Human Papilloma Virus (HPV)

The WHOLE truth about HPV:
What today’s woman needs to know to stay on point about the most common STD in the U.S.

September is gynecologic cancer awareness month; and I could not think of a better time to put the truth on the line about Human Papilloma Virus (HPV). Firstly, HPV is not one virus, but many; of which, thirty types infect the male and female genital tract. As scientists have studied these types in the 21st century, Harold zur Hausen was awarded the 2008 Nobel Prize for finding the link between HPV and cervical cancer. This led the National Toxicology Program to label HPV as an official carcinogen (cancer causing agent; i.e. as dangerous as asbestos). HPV viruses can cause effects from warts to cancers. There are 15-18 types categorized as high risk because they are the types which can cause cervical, vaginal, vulvar, anal, penile and scrotal cancers. The other types affecting the genital tract are low risk, and generally only cause warts (rarely leading to cancer). Both high and low risk types of HPV are transmitted sexually via genital contact, regardless of intercourse.
In the United States, nine out of ten sexually active adults will have come into contact with HPV. Most infections have no symptoms. Infection is most common during the teens and early twenties, decreasing by ages 25-28. Infection generally occurs shortly after the onset of sexual activity, and within 1-2 years, it generally either clears or goes into a latent state. It is our immune system that detects the virus and allows our bodies to develop a protective response so that only 9% or less of infections will persist in an active state for over two years. Although medical science has not uncovered answers to what actions a person can take to improve the likelihood of immune clearance of the virus, overall good health and healthy habits keep our immune systems optimal. Puberty in girls is marked, not only by beginning to have menstrual cycles, but the cervix (entry to the womb, and end of the vagina) actually “blossoms” as does a flower at springtime. The inner part of the cervix becomes exposed, and the female body actually is more vulnerable to sexually transmitted infection at the pubertal time. Studies have shown that with teens becoming sexually active earlier, there has been an increase in the incidence of abnormal cervical findings due to HPV in this age group.
Cervical cancer has a worldwide incidence of 500,000 newly diagnosed cases every year. Over 5000 women die in the United States annually from cervical cancer. The Pap smear is a screening test that takes cells (cytology) from the cervix which are evaluated by a doctor who looks at them under a microscope for abnormal/ precancerous changes (dysplasia). The Pap smear has decreased the incidence of cervical cancer drastically. Studies have shown that women who develop cervical cancer are likely to have never or rarely had Pap smear screening.
The Pap smear can be performed either by placing the cells onto a slide or in a liquid medium (most commonly done). The liquid based cytology has advantages of filtering blood, inflammatory cells, and debris, so that the doctor has a more clear view of the cells of importance. Also, testing for HPV, Gonorrhea, and Chlamydia infections can be performed from the same specimen in liquid based testing. Pap smears have been performed across the world since the 1940s, but only in the 21st century has the understanding of the causal effect of HPV been fully understood. The nomenclature of classification for reporting of Pap smears developed in 1988 (and modified several times thereafter) is known as the Bethesda Classification System. This report is sent by the lab which evaluated the Pap smear to the doctor who performed the test. The American Society for Colposcopy and Cervical Pathology (ASCCP) is the organization the defines the guidelines (standard of care) for how doctors manage abnormal results and determine what further testing and what time interval of follow up is appropriate based on these results. The general recommendations for Pap smear screening are that it begin for all women at age 21, and be done every two years until the age of 30. This is because there is a very low incidence of cervical cancer in women under 21; and, recent studies show that excisional procedures in this age group lead to an increase in premature birth (excisional procedures are done after abnormal Pap smears, but teens and young women are the most likely age group to have spontaneous clearing of abnormal results proving many procedures are unnecessary for this age group). These recommendations represent a consensus of the organizations such as American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) that shape women’s healthcare in our country. They are based also on the widespread use of vaccination against HPV in teens and young women.
In 2006, Gardasil became the first FDA approved vaccine against HPV infection. It specifically protects against types 6, 11, 16, and 18 (the types which give rise to 70% of all cervical cancer & 90% of all genital warts). Studies show that in a person unexposed to the HPV virus, the vaccine provides 100% protection from the common types of HPV. In girls, the vaccine is indicated for prevention of anogenital warts, cervical, vulvar, and vaginal lesions & cancer. In boys, the vaccine is indicated for prevention of anogenital warts. Studies have already shown a 34% reduced rate of vulvar, vaginal, and perianal precancerous lesions, and a 20% reduction of cervical lesions. A second vaccine, Cervarix, has also been FDA approved. It provides protection against HPV types 16 and 18; and thus protects against high risk types which can cause cervical cancer but not low risk types which can cause anogenital warts and lesions. It is indicated for girls ages 9-25.
HPV incidence in young women since the introduction of the Gardasil vaccine is dropping. It is indicated for ages 9-25 of both genders. It is advisable to be given prior to onset of sexual activity. It is given in three separate doses over a six month time period. It reduces the number of abnormal Pap smears, invasive (excisional) procedures, and disease incidence. Even women who have a history of previous surgical treatment for precancerous lesions were 40% less likely to need another procedure when given the vaccination.
Parents have expressed hesitance in initiating HPV vaccination at the Pediatrician’s office for a number of reasons- lack of education about both the risks of HPV and the vaccine itself, negative stigma about vaccination, discomfort with approaching the subject of sexual activity, and poor doctor/patient communication overall about HPV. Since the introduction of HPV vaccination, only about one in five girls in the U.S. has received the HPV vaccine series. Therefore, it becomes a public health priority for OB/Gyns (Obstetrician/Gynecologists) to educate teens and young women (under the age of 26) directly in order to break down obstacles to women’s health and empower young women about their bodies, their risks for infection & disease, and their future fertility.
Worldwide use of vaccination has been a critical step in conquering deadly disease. This includes the use of both Hepatitis B and Meningitis vaccines for newborns, infants, and young children to prevent death. It includes prevention of Measles, Rubella, Tetanus, and Whooping Cough. It historically eradicated Polio, a deadly and debilitating disease. Thus, fear of vaccination is no more logical than fear of the use of antibiotics. Appropriate counseling, examination and healthcare provider guidance are always prerequisite to administration of a vaccine in order to ensure safe protocol and outcome. Most importantly, educating teen and young adults (especially in an era where all sexual/ health education in our public school system is elective) about the importance of adding HPV vaccination to their, already initiated, vaccine series in the pursuit of excellence health and disease prevention is a health priority.
As young women step into leadership roles in their schools, churches, and communities, they must be prepared to intelligently discuss the HPV epidemic in our nation and understand preventive measures against Cervical Cancer. This article prepares them to do just that in honor of Gynecologic Cancer Awareness Month.

Dr. Afriye Amerson

References & Resources:
1. American Cancer Society
http://www.cancer.org/downloads/STT/500809web.pdf

2. National Institutes of Health
http://www.consensus.nih.gov

3. American College of Obstetricians and Gynecologists
http://www.acog.org/publications/patient_education

4. US Preventive Services Task Force
http://ahrg.gov/download/pub/prevent/pdfsr/cervcanser.pdf

5. 2006 American Society for Colposcopy and Cervical Pathology- sponsored consensus conference.AmJObstetGynecol 2007; 197: 345-55
http://www.asccp.org/consensus2012

6. http://www.gardasil.com or 1-800-GARDASIL

7. Centers for Disease Control & Prevention
http://www.cdc.gov/STD/vaccines/hpv/default.htm

8. National Network for Immunization Information
http://www.immunizationinfo.org

9. http://www.hpvresource.org

10. http://www.thehpvtest.com

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