Ryanne Radford had been getting an annual Pap test for about eight years without any complications. But after a Pap test in April 2011, Radford, 28, of Calgary, Alberta, Canada, noticed some vaginal bleeding when she returned home. “It was like a medium-to-light period,” she says. “And I had a little discomfort.”
Radford, who has severe factor V deficiency, was a little worried, particularly because treatment for her extremely rare bleeding disorder involves receiving fresh frozen plasma for 4 to 6 hours by IV in the hospital.
She contacted her hemophilia treatment center and was advised to monitor the amount of bleeding and to take Cyclokapron™, an oral form of tranexamic acid available in Canada that helps slow down or stop bleeding. After Radford took Cyclokapron for two days, the bleeding stopped. Now she feels confident about handling bleeding related to future Pap tests. “I know what to expect, and I won’t feel scared about it if I were to have bleeding again.”
Women with bleeding disorders should not worry they’ll experience heavy bleeding after a pelvic exam or Pap test. When bleeding does happen, it is usually light and not serious, disappearing after a few days, says Andra H. James, MD, director of the Women’s Hemostasis and Thrombosis Clinic and associate professor of obstetrics-gynecology, Division of Maternal Fetal Medicine, at Duke University in Durham, North Carolina. “Women may experience bleeding after a Pap test, but they should be no more fearful than they would be about brushing their teeth,” James says. “They should not worry about going for routine gynecologic examinations because they have a bleeding disorder.”
The benefits of regular pelvic exams and Pap tests far outweigh any bleeding risks, says Emily Czapek, MD. She is medical director of the Women’s and Girls’ Comprehensive Bleeding Disorders Clinic and associate medical director of the Comprehensive Hemophilia and Thrombophilia Center at Rush University Medical Center in Chicago.
Preventing Cancer Through Regular Exams
The Pap test can detect cervical cancer or precancerous changes in the cervix before they develop into cervical cancer. “Cervical cancer is curable if it’s caught early,” Czapek says. The primary cause of cervical cancer is the human papillomavirus (HPV), which is spread through sexual contact. Most HPV infections will clear up on their own, but in some women HPV causes changes in cervical cells. Sometimes, those changes lead to cancer.
Two vaccines are now available that protect against some types of HPV that can cause cervical cancer and genital warts. The Centers for Disease Control and Prevention recommends an HPV vaccine be given to girls and boys at ages 11 to 12. All girls and women ages 11 to 26 should be vaccinated with the three-dose HPV series. The second dose is given one to two months after the first; the third is given six months after the first. Cancer protection is greater if girls are vaccinated before they begin to have sex.
However, the vaccines have not been approved for use in women older than 26. There isn’t as much benefit in vaccinating older women because of their prior HPV exposure and a lower incidence of new HPV infections. After a woman has been infected with one type of HPV, the vaccine will not protect against that particular type.
The latest guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend that Pap tests begin at age 21. Women ages 21 to 29 should be screened every two years, not every year as previously advised. Women age 30 and older can switch to every three years once they’ve had three normal Pap tests in a row. However, ACOG cautions that women with certain risk factors and health issues may need more frequent screening.
To conduct a Pap test, your medical provider will use a speculum (a medical tool designed to investigate body cavities) to open up your vaginal walls and insert a small brush to take a sample of cells from your cervix (the lower portion of the uterus where it joins with the vagina). The cells are examined in a laboratory for abnormalities. During the appointment, your doctor or nurse practitioner will also conduct a pelvic exam of your vagina and cervix.
Infusing should not be necessary for a routine gynecologic exam, including a Pap test, but Czapek recommends your ob/gyn and HTC discuss any precautions. “Individuals with bleeding disorders should keep their HTC informed if they need some type of screening or diagnostic procedure, such as a Pap test or colonoscopy,” she says. “The HTC can advise whether the procedures require replacement factor or not.”
Previously, women had been advised to schedule gynecologic exams between menstrual periods, which poses a problem for women with bleeding disorders who may bleed several weeks at a time. However, this is no longer the case, James says. Advancements in Pap testing now allow clinicians to conduct Pap tests on women during their menstrual cycles.
Advocating for Women’s Health
Silvana Moran, who has type 3 von Willebrand disease (VWD), the most severe type, went in for her first Pap test last year. Moran, 24, of Winnipeg, Manitoba, Canada, wasn’t worried about bleeding because she infuses prophylactically, but she was apprehensive about any abnormalities the test might reveal. However, the results were normal, and her ob/gyn noticed only small spots of blood after her exam. “It was probably the best experience I could have asked for,” Moran says.
Moran now urges other women, particularly those with bleeding disorders, to not dread or delay their gynecologic exams. “A Pap test takes less than five minutes,” she says. “A little push and swab isn’t as bad as an elbow bleed or bruise to the shin. And it beats having cancer.”
[Steps for Living: Bleeding Disorders in Women]