Let’s face it: the female reproductive system has a lot of parts. And because our society is a bit squeamish when it comes to discussing sexual organs — particularly women’s — the names may be familiar, but we don’t always know which bits are which or what they do.
In keeping with our mission of putting women in control of their health, we’d like to present: your body.
Obviously, the more you know about your body, the better you’re able to monitor your health and stay on top of changes. However, because virtually everything about our reproduction is hidden up inside, it can be tricky to know what’s going on in there.
With the help of our Chief Medical Officer, OB/GYN Dr. Rebecca Dunsmoor-Su, we’ll take you through the parts, where they are, what they do, how they fit into your body and wellness as a whole, and how the choices and decisions you make affect them.
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Your cervix
The cervix is a short tube that connects the lower uterus to the upper vagina. There are a couple of parts to it: the ectocervix, the bit that’s exterior enough to be seen in a pelvic exam, and the endocervix, the canal that leads from the opening of the cervix (the “external os”) through to the uterus. The border between ecto and endo overlaps and is known as the “transformation zone” or “transition zone.”
The cervix is narrow and produces mucus to protect the uterus from harm like bacteria; it expands to allow blood and babies out.
The “glandular” cells that line the tube are known as the endocervical cells. They are a different type of cell than the tougher, “squamous” cells that make up the outside of the cervix. There is a line where the external cells give way to the internal ones, and this transitional zone is the most vulnerable to HPV.
In younger women, the transitional zone is larger and more exposed. As a woman ages, that zone shrinks and climbs up into the cervix, making it less vulnerable. HPV tends to live in the transitional zone and/or the endocervical cells, which is why that’s the area your OB/GYN tests in a pap smear.
HPV, cervical cancer, and pap tests
With the cervix, the biggest concern is cervical cancer.
All cervical cancer is caused by the human papilloma virus (HPV), though not all strains of HPV cause cancer. There are hundreds of types of HPV, some which cause warts on different parts of the body, and some which cause warts on the genitals. There are also versions that are higher risk for becoming cancerous.
In the past, many if not most women contracted HPV at some point in their lives, and for many, their immune system was able to clear it. However, sometimes that HPV can lead to HPV disease in which cells become pre-cancerous, ultimately causing cancer if not treated.
A problem with HPV is that many women can have it and show zero symptoms. It can be “sitting in your cervix and doing absolutely nothing you would ever notice,” says Dr. Dunsmoor-Su, “but we can pick it up on a pap smear when we test for HPV.”
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Decisions you need to make regarding your cervix
Depending on your age, you may want to consider the HPV vaccine. Now approved for women up to age 47, the HPV vaccine may help protect you against some kinds of high-risk HPV. (It may be worth getting the jab for women older than age 47, says our Doc, but as it hasn’t been studied in older women, it hasn’t been approved and thus may not be covered by insurance.)
Pap tests. According to Dr. Dunsmoor-Su, the recommendation is that women of perimenopause and menopause age be tested for HPV during their pap test. To clarify: a pap test looks for abnormal cells that could indicate cervical cancer or that could become cervical cancer. The HPV test tests for the presence of HPV – these are not the same thing. If both tests come up negative, a woman is good for five years.
Why only every five years? Well, because of the age-related changes to the external cervix, and because older women generally have fewer partners, the chances of a woman contracting HPV and of it developing into something more serious within that five years are low. There is a particularly aggressive cancer that can invade the glandular cells, called cervical adenocarcinoma, but it’s fairly uncommon. Of course, if a woman of any age has persistent HPV or other changes in the cells, her doc might recommend she be tested more often.
Younger women are tested more often, says Dr. Dunsmoor-Su, because there are two distinct “waves” of cervical cancer: it is most common in younger women in their 20s and 30s, then again in older women in their 50s and 60s.
Younger women may develop cervical cancer more because they tend to have more sexual partners, but also because that transitional zone we spoke about earlier is larger and more exposed. Older women may have had asymptomatic HPV for years, only to have it develop into cancer later.
Pelvic exam vs pap test
We’d like to take a slight detour here to talk about the difference between a pelvic exam and a pap test. These are often done at the same visit, but they aren’t the same thing. The pap, which tests for abnormal cervical cells (and can include an HPV test), is done when the doc inserts a paddle and scrapes a few cervical cells for testing.
A pelvic exam is when the doc inserts their fingers, places a hand on the abdomen, and feels the uterus and ovaries. This should be done every year, says Dr. Dunsmoor-Su, as this is the best test we currently have for ovarian cancer. The doc is feeling for abnormalities, like an ovarian tumor or nodules, and for flexibility in the pelvis (the uterus should be able to move when the doc moves it). Regardless of age or HPV status, women in menopause should continue to get an annual pelvic exam, ideally with the same doc.
What if your doc discovers something concerning?
A pap test tells the doc what the individual cells scraped from the cervix look like, that’s its purpose. “We’re looking at the form of the cell.” If there’s something of concern, your doc will likely call you back in for a test called a colposcopy. This is a scope of the upper vagina. The test consists of the doc placing the speculum, painting the upper vagina with white vinegar (abnormal cells pick up the vinegar and turn white very quickly), and looking at the area with a high-powered microscope. It’s much like having a really long pap test. “If I see anything of concern at that point,” says Dr. Dunsmoor-Su, “that’s when I’ll take a biopsy.” (Pro tip: If you have to have a biopsy, ask your doc to give you a countdown, then cough when it happens. You may well not feel anything, says our doc, though you should let your doc know what you’re planning.)
The biopsy looks at the cells in situ (in its original context), to determine what proportion of cells are abnormal, how deep the abnormality goes, and how much change there’s been to the tissue structure. The results are graded as 1 – 3. If a woman’s cells rate a “1,” it’s a “come back next year; let’s keep an eye on it” situation. Two and three are more concerning, as it can mean the abnormality has gone deeper into the cervix.
LEEP and cone biopsies. In the LEEP procedure (Loop Electrosurgical Excision Procedure) — hang on, this is going to sound worse than it is — the cervix is numbed, and the doc takes a wire loop, turns on some electricity, and basically removes the transition zone of the cervix. This can function as a larger biopsy, taking the whole “concerning” part of the cervix out. A pathologist can then look to see if there’s been further invasion, or if this was pre-cancerous vs cancer. A cone biopsy is done with a scalpel and takes a deeper sample. Both of these biopsies can also be effective treatments. As long as the lesion or concerning cells don’t extend beyond the area removed, these biopsies can actually be curative, taking all the cells and HPV along with them.
If these procedures don’t address the issues completely, or if the abnormalities recur, a woman may be offered a hysterectomy. “We don’t need to take the ovaries,” says Dr. Dunsmoor-Su. “Those have a separate blood supply, so we leave them because they may still be hormonally active. Even in menopause, they can still be producing testosterone, and many women just feel better if they’re left in. If there’s no medical reason to remove them, we generally don’t.”
So, your takeaways:
- Always wear a condom, even after menopause. Condoms aren’t 100 percent effective against HPV because other body parts also carry HPV and aren’t covered by the condom, but they’re still pretty darn good and definitely better than nothing.
- Get the HPV vaccine, unless your doctor advises against it.
- Get annual pelvic exams and pap tests on the schedule your doc recommends.
Women in perimenopause and menopause are not immune to HPV disease and cervical cancer, even if they’re not currently sexually active. While women’s bodies generally pass HPV out and “clear” it, they may not always be able to, and HPV that’s hung out for years doing nothing harmful can suddenly turn harmful.
Knowing your body, knowing how to keep it healthy and what to do when problems arise are powerful ways of taking control of your health. Stay tuned for more information on the female body, in all its complicated, sometimes challenging, glory.
What about your body would you like to understand better? If this is helpful to you, or you’d like to suggest what part we discuss next, we’d love to hear from you. Drop your suggestions and any other thoughts into our community forum.
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