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Understanding Cervical Changes: A Health Guide for Women

  • Posted: 01/21/2010

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Introduction

A Pap Test Showed Cell Changes in Your Cervix

You're probably reading this booklet because your health care provider told you that your recent Pap test (sometimes called a Pap smear) showed cell changes in your cervix. Although it is quite common to feel uneasy about your Pap test results, it may comfort you to know that each year more than 3 million women receive similar news.

“I didn't understand my results at first—and a part of me didn't want to understand. But I knew this was important…and in the end, everything turned out fine.”
MARLENE, AGE 45

Many Cell Changes Are Not Cancer

The good news is that, almost always, women with cell changes do not have cancer of the cervix (also called cervical cancer). But it is important that you protect your health by getting the follow-up tests and care that your health care provider suggests. Having cell changes does not mean that you will get cancer of the cervix. In fact, when cell changes are found and treated early, almost all women can avoid getting cervical cancer.

Getting Your Questions Answered

So what is the next step? What do your results mean? Does this mean you need treatment and, if so, what kind? This booklet helps answer these questions and discusses:

  • Types of changes in your cervix
  • Common tests and treatments
  • How to find the support and resources you need

You will probably have other questions, or you might be concerned about the choices you may need to make. These reactions are normal. But understanding your Pap test results—and what to expect when the results are not normal—can help you make informed decisions and plan your next steps.

To order free copies of this booklet, call the National Cancer Institute (NCI) at 1-800-4-CANCER (1-800-422-6237) or click here to get free copies sent to you.

What Is the Cervix?


The cervix
It is important to get a Pap test at least once every 3 years to check for changes that could be cancer.

The cervix is the narrow, lower part of the uterus where it connects to the upper end of the vagina.

The passageway through the cervix is called the endocervical canal. This passageway lets blood flow from the uterus into the vagina during a woman's menstrual period. During childbirth, it opens much wider to let the baby pass through.

The inner lining of the cervix has two different types of cells:

  • Tall cells, called glandular cells (or columnar cells) toward the top of the endocervical canal. They make mucus, which helps guard the entrance to the uterus.
  • Thin, flat cells, called squamous epithelial cells (or squamous cells). Arranged in layers, they protect the tissues beneath them.

Pap tests can help reveal changes in these cells.

Cells of the cervix, glandular and squamous epithelial
Normal cervical cells
Normal cervical
cells
Mix of normal and precancerous cells
Mix of normal and
precancerous cells
Precancerous cervical cells
Precancerous
cervical cells

Common Changes in Cervical Cells

Cervical cells can go through many types of changes that are not cancer. These changes can be caused by:

Although many cervical cell changes are very common and not related to cancer, they sometimes make cervical cells look like abnormal cells. So your health care provider may suggest that you repeat your Pap test or have other follow-up tests to be certain that the cell changes are not cancer. (See the tables beginning at Table 1 for more information.)

Cell Changes Caused by HPV Are a Special Concern

Some cervical cell changes are caused by infection with a virus called HPV (human papillomavirus). Most HPV infections eventually go away, or clear, on their own, but sometimes they do not. In infections that do not clear, the HPV-infected cells may become precancerous. If these precancerous cells are not detected and treated early, they can develop into invasive cancer of the cervix. An HPV test can detect the virus in cervical cells.

What is HPV?

  • It is a very common virus.
  • There are more than 100 types.
  • Some types cause benign warts on the fingers or feet.
  • More than 30 types can be transmitted sexually.
  • About 15 sexually transmitted types, called high-risk types, can cause cervical cancer.
  • Some other sexually transmitted types, called low-risk types, cause external warts on the genitals that are not cancerous.

Other Risk Factors for Cervical Cancer

An ongoing, or persistent, infection with a high-risk HPV type is the most important cause of and risk factor for cervical cancer. However, studies have shown that other factors may act together with HPV to increase a woman's risk of developing cervical cancer. These factors include cigarette smoking, having given birth to many children, and use of birth control pills for five or more years. Also, if you have a weak immune system, you may be at higher risk because your body may not be able to clear HPV infections on its own. For example, if you take medicine to block your body's immune response or if you are infected with HIV, you may be at higher risk of developing cervical cancer.

What Should I Know About HPV Infection?

How Do Women Get HPV?

Almost all HPV that affects the cervix is spread by sex (through intimate genital to genital contact, including vaginal or anal intercourse, finger to genital contact, and finger to anal contact). Genital HPV infections are very common. The majority of sexually active men and women will get a genital HPV infection at some point in their life. Partners in long-term monogamous relationships may be surprised by the diagnosis of an HPV infection. But because most infections cause no symptoms, they can remain undetected for years. Nevertheless, you are at higher risk of getting a cervical HPV infection if:

  • You have had more than one sex partner, or
  • Your sex partner(s) has had other partners.

For more information about HPV, see the Resources section.

How Can I Tell if I Have HPV? And What Can Happen to Me if I Have It?

Most women with an HPV infection do not know they have it. Most of the time, it does not cause any symptoms. Certain types of HPV can cause warts on the outside of the genitals, but these types do not cause cervical cancer. The only way to know for sure whether you are infected with an HPV type that causes cervical cancer is by seeing your health care provider.

Almost all cervical HPV infections clear up on their own. Many women with HPV infections will have cell changes, at least briefly, within a few months to a year after becoming infected. But most types of HPV do not cause cancer. However, if the HPV is a high risk type and the infection does not go away, you are at higher risk of developing a precancerous change that needs to be treated. It is best to see your health care provider on a regular basis.

“I was really afraid when I found out I have HPV, but talking to the nurse really helped me understand what it is and what we can do about it…”
JESSICA, AGE 28

How Is an HPV Infection Treated?

Although an HPV infection itself cannot be treated, simple treatments that remove or destroy infected cells may prevent cancer. This is why regular pelvic exams and Pap tests are important, along with care for cell changes.

If I Have HPV and It Goes Away, Can I Get It Again?

If you or your partner has HPV, you will share it until your bodies' immune systems get rid of the infections. If you have sex only with each other, you will not pass the HPV virus back and forth. This is because when the HPV goes away, the immune system will "remember" that HPV type and keep you from getting it again. But even though you are protected from one type of HPV, you are not protected from getting other types of HPV.

Finding Abnormal Cells

The Pap Test

The Pap test can find many kinds of cell changes, but the main purpose is to detect cancer or abnormal cells that may lead to cancer.

These cell changes can almost always be treated so you don't get cervical cancer. Most changes in the cervix happen very slowly.

If the lab finds cell abnormalities, the Pap test result is called a positive test result or abnormal. If the cervical cells look healthy, the result is called a negative test result or normal.

The Pap test is not always 100 percent accurate. If one Pap test misses cell changes, they can often be found on your next test. This is why it is very important that you have regular Pap tests. You should also go back to your health care provider for care if you get an abnormal result.

The Pap Test and DES

If you were born between 1940 and 1971 and your mother was given a synthetic form of the hormone estrogen called diethylstilbestrol (DES) when she was pregnant with you, be sure to tell your doctor. Your doctor may want to take additional cells to check for a rare type of cancer.

The HPV Test

Almost all cervical cancer begins as an infection with HPV. An HPV test can detect the virus in cervical cells.

How Is the HPV Test Done?

In an HPV test a small number of cells is collected from the cervix, much as they are collected for a Pap test. Sometimes, the same cell sample that was taken for the Pap test can be used to check for HPV. A lab then looks for the presence of DNA from high-risk HPV types.

When Is an HPV Test Useful?

An HPV test can be useful in screening for cervical cancer in two ways:

  • For women of all ages, an HPV test can be useful as a follow-up to a Pap test with a result of ASC-US (see Table 1).
  • For women age 30 or older, an HPV test can be useful if it is done together with a Pap test as routine screening for cancer once every 3 years.

But if you are under age 30, getting an HPV test and a Pap test together on a regular basis is not recommended. In fact, routine HPV tests would lead to unnecessary treatment, because HPV infections are very common in women under 30 and usually go away on their own.

Pap Test Results

Pap test results show if cervical cells are normal or abnormal. If you have an abnormal result, it's important to get the follow-up care and any needed tests or treatment that your health care provider suggests. Or, you may have an "unsatisfactory" result and need to have another Pap test.

How you can help improve the chances that your Pap test results will be correct:

  • Don't have a Pap test when you are having your menstrual period. The best time to schedule a Pap test is between 10 and 20 days after the start of your period.
  • For about 2 days before a Pap test, do not:
    • Douche
    • Use any creams or medicine in your vagina, unless your doctor tells you to do so. These may wash away cells or hide cells with changes.
  • Don't have sexual intercourse for 1 or 2 days before your Pap test. This may cause unclear results.

"My doctor helped explain what my Pap test results meant, and what I needed to do."
GRETCHEN, AGE 60

Normal Results

  • No abnormal cells were found.

Abnormal Results

This can mean one of the following:

  • The cells don't look completely normal, but doctors are uncertain about what the cell changes mean (ASC-US, ASC-H, or AGC),
  • Mild cell abnormalities were seen (LSIL),
  • Precancerous cells were present (HSIL or AIS), or
  • Cancer cells were seen.

Unsatisfactory Results

  • The lab sample may not have had enough cells, or the cells were clumped together or hidden by blood or mucus. You will need to have another Pap test.

See the Table 1 for more information about what Pap test results mean and what your health care provider might recommend you do next.

Is It All Right if I Don't Get Tested Again Right Away?

Changes in the cervix happen very slowly. So a few months' delay in getting another test usually does not mean the difference between getting cancer and not getting cancer.

More serious problems can develop when you do not have regular Pap tests or when you do not go back to your health care provider for care after an abnormal result.

Questions To Ask Your Health Care Provider

If you have cervical cell changes, your health care provider may want to do a series of tests or treatments, or may refer you to another provider.

  • Tests help your health care provider learn more about the changes in your cervix (see Table 2).
  • Treatments remove or destroy cells with changes so that healthy cells can grow back (see Table 4).

You should always feel at ease asking your health care provider about the reason for a test or treatment and what you should expect during and after it.

"When I learned that my Pap test results were abnormal, I wondered just what the doctormeant by 'abnormal.'"
NANCY, AGE 42

Here are some questions you may want to ask:

  • What does my test result mean?
  • What care is best for me?
  • Is this a test designed to help learn more about the changes in my cervix? Or is it a treatment to cure the changes?
  • What are the possible results? Will I need more care afterward?
  • Are there any risks or side effects? How can I manage them?
  • Do I need to do anything special to prepare for this test or treatment?
  • Do I need to do anything special to care for myself afterward?
  • Will this condition affect my ability to get or stay pregnant?
  • Will my health insurance pay for the treatment you suggested?

Getting a Second Opinion

If you are concerned about your Pap test result or the recommended treatment, you may want to get a second opinion. Changes in the cervix happen very slowly. Most of the time, it takes many years for precancerous conditions of the cervix to become cancer. Waiting a few months before follow-up care usually does not affect the success of the care you choose. You may want to use this time to:

Some women feel uncomfortable asking for a second opinion. They may feel that they are being a bother or that they will offend their health care provider. However, it is very common for women to seek one, and doctors often expect patients to ask for one. A second opinion may help you feel more certain that you have made the best choices about your health.

If you have health insurance, many insurance companies will pay for a second opinion if you ask for one. Some insurance companies may require a second opinion in some cases.

Most of the time, your health care provider will suggest the name of another specialist if you want a second opinion. Or, you may get names of specialists from your local medical society, a nearby hospital or medical school, or your friends or family members.

NCI cancer information specialists (see the Resources Section) can also help you find qualified doctors and programs through cancer centers and other cancer programs.

Finding the Support You Need

It can be scary when you find out your Pap test is abnormal. You may find it helpful to:

  • Ask friends or loved ones for support. They can go to the health care provider's office with you while you are learning about choices in follow-up testing and treatment.
  • Ask your health care provider to:
    • Help you understand medical terms that are confusing
    • Tell you how other people have handled the types of feelings that you are having
  • Contact the organizations listed in the Resources section.

"I owed it to myself and my family to find out if anything was wrong. And once I had the facts, it was easy to take the next step."
JENNY, AGE 46

Table 1: What Your Pap Test/HPV Test Results Mean and Follow-Up

AGC

Possible ResultWhat It Means to YouWhat Your Health Care Provider May RecommendPossible Outcomes
NormalOnly normal cells were seen on the Pap test.Continue to get Pap tests at least once every 3 years.A False Negative (Looks Normal, But May Not Be)
The Pap test is a very good screening test, but it is not perfect. A single Pap test may miss up to 20 percent of abnormalities. Changes that are missed once are usually found the next time. This is why it is important to get a Pap test at least once every 3 years.
ASC-USASC-US (atypical squamous cells of undetermined significance)
  • Some cells from the lining of the outer cervix (also called squamous cells) do not appear normal.
  • Your health care provider will need to do additional tests to clarify the results.
  • Follow-up with repeat Pap tests every 6 months
  • Testing for high-risk HPV
  • Immediate colposcopy (a test that can be done in the doctor's office to get a magnified view of your cervix)
  • Biopsy
  • Estrogen cream

Abnormal Pap Test Result
If a repeat Pap test is abnormal, your health care provider will probably recommend a colposcopy.

Positive HPV Test Result
If your HPV test is positive, your health care provider will probably recommend a colposcopy.

Negative HPV Test Result
If your HPV test is negative, your health care provider may recommend a repeat screening in 1 year. Because ASC-US can also be caused by an estrogen deficiency, your health care provider may prescribe an estrogen cream if you are near or past menopause.

Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy, endocervical curettage, or both.

ASC-H

ASC-H (atypical squamous cells, cannot exclude HSIL)

  • Cervical cells do not appear normal.
  • A high-grade lesion may be present, but the cell changes are too minor to be sure.

AGC (atypical glandular cells)

  • Some glandular cells in the lining of the cervix appear abnormal.
  • Colposcopy
  • Biopsy

Normal Colposcopy Result
If cervical tissue looks healthy, your health care provider may not need to do any further testing or treatment right away, but may recommend an HPV test in 1 year or repeat Pap tests after 6 and 12 months.

Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy, endocervical curettage, or both.

LSIL

LSIL (low-grade squamous intraepithelial lesion)

  • Squamous cells are abnormal, but are usually not precancerous.
  • Colposcopy
  • Biopsy

Normal Colposcopy Result
If cervical tissue looks healthy, your health care provider may not need to do any further testing or treatment right away but may recommend an HPV test in 1 year or repeat Pap tests after 6 and 12 months.

Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy, endocervical curettage, or both.

Precancer

HSIL

AIS

If you have one of the results below, it is very important that you get the necessary tests and treatments.

HSIL (high-grade squamous intraepithelial lesion)

  • The lesion is precancerous; without treatment, it may turn into invasive cancer.

AIS (adenocarcinoma in situ)

  • A precancerous lesion is found in the glandular tissue of the cervix.
  • Colposcopy
  • Biopsy

Normal Colposcopy Result
Even if cervical tissue looks healthy, your health care provider may need to do further testing or treatment, including loop electrosurgical excision procedure (LEEP) or repeat colposcopy and Pap tests after 6 and 12 months.

Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider will probably do a biopsy, endocervical curettage, or both.

CancerCancer cells are present in the cervix.
  • Colposcopy
  • Biopsy

Your health care provider will probably refer you to a gynecologic oncologist.

Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider will probably initially do a biopsy, endocervical curettage, or both, and then refer you to a gynecologic oncologist for further evaluation and treatment.

In some cases, follow-up treatment may be different for women who are younger than age 21 or pregnant.

This table is based on the American Society for Colposcopy and Cervical Pathology (ASCCP) consensus guidelines.

For more information on cells of the cervix, see the What is the Cervix in this booklet.

Table 2: Tests or Follow-Up Treatments That Health Care Providers Use for Abnormal Pap Tests


Possible Test or TreatmentWhat It IsWhat To ExpectWhat Your Health Care Provider May Recommend
Repeat Pap test
  • Same procedure as the first Pap test
  • Done if you have minor cell changes or if the result of the first Pap test was unsatisfactory
Same procedure as the first Pap test

You may need to return for repeat Pap tests every 4-6 months until you have two normal results in a row.

After two normal results in a row, you can go back to having Pap tests at least once every 3 years.

HPV testing
  • A sample of cells from your cervix is tested in the lab. This looks for HPV DNA in the cells.
Procedure is similar to a Pap test.If the test shows that you have HPV, your health care provider may recommend a colposcopy.
Hormone therapy
  • An estrogen cream applied to your vagina/cervix for a few weeks
  • Prescribed by your doctor if you have ASC-US and are near or past menopause
Cell changes caused by low hormone levels will go away, and other changes will remain.

A repeat Pap test is done after 6-8 weeks.

If the results of the repeat Pap test are abnormal, your health care provider may recommend a colposcopy.

Colposcopy
  • The most common test for women who get an abnormal Pap test result
  • Your health care provider uses a special tool, called a colposcope, to view your cervix from outside the body. The colposcope has a bright light with a magnifying lens.

Can be done in your health care provider's office in about 15 minutes

Your health care provider:

  • Puts a speculum into your vagina to see your cervix
  • Applies diluted white vinegar to the surface of your cervix

Areas that are abnormal turn white from the vinegar and can be seen more easily.

You may feel nothing at all or a mild tingling.

Depending on the results, your health care provider may recommend further tests or treatments.
Colposcopy with biopsy and/or endocervical curettage
  • Done if the colposcopy found any abnormal tissue in your cervix (see previous page)
  • For a biopsy, your health care provider will remove a small piece of tissue from the abnormal area. This specimen is sent to a lab for study.
  • For an endocervical curettage, your health care provider will remove cells from inside your endocervical canal with a small spoon-shaped tool called a curette; this takes about 10 seconds. This specimen is sent to a lab for study.

May cause mild pain and cramping (much like menstrual cramps)

You may have less pain and cramping if you take ibuprofen (brand names include Advil®, Motrin®, and Nuprin®) about an hour before the test.

You may have a brown discharge from your vagina for a few days afterward; you may want to wear a pad.

It takes several days for your cervix to heal. To help prevent infection and bleeding during this time:

  • Do not use tampons.
  • Do not douche.
  • Do not do any heavy lifting.
  • Do not have sex.
Depending on the results, your health care provider may recommend further tests and/or treatments.

Table 3: What Does It Mean: Results From Your Biopsy or Endocervical Curettage


Possible ResultWhat Your Health Care Provider May Recommend
Tissue appears normalYour health care provider may not need to do any further testing or treatment right away but may recommend a repeat Pap test or HPV test in 6-12 months.
Tissue shows only mild changes (low-grade)

Your biopsy may have removed all abnormal tissue.

You may or may not need more treatment—even if some abnormal tissue remains.

Your health care provider may not need to do any further testing or treatment right away, but may recommend a repeat Pap test or HPV test in 6-12 months.

Results are unclearYour doctor may do more tests, such as conization.
Severe (high-grade) changes are found

You will need treatment to remove more tissue.

Your doctor may perform LEEP, cryotherapy, laser therapy, or conization.

Invasive cancer cells are found

Your doctor will do more tests to find out the stage (extent) of the cancer. Your treatment will depend on:

  • The stage of your cancer
  • Your age
  • Whether you may want to become pregnant in the future
  • Your general health
  • Other factors

To learn about more treatment options, see the National Cancer Institute booklet, "What You Need To Know About Cancer of the Cervix," or visit www.cancer.gov and search for "cervical cancer."

Table 4: Treatments for Major Cell Changes


TreatmentWhat It IsWhat To ExpectWhat You Should Do
LEEP
  • A procedure that uses an electrical current passed through a thin wire loop to cut away tissue
  • Provides a tissue sample for the lab to study

This procedure is usually done in your doctor's office and takes only a few minutes.

During
Your doctor will:

  • Put a speculum into your vagina to view the cervix
  • Numb your cervix using a small needle
  • Begin the LEEP when the cervix is numb

After

  • It takes several weeks for the tissue to heal and grow back.
  • You may have mild bleeding and a discharge for several weeks.

Before
You may have less pain and cramping if you take ibuprofen (brand names include Advil ®, Motrin®, and Nuprin®) about an hour before the procedure.

After
It takes several weeks for your cervix to heal. To help prevent infection and bleeding during this time:

  • Do not use tampons.
  • Do not douche.
  • Do not do any heavy lifting.
  • Do not have sex.
Cryotherapy
  • A procedure that uses a special cold probe to freeze abnormal tissue
  • The tip of the probe freezes to the cervix and stays attached while a round piece of tissue is destroyed.

This procedure is usually done in the doctor's office and only takes a few minutes.

During
Your doctor will:

  • Put a speculum into your vagina to view the cervix
  • Insert a special cold probe for about 3 minutes to freeze a controlled amount of tissue
  • Warm the probe after the tissue has been destroyed and remove it from the cervix

After

  • It takes several weeks for your cervix to heal.
  • You may have a watery, brownish discharge for several weeks.

Before
You may have less pain and cramping if you take ibuprofen (brand names include Advil®, Motrin®, and Nuprin®) about an hour before the procedure.

After
It takes several weeks for your cervix to heal. To help prevent infection and bleeding during this time:

  • Do not use tampons.
  • Do not douche.
  • Do not do any heavy lifting.
  • Do not have sex.
Conization
  • Uses a knife or laser to remove a cone-shaped piece of tissue from the cervix and cervical canal
  • The amount of tissue removed depends on the size of the lesion

This procedure is usually done in a hospital.

Before
Your doctor will give you anesthesia before performing the operation.

After
 

  • Stitches are often needed to close the wound.
  • Bleeding may occur.
  • It takes several weeks for your cervix to heal.


 

Before
You may have less pain and cramping if you take acetaminophen (brand names include Tylenol® and Anacin-3®) about an hour before the procedure.

After
It takes several weeks for your cervix to heal. To help prevent infection and bleeding during this time:

  • Do not use tampons.
  • Do not douche.
  • Do not do any heavy lifting.
  • Do not have sex.
Hysterectomy
  • Surgical removal of the uterus, including the cervix
  • This surgery is done in the hospital and usually requires an overnight stay.
  • Your doctor will give you an epidural or anesthesia before performing the surgery.
  • The doctor removes your uterus either through a surgical incision (cut) in your abdomen or through your vagina.
  • You will not be able to become pregnant after having this surgery.

This is major surgery.

You should discuss follow-up care with your doctor.

Resources to Learn More

National Cancer Institute

NCI has comprehensive research-based information on cancer prevention, screening, diagnosis, treatment, genetics, and supportive care. We also have a clinical trials database and can offer tailored searches.

Phone   1-800-4-CANCER (1-800-422-6237)
TTY   1-800-332-8615
Web site   www.cancer.gov or www.cancer.gov/espanol
LiveHelp   www.cancer.gov/livehelp
Email   cancergovstaff@mail.nih.gov

Order publications at www.cancer.gov/publications or by calling 1-800-4-CANCER.

We invite you to call or go online to talk with our trained information specialists, who speak English or Spanish, to:

  • Get answers to any cancer-related questions you may have
  • Get free NCI publications
  • Learn more about specific resources and organizations in your area

American Social Health Association (ASHA)

ASHA's HPV and Cervical Cancer Prevention Resource Center provides in-depth information about HPV and cervical cancer prevention and helps you find referrals and join support groups.

Phone   1-877-478-5868
Web site   www.ashastd.org

Centers for Disease Control and Prevention (CDC)

CDC conducts, supports, and promotes efforts to prevent cancer and increase early detection of cancer.

CDC-INFO is available 24 hours a day, 7 days a week, 365 days a year for STD information and referrals to STD clinics. Calls are answered by English- or Spanish-speaking experts.

Phone   1-800-CDC-INFO (1-800-232-4636)
TTY   1-888-232-6348
Web site   www.cdc.gov

CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides these services for underserved women:

  • Pap tests
  • Pelvic examinations
  • Diagnostic tests if results are abnormal
  • Referrals to treatment

Centers for Medicare & Medicaid Services (CMS)

CMS provides information for consumers about patient rights, prescription drugs, and health insurance issues, including Medicare and Medicaid.

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure. It covers Pap tests and pelvic exams to check for cervical and vaginal cancers, among other services. Medicare has information about providers in your area. English- or Spanish-speaking representatives can help you.

Phone   1-800-MEDICARE (1-800-633-4227)
TTY   1-877-486-2048
Web site   www.cms.hhs.gov

Medicaid is a program for people who need financial help with medical bills. You can learn more about this program by calling your local state welfare offices, state health department, state social services agencies, or your state's Medicaid office. Spanish-speaking staff is available in some offices.

Web site   www.cms.hhs.gov

National Women's Health Information Center (NWHIC)

NWHIC is a gateway to women's health information. NWHIC has English- and Spanish-speaking Information and Referral Specialists who will order free health information for you. They can also help you find organizations that can answer your health-related questions. NWHIC is a service of the Office on Women's Health (OWH) in the US Department of Health and Human Services (HHS).

Phone   1-800-994-9662
TDD1-888-220-5446
Web site   www.womenshealth.gov

Planned Parenthood Federation of America

Planned Parenthood is a non-governmental organization that provides information and services related to HPV and cervical cancer screening, among other services.

Phone   1-800-230-PLAN
Web site   www.plannedparenthood.org