PROTECT YOURSELF JANUARY 2022 NEWSLETTER
PART I
HUMAN PAPILLOMAVIRUS (HPV) INFECTION
HOW CAN YOU GET CERVICAL CANCER? Human Papillomavirus (HPV) Infection
WHAT IS HPV? HPV is a group of more than 200 related viruses that affects the skin, some of which are spread through vaginal, anal, or oral sex. It’s the most frequent sexually transmitted disease in both males and females. Sexually transmitted HPV types fall into two groups, low risk and high risk.
LOW RISK HPVS Low-risk HPVs are “non-oncogenic” and mostly cause no disease because they are usually controlled by the immune system. However, a few low-risk HPV types can cause warts on or around the genitals, anus, mouth, or throat if they were unsuccessfully controlled by the immune system. HPV 6 and HPV 11 are low-risk types of HPV. They are linked to approximately 90 percent of genital warts. HPV 11 can also cause changes to the cervix. Low-risk types can’t cause cervical cancer and are treatable.
HIGH RISK HPVS High-risk HPVs are “oncogenic” and can cause abnormal cells to form on the cervix, which can develop into cancer if they’re left untreated. There are about 14 high-risk HPV types including HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68. Infection with these HPV does not usually cause symptoms. Two of these, HPV16 and HPV18, are responsible for most HPV-related cancers. When a high-risk HPV infection persists for many years, it can lead to cell changes that, if untreated, may get worse over time and become cancer.
According to
The Centers for Disease Control and Prevention (CDC) HPV is the most common sexually transmitted infection (STI). Nearly all sexually active people, even if they have few sexual partners, are infected with HPV within months to a few years of becoming sexually active. Around half of these infections are with a high-risk HPV type. HPV can infect both males and females.
HOW DOES HPV INFECTION LEAD TO CERVICAL CANCER? When the body’s immune system can’t get rid of an HPV infection with oncogenic HPV types, it can linger over time and turn normal squamous cells that line the inner surfaces of organs (such as the cervix, oropharynx, anus, penis, vagina, and vulva), into abnormal cells and then cancer. For this reason, most HPV-related cancers are a type of cancer called squamous cell carcinoma. About 10% of women with HPV infection on their cervix will develop long-lasting HPV infections that put them at risk for cervical cancer. Similarly, when high-risk HPV lingers and infects the cells of the vulva, vagina, penis, or anus, it can cause cell changes called precancers. The precancerous cell changes caused by a persistent HPV infection at the cervix rarely cause symptoms, which is why regular cervical cancer screening is important. Precancerous lesions at other sites in the body may cause symptoms like itching or bleeding. Moreover, if an HPV infection develops into cancer, the cancer may cause symptoms like bleeding, pain, or swollen glands. There is no way to know who will develop cancer or other health problems from HPV.
HOW DOES HPV INFECTION LEAD TO CERVICAL CANCER? Although most HPV infections clear up on their own and most pre-cancerous lesions resolve spontaneously, there is a risk for all women that HPV infection may become chronic and pre-cancerous lesions progress to invasive cervical cancer. People with weak immune systems (including those with HIV) may be less able to fight off HPV. It takes 15 to 20 years for cervical cancer to develop in women with normal immune systems. It can take only 5 to 10 years in women with weakened immune systems, such as those with untreated HIV infection. Worldwide, the burden of HPV-related cancers is much greater. High-risk HPVs cause about 5% of all cancers worldwide. Cervical cancer is among the most common cancers and a leading cause of cancerrelated deaths in low- and middle-income countries, where screening tests and treatment of early cervical cell changes are not readily available.
HOW CAN YOU GET HPV? HPVs are easy to catch. You can get HPV from:
Any skin-to-skin contact of the genital area, not through an exchange of bodily fluid. Vaginal, anal or oral sex (even without penetrative sex) Sharing sex toys Since HPV has no symptoms, many people have HPV and do not even know it, which means people can still contract it even if their partner is asymptomatic. It is also possible to have multiple types of HPV. It is estimated that 80% of women will contract at least one type of HPV during their lifetime. Important: Condoms and dental dams can lower the chance of HPV transmission but do not prevent it completely.
Other factors that may put someone at an increased risk for HPV infection:
Unprotected vaginal, oral, or anal sex Number of sexual partners: The more sexual partners you have, the more likely you are to contract a genital HPV infection. Having sex with a partner who has had multiple sex partners also increases your risk. Age: Common warts occur mostly in children. Genital warts occur most often in adolescents and young adults. Weakened immune systems: The immune systems can be weakened by HIV/AIDS or by immune system-suppressing drugs used after organ transplants. Damaged skin: Areas of skin that have been punctured or opened are more prone to develop common warts. Personal contact: Touching someone's warts or not wearing protection before contacting surfaces that have been exposed to HPV — such as public showers or swimming pools — might increase your risk of HPV infection.
HOW CAN YOU GET HPV? If you contract a high-risk type of HPV, some factors can make it more likely that the infection will continue and may develop into cancer: A weakened immune system Having other STIs, such as gonorrhea, chlamydia, and herpes simplex Chronic inflammation Having many children (cervical cancer) Using oral contraceptives over a long period of time (cervical cancer) Using tobacco products (mouth or throat cancer) Receiving anal sex (anal cancer)
HPV AND PREGNANCY
Contracting HPV doesn’t decrease your chances of becoming pregnant. If you’re pregnant and have HPV, you may wish to delay treatment until after delivery. However, in some cases, HPV infection can cause complications. Hormonal changes that occur during pregnancy may cause genital warts to grow and, in some cases, these warts may bleed. If genital warts are widespread, they may make a vaginal delivery difficult. When genital warts block the birth canal, a C-section may be required
NATURAL TREATMENTS FOR HPV At this time, there are not any medically supported natural treatments for symptoms of HPV. According to an article in Science News, a 2014 pilot study explored the effects of shiitake mushroom extract on clearing HPV from the body, but it produced mixed results. Of the 10 women studied, 3 appeared to clear the virus, while 2 experienced declining virus levels. The remaining 5 women were unable to clear the infection. The study is now in phase II of clinical trials.
TRADITIONAL TREATMENTS FOR HPV SYMPTOMS
Many warts will clear up without treatment, but if you prefer not to wait, you can have them removed by the following methods and products: Topical creams or solutions, such as salicylic acid products for common warts or imiquimod (Aldara, Zyclara), podofilox (Condylox), trichloroacetic acid or podophyllincan. However, do not use these products on warts in the genital area. Cryotherapy, or freezing and removing the tissue. Electrocautery: This involves using an electrical current to burn away the warts. Laser or light therapy: This involves using a high-powered, targeted beam to remove the unwanted tissue. Surgical removal: A surgeon can cut away warts in an outpatient procedure that involves a local anesthetic.
TRADITIONAL TREATMENTS FOR HPV SYMPTOMS Do not use over-the-counter products on genital warts. Treatments can remove warts, but the virus will remain in the body and remain transmissible. There is not a one-size-fits-all approach for wart removal. The best option for you will depend on several factors, including the size, number, and location of your warts. If precancerous or cancerous cells are discovered in the cervix, your doctor will remove them in one of three ways: Cryotherapy Surgical conization, which involves removing a coneshaped piece of tissue Loop electrosurgical excision, which involves removing the tissue with a hot wire loop If precancerous or cancerous cells are discovered in other areas of the body, such as on the penis, the same options for removal can be used.
PART II
CERVICAL CANCER
INTRODUCTION WHAT IS CERVICAL CANCER? It is a type of cancer that occurs in the cells of the cervix, which is the lower part of the uterus that connects to the vagina. Various strains of the human papillomavirus (HPV) play a role in causing most cervical cancer. In a small percentage of people, the virus survives for years, contributing to the process that causes some cervical cells to become cancer cells. You can reduce your risk of developing cervical cancer by having screening tests and receiving a vaccine that protects against HPV.
WHAT ARE THE SYMPTOMS OF CERVICAL CANCER? COMMON
Pelvic pain
Bleeding
Vaginal discharge
RARE
Bowel/bladder issues
Back pain
Leg Swelling
INTRODUCTION WHAT CAUSES CERVICAL CANCER? Cervical cancer begins when mutations in the DNA of the healthy cells in the cervix occur. This leads to an abnormal and uncontrolled multiplication of the cells. The accumulating abnormal cells form a mass (tumor), which can invade nearby tissues and eventually break off from the tumor to spread (metastasize) elsewhere in the body.
WHAT ARE THE TYPES OF CERVICAL CANCER? Squamous cell carcinoma
This type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. Most cervical cancers are squamous cell carcinomas.
Adenocarcinoma
This type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal. Sometimes, both types of cells are involved in cervical cancer.
FROM A GYNECOLOGIST'S POINT OF VIEW:
DR. ELIE BARAKAT
Obstetrician - Gynecologist (OBGYN)
Instagram: dr.eliebarakat Email: dr.eliebarakat@gmail.com
FROM A GYNECOLOGIST'S POINT OF VIEW:
UNDERSTANDING CERVICAL CANCER PREVENTION SERVICES 1. Human papillomavirus (HPV) Vaccination Vaccines have been specifically developed to protect against the acquisition of HPV infection and development of HPV-associated diseases including cancers. There are three different HPV vaccines available today. They vary in the number of HPV types they target. Gardasil Quadrivalent Targets types 6, 11, 16, & 18.
Gardasil 9 9-valent Targets additional types 31, 33, 45, 52 & 58.
Cervarix Bivalent Targets types 16 & 18 only.
These are all prophylactic vaccines, designed to prevent initial HPV infection and subsequent HPV-associated lesions. Therapeutic vaccines designed to induce regression of existing HPV-associated lesions are in development but are not clinically available yet.
1. Human papillomavirus (HPV) Vaccination A. Why Should Both Males & Females Get Vaccinated against HPV? Vaccination with the HPV vaccines provides direct benefit to both male and female recipients by protecting them against cancers that can result from persistent HPV infection. This preventive effect is most notable with cervical cancer, one of the most common female cancers worldwide. The most cancerous HPV types, 16 &18, cause 70% of cervical cancers, 90% of anal cancers and a substantial proportion of vaginal, vulvar, oropharyngeal, and even penile cancers. Those two types are targeted by all vaccines. Other cancerous HPV types 31, 33, 45, 52, & 58, are targeted by the 9-valent vaccine. Vaccination with the quadrivalent or 9-valent HPV vaccine also protects against benign anogenital warts caused by types 6 &11. Despite being benign, these warts are not only physically and psychologically morbid to both males and females but also commonly resistant to treatments. The overall burden of HPV-associated cancers among males is obviously less than the burden of cervical cancer in females. However, the overall benefit of vaccinating males is spreading herd immunity, a much-needed population benefit especially in countries where female vaccination rates are insufficient and unstandardized, such as in Lebanon. In fact, various models have shown that the cost-effectiveness of male vaccination is higher in the setting of lower levels of female coverage.
1. Human papillomavirus (HPV) Vaccination B. How & Whom to Vaccinate against HPV? The primary target population for HPV vaccination is males and females ≤ 26 years of age and the vaccines are usually administered at 11-12 years of age. The optimal time for HPV immunization is prior to an individual's first sexual contact: studies have shown that the vaccine efficacy is highest among those who have not been infected with HPV (HPVnaïve). Nevertheless, individuals ≤ 26 years of age who are already sexually active should still be vaccinated. Individuals younger than 15 are administered a “2-dose series”, at least 6 months apart. Individuals older than 15 are administered a “3-dose series” at 0, 2 and 6 months. The additional 3rd dose of vaccine is recommended because of the lower immunologic response to HPV vaccination in the latter age group. These recommendations are derived from expert groups in the US and Europe, including the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Cancer Society, the American Society of Clinical Oncology, and the International Papillomavirus Society.
1. Human papillomavirus (HPV) Vaccination B. How & Whom to Vaccinate against HPV? For most individuals >26 years of age, vaccination is not indicated as most have already been exposed to different HPV strains and vaccination is unlikely to assist in boosting immunity. Exceptions for whom vaccination is still recommended after the age of 26 include Previously unvaccinated adults aged 27 to 45 years who have a low likelihood of prior HPV exposure (e.g., no prior sexual contact or a limited number of prior sexual partners) but have a future risk of HPV exposure (e.g., new sexual partners) Health-care workers who have repeated exposure to HPV in vapors generated during surgical excision or ablation of HPVassociated lesions (e.g., health care providers and operating room and office staff in the fields of gynecology, and dermatology). A history of genital warts, a positive HPV test result, or abnormal cervical, vaginal, vulvar, or anal cytology all indicate a prior HPV infection, but not necessarily with the HPV types included in the vaccines. Vaccination is still recommended in individuals within the recommended age range who have evidence of prior HPV infection, as it can still provide protection against infection with HPV vaccine types not already acquired. However, these patients should be advised that vaccination will have no proven therapeutic effect on existing HPV infections or HPV-associated diseases, and that the overall benefit of HPV vaccination is reduced in their case. It is also important to inform patients that HPV vaccination status does not impact cervical cancer screening recommendations.
1. Human papillomavirus (HPV) Vaccination C. What if a Vaccine Series Is Interrupted? Patients often do not follow up for their immunizations on schedule especially resource-poor countries such as Lebanon where vaccines are not provided by the state, are too expensive, or simply not available anymore. Luckily, the Advisory Committee on Immunization Practices (ACIP) recommends that if the vaccination series is interrupted for any length of time, it can be resumed without restarting the series.
D. Which Vaccine Should Be Chosen? Not all HPV vaccines are available in everywhere. If cost and availability are not an issue, the 9-valent vaccine “Gardasil 9” is the vaccine of choice due to its broad spectrum of protection against HPV types. Opting for the cheaper bivalent “Cervarix” vaccine still provides an acceptable protection against HPV-related lesions and cancers. Individuals should choose the vaccine that is available and/or affordable to them. Ideally, the same formulation should be used to complete the 2 or 3vaccination series. However, if the vaccine initially used is unknown or unavailable, or if the 9-valent vaccine is being introduced into the formulary, a different HPV vaccine can be safely used to complete the series.
1. Human papillomavirus (HPV) Vaccination E. Are the HPV Vaccines Safe? Data from both registration trials and post-licensure safety surveillance systems demonstrate that the vaccines are safe and well tolerated apart from mild injection site reactions. They all use virus-like particles, which mimic the viral capsid, do not contain genetic material, and are produced in biologic systems, which have well-established safety records. The WHO Global Advisory Committee on Vaccine Safety warned against claims of harm that are raised based on anecdotal reports in the absence of biological or epidemiological substantiation. Data on HPV vaccination safety during pregnancy is still lacking but is increasingly available and reassuring. Thus, if a woman is found to be pregnant after initiating the vaccination series, she can be reassured that available evidence does not indicate any increase in risk of adverse pregnancy outcome. Nevertheless, the remainder of the series should be delayed until the woman is no longer pregnant.
1. Human papillomavirus (HPV) Vaccination F. How to Improve Vaccine Coverage in Lebanon? Parents who did not want to have their daughters vaccinated gave the following as their top five reasons: i. The vaccine was not needed ii. The vaccine was not recommended iii. Concern about vaccine safety iv. Lack of knowledge about the vaccine or disease, and v. Lack of sexual activity by their daughter This clearly highlights a lack of understanding of the rationale for HPV vaccination by some parents or caregivers and emphasizes the important role health care providers, namely general practitioners, family doctors, pediatricians, gynecologists, and pharmacists play when it comes to educating parents or caregivers about HPV infections, its consequences, and the importance of vaccination. In Lebanon, HPV vaccine awareness and coverage is alarmingly scarce and interventions by health-care providers and educational institutions to improve awareness and uptake of HPV vaccine are critically needed. Pharmacists in Lebanon are encouraged to promote HPV vaccination through many methods: Short surveys that not only evaluate the extent (or lack-of) awareness but also raise new interest among patients about the matter. Clear and simple explanations of the benefits of the vaccines, their recommended protocols and their proven efficacy and safety. A shortlist of patients interested in or requesting to be vaccinated, especially when the vaccine’s availability is compromised. Additionally, medical representatives should promote locally available vaccine brands to family physicians, pediatricians, and gynecologists, while reminding them of the latest recommendations, protocols, and prices.
1. Human papillomavirus (HPV) Vaccination F. How to Improve Vaccine Coverage in Lebanon? However, the biggest limiting factor that has put the HPV vaccine roll-out in Lebanon in total jeopardy for the past year or two has been the disastrous financial crisis that heavily hit the pharmaceutical sector, and on multiple fronts. Ever since the withdrawal of subsidies and worsening devaluation of the Lebanese Lira, drugs and vaccines have become unaffordable to the general population with an ever-reducing purchasing power. The 9-valent Gardasil 9 is currently officially priced at 280,000 LBP/dose or 840,000LBP for the 3-series protocol, while the “cheaper” bivalent Cervarix is priced at 110,000 LBP/dose or 330,000LBP for the 3-series protocol. What is even worse is that even if an individual could afford the vaccines, they have been locally unavailable for more than a year and a half now. Even black-market HPV vaccines, staggeringly priced at over a million Lira per shot, have also been very hard to find in the past months. Health care providers, notably pharmacists and the Order of Pharmacists in Lebanon should put pressure on the Ministry of Health and pharmaceutical providers to make the vaccines not only locally available, but also more affordable by subsidizing the shots. It is important to note that the WHO recommends that in resource-limited settings such as Lebanon, the primary target of HPV vaccination programs are no longer males and females under the age of 26, but females aged 9 to 14 years and that local public health programs should recommend vaccination of older females only if affordable and cost-effective and does not divert resources and limited stocks from vaccinating the modified primary target population. For this reason, health care providers in Lebanon, especially pharmacists, should consider reserving the long-awaited and limited next batch of HPV vaccines exclusively to the 9- to 14-year-old girls first, before offering it to those over 15 or males under 26.
1. Human papillomavirus (HPV) Vaccination Conclusion Human Papilloma Virus infections are not only the most common STIs around the world but also the leading cause of cervical and anal cancers. Awareness on HPV-related diseases and how to prevent them through vaccination should be wide-spread and reinforced by the Ministry of Health, educational programs, and most certainly healthcare providers. Lebanon has been going through one of the most severe financial crises in history and HPV vaccinations have been suspended for nearly two years now. It is our duty as healthcare providers not only to raise awareness about the matter, but to also make sure that the incoming stock of vaccines get equitably and mindfully distributed to the modified target population according to the WHO as long as quantities are limited, and at state controlled and fixed prices without giving room for marketing scams and monopolization of doses by financially and/or politically powerful individuals and groups.
Screening for Cervical Cancer
2.
Cervical cancer is the third most common gynecologic cancer worldwide and a significant cause of morbidity and mortality especially in countries with insufficient screening and vaccination programs such as Lebanon. Screening can detect suspicious or precancerous lesions, enabling early treatment to prevent the development of invasive cervical cancer and reduce cervical cancer mortality. The available methods for cervical cancer screening are Pap-test (cytology), HPV testing, and Co-testing (with both cytology and HPV). Cervical cancer screening recommendations in averagerisk patients is generally based on the patient's age:
<
Age 21
Screening is not recommended in healthy women under the age of 21 regardless of the age of initiation of sexual activity. Adolescents are also more likely to spontaneously clear HPV infections within a couple of years. Even if a precancerous disease occurs, more than 90% of low and high-grade lesions (LSIL; HSIL) will regress spontaneously at that age.
Age 21 to 65
Screening for cervical cancer is initiated at the age of 21 with cervical cytology (Pap test) every year for the first 3 years then every 3 years if all the previous were normal. The American Society of Cancer also recommends another approach by starting at age 25 with a primary HPV test every 5 years. Studies have shown less false-positive results with Pap tests compared to HPV testing within that age group. The latter is preferred in HPV-vaccinated patients.
>
Age 65 years
The decision to discontinue screening depends on the patient's risk assessment, prior results, life expectancy, and preferences. Discontinue screening in patients over the age of 65 who have adequate prior screening (3 consecutive negative tests within the past 10 years) and no factors that warrant extended screening.
Screening for Cervical Cancer
2.
What if the patient is hysterectomized? Discontinue cervical cancer screening for those who have undergone a total hysterectomy (cervix removed) and have no history of cervical diseases. Patients who have undergone subtotal hysterectomy (cervix intact) and have no cervical diseases should continue cervical cancer screening following their normal age-group recommendations.
What if the patient reports sexual abstinence? Patients should be screened even if they report sexual abstinence. Patients may have a variety of reasons for not disclosing prior sexual activity, including social, religious, or cultural norms or expectations regarding modesty, virginity, and shame as well as reluctance to acknowledge prior sexual abuse or rape. Furthermore, HPV can be transmitted in skin-to-skin genital touching, which patients may not consider as sexual activity.
What if the screening result is abnormal? Patients who have abnormal Pap and/or HPV testing results need appropriate follow-up and possibly further subsequent evaluations. An abnormal cervical lesion can include “Atypical squamous cells” ranging from undetermined significance (ASC-US) or cannot exclude high-grade lesion (ASC-H), or low-grade squamous intraepithelial lesions (LSIL), all the way to high-grade squamous intraepithelial lesions (HSIL). The patient’s management will then be assessed based on the immediate and 5-year risks for developing cervical intraepithelial neoplasia (CIN) 3+ with options including: expedited treatment, a choice between expedited treatment and colposcopy, colposcopy, or just close surveillance. Any abnormal cervical cancer screening result should prompt a follow-up with the treating physician the soonest possible.
Elie BARAKAT, MD. Obstetrics & Gynecology. Lebanon
TREATMENT
Tertiary prevention of cervical cancer comprises treatment of cervical cancer and palliative care, which include chemotherapy, radiotherapy, and surgical treatment. The purpose of tertiary prevention is reducing mortality rates associated with cervical cancer. Treatment of cervical cancer depends on the clinical stage assigned upon physical examination and basic imaging studies. Cervical cancer is first divided into early-stage and locally advanced cervical cancer, and each group is subdivided depending on the advancement and enlargement of the tumor.
Early Stage Stage IA
Invasive carcinoma that can be diagnosed only by microscopy. Depth < 5mm
Stage IA1
Depth≤ 3mm
Stage IA2
Depth > 3mm & ≤ 5mm
Stage IB
Depth > 5mm
Stage IB1
Greatest dimension ≤ 2cm
Stage IB2
Greatest dimension >2cm &≤ 4cm
Locally Advanced Stage IB3
Clinically visible tumor >4cm
Stage II
Invades beyond uterus
Stage III
Pelvic sidewall/lower third of vagina involvement
Stage IVA
Invades bladder or rectum mucosa
TREATMENT Preferred Treatment Options Early-Stage
Surgical therapy is preferred over radiotherapy (benefits >> risks), due to the risks of decreased quality of life and increased ovarian failure (this is very important, since ~40% of diagnosed patients are under 45 years and may want to get pregnant)
Locally advanced
Radiotherapy along with chemotherapy is the preferred option in stages IB3 and upwards since this has proven to decrease the recurrence rate and the rate of serious complications.
Early stage cervical cancer algorithm
Tumor staging IA1
IB1 & IB2
IA2
Invasion into lymphovascular space?
Yes
Radical hysterectomy +lymphadenectomy
No
Intermediate - high Risk features still present?
Margins positive? No
Stop treatment
Yes
Conization or hysterectomy No
Stop treatment
Yes
Add chemoradiation
TREATMENT Chemotherapy Used Cisplatin 40 mg/m2 weekly with or without fluorouracil (5-FU)
Carboplatin or Gemcitabine can be used as alternatives to cisplatin.
Types of Surgeries 1. Conization
A procedure in which a cone-shaped piece of abnormal tissue is removed from the cervix. Used in diagnosis and treatment of early stage cancer, and preserves fertility.
2. Hysterectomy
surgical removal of the uterus does not preserve fertility. Radical hysterectomy involves the additional removal of 1/3 to ½ of the upper part of vagina.
3. Lymphadenectomy
A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope.
MENTAL HEALTH
Any cancer diagnosis can affect the emotional health of the patients. The pain accompanying treatment and fear of adverse effects can lead to anxiety, distress, and depression. Patients with cervical cancer will also face changes in hormonal and sexual function such as sexual inactivity or loss of libido, which can be overwhelming.
Here are some tips to boost your Mental Health: Recognize that there are situations you can control and those you cannot. As hard as it sounds, many people find it helpful to let go of things they cannot change and focus on things they can. Learn as much as you can about cancer and its treatment. Having the right information can help you know what to expect. Give yourself time to accept and adapt to a cancer diagnosis and the changes in your life and body that come with it. Talk with people facing the same challenges and attend support groups. Build a network of friends and family who support you and help you be more positive. Ask for and accept help. Let your healthcare team know your worries and concerns and don't hesitate to ask them about possible reconstructive surgeries, prosthetic devices and cosmetic solutions. Remain physically active as much as you can. Keep a journal and jot down your feelings and experiences. Most importantly: seek professional help from a psychotherapist.
ARE YOU UP FOR THE CHALLENGE?
Across
7. Symptoms of late-stage of the disease 8. Ask for help 9. Primary prevention 11. Cone-shaped piece of abnormal tissue is removed from the cervix 12. HPV complication 14. Mode of transmission 15. Diagnostic test 16. Most affected area 17. Developed in children, when an infected mother transmits the virus to her baby during delivery
Down
1. Penetration of HPV in the body 2. Surgical removal of the uterus 3. HPV stands for 4. Chemotherapy agent 5. Decrease risk of HPV infection 6. Small skin bump 10. Effect socially 13. Presentation at the beginning
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