There is no question that women are called upon to make a variety of sacrifices during the course of their reproductive lives. Dealing with the physical, emotional and psychological demands of the monthly reproductive cycle, of pregnancy and of childrearing can prove exhausting for manyespecially when coupled with the rigors of managing a home and full time employment outside the home. So why is it that these same women have been askedand at times, requiredto make health care choices which further compromise their overall wellbeingwhile mentheir partners and soulmatesare left with little or no responsibility for such issues as STD prevention and birth control? In a guidebook tailored for both women and men, a seasoned doctor combines facts and advice relevant to women and their families that will empower them to make informed decisions about future health care. Dr. John Littell, a family physician with more than twenty-five years of experience that includes obstetrics and gynecology, shares valuable insight about controversial issues in women's health care that range from HPV vaccination in children to the diagnosis and treatment of HPV-related disease to the numerous choices related to contraception and family planning. With an emphasis on natural options, Dr. Littell includes guidance and case studies related to common gynecologic health issues encountered by teenagers and women throughout their reproductive lives while exposing much of the deception in women's health care today.
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About the Author
John Thomas Littell, MD, is a board-certified family physician. After earning his MD from George Washington University, he served in the US Army, receiving the Meritorious Service Medal for his work in quality improvement, and also served with the National Health Service Corps in Montana. During his eighteen years in Kissimmee, FL, Dr Littell has served on the faculty of the UCF School of Medicine, President of the County Medical Society, and Chief of Staff at the Florida Hospital. He currently resides with his wife, Kathleen, and family in Ocala, Florida, where he remains very active as a family physician with practices both in Kissimmee and Ocala.
Read an Excerpt
The Hidden Truth: Deception in Women's Health Care
A Physician's Advice to Womenâ"and All Who Care for Them
By John T. Littell
iUniverseCopyright © 2015 John T. Littell, MD, FAAFP
All rights reserved.
The HPV Deception
"Let's Keep That to Ourselves"
There are many learning styles that students use in order to succeed academically. My style has tended to be that of the "active listener"—I try to listen intently to what teachers and lecturers have to say and then come up with challenging questions to ask the teacher in the hope that the answers might better allow me to retain the most important facts presented. Simply writing down the information presented by the teacher, and regurgitating this information in the next exam, never helps me when it comes to trying to retain knowledge of the facts in my daily life. While this applies, I think, to students at all levels of education, it seems wise to ask even more questions, to challenge those who are the supposed "experts," when it comes to the field of medicine, and as I hope to convince you, particularly in the field of women's health—where the "experts," it can be shown, often have an extraordinary bias when it comes to presenting the "facts" to medical students, physicians, and patients that are trying to figure out the best approach to treatment of a variety of gynecologic health concerns.
Please, my dear reader, do not let me dupe you into believing that I was somehow "above" all of these other physicians when it comes to allowing misinformation and personal bias to influence my decisions. Indeed, my false assumptions about women's health issues caused me to mislead a number of young resident physicians (and a great many female patients!) during the early years of my medical career, while I was a faculty member in the army, and previously while teaching biology to high school students. And I am not all too sure that a book such as this would have convinced me to change my views; after all, I was the "expert," was I not?
Yet, thankfully, I had taken advantage of many opportunities to do independent research into topics such as contraception, cervical cancer, and HPV during the late 1990s. And so it was at a conference on women's health care in Orlando in 2003 that I asked the "expert" physician lecturer, a faculty member in obstetrics and gynecology at Columbia University Medical School, why he did not comment on the increased risk of cervical cancer in women that are using oral contraceptives (OCs). He had just given a forty-minute presentation on human papillomavirus (HPV), and in his slide presenting the risk factors for HPV, he left out oral contraceptive use but included such risk factors as pregnancy, smoking, and diabetes. Having spent the previous five years reviewing this issue in detail, I knew full well that OC use doubles (at least) the risk of cervical cancer in women—and so did this ob-gyn!
Which explains my utter disbelief when he responded, without hesitation, "Let's keep that to ourselves." He then quickly added, by way of explanation, that any discussion of the risks of cervical cancer would frighten women into getting off the pill and thereby deprive them of the many "health benefits" of the pill—first and foremost of which is the prevention of pregnancy.
So let's try to understand the thinking of this expert and his ilk on women's health.
According to them, we in the medical profession ought not to disclose factual information about the dangers of oral contraception to our patients so as to ensure that they do not make what, according to American College of Obstetricians and Gynecologists (ACOG), the US Centers for Disease Control (CDC), and others, is the utterly irrational decision to stop using the pill—and thereby become pregnant. As the reader by now must clearly see, the medical profession has determined that the "disease" of fertility and pregnancy must be prevented regardless of the known dangers of artificial contraception. This is a great example of the paternalism so often seen in women's health care—the physician assumes the woman is incompetent to make the best decisions and thereby assumes the role of the all-knowing "father" and makes the decision for her.
Making Informed Choices
And so we have patients such as "Sarah," a twenty-three-year-old who acquired HPV some years ago, and who had been encouraged by me to use natural family planning in her current relationship and avoid use of the pill due to my concerns about her progression to cervical cancer. Her mother, like every mother, was determined to see that her daughter not get pregnant out of wedlock and advised Sarah to get a second opinion from her gynecologist, who then, to no one's surprise, prescribed oral contraceptives (OCs) and provided no further information about her likelihood of cervical cancer. Several months later, Sarah underwent further evaluation of her cervix when her Pap smear revealed preliminary signs of cervical cancer. I finally saw Sarah back in the office and, not able to hide my disappointment that she had chosen to ignore my previous advice, I again encouraged her to consider coming off of the Pill ASAP and pursue at least some form of NFP or periodic abstinence—or better yet, abstinence altogether until, at least, her cervical health improved. When I last visited with Sarah, she had in fact stopped using OCs, but had instead had the contraceptive implant, Implanon, placed in her upper left arm—quite effective for prevention of pregnancy perhaps, but still placing her at increased risk of cervical cancer, among other conditions.
Hopefully, Sarah will eventually follow my advice and not end up like "Cindy," who came into my office a few years back looking not at all like the woman I had met several years before, after she had given birth to the second of her two sons. She was depressed, pale, aching, and bloating. She was only twenty-five, and she was facing something no one, at least in this country, no matter how old she is, should have to face—cervical cancer.
You see, Cindy had been prescribed oral contraceptives when she first became sexually active at the age of sixteen. She had come off of the OCs to become pregnant twice, and when I had last done her gynecologic exam, some years prior, I had noted that she was positive for HPV. At the time, I strongly suggested that she discontinue artificial contraception, due to the known increased risk of cervical cancer while on OCs. She chose instead to remain on OCs as her cervix continued to develop precancerous changes and, ultimately, invasive cervical cancer. She was, when I last saw her, undergoing chemotherapy after having had a complete hysterectomy and was hopeful that she would survive to see her two young sons grow and prosper.
Then there was the mom who shared with me the humiliating experience she had at her children's pediatrician's office. She was told she was not being a responsible mother if she did not give her eleven-year-old daughter a vaccine against HPV when she insisted that she wanted to research the matter more fully. She was also not expecting her daughter to acquire HPV or become sexually active in any way anytime soon. How many millions of parents have found themselves in the same situation—bringing their children to the pediatrician for a well child visit and finding their young daughters (and now even sons) on the receiving end of a series of vaccines against a sexually transmitted disease with no provision for truly informed consent?
Something is incredibly not right in the world of women's health care, and it's time to set the record straight.
So What Is HPV?
Human papillomavirus is actually a very common virus; its name literally translates to "wart virus," as papilloma is the Latin term for wart. First identified as the cause of warts (even common skin warts) in 1949, more than one hundred strains, or serotypes, of HPV have been identified over the past fifty years. Every child who sees me with any number of warts on his or her hands or feet has acquired HPV (typically, serotype 1). The same holds for all those who have dealt with "plantar warts" (warts that occur on the plantar side—the bottom—of the feet!). As we will see, the treatment of HPV on the hands or feet is in many ways identical to the treatment of warts found in the genital region and on the cervix.
It is important to remember that researchers are continually isolating and identifying new HPV types based on small changes in the genetic makeup of the HPV, which are similar to changes seen with influenza strains, which seem to change from year to year. As it now stands, there are at least thirteen known "high-risk" HPV types—meaning that these thirteen have been demonstrated to lead to cancer. Four of these (16, 18, 31, 45) are responsible for 75 percent of all cervical cancers, and another nine (at least) are considered "intermediate risk" and responsible for the remaining 25 percent of cervical cancers. There are a host of "low-risk" HPV types (6, 11, and many others) that, while causing genital warts (on the penis, scrotum, and vulva) are not associated with cervical cancer. (As of this writing, physicians typically do not screen for low-risk HPV in women while performing the Pap smear, so they may not be aware that they are at risk of spreading this to their male partners.)
How Is HPV Transmitted?
As far back as 1835, it was known that common skin warts can be transmitted from one person to another through direct contact with the skin. Yet it was not until 1989 that researchers first developed a test that easily allows physicians to identify genital HPV, specifically on the cervix, and thereby determine whether a woman is at risk of cervical cancer. Since 1989, it has become evident that the primary method of HPV transmission from one person to another is through sexual activity. Since the HPV lives on the skin of the genitalia, keep in mind that any skin-to-skin contact with HPV-infected genitals can lead to transmission of this virus. (Hence, the use of condoms does not at all eliminate the risk of HPV transmission from skin-to-skin contact of the genitals.)
As stated above, there are literally dozens of low-risk types of HPV that are the cause of most of the visible genital warts and other nongenital warts (the usual troublesome warts of childhood). These visible warts have virtually no risk of progressing to any sort of cancer and can be easily treated with a number of remedies, such as freezing with liquid nitrogen.
In contrast, the several high-risk types of HPV have an affinity for the type of skin surface to be found on the cervix, as well as within the anus and the throat. Here, the skin cells make a transition from the typical squamous epithelium that we identify as normal skin, to another type of skin cell known as "columnar" cells or epithelium. It is at this transition point (known as the "squamocolumnar junction," or SCJ, on the cervix) that the high-risk HPV takes root and eventually progresses, if untreated, to cervical cancer, and in similar fashion to anal and throat cancers.
It is imperative that young women be screened for HPV once they become sexually active, and that includes any penetration of the vagina or even casual genital contact with a potentially HPV-infected partner. The reason for this urgency lies in the fact that younger women—those in their teens, prior to their first completed pregnancy—have what is known as a "vulnerable epithelium" at the cervix. This means that the transition zone—the SCJ—of the cervix is more easily infected by the HPV, and that the HPV is more likely to persist at the cervix in these women than in women who have completed a pregnancy. With each pregnancy, this transition zone becomes less and less available to the HPV (it migrates farther into the interior canal of the cervix). If that young woman is on OCs, the SCJ/transition zone becomes even more prominent and HPV acquisition and persistence more likely. Cigarette smoking carries a similarly increased risk but for somewhat different reasons. Hence any persons or any organizations that would dare suggest that young, sexually active women be denied screening for cervical cancer (with Pap smears and/or the specific tests for HPV) for the sake of providing contraception (as recently recommended by ACOG and CDC, among others) are clearly off their rockers! Young, sexually active women with their vulnerable epithelium, and especially those on oral contraceptives, or with multiple sexual partners, or those who smoke, must be educated about HPV and given an opportunity to clear the HPV from their bodies, and thereby eliminate the danger of cervical cancer while preserving their fertility.
Since HPV in any of its more than one hundred strains may truly be found virtually anywhere on the skin of the person, you might wonder whether even casual skin-to-skin contact with any area of the body infected with HPV might lead to transmission of the wart virus (say, if one not-so-clean HPV-infected male scratched his scrotum and then shook your hand, or if you had contact with toilet seats that have previously been used by an HPV-infected individual). Thankfully, these types of transmission (known as fomite transmission) have not as yet been proven possible (whew!). It appears that what is needed for the HPV to be successfully transmitted from one individual to another is the occurrence of typical forms of sexual contact, with repeated skin-to-skin, intense rubbing and penetrating activities (particularly when one has had multiple sexual partners). As a consequence of the many possible forms of sexual behavior and genital contact seen today, we now often see HPV transmission—and the subsequent development of oral and anal cancers—resulting from oral and anal sex, as well as vaginal intercourse.
The Presumption of Promiscuity
While our knowledge of HPV has increased exponentially over the past twenty years, little of this knowledge has been passed from physician to patient, and certainly not from mother to daughter. For the past sixty years or more, young women from the ages of sixteen to eighteen have heard from their mothers, their aunts, and their doctors that they must have their first Pap smear once they come "of age," whether or not they had become sexually active. In medical school, I was taught that all women over the age of eighteen need to have a Pap smear annually. And until quite recently, that was also the position taken by ACOG and the CDC, among others. The most recent consensus statement, as of October 2013, from both ACOG and the CDC, as well as the American Cancer Society and the US Preventive Services Task Force (USPSTF) advised that:
"Cervical cancer screening begin at 21 years of age, regardless of the age of onset of sexual intercourse; that screening occur every three years for women age 21 to 29 years of age; and that women 30 to 65 years of age be provided the option of co-testing with cytology and HPV testing every five years, rather than cytology testing alone every three years."
Now I realize that is a lot for any reader—physician or nonphysician—to understand. Allow me to summarize these latest guidelines (based on "expert opinion," I might add) in more easily understood terms: All women, upon attaining the age of twenty-one, are to undergo Pap smear screening so as to detect early signs of cervical cancer (even those who have remained virgins). This screening for cancer is to be conducted every three years until age thirty. Only at thirty years of age are women to be tested for HPV, which is the actual cause of cervical cancer. From then on, women can be offered screening for both HPV and cervical cancer every five years.
Let me assure you, however, that this supposed "consensus opinion" on Pap smear and HPV screening for cervical cancer is based upon assumptions about women that simply cannot and ought not be tolerated by any woman. It assumes, as we will see, that women are routinely exposed to the sexually transmitted virus HPV by the time they are twenty-one years of age. There is no consideration given to the woman's actual level of sexual activity and so her actual likelihood of exposure to HPV.
Even more upsetting is the recommendation to hold off on screening for the actual HPV virus until age thirty, based on the consensus belief that adolescents and young women who acquire HPV will, in most cases, eliminate the HPV from their genital tract with no need for treatment. Yet what about the many women who, having acquired HPV, continue to engage in lifestyles that instead increase their risk of cervical cancer (e.g., smoking, OC use, and/or engaging in sex with multiple partners or with men who have multiple partners)? Are not these young women entitled to know that they are infected with HPV, so that they might take measures to prevent the development of cervical cancer?
Excerpted from The Hidden Truth: Deception in Women's Health Care by John T. Littell. Copyright © 2015 John T. Littell, MD, FAAFP. Excerpted by permission of iUniverse.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Part 1: HPV, PAP Smears, and Cervical Cancer,
Chapter 1: The HPV Deception, 7,
Chapter 2: Understanding HPV, Pap Smears, and Cervical Cancer, 26,
Chapter 3: Preventing HPV and Cervical Cancer—Naturally!, 34,
Part 2: The Contraception Deception,
Chapter 4: Out of Balance, 55,
Chapter 5: The Glorious Symphony, 67,
Chapter 6: Restoring the Balance, 85,
A Compendium of Available Artificial Methods of Birth Control, 98,
Adverse Effects of Artificial Methods of Birth Control, 104,
Part 3: Fertility as Disease: The Assault on the Family in Modern Times,
Chapter 7: The Grand Deception, 111,
Chapter 8: Toward Natural Alternatives for Family Planning, 131,
Chapter 9: Love and Self-Control, 145,