The Pap smear is named after Dr. George Papanicolau (known as Dr Pap). It is a screening test that evaluates the cells on the cervix. Dr Papanicolau researched the cytological (cell) changes in the vaginal tissues during a women’s hormonal cycles and through his research he discovered changes that occur related to cancer of the cervix. His research started in the 1920’s but the pap smear was not put into clinical use until the 1950s.
In the 1940’s cervical cancer was the leading cause of death in women in the United States. Unfortunately, it is still the leading cause of death from cancer for women in developing countries due to a lack of screening.
With the introduction of annual pap smear screening the incidence and rate of death from cervical cancer for women in the United States has declined dramatically. Cervical cancer still occurs but most often in women who have not had a Pap in 5 years.There are two major types of cervical cancer
The leading cause of cervical cancer is persistent infection of HPV (high risk type). The factors below have been found to increase the risk of cervical cancer by increasing exposure or developing following an infectionSexual activity
Comparison of ACS/ASCCP/ASCP and USPSTF
Recommendations apply to both conventional and liquid-based cytology.
|When to Start||Age 21||Age 21|
|Intervals||Ages 21-29: Cytology alone every 3 yearsAges 30-65: HPV and cytology “co-testing” every 5 years is preferredORCytology alone every 3 years is acceptable||Ages 21-29 years: Cytology alone every 3 yearsAges 30-65: HPV and cytology “co-testing” every 5 years for women who want to extend their screening intervalORCytology alone every 3 years|
|When to Stop||Women older than age 65 following adequate negative prior screening(Women with a history of CIN2 or a more severe diagnosis should continue routine screening for at least 20 years after diagnosis.||Women older than age 65 who have had adequate negative prior screening (as defined below) and who are not otherwise at high risk(Adequate negative prior screening is defined as 3 consecutive negative cytology results or 2 negative co-tests within 10 years before cessation of screening, with the most recent occurring in the past 5 years.)|
|Post Total Hysterectomy||Women who have had a total hysterectomy (with removal of the cervix) should not be screened unless there is a history of CIN2 or more severe diagnosis in the past 20 years, or a history of cervical cancer ever||Women who have had a total hysterectomy (with removal of the cervix) should not be screened unless there is a history of high-grade precancer or cervical cancer|
Ovarian cancer is the second most common gynecologic malignancy and the most common cause of death women with a gynecologic cancer. Ovarian cancer is typically diagnosed when it has already reached an advanced stage. Successful and effective screening programs have not been developed to date.What is ovarian cancer and where does it originate?
To properly screen, diagnose, classify and properly treat ovarian cancer it is important to establish what kind of cells originated the cancer. Improved detection of abnormal cells may one day help develop strategies for prevention.
Embryology* and the Female Reproductive Tract
The ovary is derived from different embryonic* structures than the fallopian tubes, uterus, cervix and vagina. Research is narrowing in on the fact that the different origin of ovarian tissue may have important implications for screening, diagnosis, treatment and prevention.
Types of Ovarian Cancers
The most common ovarian cancer is Epithelial* Ovarian Cancer (EOC) comprising 85-90% of all cancers of the ovaries. Serous* Epithelial Ovarian Cancer is the most common type, making up about two thirds of the cases diagnosed. This is a very aggressive cancer and is responsible for the majority of the deaths from ovarian cancer.
The remaining ovarian cancers develop from cells that are not epithelial. Other types of ovarian cancers include:
CA 125 (Cancer Antigen 125) also known as MUC 16 is a protein which is encoded (produced) by gene MUC 16. It is a member of the mucin family glycloproteins*. Glycoproteins are involved in lubrication of the epithelial lumen (tube-like spaces lined by epithelial cells). CA 125 is a tumor marker that can signal the presence of cancer. It becomes elevated in 90% of advanced stage ovarian cancers.
However, it is not sensitive (may not pick up ovarian cancers) nor is it very specific (other things cause a rise in CA 125). Therefore, it can produce false negative results (poor sensitivity) and false positive results (poor specificity). CA 125 may be elevated in patients with: cirrhosis of the liver, pancreatic cancer, fallopian tube cancer, uterine cancer, endometriosis, colon cancer and even in normal menstruating women.
No clear biomarker has been discovered yet that can serve as an effective, sensitive and specific tool for screening for ovarian cancer.What sort of screening can be done?
Women at High Risk
Studies performed on tissue obtained from preventive removal of the ovaries and fallopian tubes in women with BRCA gene mutations showed higher than expected occurrence of early stage cancer in the distal (end part) of the fallopian tube. This finding led to Fallopian Tube Cancer being added to the list of cancers that appear to be related to BRCA gene mutations.
Through genetic analysis and the study of gene mutations it has been found that there is a strong association between tubal carcinomas and ovarian cancer. Although this association has not been shown in all serous epithelial ovarian cancers, the association is significant enough to have challenged previous theories about the origin of ovarian cancer. Research continues to try to answer the question of where ovarian begins. As our understanding increases, better recommendations for prevention, screening and treatment are likely to follow. This may permit more refined tailoring of treatment options based upon risks and eventually equip women to optimize their health.What are the risks for ovarian cancer?
There are two primary risk factors associated with ovarian cancer, family history and ovulation. Women with a family history of ovarian cancer can undergo genetic testing to determine if they have mutations of BRCA1 and BRCA 2 genes.
Useful information can be found at the website for Myriad Genetics, a leading genetics diagnostic company.
Currently, patients found to have the mutation of the BRCA gene will be encouraged to undergo surgery to remove the ovaries and fallopian tubes (BSO*). The timing for this surgery is a decision left to a woman and her physician.
Studies have demonstrated a protective benefit (reduced risk of developing ovarian cancer) for women who have taken birth control pills and suppressed ovulation. A previously held notion that infertility increased the risk of ovarian cancer has been disproven.What are the symptoms of ovarian cancer?
The symptoms of ovarian cancer are similar to many other conditions arising in the pelvis. These symptoms may or may not include www.cdc.gov/cancer/ovarian:
If symptoms of this sort persist, it is recommended that a person consult their doctor.
In Asheville NC area HOPE Cancer Center for Women www.hopewcc.com has outstanding and caring physicians who have dedicated their medical careers to caring for women with gynecologic malignancies (cancers). If you are diagnosed with ovarian cancer you can trust you will receive excellent care by their physicians and staff. Further questions about your cancer will be handled in a step by step fashion with personal sensitivity and care.
Breast Cancer and Screening Recommendations
Breast cancer is the second leading cause of cancer death in women exceeded only by lung cancer in the US.
How and where does breast cancer start
Cancer in general is a broad group of diseases involving cells that divide and grow uncontrollably and invade other tissue. These rapidly growing and dividing cells can move through the body in the lymphatic system and the bloodstream. Breast cancer starts in the breast tissue, primarily the ducts (tiny tubes that carry milk from the lobules to the nipple), lobules( milk producing glands) and the stroma (fatty tissue surrounding the ducts and lobules). Research has shown that gene expression may be responsible for initiating cancer growth. Currently, the type of breast cancer is established based upon how the cells look under a microscope. Newer classification systems utilize the molecular features (genetic patterns) to distinguish between different types of breast cancer.
The American Cancer Society has a wealth of information about breast cancer at:
The most common breast cancer is Invasive Ductal Carcinoma (IDC) which originates in the duct.
Ductal Carcinoma In Situ (DCIS) is non invasive and is a cancer which begins in the tissue but does not spread through the wall
The second most common type is Lobular Carcinoma (ILC) which originates in the lobules.
Lobular Carcinoma In Situ (LCIS) is non invasive.
Other types of breast cancer include: Inflammatory Breast Cancer (rare and aggressive form of breast cancer which starts in the soft tissue, Paget’s disease, sarcoma of the breast, medullary carcinoma, tubular carcinoma, mucinous carcinoma, metastatic carcinoma, adenocystic carcinoma, phyllodes tumor and angiosarcoma. There are other types not listed above.
The classification of breast cancer includes a determination of the receptor status for estrogen & progesterone. The breast tissue has receptors for estrogen (ER) and progesterone (PR), hormones that stimulate and promote tissue growth and that play a role in breast cancer formaton. Breast cancer with ER/PR receptors can be treated with medications that block the hormone and thereby inhibit the growth promoting effect of these hormones. HER2/neu is a growth promoting protein which if present, can be treated with drugs to that target (and disable) the protein.
Staging of cancers are completed after excision (removal) of the cancer and sampling of the lymph nodes.
Screening is looking for cancer before a person has any symptoms.
Mammography is the only screening tool there is available to date. The five year survival rate is 98 % for women who are diagnosed early. Early detection, in order to improve breast cancer outcome and survival, remains the cornerstone to breast cancer control. The American Cancer Society recommends mammograms start at age 40. Although women 40 -50 are less likely to develop breast cancer, the rate of growth is faster than in women in the 70-80 yr old age group.
The American College of Gynecology also recommends screening mammography at age 40. Mammography does have limitations and the controversy in the scientific community is based on the potential to further investigate findings which are not cancer and the missed cancer which can occur.
For women with high risk for breast cancer, MRI and mammogram is recommended. High risk includes:
Here is a link to information from the National Cancer Institute about the genetics of breast and ovarian cancer:
ACOG recommends breast exams, now called clinical breast exams to distinguish them from breast self-exams, every 1-3 years for women 20-39 and yearly after age 40. Breast MRI is recommended only for women in the high risk category.
The medical research has improved the treatment and prognosis of women with breast cancer. Hopefully, our understanding of the causes and natural history will elucidate how prevention can be better understood and what steps can be taken to decrease the incidence in the US.
Here is a link to the American Cancer Society’s Early Detection and Screening Guidelines
October 17th, 2006 by Tori Hudson, N.D. by Tori Hudson, N.D.
Osteoporosis is defined as a skeletal disease characterized by low bone mass and a deterioration in bone microarchitecture leading to bone fragility and susceptibility to fracture. The World Health Organization has defined osteoporosis as a bone mineral density (T-score) that is 2.5 standard deviations below the mean peak value in young adults. This definition is useful because it provides objective criteria, but it has limitations because it ignores the importance of other determinants of bone strength. In addition, it also ignores other risk factors for fractures in elderly women such as a maternal history of hip fracture. Osteoporosis-related fractures will develop in half of all women and one-fifth of all men older than 65 years. Within the first year following a hip fracture, the mortality rate is increased by up to 20 percent, and as many as 25 percent of the survivors will be confined to long-term care facilities one year after the fracture.
Osteoporosis is far easier to prevent than to treat. Osteoporosis prevention strategies need to start in the teenage years. Education should include several key areas: 1) medical problems early in life that can lead to osteoporosis; 2) medications that can interfere with calcium metabolism; 3) the role of nutrition and exercise early in life and their necessity in achieving peak bone density; 4) awareness of the long-term consequences for bone health, if anorexic.
Several approaches are available to prevent osteoporosis and to treat both those who are at high risk and those who have developed the condition. Natural medicines are especially key in prevention. Once osteoporosis has been diagnosed, many of the natural interventions such as diet, exercise, nutritional supplementation and herbal medicines could be used aggressively in milder cases to slow bone loss, reduce fracture rates and possibly have a small impact on increasing bone density. In more serious osteoporosis cases, the natural intervention will become adjunct to a primary antiresorptive therapy. Natural hormone replacement therapy may be considered as a substitute for conventional hormone replacement therapy in selected individuals with monitoring. Natural interventions for osteoporosis include dietary and lifestyle factors, exercise, nutritional supplementation, soy phytoestrogens and natural hormone replacement therapy. Each of these areas deserves special attention. The purpose of this article is to provide an overview of the dietary and nutritional supplementation strategies.
Several dietary factors affect bone health and are involved in the development of osteoporosis: insufficient calcium intake, vitamin d deficiency, low calcium, high phosphorus intake, high animal protein diets, excess salt intake and other mineral deficiencies.
Studies have shown that excessive dietary animal promote may promote bone loss. Animal protein particularly causes an increase in urinary excretion of calcium. Raising daily protein intake from 47-142 grams doubles the excretion of calcium in the urine. Calcium is mobilized from the bone to buffer the acidic breakdown products of protein. In addition, the amino acid methionine, found highest in meat, dairy products, and eggs is converted to homocysteine, which in high amounts may also cause bone loss. A vegetarian diet, on the other had, is associated with a lower risk of osteoporosis, even though vegetarians do not have greater bone mass in their twenties, thirties, and forties. Several studies have shown that vegetarians do have significantly higher bone mass later in life which would indicate that vegetarians lose bone more slowly than nonvegetarians. Many high protein animal foods also contain high amounts of phosphorus, which mobilized calcium from the bones in order to maintain homeostasis in the bloodstream.
Numerous other factors are implicated in osteoporosis development: high phosphorus beverages (associated with low blood calcium levels), refined sugar (increases the loss of calcium by causing an increase in the fasting serum cortisol levels), high sodium intake (causes an increase in urinary excretion of calcium) and refined grains( lack of nutrient-rich germ and bran and deficiencies of vitamin B6, folic acid, calcium magnesium, manganese, copper and zinc).
One of the best general dietary preventive habits to acquire is to eat a lot of dark green leafy vegetables.
These dark greens are a rich source of vitamins and minerals including calcium, vitamin K, and boron.
Soybean products containing soy isoflavones may also slow bone loss. Soy diets have been studied in animal models where it has shown an ability to inhibit bone loss although not to the extent of estradiol. A study conducted at the University of Illinois found that menopausal women had an increase in mineral levels and density in their lumbar spines after taking 55-90 mg of isoflavones for six months. The placebo group showed the lowest bone density and the greatest bone loss, while the estrogen group showed the highest bone density and the slowest bone loss. What was surprising was that the soybean protein diet was effective in preventing bone loss in the fourth lumbar vertebra and, although less so, in the right hip as well. Soybean protein seems to have more of an effect on trabecular bone than on cortical bone. Foods high in calcium include kelp, Swiss and cheddar cheese, carob flour, dulse, collard greens, turnip greens, molasses, almonds, brewer’s yeast, parsley, corn tortillas, dandelion greens, sunflower seeds, Brazil nuts, tofu, calcium fortified soy milk, Goat’s milk, whole milk, sesame seeds, buckwheat, broccoli, walnuts, cottage cheese, spinach and sardines.
Alcohol and smoking
Consumption of alcohol appears to promote bone loss. Scientific evidence links excessive alcohol (seven ounces or more per week) with lower bone mass, increased bone loss, and a higher incidence of fracture. However, in another study, moderate alcohol intake, less than seven drinks per week, was found to be associated with a lower risk of hip fractures compared to women who did not drink. The results of most studies show that smokers lose bone more rapidly and have a lower bone mass than nonsmokers. In female smokers, the risk of hip fracture is increased by 1.5-2.5 fold. Smoking tobacco increases estrogen metabolism by the liver and consequently increases bone loss in women taking estrogen replacement therapy.
When women think about what they can do to prevent osteoporosis, most women think of calcium supplementation. Indeed, calcium supplementation has been shown to decrease bone loss in postmenopausal women. The effects have been greatest in women whose baseline calcium intake was low, in older women, and in women with osteoporosis. Many studies have been done to better understand the effect of calcium and vitamin D supplementation both as a preventive measure and as an additional treatment intervention. In a study of 3,270 institutionalized women in France who were treated with calcium (1,200mg per day) and vitamin D (800 IU per day) for three years, the risk of hip fractures was 30 percent lower than in the placebo group. A more recent study demonstrated that 389 men and women over age 63, who were treated with 500 mg calcium per day and 700 IU vitamin D per day, had a decrease in the rate of nonvertebral fractures. This study stands out because, although the fracture rate was decreased, the bone mineral density of the femoral neck increased only 1.2 percent and the total body, 1.2 percent. This is considered a very small increase. Although calcium alone or vitamin alone appear to be beneficial to bone health, better results are achieved with a combination of both nutrients.
There is a great deal of confusion and controversy about which form of calcium is best. I discourage women from using either oyster shell or bone meal calcium. These calcium supplements may contain substantial amounts of lead. Other sources of calcium from various chelates may also contain lead. A study of lead content in 70 brands of calcium supplements was conducted in 1993. Lead was the highest in bone meal, unrefined calcium carbonate, and dolomite. Lead was the lowest in calcium chelate supplements and refined calcium carbonate. Calcium chelates are bound to citrate, fumarate, malate, succinate, and aspartate. These forms of calcium are often better absorbed in most individuals than calcium carbonate.
The Institute of Medicine of the National Academy of Sciences released new calcium recommendation in 1997. These new guidelines call for increased intakes for most age groups. The new calcium recommendations were set at levels associated with maximum retention of body calcium, because bones that are calcium-rich are known to be less susceptible to fractures.
Remember that these numbers have to do with total calcium intake. Estimate the amount that is being taken in the diet, and then supplement the difference to bring it up to the desired recommended levels. This issue is important because higher doses of calcium may interfere with the absorption of other nutrients, especially zinc.
If using calcium citrate or citrate with malate, comparable doses may be anywhere from 20 percent less to one-fourth the dose of calcium carbonate that is required. The variation may be influenced by the individual’s digestion and intestinal absorption. I estimate and prescribe less calcium citrate than the recommendations for carbonate.
Even though calcium has received the most attention, alternative medicine views the importance of magnesium in skeletal metabolism and calcium regulation in a little bit different and perhaps broader context. Magnesium influences both matrix and mineral metabolism in bone. Magnesium depletion causes cessation of bone growth, decreased osteoblastic and osteoclastic activity, osteopenia, and bone fragility. Adequate serum magnesium levels are necessary for proper calcium metabolism; however, adequate calcium intake may not ensure proper bone health if magnesium status is abnormal. Magnesium deficiency has been shown more than once to be related to osteoporosis. Magnesium status appears to have a major influence on the type of calcium crystals present in the bones, and therefore its deficiency is associated with abnormal calcification of the bone. In order to assess the effects of magnesium on bone density, a group of osteoporotic postmenopausal women were given magnesium over a period of two years. At the end of the study, magnesium therapy appeared to have prevented fractures and resulted in a significant percent in crease in bone mass density after the first year of treatment. There was, however, no change in density from then on to the end of the study.
Manganese may be one of the most important trace nutrients related to osteoporosis. Manganese deficiency causes a reduction in the amount of calcium laid down in the bone and thereby an increased susceptibility to fracture. Manganese stimulates the production of mucopolysaccharides that provide a structure on which calcification takes place.
Boron appears to also have an effect on bone loss in postmenopausal women. Boron supplementation has been shown to reduce the urinary excretion of calcium by 44 percent, reduce urinary magnesium excretion and markedly increase the serum concentration of 17 beta-estradiol and testosterone. Zinc is essential for normal bone formation, enhances the biochemical actions of vitamin D, and is required for the formation of osteoblasts and osteoclasts and for the synthesis of various proteins found in bone tissue. Zinc levels have been found low in the serum and bone of elderly people with osteoporosis.
Copper deficiency may be a related cause of osteoporosis. Copper deficiency is known to produce abnormal bone growth in growing children. Copper supplementation has been shown in laboratory studies to inhibit bone resorption. Its supplementation is deemed necessary in women at risk or with diagnosed osteoporosis. Accelerated bone loss in menopausal women may in part be due to the increased levels of homocysteine, a breakdown product of methionine. Homocysteine has the potential to promote osteoporosis if it is not eliminated adequately. Since folic acid is involved in the breakdown of homocysteine, supplementing postmenopausal women with this nutrient results in significant reductions in homocysteine levels.
Vitamin K is a strong contributing factor in the prevention of osteoporosis. It is required for the production of osteocalcin, the protein matrix on which mineralization occurs. Osteocalcin attracts calcium to bone tissue, enabling calcium crystal formation to occur. Vitamin K plays a key role in the formation, remodeling, and repair of bone by helping the calcium adhere to the site of this protein matrix.
A synthetic derivative of isoflavones, ipriflavone, is now available over the counter in natural food stores or from alternative practitioners. Two multicenter, two-year clinical trials evaluated the efficacy and bioavailability of ipriflavone in postmenopausal women with low bone mass. Study A showed a bone-sparing effect of 1.6 percent in the spine, and study B, 3.5 percent in the wrist after two years. A significant difference was found between the treatment groups and the placebo groups in both studies. It seems as though ipriflavone has a direct ability to inhibit the osteoclastic cell activity, but how it does this is unknown. Although the effect on the spine and wrist is encouraging, these small increases in bone density do not necessarily mean there is a reduced fracture rate, the true test of an effective treatment for the prevention and treatment of osteoporosis.
Osteopathic Medicine Osteopathic medicine provides all the benefits of modern medicine with the added benefit of training in hands on treatment with osteopathic manipulative therapy. DO’s are trained to look at the whole person and emphasizes helping each person achieve a higher level of wellness.
Allopathic Medicine The science of evidence based medicine and use of pharmaceuticals to treat or suppress symptoms of diseases.
Naturopathic Medicine Effort is made to determine the cause of disease and uses different methods that help the body heal itself.
Homeopathy Uses very small doses of substances to trigger the body to heal itself.
Ayruvedic Medicine A system from India emphasizing balance among body, mind and spirit
Chiropractic Medicine Chiropractic focuses on disorders of reh musculoskeletal system and nervous system Integrative/Functional Medicine
Accupuncture Key component to traditional Chinese Medicine that treats a range of conditions by correcting imbalances in the flow of qi through channels known as meridians
Therapeutic massage Massage is manipulation of superficial layers of muscle and connective tissue to promote relaxation and well being.
Craniosacral Therapy Gentle hands on approach that releases tensions deep in the body and improves whole body health. Osteopathic physician John E Upledger pioneered and developed technique after years of research and clinical testing at Michigan State University.
Ortho-bionomy Osteopathic based form of body work through gentle movements and positions.
Muscle energy Manual therapy emerged as a form of osteopathic manipulation in which the patients muscles are actively used on request to counter force.
Strain/Counterstrain Technique used in osteopathic medicine in which the clinician identifies a point of musculoskeletal pain, trigger point and and positions the patient such that the tenderness to palpation is minimized.
Mindfulness training Goal is to become more clear and conscious throughout the day.
Cognitive Behavioral Therapy This form of psychotherapy emphasizes the important role of thinking in how we feel and what we do.
Meditation An exercise of the mind in which you learn to become an observer of your thoughts.
Alexander Technique Movement therapy that correct improper posture and habits
Music Therapy Therapy which improves clients physical and mental health through music
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Thank you for your patience during the past few weeks as we finalized arrangements for the relocating and affiliating our practice. We will be joining AdventHealth Medical Group Multispecialty at South Asheville and seeing patients in the Long Shoals Road location. We hope to see you at our new location. We are excited about how much more can be done to promote women’s health with the support of other providers and the AdventHealth system who share our dedication to providing whole woman care with attention to each person’s unique needs.
Through June 23, 2023, please contact us at our current Gerber Village location. Beginning in early July you can schedule appointments by calling (828) 654-5005 and find more information by visiting the website here. We are working hard to make this a smooth transition.