Crepes and Colposcopies

So I didn’t end up making it to Lord Vishnu Temple on Monday because we had dinner with our lovely dietitians, Cristen and Caryn, along with some other medical folk over at Cristen’s place in Winterton (a little town out in the Berg about 20 minutes from where we spent the weekend). Cristen made pancakes for dinner (crepes, to all my American friends…South Africans have “flapjacks” for breakfast) and we all pigged out. Delicious.

Then it was back to Ladysmith for some more work. Today I wandered up to theatre to watch a colposcopy (basically just the removal of pre-cancerous tissue in the cervix). This procedure is the follow-up to an abnormal Pap smear, assuming the results suggest pre-cancerous or cancerous cells. Normally this doesn’t happen until the patient is older, in her fifties or above. But if there’s one thing I’ve learned since being in South Africa, it’s that HIV complicates everything. Here, a number of our cervical cancer patients are quite young–in their twenties and thirties. This is because someone who’s HIV positive is less able to mount an effective immune response to an HPV (Human papillomavirus)  infection.

Normally, HPV lies dormant amongst the cervical cells for years before slowly converting normal cells to cancerous ones (this is why the HPV vaccine is so important!!*). Certain strains of HPV also cause genital warts, and the high incidence of those amongst the patients I’ve seen suggests that the immune response to those strains isn’t so good either (don’t worry, the vaccine protects from those too). Normally, the body does a pretty good job fighting this stuff and can even rid the cervix of the pre-cancerous cells by itself, which is why usually women with abnormal Pap smears are told to simply repeat the exam in six months. But if you’re HIV+, especially if you’re CD4 count is low, you can’t fight off the pre-cancerous cells so they have to be removed before they become malignant. Thus…the colposcopy.

I couldn’t see too much during the procedure, but the doctors were kind enough to let me peek in through the machine from time to time. I think I was able to tell which parts of the cervix looked abnormal…

Then it was off to the monthly district morbidity and mortality meeting. Apparently our stats look better than in previous months and improvements have been made since the last quarterly meeting, so it was mostly good news. And then, towards the end of the meeting, we suddenly shifted gears and began to talk about CTOP. No, not the UNC first-year orientation program. In this context, CTOP refers to abortion. Although abortion is legal in South Africa, there are few providers (especially in KZN province). The clinic sisters told us that they were being flooded by women looking for abortion providers and that they had no one to refer these patients to. Many of these women later end up in our Casualty ward as a result of a botched back alley abortion, or an incomplete medical one started by a doctor who was unwilling to do the follow-up work. There has been talk of building an abortion clinic here for two years and it looks like all this work may finally come to fruition, “may” being the key word. There has been a big debate (which continued even today) about the location of the clinic that had basically all the same arguments as one might here in the States. Just a little kick in the pants for me in case I’ve been getting too comfortable in maternity…

*NOTE: HPV has also been implicated in certain anal and penile cancers so guys should really think about the vaccine too, even though it’s only being marketed for girls at the moment. That being said, it’s not even offered here in South Africa’s state hospitals because the government can’t afford to get it for folks. Definitely felt that invisible knapsack of privilege again when I learned that, since I’m one of the lucky ones that has been vaccinated….

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