INTRODUCTION
The pap smear is a simple yet very effective screening test which is intended to detect cancer of the cervix, as well as precancerous abnormalities. Early detection and treatment has greatly improved the cure rate of cervical cancer, and treatment of precancerous changes, known as dysplasia, effectively prevents cervical cancer.

The Papanicolou smear is obtained by gently scraping the surface and canal of the cervix with a small spatula and brush to remove some of the surface cells. The cells are fixed and sent to a pathology lab where they are examined under a microscope by trained technologists. The cells on the slide are carefully examined to determine if they are normal or abnormal. Abnormal cells are categorized based on special characteristics as being cancer, dysplasia (pre-cancer), or atypical (borderline).

Even the most accurate test is not absolutely perfect. Because it is a screening test, the pap smear is not a perfect test either. It can appear to be abnormal when there are no abnormal cells present, or it can appear normal when there are abnormal cells present. It detects many cellular changes which are not uncommon or harmful. Many "abnormal" paps are in fact normal, as determined by further testing. The reason this occurs is because some cellular changes cannot be determined with certainty to be normal or abnormal by the pap smear alone. The most common example is "borderline" pap smears. These pap smears are said to contain atypical cells. About 25% of patients who have atypical cells on a pap smear will actually have dysplasia. By evaluating atypical pap smears, as well as clearly abnormal paps, more patients with truly abnormal cervical cells will be detected.

Pap smears can also miss abnormalities. In these cases the pap smear appears normal even if abnormal cells are present on the cervix. This is called a false negative test, and it occurs in about 5% of pap smears. Because false negative tests can occur, the pap smear should be repeated every year in most patients.

Thin Prep and computer screened slides are being investigated as tools to improve detection. They increase the number of early changes detected, but have not changed the number of lives saved. More information is needed before these tests become universal.

WHAT CAUSES DYSPLASIA?
Dysplasia can be caused by a virus known as human papilloma virus (HPV). This virus infects skin and mucous membranes, and is transmitted by direct contact with an infected individual. Infection of the genital area is sexually transmitted, and is common in sexually active people. Approximately 40% of adults have evidence of HPV in the genital tissues. The percentage of people with the virus declines with age, suggesting that the infection is not permanent. In a small percentage of people with the virus, infection causes genital warts or dysplasia of the cervix, vagina, or vulva. In some cases the dysplasia can progress to cancer. In the majority of people, however, HPV causes no abnormalities at all. The reason HPV can cause problems in some, but not others, is probably due to the presence of more aggressive strains of the virus, in combination with the fact that some women are more susceptible to infection, such as those who smoke.

Human papilloma virus itself is not harmful, but in some cases the abnormalities that it can cause require treatment. This is the case with cervical dysplasia. Although there is no way to eradicate the virus from the body, treatment of dysplasia is relatively easy and very effective. Because HPV is common and present in many tissues, dysplasia can sometimes occur again after it is treated. For this reason regular pap smears should be obtained annually in most women.

EVALUATION
Atypical or "borderline" pap smears can result from infection, inflammation, lack of estrogen (as in post-menopausal women), irritation from various causes, and other reasons. Patients with a pap smear showing atypia should be examined for treatable causes, such as an infection, and appropriate treatment should be given. The pap smear can then be repeated in about three months. This time period is necessary for the cellular changes to subside and the surface cells of the cervix to regenerate after a pap smear. In the majority of cases the repeat pap smear is normal. If atypia persists, further testing is needed since approximately 25% of these patients will have dysplasia.

Patients with pap smears showing dysplasia require further testing to confirm the diagnosis. The definitive test is called colposcopy, in which the cervix is examined under magnification. The degree and extent of any abnormal cervical tissue can then be determined. Biopsies of any abnormal areas are taken to establish an exact diagnosis. Treatment is based on the colposcopy and biopsy results, not on the pap smear alone.

Dysplasia is categorized as mild, moderate, or severe, depending on the amount and degree of abnormal cells in the tissue. If left untreated, dysplasia can progress into cancer in some cases. This process usually takes 2- 5 years, and is more likely to occur in cases of severe dysplasia. Severe dysplasia usually persists, and if it is not treated, can progress to cancer in about 50-70% of cases. Mild dysplasia is actually most likely to resolve without treatment. Only about 10% of mild dysplasia will progress to cancer if untreated. Again this progression takes many years to occur. Moderate dysplasia may resolve, remain the same, or progress, and falls somewhere in between mild and severe dysplasia.

TREATMENT
Only dysplasia and cancer truly require treatment, and in cases of mild dysplasia close observation without treatment may be appropriate. Cancer is fortunately uncommon. When it is discovered, it is treated with either a simple hysterectomy, radical hysterectomy, or with radiation therapy with or without a hysterectomy, all depending on the stage or extent of the cancer.

Dysplasia is relatively easy to treat by procedures that can be done in the office. The abnormal tissue is usually removed. The abnormal tissue can be removed by cutting out a cone-shaped piece of cervix, which can be done in the operating room with a scalpel or laser, or in the office with a prodecure known as LEEP (loop electrosurgical excision procedure).

The LEEP procedure is simple, effective, and has minimal risks and discomforts. Because it can be performed in the office it is convenient and less expensive. It removes the abnormal tissue of the cervix thereby treating the condition, and the tissue can be sent to the pathology lab to confirm the diagnosis and confirm that all abnormal tissue is removed.

After treatment for cervical dysplasia, pap smears should be obtained about every four to six months for two to three years, depending on the severity of the dysplasia. The overall cure rate is greater than 95%. If dysplasia returns or persists, retreatment is generally curative. In rare cases, hysterectomy may be necessary to completely resolve the problem.

CLOSING
Abnormal pap smears are actually very common. Fortunately, the majority are only minor abnormalities that require little to no treatment. Others require further evaluation, treatment, and careful follow-up. The cure rate for mild, moderate, and even severe dysplasia is very high. But it is important that this condition be evaluated and treated correctly and in a timely manner. Even abnormalities that do not require treatment should be followed frequently and carefully.

Chronic Pelvic Pain

INTRODUCTION
Many women suffer for months or years from pain in their lower abdomen or pelvis. Although there are some diseases known to cause chronic pain, many women who have experienced pain for a long time and have been unable to obtain relief may not know the cause of their pain. They have often seen many different doctors, undergone multiple tests and procedures, and may have even had major surgery, all without relief. The pain continues, the cause remains unknown, and attempts at treatment are ineffective. Situations such as this are referred to as a chronic pain syndrome. You may have heard of conditions with names like "neurogenic pain syndrome," "fibromyalgia," or "myofascial pain." All of these are terms that most likely refer to different varieties of the same chronic pain condition.

Chronic pain can come on suddenly, but it usually arises gradually. Because many physicians do not understand chronic pain syndromes well, patients are usually diagnosed as having other conditions. However, treatment which is usually successful for other conditions fails to relieve the chronic pain syndrome. As a result, the pain continues and patients often undergo more tests, receive more ineffective treatment, and go on to see doctor after doctor in what may seem like a wild goose chase. Meanwhile, the pain continues unabated. This leads to frustration, anger, fear, depression, and anxiety. Relationships with family, friends, and loved ones become strained and moral support from others may dwindle or disappear completely. This creates a vicious cycle that results in poor coping ability and worsened pain.

CAUSES OF CHRONIC PAIN
Chronic pain is a very complicated problem that medical science does not understand well. Because of this incomplete understanding, we are sometimes unable to find a cause for the pain. We know that pain is a process that depends on chemicals, which are produced by tissues in the body. These substances are called pain mediators. They stimulate nerve endings which send pain signals to the brain. Pain mediators are produced in reaction to tissue trauma, such as burns, cuts, infections, etc. We also know that the body's nervous system does not send pain signals to the brain unless the nerves are stimulated beyond a certain point. This point is called the pain threshold. When the threshold is exceeded, the nerves are stimulated and pain signals are sent to the brain.

There are some cases of chronic pain that are caused by conditions that can be diagnosed and treated effectively. Some of the more common gynecologic conditions that can cause chronic pain include endometriosis, adenomyosis, uterine fibroids, and primary dysmenorrhea. Other organ systems also cause pain, especially the gastrointestinal tract. Irritable bowel syndrome, inflammatory bowel disease, and diverticulosis are a few conditions known to cause pain. Interstitial cystitis is a chronic inflammation of the bladder that causes pain. Vertebral disc misalignments, arthritis of the spine or hip, and muscle strain or spasm can also cause chronic pain. We believe that most cases of chronic pain are caused by one of two basic mechanisms. The first is excessive amounts of pain mediators present in certain areas of the body. This stimulates nerve endings past the pain threshold, and pain signals are produced. The second, and perhaps more common cause, is a lower-than-normal pain threshold. The nerves are hypersensitive and therefore send pain signals even though there is little or no stimulation for them to do so.

As a result of long standing chronic pain, most patients experience tremendous stress. Frustration, anger, anxiety, and depression are all very common. These emotions usually lower the body's ability to cope with the stress of pain, leading to more severe pain, which creates more stress. Thus, the cycle of pain is established.

EVALUATION OF THE PATIENT WITH CHRONIC PAIN
It is important for everyone to realize that the pain of a chronic pain syndrome is real. It is not imagined. If multiple tests fail to identify a cause of the pain, many doctors, co-workers, friends, family, and even the patient herself, may begin to doubt if there is really any pain at all. However, the absence of identifiable disease, infection, trauma, or other abnormality, does not mean the pain does not exist. Likewise, just because a specific cause cannot be found, does not mean the patient is crazy, or that the pain is "all in her head." Patients with a chronic pain syndrome are often frustrated, angry, depressed, and afraid. Although it can be incapacitating, chronic pain is not life threatening, it is not cancer, and it will not cause paralysis or insanity.

The search for the cause of pain starts with a thorough history. Clues can sometimes be found by determining when the pain occurs, what type of pain it is, and what makes the pain better or worse. A physical examination is performed. Various tests may be done, depending on what is found in the history and physical. The goal is to determine if there is a treatable cause for the pain. In some cases a team approach is used, where different doctors with expertise in various areas of medicine evaluate different organ systems to find the cause of the pain. In many cases a single, definite cause for the pain cannot be identified and multiple factors contribute to the pain.

TREATMENT
If a primary cause of the pain can be identified, then treatment is directed at that cause. Gynecologic causes of pain can be treated with medication to suppress the hormonal fluctuations of the menstrual cycle and thereby prevent ovulation, menstrual bleeding, and other consequences that can cause pain. In some cases conservative surgery can alleviate gynecologic pain. In other cases a hysterectomy (removal of the uterus) and/or oophorectomy (removal of the ovaries) may be necessary. There are many patients who suffer from chronic pelvic pain who have already had a hysterectomy, and perhaps other surgical procedures, and yet continue to have significant pain. There are also many patients who have chronic pain who have had many tests, but no abnormality can be found. These patients most likely have a chronic pain syndrome, which can be effectively treated in most cases.

Treatment begins with identification of any hypersensitive areas, known as trigger points. These are tender areas that, when exposed to minimal stimulation, cause the patients typical pain. Trigger points are usually located in the wall of the lower abdomen, just beneath the skin. They may also be located in the lower back, hips, and other areas. If trigger points are present, they are injected with a small amount of local anesthetic, which blocks the pains signals from those areas. This usually results in complete pain relief that lasts for several days to one or two weeks. The trigger point injections are repeated every few weeks, and in most cases the period of pain relief lasts longer and longer as time goes on. Although not every patient responds the same way, ultimately about 90% of patients with this type of pain obtain relief with trigger point injections.

Many factors are known to worsen chronic pain and cause flare-ups. Ovulation, menstruation, and sexual intercourse increase the pain in many patients. Suppression of the menstrual cycle with medication can effectively eliminate these sources of pain. Avoiding intercourse at certain times, or avoiding certain sexual positions, can be helpful. Treatment of depression, anxiety, and insomnia, and reduction of stress, will raise the pain threshold and reduce the intensity and frequency of pain. Emotional support from the patient's spouse, family, and friends is extremely beneficial, as is participation in support groups and counseling. Good nutrition, regular exercise, and a positive mental attitude will optimize the body's physiologic state and reduce pain and suffering.

A very important component of the treatment of chronic pain is proper use of medication to relieve pain. Narcotic pain relievers are extremely effective when taken in adequate doses, because this type of pain medication directly raises the pain threshold. Many doctors and patients are afraid that long-term use of narcotics will lead to addiction and other problems. The fact is that studies have clearly shown that most patients suffering from significant, chronic pain can successfully use narcotics to obtain excellent pain relief, regain a normal lifestyle, and not experience addiction or other serious complications.

Studies have also shown that taking pain medication at regular time intervals and maintaining a minimum level of medication in the body is more effective than waiting to take the medication only when the pain becomes severe. In other words, if pain relievers are taken before the pain becomes severe, the pain can be kept to a minimum and flare-ups can be avoided. Waiting until the pain becomes severe is much less effective, as the pain will continue to worsen until the medication takes effect, and by then more medication will be needed. Patients should take their pain relievers as often as needed to maintain comfort, but avoid excess amounts that can cause drowsiness or other side effects.

CONCLUSION
Chronic pain is not a completely understood entity, but some aspects of the problem are clear. Because a specific cause cannot always be found, a complete cure is not always possible. However, proper treatment with trigger point injections, pain relievers, and when necessary, antidepressants and other therapies can relieve pain and suffering, and allow patients to resume a normal, active lifestyle. Many patients who have suffered for years have obtained excellent pain relief.