6 Sex Mistakes Women Make and Why

6 Sex Mistakes Women Make


WebMD explains the 6 biggest sex mistakes women make and reasons why women make them.

By Lisa Zamosky

WebMD FeatureReviewed by Louise Chang, MD

Ladies, be honest: when your sex life becomes a little humdrum, out comes the mental catalogue of all the ways your partner isn’t quite measuring up. Guys tend to get a bad rap when it comes to understanding women’s bodies and what turns us on, making them easy targets in the blame game when sexual satisfaction starts to wane. And sure, they make their fair share of bedroom errors. But as the saying goes, it takes two to tango. As it turns out, top sex and relationship experts say that women make plenty of sex mistakes of their own. Here’s what they have to say about the six most common mistakes women make in the bedroom and what you can do to get the satisfaction you so rightly deserve.



Sex Mistake #1: Not Initiating Sex With Your Partner

It’s 2009 and still, many of us worry about ladylike behavior. We don’t want to appear pushy or come on too strong for fear of being labeled aggressive. According to Les Parrot, professor of psychology at Seattle Pacific University and author of a new book called Crazy Good Sex, failing to initiate sex is one of the biggest mistakes women make.



“Most guys feel like they are always the initiator and that sets up disequilibrium on the passion scale in the relationship,” he says. Generally, men want to be pursued by their partners just as much as women do.



Holding onto outdated ideas about sex roles also inhibits satisfaction with our sexual relationships, says "Dr. Ruth," aka Ruth Westheimer, PhD, a psychosexual therapist, professor at New York University, and lecturer at Yale and Princeton universities. “They used to think that women are less interested in sexual activity and I don’t want to say that anymore. I think there are women who are as interested in sex [as men].”



Show your interest by taking the first step from time to time. Your partner will likely appreciate it, and you may find a new level of satisfaction in taking responsibility for your sexual experience, something Westheimer feels strongly women must do.



Sex Mistake #2: Worrying About What You Look Like



Thinking about how you look during sex stops you from enjoying yourself and ruins your chances of achieving an orgasm.



“Don’t think about the fat on your belly or the makeup on your face,” advises Westheimer. “Concentrate on the pleasure of the act. You must give yourself permission to have an orgasm.”



“Men want their wives to abandon themselves in sex play, and that’s not likely if she is anxious about her physical concerns,” Parrott says.



Helen Fisher, PhD, a cultural anthropologist at Rutgers University and author of a new book called Why Him, Why Her, says men don’t notice half the things women obsess about anyway.

Sex Mistake #2: Worrying About What You Look Like continued...


“It’s amazing what men don’t notice if you’re enthusiastic, energetic, interested in them, and flexible minded.”



According to Fisher, there is an evolutionary explanation for the selective blindness men show to our physical flaws. For Darwinian reasons, says Fisher, men are (unconsciously, of course) looking for women who are able to bear healthy babies. Starting millions of years ago, men who attracted fertile women and had a lot of children lived on. Those who couldn’t died out. Although maybe not as necessary today, Fisher says that primal survival mechanism lives on.



“Men are much more attracted to women who show signs of health and youth and fertility. Rather than worry about the shape of your waist and hips, worry about your energy level and enthusiasm and interest in him,” Fisher advises.



Sex Mistake #3: Assuming Sex Is Casual for a Man

Westheimer believes we should all let go of old-fashioned notions, such as women are not sexual or that sex is just sex to men. “For some men, sex is a very important act. Don’t minimize it.”



The research, says Parrott, supports the idea that both men and women find sexual intimacy in the context of a committed relationship to be more satisfying.



“Numerous research studies make it very clear that the people who have the best quality and most frequent sex are married couples. That says a lot about the inadequacies of ‘casual sex,” Parrot says.



In a study being conducted by Fisher and her colleagues of university students engaging in one-night stands, the numbers show that men are just as serious about sex and relationships as women. In fact, more than 50% of women and 52% of men who went into a one-night stand, according to Fisher, reported that they did so hoping to create a longer relationship. One-third of them actually did so. What’s the lesson?



“Never assume that a man is not romantic,” Fisher says. “Two huge mistakes in this culture are that women are not sexual and that men are not as romantic [as women].”



Sex Mistake #4: Believing He’s Always Up for Sex



Sure, most teenage boys are ready and willing just about any time you ask, but not true for men. The pressures of everyday life -- family, work, bills -- can zap a man’s libido. This comes as a big surprise to many women, and often his lack of interest in sex is something we take personally.



“It comes as such a shock [to women] that they just don’t believe it,” Fisher says about the reaction many women have when their partner says they aren’t in the mood for sex. “They know themselves that they are not always interested in sex but they still love the man. But when they discover he doesn’t want to have sex, they think, ‘he doesn’t love me.’ Not true. He just doesn’t want to have sex.”
Sex Mistake #5: Not Giving Him Guidance




Talking very directly about sex, what we like and don’t like can make us feel uncomfortable, even with a partner we’ve been with for a long time and otherwise feel close to, says Parrott. But it’s the only way to achieve a satisfying sexual relationship.



“A woman must take responsibility for her sexual encounter,” says Westheimer. “No man can bring a woman to orgasm if she doesn’t take responsibility for her sexual experience. Even the best lover can’t know what she needs without her letting him know.”



The good news, according to Fisher, is that men very much want to please women.



“If you can tell them in a way that doesn’t kill their ego, they will appreciate it,” says Fisher. She advises women to sandwich what they don’t like in between five things they do, because he’s listening. “You won’t find out until the next time you’re in bed with him. But men do listen, particularly if you’re quite clear about it.”



Sex Mistake #6: Getting Upset When He Suggests Something New



After a couple has been together for a while, it’s natural to want to spice things up with a little variety. Just because your man wants to try something new doesn’t mean he’s unhappy with you or your sex life. In short: Don’t take it personally.



Still, it’s important that you tune into your comfort zone says Parrott.



“Nobody should ever feel obligated to do something they don’t want to do in the personal and intimate area of sexuality,” Parrott says. “If your man asks you about trying something that’s outside of your morals, make it clear that it’s off limits for you and explain why. Of course, do this in a loving way as best you can. If it is something that is not really a moral issue for you but you still don’t want to, again explain why. If it is a simply a startling request and you’re initially uneasy about it, try not to overreact. Instead, let him know you need some time to think about it.”
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Leukemia Symtomps, Types, Causes, Diagnosis and Treatment Option

What is leukemia?


Leukemia is cancer of the blood cells. It starts in the bone marrow, the soft tissue inside most bones. Bone marrow is where blood cells are made.



When you are healthy, your bone marrow makes:



White blood cells, which help your body fight infection.

Red blood cells, which carry oxygen to all parts of your body.

Platelets, which help your blood clot.

When you have leukemia, the bone marrow starts to make a lot of abnormal white blood cells, called leukemia cells. They don't do the work of normal white blood cells, they grow faster than normal cells, and they don't stop growing when they should.



Over time, leukemia cells can crowd out the normal blood cells. This can lead to serious problems such as anemia, bleeding, and infections. Leukemia cells can also spread to the lymph nodes or other organs and cause swelling or pain.



Are there different types of leukemia?

There are several different types of leukemia. In general, leukemia is grouped by how fast it gets worse and what kind of white blood cell it affects.



It may be acute or chronic . Acute leukemia gets worse very fast and may make you feel sick right away. Chronic leukemia gets worse slowly and may not cause symptoms for years.

It may be lymphocytic or myelogenous . Lymphocytic (or lymphoblastic) leukemia affects white blood cells called lymphocytes. Myelogenous leukemia affects white blood cells called myelocytes.

The four main types of leukemia are:



Acute lymphoblastic leukemia, or ALL. ALL is the most common leukemia in children. Adults can also get it.

Acute myelogenous leukemia, or AML. AML affects both children and adults.

Chronic lymphocytic leukemia, or CLL. CLL is the most common leukemia in adults, mostly those who are older than 55. Children almost never get it.

Chronic myelogenous leukemia, or CML. CML occurs mostly in adults.

What causes leukemia?

Experts don't know what causes leukemia. But some things are known to increase the risk of some kinds of leukemia. These things are called risk factors. You are more likely to get leukemia if you:



Were exposed to large amounts of radiation.

Were exposed to certain chemicals at work, such as benzene.

Had some types of chemotherapy to treat another cancer.

Have Down syndrome or some other genetic problems.

Smoke.

But most people who have these risk factors don't get leukemia. And most people who get leukemia do not have any known risk factors.



What are the symptoms?

Symptoms may depend on what type of leukemia you have, but common symptoms include:



Fever and night sweats.

Headaches.

Bruising or bleeding easily.

Bone or joint pain.

A swollen or painful belly from an enlarged spleen.

Swollen lymph nodes in the armpit, neck, or groin.

Getting a lot of infections.

Feeling very tired or weak.

Losing weight and not feeling hungry.

How is leukemia diagnosed?To find out if you have leukemia, a doctor will:




Ask questions about your past health and symptoms.

Do a physical exam. The doctor will look for swollen lymph nodes and check to see if your spleen or liver is enlarged.

Order blood tests. Leukemia causes a high level of white blood cells and low levels of other types of blood cells.

If your blood tests are not normal, the doctor may want to do a bone marrow biopsy. This test lets the doctor look at cells from inside your bone. This can give key information about what type of leukemia it is so you can get the right treatment.



How is it treated?

What type of treatment you need will depend on many things, including what kind of leukemia you have, how far along it is, and your age and overall health.



If you have acute leukemia, you will need quick treatment to stop the rapid growth of leukemia cells. In many cases, treatment makes acute leukemia go into remission. Some doctors prefer the term "remission" to "cure," because there is a chance the cancer could come back.

If you have chronic lymphocytic leukemia, you may not need to be treated until you have symptoms. But chronic myelogenous leukemia will probably be treated right away. Chronic leukemia can rarely be cured, but treatment can help control the disease.

Treatments for leukemia include:



Chemotherapy, which uses powerful medicines to kill cancer cells. This is the main treatment for most types of leukemia.

Radiation treatments. Radiation therapy uses high-dose X-rays to destroy cancer cells and shrink swollen lymph nodes or an enlarged spleen. It may also be used before a stem cell transplant.

Stem cell transplant. Donated stem cells can rebuild your supply of normal blood cells and boost your immune system. Before the transplant, radiation or chemotherapy is used to destroy cells in bone marrow and make room for donated cells.

Biological therapy. This is the use of special medicines that improve your body's natural defenses against cancer.

For some people, clinical trials are a treatment option. Clinical trials are research projects to test new medicines and other treatments. Often people with leukemia take part in these studies.



Some treatments for leukemia can cause side effects. Your doctor can tell you what problems are common and help you find ways to manage them.



Finding out that you or your child has leukemia can be a terrible shock. It may help to:



Learn all you can about the type of leukemia you have and its treatment. This will help you make the best choices and know what to expect.

Stay as strong and well as possible. A healthy diet, plenty of rest, and regular exercise can help.

Talk to other people or families who have faced this disease. Ask your doctor about support groups in your area. You can also find people online who will share their experiences with you.

Frequently Asked Questions

Learning about leukemia:

What is leukemia?

What causes it?

Can I prevent leukemia?

What are the symptoms?

What increases my chances of getting leukemia?

How common is it?

What happens in leukemia?



Being diagnosed:

How will my doctor diagnose leukemia?

What is a bone marrow aspiration and biopsy?



Getting treatment:

How is leukemia treated?

What type of medicines will I need to take?

What is radiation therapy?

What is a bone marrow transplant?

What is a stem cell transplant?

What is a clinical trial?

When is surgery needed?



Ongoing concerns:

When should I call my doctor?



Living with leukemia:

What can I do at home to ease my symptoms or manage the side effects of treatment?

How can I control nausea and vomiting caused by chemotherapy?



End-of-life issues:

How can I prepare for end-of-life issues?
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Sexually Transmitted Diseases in Women Who Have Sex with Women

Relatively few data are available to inform estimates of the risk of female-to-female sexual transmission of STDs. The available data come primarily from four sources.

First, review of records from clinics that provide STD services (STD clinics) has provided estimates of some outcomes, including diagnosis of STD syndromes, laboratory results, and risk reporters. Such studies have the advantages of capturing a reproducible population
of women who can be characterized relative to heterosexual women attending the same venue and of relying on clinician-based or laboratory-defined reports of outcomes,
but are limited primarily by the relatively small number of WSW who attend these clinics.

Second, several studies have recruited women who either self-identify as lesbian or who report recent samesex behavior, regardless of stated identity. Although this of WSW and frequently includes laboratory diagnosis of STDs, the sample of women included is likely biased due to self-selection for enrollment.

Third, although population-based surveys attempt to enroll a more representative sample of women, including WSW, because these surveys are generally expensive and complex to undertake, most do not include laboratoryconfirmed assessment of STDs but rely on self-reported STD history.

Finally, case reports of STD transmission between women provide the only documented evidence available for some STDs. Despite their obvious limitations, these reports are valuable in that they can demonstrate the potential for STD transmission between women and, as such, help to emphasize the need for more robust, population-based data to inform WSW patients and their providers about the true risks associated with samesex behavior between women.
Numerous studies have demonstrated that important barriers to health care exist for WSW. These barriers include, but are not limited to, lack of patient educational materials aimed at their specific risks and circumstances, lack of knowledge among providers, low socioeconomic
status, absence of spousal benefits, and impact of negative experiences within the health care system.

Among the latter are included outright instances of homophobia and general invisibility. For example, many office registration materials still list options for marital status as “single” or “married”—terms that do not apply to WSW who may be in domestic partnerships, particularly those that are not recognized by regulatory authorities. Even providers who are comfortable assessing STD-related risks may not be knowledgeable about the sexual practices engaged in
by many WSW, or about the limited disease-specific information in the literature. For these reasons, education of providers in this area is paramount.

Because recent national (USA) surveys indicate that same-sex behavior among women is relatively common, providers should familiarize themselves with information about this patient population, and be aware of referral options for more detailed information. Available information on transmission of specific STDs in WSW is discussed later,
under Laboratory Studies. Risk Assessment Risk assessment in WSW should begin the way all STDrelated risk assessment begins in every patient: with a thorough sexual history. Most importantly, providers should not make assumptions about sexual practices based on the patient’s self-reported identity—in this case, specifically, as a lesbian. Assuming that a self-identified lesbian has not previously been or is not currently sexually
active with men is usually incorrect. In one study, 74% of self-identified lesbians had male partners in the past, and of self-identified bisexual women, 98% had
prior or current male partners. Among lesbians recruited for studies in Seattle, 80–86% reported prior sex with men, 23–28% had had sex with a man in the last year, and the median number of male and female lifetime partners was the same. In a sample of women
evaluated at a London STD clinic, 69% of those identifying as lesbian had prior male partners, and at another London clinic specializing in the sexual health of lesbians,
91% had prior male partners. Heterosexual intercourse transmits the full range of STDs, some of which (notably, chronic viral infections, including HPV, genital
herpes, hepatitis B virus, and HIV) may remain undetected for years.
Important components of the sexual history include number of recent (prior 2 months and 1 year) and lifetime sexual partners, both male and female. Other key components should include types of sexual practices that could pose a risk of transmission of STDs. Some
sexual practices—including oral-genital sex; vaginal or anal sex using hands, fingers, or penetrative sex toys; and oral-anal sex—are practiced commonly between
female sex partners. Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex toys, present a plausible means for transmission
of infected cervicovaginal secretions.

In several studies, women who report sex with both men and women report more sex partners over their lifetimes than women who have sex exclusively with either
men or women. One population-based survey in lowincome neighborhoods found that women who had sex with men only reported a mean of 16 lifetime partners, whereas women reporting sex with men and women reported a mean of 307 lifetime partners.

Similarly, among patients attending an STD clinic in Seattle, women with only female partners in the previous 2 months reported 3.4 partners in the past year; women with only male partners, 5.3 partners in the past year; and women with male and female partners, 16.5 partners in the past year. Women who report sex with both men and women are likely to be at higher risk for STDs than women who report sex with women or men only.

WSW may have male partners who are at higher risk for HIV and STDs than the partners of women who have sex with men only. In one study of patients at an STD clinic, 10% of women who had sex with only women in the previous 2 months had a prior male partner who was gay or bisexual, compared with 6% of women reporting sex with men only. Of women reporting sex with both men and women in the prior 2 months, 29% had a prior gay or bisexual male partner.

Women who reported sex with both men and women in the previous 2 months were also more likely than women who had sex with only men or only women to have had more than four male sexual partners in a year, more likely to exchange sex for money or drugs, and more likely to
have used intravenous drugs. In summary, lesbian and bisexual women may have past or current sex partners at high risk for HIV and other STDs.

Risk Reduction Counseling

No studies have directly addressed the acceptability or efficacy of STD risk reduction interventions among WSW. However, measures that reduce the potential for transmission of cervicovaginal secretions are likely to be effective in reducing STD transmission.
For women who practice digital-vaginal or digital-anal sex (hands or fingers in partner’s vagina or anus), the risk is probably low unless secretions are actually transferred on the hands from the infected partner to the other.

Interrupting this progression by avoiding the behavior or by using and removing gloves after contact is likely effective.

For minimizing transfer of infected secretions associated with insertive sex toys, several approaches are likely effective. These include minimizing sharing of unclean
sex toys (either not sharing toys at all or cleaning them between use by one partner and the other), use of condoms on sex toys, and avoiding use of sex toys anally and
vaginally in succession.

With regard to oral sex and STDs, WSW may be at increased risk of genital herpes infection with herpes simplex virus type 1 (HSV-1) due to a relatively higher frequency of orogenital sex. Serologic screening for HSV-1 is not useful to screen for potential infectiousness, because most adults are infected with HSV-1 orally, and serology does not distinguish between oral and genital infection.

However, women should be counseled to avoid performing oral sex when lesions consistent with an oral herpes outbreak (eg, a cold sore, recurrent ulcer, or vesicle) are evident or if a recognizable prodrome (eg, ear pain or local lymphadenopathy) is underway.
Other important components of complete risk reduction counseling for all patients include a discussion of sex partner selection, sexual network assessment, and the patient’s ability to negotiate safer sex practices.
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Genital wart therapy


Treatment options for genital warts include therapies that are patient applied and those that are clinician administered, based on the size and location of lesions.
Some patients elect to forgo treatment, because many lesions regress spontaneously. However, many patients have recurrent disease within 3–6 months after treatment,
particularly those who are infected with HIV. The goals in treatment of external genital warts are to provide symptomatic relief or cosmesis, or to alleviate anxiety. The type of treatment chosen depends on the size and location of the lesion, and the reasons for treatment.
Other factors that may influence treatment choices include patient preference, cost, adverse effects of treatment, and provider experience.

As noted below, some treatment options are contraindicated in pregnancy, and this needs to be considered. In general, smaller lesions are easier to treat than larger ones. Warts that are smaller than 1 cm2 at the base are more likely to be successfully treated by topical therapy alone. In contrast, diffuse and large lesions may require surgical intervention.
outlines a treatment algorithm for genital warts. We sometimes choose not to treat large, circumferential perianal genital warts if they are not symptomatic. The reason for this is that multiple staged procedures are usually needed for complete treatment, surgery is
painful, and lesions are often recurrent. We would only recommend surgery in these cases to remove foci of disease that are causing symptoms, or if the goal is to rule
out invasive cancer.

Warts that are located on dry surfaces, are chronic (duration >1 year), or are multiple (>10) are more difficult to treat. Many patients require multiple treatments before successful removal of genital warts, and warts may recur after several months. There is no evidence
that one therapeutic modality is superior to another, and the agent chosen may depend on local availability or experience of the clinician in using a particular treatment modality. The impact of treatment on the transmission of genital warts is unknown.

A. PATIENT-APPLIED THERAPIES


Imiquimod 5% cream (Aldara) is a topical immune response modifier that induces cytokines locally without a direct antiviral effect. Patients apply 5% cream once daily
before bedtime, three times a week for up to 16 weeks. Six to ten hours following the application, the affected area should be washed off with soap and water. Unlike podophyllotoxin (discussed below), there is no limit to the surface area that can be treated.

The major adverse effect is mild to moderate local erythema. The safety of imiquimod in pregnancy has not been established, and it should not be used by pregnant women (category C).
Podofilox 0.5% solution or gel (Condylox Gel) works by arresting the cell cycle in metaphase, leading to cell death. Patients can apply the gel with a finger, or the
solution with a cotton swab to palpable warts. Podofilox is used twice daily for 3 days, followed by no therapy for 4 days. Up to four cycles may be performed. A maximum
surface area of 10 cm2 is recommended, and the total daily volume of podofilox should not exceed 0.5 mL.

Adverse effects include mild skin irritation, but local ulceration and pain can occur depending on the duration of use. Safety in pregnancy has not been established
(category C).

B. PROVIDER-APPLIED THERAPIES

Cryotherapy can be performed in the office using liquid nitrogen spray, a liquid nitrogen–soaked swab, or a cryoprobe cooled with nitrous oxide. The freeze-thaw cycle produces cell lysis and destruction of the wart. The freeze margin should extend 2–3 mm beyond the margins of
the wart. Cryotherapy can be repeated every 3 weeks.
Adverse effects include some pain during and for a variable time after the procedure. Swelling and erythema may also occur. This treatment modality is safe for use during pregnancy.
Podophyllin resin 25% in tincture of benzoin (Podocon-25; Paddock Laboratories, Minneapolis, MN) is similar to podofilox except that it is provider applied. The liquid is applied to the affected area, allowed to dry, and washed off after 6 hours. Total volume should not
exceed 0.5 mL per session. Therapy may be repeated in 1 week. Adverse effects include skin irritation, ulceration, and pain, depending on how much solution is applied.
Rarely, polyneuritis, paresthesias, leucopenia, and thrombocytopenia may occur. Safety in pregnancy has not been established (category C).

Trichloroacetic acid (TCA), 80%, destroys affected tissue by protein coagulation. Typically, a small quantity of TCA is applied to the lesion until it appears white or
frosted; the acid is then allowed to dry. Care should be taken to ensure that TCA does not run off the lesion to cover areas of normal skin. To provide greater control,
we soak the stick end of a cotton swab in a small amount of TCA and apply it by touching the stick end to the lesion. Temporary burning may occur at the time of application to the wart. If too much TCA is applied, or if surrounding tissue is inadvertently treated—resulting
in substantial pain—talc, liquid soap, or sodium bicarbonate can be used to neutralize the acid. A barrier of petroleum jelly could also be used to protect areas adjacent
to the wart undergoing treatment. As with cryotherapy multiple treatment applications are often necessary. TCA is safe for use during pregnancy.

C. SURGICAL OPTIONS
Use of an infrared coagulator (Redfield Corporation, Rochelle Park, NJ) is an FDA-approved option for the treatment of genital warts. The infrared coagulator uses
light technology to generate intense heat at the tip of the device, producing coagulative necrosis without a smoke plume. This procedure can be performed in the office using local anesthesia only. The infrared coagulator is particularly useful for larger lesions that would have normally required intraoperative fulguration or laser surgery.
Laser surgery is an option for extensive genital warts, particularly those that have been refractory to other treatment modalities. Trained operators focus the laser
on affected tissue. Laser energy is converted into heat, vaporizing the genital wart. The maximum recommended depth of tissue destruction is 1 mm. Adverse effects include pain and scarring, and operators may develop warts by dispersion of virions during the procedure.

This procedure is performed in the operating room under anesthesia and is one of the most expensive treatment options for genital warts. It can also be done in the office.
Scissor excision and other excisional procedures are considered first-line therapy by some providers for large warts causing obstructive symptoms. After local anesthesia,
the wart is usually excised down to normal tissue or mucosa (using fine scissors or a scalpel), and the roots of the lesion are destroyed by electrocautery, with no
further hemostasis required. Suturing is rarely needed.

Complications include strictures and scarring, particularly if subcutaneous tissue or submucosal fat is inadvertently cauterized.

D.OTHER TREATMENT OPTIONS

5-Fluorouracil (5-FU) can be used as a gel with epinephrine and injected intralesionally for the treatment of genital warts. 5-FU acts by blocking the methylation of
deoxyuridylic acid, arresting DNA synthesis and causing cell death. Adverse effects—pain and ulceration, with dysuria if used in the urethra—limit the use of this drug.
5-FU is not recommended during pregnancy (category D). Cidofovir disrupts viral chain elongation by competitively inhibiting the incorporation of deoxycytidine
triphosphate (dCTP) into viral DNA. Applied topically as a 1% gel, cidofovir has been demonstrated to be effective in a randomized controlled trial of the treatment of
genital warts. This therapy is still experimental.

Interferon alfa can be given systemically, topically (not generally effective), or, as is more often the case,intralesionally. Intralesional interferon is not FDAcleared for the treatment of genital warts although it is used widely.
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HPV Testing Method for Cervical Cancer

In low-resource settings, testing for human papillomavirus (HPV) might be the most effective method of cervical cancer screening. Compared with cytologic testing and visual inspection of the cervix with acetic acid (VIA), a single round of HPV testing significantly reduced the incidence of advanced cervical cancer and related mortality among women in rural India.
These are the conclusions of a study published in the April 2 issue of the New England Journal of Medicine.
The implications of the findings of this trial are immediate and global, according to Mark Schiffman, MD, MPH, and Sholom Wacholder, PhD, who are both from the National Cancer Institute.
"International experts in cervical cancer prevention should now adopt HPV testing for widespread implementation," they write in an accompanying editorial. "Low-resource countries do not need to establish large cytologic-testing (Papanicolaou) programs whose effectiveness requires repeated screening. VIA that is performed by health workers, the least expensive but least accurate option, may reduce mortality slightly."
International experts in cervical cancer prevention should now adopt HPV testing for widespread implementation.
There is a lack of effective screening programs for cervical cancer in developing countries, where 80% of cases occur every year. "A single HPV test that is performed 15 to 20 years after the median age of first sexual intercourse will detect many easily treatable, persistent infections and precancers, while limiting overtreatment," the editorialists note, but widespread implementation of HPV screening still faces a number of challenges.
To implement wide-scale HPV screening, they point out that regional, age-specific HPV prevalence patterns need to be defined; low-cost, simple, and accurate HPV tests need to be validated; and an infrastructure aimed at the treatment of HPV-positive women will have to be developed.
The introduction of prophylactic HPV vaccines does not diminish the importance of HPV screening, they emphasize. "Even when the vaccines become affordable and widely used, they will not substantially decrease rates of cervical cancer for decades because of the long latency between infection and cancer," they write.
In this study, researchers evaluated the effectiveness of a single round of HPV testing, cytologic testing, or VIA in reducing the incidence of cervical cancer and associated mortality rate in women residing in rural India.
All of the women with positive screening results, regardless of the modality used, were investigated, treated, and monitored in the same way, explained lead author Rengaswamy Sankaranarayanan, MD, who is head of the screening group at the International Agency for Research on Cancer, in Lyon, France.
"They had colposcopy, directed biopsy from colposcopically abnormal areas, and treatment of precancerous lesions with cryotherapy or excision," he told Medscape Oncology. "Invasive cervical cancer cases were referred for cancer-directed treatment."
Advanced Cancers and Death Rate Lowest in HPV-Testing Group
Screening took place between January 2000 and April 2003. A total of 131,746 healthy women between the ages of 30 and 59 years, from 52 clusters of villages, were randomly assigned to 1 of 4 groups: HPV testing (34,126 women), cytologic testing (32,058), VIA (34,074), or standard care (31,488, control group).
In the HPV-testing group, 2812 (10.3%) had positive results, as did 1787 (7.0%) in the cytologic-testing group, and 3733 (13.9%) in the VIA group.
The detection rate of cervical intraepithelial neoplasia (CIN) grade 1 was higher in the VIA cohort than in the other 2 groups, whereas detection rates of CIN grade 2 or 3 lesions and invasive cancer were similar in the 3 groups (P = .06 for CIN grade 2 and P = .16 for CIN grade 3 for all comparisons). The positive-predictive value for detecting CIN grade 2 or 3 lesions was 11.3% in the HPV-testing group, 19.3% in the cytologic-testing group, and 7.4% in the VIA group.
The proportion of stage I cancers was highest in the HPV testing and cytologic-testing groups (about 60%), 42% in the VIA group, and lowest in the control group (28%). The researchers noted that the incidence rate of stage II or higher cervical cancer and subsequent related death rates were significantly higher in the cytologic-testing group and the VIA group than in the HPV-testing group.
Clinical Stages of Cervical Cancer and Death Rate in All Women Assigned to Screening
Stage at Diagnosis HPV Testing,
n/total n (%)
Cytologic Testing,
n/total n (%)
VIA,
n/total n (%)
IA 47/127 (37) 60/152 (39.5) 35/157 (22.3)
IB 33/127 (26) 29/152 (19.1) 31/157 (19.7)
II or higher 39/127 (30.7) 58/152 (38.2) 86/157 (54.8)
Unknown 8/127 (26.8) 5/152 (3.3) 5/157 (3.2)
Death from cervical cancer 34/127 (26.8) 54/152 (35.5) 56/157 (35.7)
HPV Test More Sensitive
"We believe that HPV testing was more sensitive than VIA or cytologic testing in identifying women with real precancerous lesions with a potential to progress to frank cancer in our study," said Dr. Sankaranarayanan. "The early detection and treatment of such lesions resulted in a lower rate of advanced cancers, and a lower number of invasive cancers and cervical cancer deaths in the HPV-testing group."
He also pointed out that, compared with the other screening modalities, fewer of the HPV-test negative women developed cervical cancer during the 8-year follow-up period. "This reinforces the conclusion that HPV testing has a possibly high sensitivity to lead to the detection of biologically progressive precancerous lesions," he said. "The lower death rate in the HPV-testing group is due to lower advanced disease and higher prevented invasive cancers due to early detection and treatment of more 'real' precursor lesions."
HPV testing has a possibly high sensitivity to lead to the detection of biologically progressive precancerous lesions.
Compared with the control group, the hazard ratio for the detection of advanced cancer in the HPV-testing group was 0.47 (95% confidence interval [CI], 0.32 to 0.69) and the hazard ratio for death was 0.52 (95% CI, 0.33 to 0.83). There were no significant reductions in the numbers of advanced cancers or deaths observed in the cytologic-testing group or in the VIA group, compared with the control group.
HPV Test Most Objective and Reproducible
Overall, the researchers found HPV testing to be the most objective and reproducible of all cervical screening tests, as well as being less demanding in terms of training and quality assurance. A drawback is that it is more expensive and time-consuming than other types of screening tests, and it requires a sophisticated laboratory infrastructure.
However, they note that a simple, affordable, and accurate HPV test (careHPV test, Qiagen) has been evaluated in China. It produces results within 3 hours, and its accuracy is similar to that of the Hybrid Capture II test used in the current study. The careHPV test is expected to enter the market in the near future for use in developing countries.
The study was funded by the Bill and Melinda Gates Foundation, through the Alliance for Cervical Cancer Prevention. Dr. Schiffman reports being a medical monitor of a trial of prophylactic HPV vaccination sponsored by the National Cancer Institute (NCI). Dr. Wacholder reports serving as the statistician for the same NCI-sponsored HPV vaccination trial.
N Engl J Med. 2009;360:1385-1394.
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