPV infection within two years.  The lifetime risk of a genital HPV infection is 80%, but very few of these women will develop cervical cancer.”  The conclusion of the abstract states that “… many facts regarding HPV transmission, replication, and detection need to be clarified, before HPV detection can be of clinical value” (Bekkers, 2004).

Originally doctors thought that sexual promiscuity was a related cause of cervical cancer, and that sex at a young age contributed to the condition by bringing toxins into the vaginal canal while the reproductive system was still forming. It was not clear how those toxins were defined. Many professionals felt there was a definite connection between cervical cancer and multiple sex partners. One theory being  that protein substances in sperm may create cellular changes in some women, another is multiple sex partners open the door for multiple forms of bacteria to enter into the reproductive system. The Boston Women’s Health Book Collective (1998) explains that risk factors amongst adolescents are increased due to changes in the cells that line the vagina. “As we age, more vulnerable softer cells are replaced by tougher (squamocolumnar) cells.”  HPV was the necessary “missing link”. 

The discovery of HPV has generated more literature on cervical cancer as an STD than most any other point of contemplation on the disease.  Researchers suspect that two sexually transmitted diseases are involved in cervical dysplasia:  HPV, or visible and non apparent warts, and also Herpes Simplex II. (Page, 1997).  HPV is found in many invasive cervical cancers such as squamous intraepithelial lesions (SILS).  Initially, the abnormal growth of cells is precancerous.  The precancerous cells form into dysplasia (SILS), and then evolve into cervical intraepithelial neoplasia (CIN).   HPV-16 is considered to be the cause of 50% of cervical cancers (Gale, 2001). 

 In 2003 the Food and Drug Association (FDA) approved a new approach to cervical cancer screening with the Hybrid Capture II HPV test to be used with the PAP (SGO, 2005). In the autumn of 2005 a “genetically engineered vaccine”, manufactured by Merck and Co., Gardasil*, passed preliminary studies privately funded by the corporation.  Gardasil was found to be 100% effective in blocking HPV 16 and HPV 18,  two of the over 100 variations of the human papilloma virus; it is also effective against virus types 6 and 11, which specifically cause genital warts.  “To have 100 percent efficacy is something you have very rarely,” Dr. Eliav Barr, Merck’s head of clinical development for Gardasil, told the Associated Press (AP), “We are breaking out the champagne.”   The study included 10, 559 sexually active women in the United States and abroad.  As of 2005, over 20 million Americans have “some form” of HPV (AP, Oct. 2005).  Merck plans on submitting Gardisil to the Food & Drug Administration in before January, 2006, with the hope of marketing it before December, 2006.  There are also government and private studies being done on vulva intraepithelial neoplasia (VIN) and penile intraepithelial neoplasia (PIN). 

*June, 2006.  Gardasil Approved.  For detailed information on Gardasil, please refer to:

http://www.merck.com/newsroom/press_releases/research_and_development/2005_1006.html

         Industry Analysis of Gardasil.

          FDA Approves Merck's GARDASIL®, the World's First and Only Cervical Cancer Vaccine

          http://www.bio.com/industryanalysis/industryanalysis_news.jhtml?cid=19400058

 

Risk factors for HPV include: having sexual intercourse before the age of 16, having multiple sex partners, and already having an STD.  Factors which increase the risk of HPV associated cancer are: having multiple children, smoking, long term use of oral contraceptives, and having an impaired immune system (Women’s Health Today, 2005, P. 13).

Beyond HPV, not a lot is known about what causes dysplasia, although research is reported as being assertively in progress.  Some factors involved in the disease are:  genetics, smoking, nutrition (including Vitamin A intake and Anti-Oxidants), early sexual intercourse, and exposure to toxins such as viruses or chemicals.   Studies regarding chemical exposure show that if a woman, and/or her sexual partner work around carcinogenic substances (mining, textile, metal, or chemical) cervical abnormalities are more common. Treatment usually requires invasive or laser surgery.  Naturopathic methods of care necessitate a certified physician.

Cervical cancer is an advanced stage of cervical dysplasia.  Symptoms of cervical cancer are rare until the disease has progressed.  Once invasive there may be notice of foul vaginal discharge, bleeding outside of menstruation, pain and vaginal bleeding during sex, and post menopausal vaginal bleeding. Pelvic pain is not necessarily apparent until after the tissue surrounding the cervix is also infected.

After an abnormal PAP smear, doctors may request a colposcopy to see the damage on the cervix. A Shiller test may also be performed.  This process involves coating the cervix with Iodine to bring out color variations between infected and non-infected flesh.  A biopsy is often mandatory so that tissue samples can be examined to confirm the presence of carcinoma.  There are different types of biopsy, such as endocervical curettage, cone biopsy (conization), and cold-knife cone biopsy.  The loop electrosurgical excision procedure (LEEP) is a cone biopsy heated by an electric current.   There is also a variation of LEEP called large loop excision in transformation zone (LLETZ). These methods, along with conventional cone biopsy, may actually treat and prevent recurrence of precancerous conditions (Gale, 2001).

Treatment

Treatment of cervical cancer depends on how advanced the disease is upon detection.  Surgery to remove the cervix is a standard method for treating the carcinoma.  When the disease is in its advance stages, radiation combined with chemotherapy may be required.  Complete hysterectomy is reserved for extreme cases.

Conventional medicine states that the treatment of cervical cancer may involve a multi-disciplinary team of a gynecologic oncologist, radiation oncologist, and medical oncologist.  There is no immediate mention of an interdisciplinary team of a gynecologic oncologist, psychological counsel, nutritionist, etc.  Though proper diet is stressed, no specific example of dietary and lifestyle changes are given outside of suggestions that Vitamin A, C and E may reduce the risk of getting the cancer (Garcia, 2002).

One natural remedy program outlined by Page (1997, p. 45) includes: 

A diet to encourage strong immune response including foods which are fiber rich, low in fat, and full of fresh fruits and vegetables.  It is explained that junk food aggravates herpes-type infections.

Animal products should be decreased because of their possible contamination with estrogen.

Anti-oxidants (especially proanthocyanidins, otherwise known as OPC’s, which are derived  from grape seed or pine bark,  should be added to meal regimes,  along with beta-carotene, vitamin C, selenium, and B-Complex  as folic acid and B6.

Anti-viral remedies including echinacea, garlic, licorice root, dandelion, wormwood, kelp, peppermint oil, and L-Lysine.

Page also outlines a specific natural choice for advanced stage dysplasia where homeopathic surgeons “burned” out the dysplastic tissue using zinc chloride solution, and an herbal ‘sanguinaria’ tincture, which assists in inspiring heavy blood flow.  Herbal and vitamin suppositories are used at bedtime for the duration of the treatment, which is done over 3-5 weeks, and should only be considered with the supervision of a qualified naturopathic physician.

Prevention & Research

Cervical cancer is now primarily considered a preventable STD by many gynecologic professionals, unlike other forms of cancer, which are considered indigenous to the body, or induced by chemical exposure.  Preventative measures are now based around safe sex or abstinence.

Supplemental

Diethylstilbestrol (DES) is another causative agent of cervical cancer.  DES is a synthetic form of the female hormone estrogen, and was prescribed between 1938 and 1971 to assist with certain complications of pregnancy, such as miscarriage.  “Use of DES declined in the 1960s after studies showed that it is not effective in preventing pregnancy complications. When given during the first 5 months of a pregnancy, DES can interfere with the development of the reproductive system in a fetus. For this reason, although DES and other estrogen may be prescribed for some medical problems, they are no longer used during pregnancy” (NCI (On-Line), 2003). 

DES was administered to an estimated 4.8 million American women between 1938 and 1971. Manufactured under more than 200 names, it was believed to prevent miscarriage, and was administered primarily in the United States, though also abroad, in the form of pills, injections, and suppositories (The Boston Women’s Health Book Collective, 1998).

DES daughters are the female children of women who used DES who were exposed in utero to DES. Many of them suffer from a rare form of cancer which affects the vagina and cervix called clear-cell adenocarcinoma.  The age range for women suffering from this rare cancer is 07 to 40, with the primary age group being 15-22. 

Cellular problems created by exposure to DES are not necessarily apparent in a PAP smear.  A DES exam consists of:  visual inspection of vagina and cervix for abnormalities, palpation exam or feeling the vagina, uterus, cervix, and ovaries for lumps,  PAP smears which include a cervical pap supplemented with a vaginal PAP called “four quadrant” from the fact that it takes cells from all sides of the vagina, bi manual exam, Schiller’s Test which is iodine staining of the vagina and cervix (normal tissue stains brown, diseased tissue does not stain), colposcopy which magnifies the view into the vagina and cervix, and biopsy to see if cancer is present in any tissue.

As recently as 2002, the National Cooperative Diethylstilbestrol Adenosis Study (DESAD) was furthering research on hormonal, fertility, and cancer issues related to DES exposure now that “daughters of DES” enter in menopause.  It is unclear what definite multi-generational effects stem from exposure.

Endometriosis
Overview

Endometriosis, unlike most of the diseases/conditions discussed, is not caused by a sexually transmitted disease such as chlamydia or gonorrhea, though research was presented at the Eighth World Conference on Endometriosis in 2002 showing a connection between Autoimmune Disorders and the condition (Kaiser Network. 2005).  “[Endometriosis] occurs in up to 10% of reproductive age women, according to conservative estimates; of these women, 30 percent to 40 percent are infertile, making endometriosis one of the top three causes of infertility” (Women’s Health Today, 2005, p. 23).

First reported in Ancient Egypt in 1600 B.C. (Disease of the 90s, 2004), endometriosis was first officially described in 1690 by the German physician Daniel Shroen (Dr. John M. Sullivan, M.D., 2005, p. 1), and was clinically recognized as a distinct disease only in the later part of the 20th century (Rosenthal, 1998). The combination of symptoms were often considered standard female complaints, and not indicative of a specific disease.

Endometriosis is a condition where tissue similar to the lining of the uterus (endometrium) grows outside of the womb, or in other parts of the body.  This tissue responds to monthly hormonal cycles, building and shedding as would the lining of the uterus during menstruation. The blood from these discarded pieces of tissue falls onto surrounding areas and organs, causing inflammation (Gale, 2000).   Most common are growths in the pelvic region, ovaries, and fallopian tubes, along with the ligaments supporting the uterus, the perineum, the outer lining of the uterus, and the lining of the pelvic cavity.  Growths may also travel to the abdomen, rectum, bladder, cervix, vagina, and vulva.  Rarely, but also possible, are growths in the lung, arm, and thigh (Rosenthal, 1998). Over time, scar tissue and adhesions form.  Cysts may also cover scar tissue, and tumors may develop (Gale, 2000).

It is estimated that five million women have endometriosis (Rosenthal, 2003).  Sadly, many women suffer with debilitating pain for years before their symptoms are correctly recognized.  “At a conference on endometriosis, representatives of patient self-help groups from the United Kingdom and North America emphasized how frequently there is a delay in diagnosis…. / … 27% of patients complained of symptoms for six years before diagnosis were made” (Rosenthal, 2004, prgph 02).  According to eMedicine, a “large-scale laparoscopic evaluation of asymptomatic women has never been performed”, and the figures do vary amongst sources.  It is known that endometriosis is an increasingly common diagnosis, though (Daly, 2001).

Endometriosis was called the “career women’s disease” (Gale, 2000) for many years, because it was thought that it was caused by middle aged women delaying in getting pregnant.  Now it is known that endometriosis may affect women throughout their reproductive years, and that many of its victims are young women between the ages of 25-29  (Daly, 2001).  According to the Endometriosis Association that age is too high.  Studies conducted within inner-city African-American neighborhoods in the Midwest, reveal girls as young as 15 are developing symptoms (Endometriosis Association, 2005). At this point in time it is thought that a woman must be menstruating before she can develop symptoms, though she may have a predisposition if maternal relatives have the condition.  Endometriosis rarely affects women before the start of their periods, or after menopause.

There are many symptoms of endometriosis.  The primary, initial complaints are chronic pelvic pain and painful intercourse.  The other symptoms seem to affect women who are not diagnosed quickly, and tend to be a “complete package” of problems.  These include, but are not limited to: abnormal periods, painful bowel movement, bowel irritability (back and forth between constipation and diarrhea), lower back pain, stomach problems, dizziness, extreme bloating, low grade fever, hot flashes, leg pain, mood swings, shaking, and cramps. (Christie, 20047). 

One of the results of these symptoms, along with the condition, is infertility.  Infertility may be temporary or permanent.  It is noted that women with pelvic pain and/or fertility problems may have more than one condition, such as PID (Daly, 2001).  It has not been established if there is a common underlying condition creating this multifaceted range of symptoms beyond the categorization presented here.

Etiology & Diagnosis

Though the exact cause of Endometriosis is unknown, there are some theories available for speculation.  The Gale Encyclopedia of Alternative Medicine and The Infertility Source Book offer the following considerations:

1. Implantation theory: Also known as Retrograde Menstruation or Trans-tubal Migration, Implantation theory states that a reversal in menstrual flow sends discarded endometrial cells into the body cavity where they attach to internal organs and seed endometrial implants.
2. Vascular-Lymphatic theory:  Suggests that the lymph system or vascular systems are the vehicles for distribution of endometrial cells out of the uterus.
3. Coelomic metaplasia theory:  Hypothesis that remnants of tissue left over from prenatal development of the women’s reproductive tract transform into endometrial cells throughout the body.
4. Induction theory:  Postulates that an unidentified substance found in the body forces cells from the lining of the body cavity to change into endometrial cells.
5. Iatrogenic transfer: Cross-contamination from a surgical or treatment procedure.
   Some factors that influence the possibility of endometriosis are:

• Hereditary.
• Immune system function.
• Dioxin exposure.
• Environmental Estrogens.

Diagnosis of endometriosis has become possible in the 1970s due to laparoscopy tests. Laparoscopy is an invasive surgical technique. By viewing into the reproductive area through the abdomen via a laparoscope, endometriomas (the scar tissue) can be cauterized, and adhesions lysed (caulderized) (Day, 2001).  Literature on laparoscopy can be confusing, as it is both a diagnostic tool and the means to assist with surgical treatment of the condition.  When a patient first goes to the doctor complaining of pelvic or uterine pain, a pelvic exam is usually performed, but endometriosis can not be detected in a manual exam.  If it is thought that endometriosis may be present, a laparoscopy must be requested, with the results considered the only definitive source of diagnosis.  There are other tests which may be done in affiliation with the laparoscopy.  These tests include: ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI).  Blood tests may also be useful, as women with endometriosis have higher levels of the blood protein CA125 (Gale, 2000). A Canadian bio-tech firm, PROCREA Bio-Sciences, has introduced Metrio Test, a “quick and minimally invasive diagnostic tool” (PR NewsWire, 2002).  “A doctor would perform an endometrial biopsy and obtain a blood sample.  The test can detect several immunological markers in the uterine lining as well as a biochemical blood serum marker” (Kaiser Network., 2002).  There is little information about the test being utilized within American gynecologic practices. 

In December, 2005, the Kaiser Daily Women’s Health Policy and the Wall Street Journal released an article examining research being conducted on new diagnostic and treatment advances by Valeo-Medical of Burlington, VT.  The life sciences is company is “trying to find a less-expensive blood test that would be an easier and less-invasive alternative to laparoscopy”, but added that, “breakthroughs in diagnosis and treatment are still years away” due to a lack of government and private funding (Kaiernework.org, p. 1, 29 November 2005).

Treatment

Treatment of endometriosis is still being researched.  It is considered a chronic disorder. There is no cure, except for complete hysterectomy in extremely severe cases.  In advanced cases, laser surgery is performed through a laparoscope to remove scar tissue.  In minor cases, ibuprophen is suggested to alleviate discomfort (Rosenthal, 1998).  Medications that may used to alleviate the discomfort of endometriosis are over-the-counter pain relievers such as Tylenol, Advil, or Motrin.  If pain is chronic or debilitating, narcotics may be prescribed, though many doctors are hesitant about prescribing any medication that may be addictive or habit forming.

Some treatments depend upon whether or not a woman wants to try to have children, or prefers to live child-free.  Hormones are administered to stop the ovary from producing estrogen and therefore stop menstruation, which exacerbates the condition. Specific hormone treatments are:  Gonadotrophin (GnRh agonists) releasing hormone analogs, Danazol, progesterone-like drugs such as Provera, and oral contraceptives.  These treatments lower hormone levels, encouraging endometriosis masses to shrink. GnHR antagonists are also being researched, as are aromatase inhibitors (which reduce estrogen levels), and selective progesterone receptor modulators (which may reduce endometriosis implants).  Hormone treatments can be very expensive, and have some unpleasant side effects, such as hot flashes, reversible bone loss, mood swings, and bleeding. (Women’s Health Today, 2005, p. 23). Also, soon after discontinuing the hormones, symptoms often return.

Surgery is categorized into two groups: “conservative” and “radical”.  Conservative surgery includes scraping, cutting, cauterizing, and laser options.  Operative laparoscopy is of great assistance in furthering conservative methods of surgery.  Radical surgery is defined as hysterectomy or oophorectomy.  Recurrence is possible after removing the ovaries, but the overall procedure is considered healthier than a complete removal of the uterus and ovaries.  Endometriosis can develop into uterine cancer, so it is important to understand why procedures may be recommended by a practitioner.

Endometriosis is one of the few gender specific conditions where alternative treatments are strongly recommended in affiliation with conventional care.  This is mainly because women have searched out relief from symptoms that doctors originally could not facilitate.  According to the Endometriosis Association (2003), 40%-60% of women who have endometriosis have used alternative medicines, along with traditional methods, and have reported relief of pain and other symptoms. The natural remedies include diet, supplements, acupuncture, acupressure, visualization, guided imagery, naturopathy, homeopathy, hydrotherapy, exercise, and meditation.   The Boston Women’s Health Book Collective (1998) adds chiropractor visits, herbs, and nutritional therapies to that established list of alternative treatments.  More specific information is found in writing by Linda Rector Page, N.D., PhD, and also Susan Lark, M.D.  Both women have dedicated an enormous amount of research to natural remedies for endometriosis.  Though it is commonly understood that hormone suppressing therapies are necessary, there are many clinicians and health care advisors that believe that therapy can not be effective without proper diet, exercise, and lifestyle changes.  For women suffering from the symptoms of endometriosis it is suggested that fat levels be lowered to reduce body fat and  excess circulating estrogen, also reduction of sugary foods, elimination of caffeine, and the elimination (or at least reduction) of dairy.  Other foods that should be restricted are acid forming foods such as red meat, eggs, cheese, sugar, and saturated fats.  The reason for the reduction in such popular foods is because   they may “produce F2 Alpha Prostaglandins that trigger muscle contraction, inflammation, constriction in blood vessels, cramps, and spread of implants” (Page, 1997.  p. 24). Green vegetables and soy are strongly recommended, as are blue-green algae drinks, bioflavonoid, evening primrose oil, burdock tea, lots of Vitamin “C”, black cohosh, and dandelion.  Lark explains that foods with a range of nutrients help keep hormones balanced, reduce estrogen levels, decrease cramping and inflammation, and improve physical and mental well-being.  She includes whole grains, legumes, vegetables, fruits, seeds, nuts, meat, poultry, and fish in her daily recommended diet.  She also recommends cooking oils with a vitamin E base.  Vitamin E is said to reduce mood symptoms, fatigue, and cramps.  It is further explained that supplements assist with balancing hormones and reducing estrogen levels.  Important vitamins to take when experiencing or recovering from endometriosis are Vitamin A (reduces heavy menstrual bleeding), Vitamin B Complex (Biochemical balance), Vitamin C with Bioflavonoid (reduces bleeding, strengthens capillaries, increases iron absorption from other food sources, and is an important anti-stress component.)  Herbs such as fennel, anise, blessed thistle, false unicorn root, goldenseal, shepherd’s purse, yellow dock, pau d’arco, tumeric, silymarin, meadowsweet, and white willow bark are listed for various ailments.  Herbal remedies should not be taken without specialized supervision by a naturopathic physician.

Prevention & Research

Presently, there are not any real preventative measures that can be taken against endometriosis, though prevention against recurrence is possible.  Adult women may consider pregnancy a temporary measure against endometriosis.  Induced menopause is another treatment strategy for extreme cases (Rosenthal, 1998).

Aerobic exercise is suggested for adolescent aged females to minimize the possibility of endometriosis (Gale, 2000).  In women with an established condition Lark explains, “...  aerobic exercise can improve both circulation and oxygenation to tight, constricted muscles…” (Lark, 1996, p. 46).

Unlike any other gynecologic disease or condition, almost every resource (traditional and complimentary) mentions the benefits of an advocacy organization, the Endometriosis Association.  The grass-roots operation, started in 1980 in Milwaukee, WI by Mary Lou Ballweg, acts as an advocate for patient’s rights and research pertaining to endometriosis. They have a wealth of information available on the subject, along with state-by-state references and community groups to assist teenagers and women with the disease.  One of the reasons, besides being extremely well organized and directed, that Ms. Ballweg’s endeavor has done so well is due to the fact that each year more and more are being diagnosed with the condition, to the point where it is considered a contemporary health crisis.

Supplemental: Uterine / Endometrial Cancer

Endometriosis, when not efficiently and properly treated, can lead to endometrial cancer, a uterine cancer that is most predominant after menopause.8 The reason for this is that uterine cancers occur when “cells in the endometrium lining grow out of control and invade the muscles of the uterus” (GCF/SGO, 2005, p. 14).  The most common risk factors for endometrial cancer are obesity, hypertension, and inappropriate use of estrogen, tamoxifen use and late menopause.  An annual pelvic exam is the most commonly recommended means of detection for endometrial cancer, though a biopsy and/or D & C may be requested if a patient is suffering from painful, excessive bleeding, or other symptoms that may indicate a problem.   

Prevention is based around a healthy diet or medical diet plan (i.e.: no dairy, no fried foods, no caffeine) and lifestyle, keeping blood sugar and pressure low.  It is important to know that a PAP will not reveal endometrial or uterine cancer.  Women who have been diagnosed with endometriosis should be advised to maintain treatment and annual tests.

Ovarian Cysts - Polycystic Ovarian Syndrome (PCOS)
Overview

 According to [T]he Washington Times, polycystic ovary syndrome affects approximately 5% to 10% of U.S. women of reproductive age and is the most common cause of infertility in women (Kaiser Foundation, 2005). An ovarian cyst, as defined by the PDR’s Family Guide to Women’s Health and Prescription Drugs (2001), is a “sac or pouch that develops in the ovary, often during ovulation.  The contents of the cysts are usually liquid, but can also be solid or a mixture of liquid and solid materials” (PDR, 2001). Polycystic ovarian syndrome (PCOS) is a “type of reproductive disorder in which excessive amounts of androgens (male hormones such as testosterone) are produced by the ovaries” (ObGynCenterOnline, 2005). Although in medical texts, the documented history of ovarian cysts details them as growing rather large, in contemporary medicine, cysts are usually established and removed before growing larger than a golf ball.
Common symptoms are abdominal tenderness and pain, along with pain during intercourse.  Cysts may also cause pressure on the bladder, the rectum, and as a result create bowel discomfort.  Occasionally cysts upset the normal balance of the menstrual cycle.  In severe cases, fever and nausea are reported.

There are various types of cysts, some problematic, some considered to be normal, or a natural function.  Functional cysts, which are categorized as follicle cysts and the corpus luteum cysts, develop as part of the “natural function of the ovary”.  Polycystic ovaries are common amongst American women, and are considered a “hormonal imbalance”, as opposed to a disease.  A danger associated with polycystic ovaries is due to the disruption of the normal menstrual cycle. The lining of the uterus may grow between sporadic periods, increasing the risk of endometrial cancer.  Endometrial cysts, nicknamed “chocolate cysts” because they are filled with dark blood, result from having endometriosis (PDR, 2001).

When cysts are not considered “functional”, they enter into the category of cystadenomas.  Cystadenomas, otherwise known as ovarian neoplasm, is carcinoma, when malignant.  Serous cystdenoma is filled with a thin, watery fluid which fills 2-6 inches in diameter.  Though most common in women between 30 and 40, these may occur anywhere between the ages of 20 and 50.  Mucinous cystadenoma has a sticky, thick substance filling it, and grows up to 40 inches large.  These are most common in women between 30 and 50 (PDR, 2001).

The last category of ovarian cyst is Dermoid cysts.  Dermoid cysts are also ovarian neoplasm.  These contain skin tissue, and are considered tumors.  These cysts are considered common, and may occur anywhere between the ages of 20 and 40 (PDR, 2001).

Etiology & Diagnosis

Symptoms that suggest seeking medical attention are abdominal and pelvic pain, pain with intercourse, unusual vaginal bleeding, odd weight gain or bloating, irregular periods, infertility, excessive levels of insulin, male-pattern hair thinning, skin tags, and hirshuitism (excessive hair growth on face and body).

A pelvic exam and PAP are the first steps towards diagnosis.  Often a doctor can feel ovarian cysts during what is called a “bimanual exam”, an exam involving two fingers and a speculum in the vagina.  Blood hormone levels may also be tested as a root cause of problem.  For example, in PCOS excessive amounts of androgen are often responsible for the condition. Horm ultrasounds and laparoscopy may be requested for in depth diagnosis.

It is essential that a women suffering from PCOS is efficiently diagnosed.  If not treated, the disorder can lead to Type II Diabetes, infertility, heart disease, high blood pressure, high cholesterol, obesity, and even uterine cancer.

PCOS has similar symptoms to other diseases and conditions.  “Because of the variable nature of the syndrome, the American Society for Reproductive Medicine (ASHRM) and the European Society for Human Reproduction and Embryology (ESHRE) redefined the guidelines for PCOS diagnosis... A woman must have two of the following symptoms: 1) Irregular or absent ovulation. 2) elevated levels of androgens. 3) polycystic ovaries (ObGynCenterOnline, 2005).

Treatment

PCOS is considered chronic and life-long, even with treatment. Treatment of cysts depends on the specific type of cysts present in the ovaries, and also the desire of the patient to conceive. Some treatments will prevent child-bearing by leaving a woman infertile.  Functional cysts are usually treated with oral contraceptives (estrogen), and monitored over a period of time to see if surgery is necessary.  Sometimes they simply heal themselves. Polycystic cysts are often treated with medroxyprogesterone, and/or oral contraceptives.  Danazol (Danocrine) is a synthetic steroid which is becoming popular with many doctors.  Originally doctors performed a “wedge resection” where part of the ovary was removed, though now hormone treatments are preferred as a companion, or as an alternative, to surgery.  Surgery is still the most common method for the removal and prevention of recurrence with Endometriomas, Cystadenomas and Dermoid cysts (PDR, 2001).

Natural therapy for ovarian cysts concentrates on hormone imbalance, and works with diet to balance the system.  Dark green, leafy vegetables, whole grains, legumes, nuts, seeds, and fresh fruit are considered good choices.  Caffeine, sugar, and chlorinated water should all be removed.  (Page, 1997)  There is also an array of herb therapies available for ovarian cysts, along with Type 2 PAP smears.

Ovarian Cancer

According to the American Cancer Society, gynecologic cancers will affect approximately 79,480 women and take 29,910 lives this year (Yahoo, 2005).  Philadelphia’s Liz Scharf recently reported on Health Beat that many women with ovarian cancer “have symptoms of the disease - and complain to their doctor about them - six months before they are finally diagnosed” (NBC 10, 2005).  Researchers in California found that “[i]n many cases, physicians initially failed to perform the best available tests to rule out ovarian cancer, including pelvic imaging and a blood test called CA125" (Kaiser Network, 2005).    If ovarian cancer is caught early, patients have a five year life expectancy rate. If detected in moderate to late stages, quality of life (QuOL) and life expectancy are diminished to an alarming degree.  Less than a quarter of all cases are caught early.  Other news articles have reported that women have reported symptoms to doctors up to twelve months prior to diagnosis only to be treated for stomach disorders.  “Raising awareness among primary care physicians and sub-specialists, particularly gastroenterologists” is essential (HealthDay News, 2005).

President George W. Bush named September 2003 ‘Ovarian Cancer Awareness Month’,  urging “individuals across the country to learn more about this disease and what can be done to reduce the number of individuals who suffer from it” (Whitehouse News Release, 2003).   He went on to say how scientists at the Centers for Disease Control and Prevention (CDCP), the National Cancer Institute (NCI), the Department of Defense, the Food and Drug Administration, other Federal agencies, and private companies are “working hard to discover the causes of ovarian cancer and to design more effective screening and treatment options”.

In 2001, Dr. David M. Gershenson of the Department of Gynecologic Oncology at the University of Texas exclaimed in an academic presidential address, “American woman are not receiving state-of-the-art gynecologic care.”  He cited an unregulated medical system, lack of education, lack of interdisciplinary care, conflicts with physician referrals, and medical competition as the most relevant concerns (Gershenson, Cancer Journal, 2001, p. 454).  These issues have not been specifically addressed in depth by the government; only in comments that there is a need for more research and education, with suggestions for funding.

Description

Gynecologic cancers are the uncontrolled growth and spread of abnormal cells originating in the female reproductive organs, including the cervix, ovaries, uterus, fallopian tubes, vagina, and vulva.

The three most common gynecologic cancers are endometrial cancer, ovarian cancer, and cervical cancer.  Cervical cancer, as discussed, is the only cancer caused by a sexually transmitted disease.  Endometrial cancer9 and ovarian cancer evade understanding in many ways.   Ovarian cancer is problematic because it comes on quickly and has a high mortality rate. Diagnosis is often late, and greatly reduces QuOL standards in the process present modes of treatment.

Etiology

Oncogenes and tumor suppressor genes are responsible for cancer.  Smoking, aging, toxins in the environment and hereditary factors are the primary cause of cancer.  Women are also in a higher risk category if they have never conceived or birthed children, have had ovarian cysts, or were obese in childhood.

There are two main categories of ovarian cancer: 1. epithelial ovarian cancer, which is most common around menopause, and is often hereditary. Inherited ovarian cancer is often caused by a mutation in BRCA genes.  2. Germ cell and Stromal cell cancer.  Germ cell cancer begins in the cells that form ovarian eggs.  Stromal cell cancer is rare, and forms in the cells that “produce female hormones and hold the ovarian tissues together” (GCF/SGO, 2005).

Symptoms and Diagnosis

The most common symptoms of ovarian cancer are abdominal pain, pressure and bloating, abdominal bleeding, indigestion, pelvic pain, and changes in the output of the bowel and bladder such as urinary urgency.  Stromal cell cancers also secrete hormones such as estrogen and testosterone. Germ cell tumors secrete pregnancy hormone HCG, so one added symptom is a false positive pregnancy test.

Common tests are annual pelvic exams, ultrasounds, blood tests that measure tumor markers, and genetic counseling.  A biopsy and pelvic ultrasound are usually the first steps in diagnosis.  However, it has been determined that many physicians omit important aspects of biopsy by not taking a large enough sampling including biopsy of “abdominal or pelvic peritoneum and sampling of the retro peritoneal lymph nodes” (Gershenson, Cancer Journal, 2001, p. 451).  It is important that the patient advocates for all aspects of biopsy, or has an advocate to assist in areas that are too medically advanced for the common patient to know to ask.

The most common cancer screening processes using ultrasonography or tumor-marker measurements have also not been effective in efficiently catching ovarian cancer due to the fact that early stage ovarian cancer (neoplasms) “spread rapidly, sometimes when they are only microscopial in size...”  (The Lancet, 2005, p. 1028).  A new method of testing for ovarian cancer is called ‘proteomics’, and involves the analysis of blood proteins.  Ovacheck is a new variation of the blood protein test currently being reviewed. 

CA125 is an established, though  controversial marker test which is not covered by most insurance carriers or recommended by physicians due to erratic results (i.e.: false positives).  The National Ovarian Cancer Coalition (NOCC) explains CA125 as,

A substance shed by cancer cells, also made by inflamed normal cells that line body parts. This substance is shed in body fluids and finds its way into the bloodstream. CA-125II is a new assay that has less variation from day to day. Since the original CA-125 test kits are no longer sold to laboratories, it is believed that few if any old plain CA-125 tests are being given in the United States since Nov. 1996. CA-125 is a test done on a blood sample drawn in a laboratory. A blood sample is drawn, just as for a variety of other laboratory tests. The assay (analysis) assesses the amount of an antibody that recognizes an antigen in tumor cells” (NOCC, 2005).

If a patient is experiencing symptoms that could be ovarian cancer, it is wise to request all possible tests, and evaluate the results in comparison with the symptoms. It is better to have as much information as possible, as opposed to not having enough information until it is too late.  Ovarian cancer “ranks fourth in cancer deaths among women and causes more deaths than any other cancer of the reproductive system” (GCF/SGO, 2005, p. 8).  That is a frightening statistic.

Treatment

Though a patient would initially seek out diagnosis from the primary care practitioner, an ob-gyn or gastroenterologist; gynecologic oncologists are the suggested professional practitioner for treating any form of cancer of the reproductive system. “[c]are studies clearly demonstrate improved outcomes and more complete surgical procedures when surgery for ovarian cancer is performed by a gynecologic oncologist than when it is performed by other surgical sub-specialists” (Gershenson, Cancer Journal, 2001, p. 451).

Most gynecologic cancers are treated using surgery, radiation, chemotherapy, and “experimental” treatments.  For ovarian cancer surgery is the preferred treatment, along with radiation therapy, though relapse is common.  One clinical trial reported in 2004 that the “goal of initial surgery for women with ovarian cancer is to remove as much of the tumor as possible. If tumor spots larger than 1 centimeter cannot be removed during the first surgery, it is less likely that the cancer can be driven into remission with chemotherapy” (GCF/SGO, 2005, p. 19).  Early detection and action are essential for positive treatment results.

Toxic Shock Syndrome (TSS) Overview

Toxic Shock Syndrome (TSS) is a rare disease caused by the bacteria Staphylococcus aureus which normally lives on the skin and in the nose, armpit, groin or vagina of one in every three people.  (Toxic Shock Syndrome Information Service (TSSIS), 1993). Though the disease most often occurs in menstruating women, it “can also affect postmenopausal women, children, and men” (ObGynCenter Online, 2005).  In rare cases certain strains of these bacteria can produce toxins that cause TSS, which, though infrequent, can be fatal.  Streptococcus pyrogenes is a secondary bacterium which causes TSS.  Originally it was believed that tampons were directly, and completely, responsible for TSS.

Laurie Garret, author of the 1994 medical shocker, The Coming Plague: Newly Emerging Diseases in a World Out of Balance, discusses the specifics of the disease in “Feminine Hygiene (As Debated, Mostly, by Men)”.  She explains the intricate process of determining what TSS actually was caused by, and how tampons were the passive carrier, not the active etiology, as many in medicine and media wanted to conclude.

In the 1980s the battle to gain an understanding of TSS was covered in the mainstream news unlike prior gynecologic conditions because of the presumed connection to tampon use.  With revised standards in the manufacture and distribution of tampons in the United States, TSS has disappeared from public attention.  It is now being seen more in developing nations as formally rural areas become more developed and/or industrialized, bringing more women into the workforce, and generating a greater need for extended tampon use, a factor in contracting the infection. 

Symptoms include high fever, vomiting, rash, diarrhea, muscle aches, dizziness, and confusion.  Though TSS can be found in men, women, and children, it was the strain of cases during 1980 of women reportedly contracting the illness as a direct result of tampon use that brought the disease into public light.  To clarify the “separated relationship” between TSS and tampon use, the following is quoted from a hypothesis by University of California at Los Angeles (UCLA) scientist Patrick Schlievert in Garret’s book:

The strain possessed a set of genes that coded for pyrogenic exotoxin A; first time infection resulted in a mild form of flu-like disease that did not meet the CDC definition of either TSS or Kawasaki syndrome.  That first exposure did set into a motion a chain of events in the immune system that sensitized the patient; following a second or third exposure to the Staph toxin the individual’s immune system went into self-destruct mode...” / “Tampons are just a passive co-factor in this disease.”

Etiology & Diagnosis

TSS presents a horrible attack on the immune system.  The toxins that create TSS are called “superantigens” because of how adversely affected the healthy immune system.  A comparison might be an entire immunological meltdown.

 “Helper T cells recognize antigens by binding to them.  When this recognition occurs, the immune system swings into action against the invader and makes specific proteins, called antibodies that tag the invader for destruction by other immune cells.  The TSS toxins are superantigens because the immune reaction they incite is nonspecific and aggressive.  Helper T cells bind to the toxins, but instead of activating one small part of the immune system -  the antibody production mechanism -- the helper T cells toxin binding “turns on” all of the immune system” (Gale (On-Line), 2001).

Early stages produce flu like symptoms, but within a few days, blood pressure can drop, and the victim may experience shock.  Since TSS enters into the circulatory system, it is important to treat the disease before it contaminates the entire system.

Treatment

“Treatment usually centers on taking care of the affected organs in addition to the use of antibiotics to kill the bacteria causing the infection.  If the illness results from an infected wound, surgery may be required to rid the affected area of the bacteria” (ObGynCenterOnline, 2005).

Prevention & Research

Due to the deaths that were reported in 1980 use of low absorbency, non fragranced tampons are suggested, as is the recommendation that tampons be changed often.  TSS is rare, and in most cases can be prevented.  Education, along with modifications in government and corporate regulation pertaining to the research, development, production of, and marketing of feminine hygiene products has been essential.

In 1993 the Toxic Shock Syndrome Information Service (TSSIS) was started with funding from Accantia Health and Beauty Ltd., Chilwood Ltd., Kimberly-Clark Ltd., and Procter & Gamble U.K. (TSSIS, 1993). This organization provides information to doctors and the public on this rare disease, assisting with the betterment of understanding and treatment.

Footnotes and References available upon request.

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