February 13, 2014

WHAT’S UP, DOC? | HPV: Could It Happen to You?

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By ALEXANDRA VILLASANTE

A 22-year-old college senior came to the clinic for her routine Papanicolau smear –– commonly known as a Pap smear –– during my obstetrics and gynecology rotation. A few days later, she received a phone call from the gynecology resident.

“Your Pap smear showed some abnormal cells,” the doctor said. “We would like to take a biopsy of your cervix, which we do under an exam called a colposcopy.”

The patient was later told that this abnormality was caused by a strain of the human papillomavirus, which is in the same virus family that causes common warts.

“Isn’t that a sexually transmitted infection?” she asked.

Nearly all sexually active people will become infected with one of the many strains of HPV at some point in their lives; half become infected within three years of becoming sexually active.

“It is, in fact. It is the most common STI in the United States, and in your age group,” the doctor said.

“I didn’t think that I was at risk for HPV; I haven’t had many partners, and I almost always use protection,” the patient said. “And I think, maybe, I was vaccinated –– at least, I remember my pediatrician talking to me about the vaccine when I was younger. Does this mean I’m going to get cancer?”

The patient had a flurry of questions. She was quite surprised and distressed. She didn’t think that she could be among the 20 million male and female Americans between 15 and 49 years old who are currently infected with HPV. In fact, 74 percent of all HPV infections occur in the patient’s age group –– in individuals from 15 to 24 years old.

What Are Some Ways to Protect Yourself From HPV?

1. Get vaccinated if you are under 26, regardless of gender, sexual orientation and sexual activity.

2. Get Pap smears annually if you are a female, starting at 21 years of age.

3. Use condoms consistently. Condom use reduces the risk of HPV infection and disease progression. Condoms are not, however, a perfect protection against HPV.

4. Consider your number of partners: HPV prevalence increases nearly linearly with increasing number of lifetime partners, despite condom use.

5. Don’t smoke: Smoking is a risk factor for persistent infections.

Nearly all sexually active people will become infected with one of the many strains of HPV at some point in their lives; half become infected within three years of becoming sexually active. Some strains are high-risk, or potentially cancer-causing, and some are low-risk, or wart-causing.

Most HPV infections will not cause symptoms or problems, and they will become undetectable within six to 24 months. Among women with a high-risk HPV infection of the cervix, the infection will be persistent in 10 percent of them: This can put the patient at risk of developing dysplasia or precancer that, if left untreated, could progress to cancer.

Cervical cancer is currently the third most common cancer in women, and 99.7 percent of cervical cancer is caused by HPV. HPV has also been associated with head, neck and some skin cancers. Approximately 5 percent of all cancers in men and 10 percent of all cancers in women are caused by HPV.

There is no cure for HPV infection, only prevention and early detection. Vaccination with Gardasil or Cervarix can prevent infection with HPV types 16 and 18, which are responsible for 70 percent of cervical cancers. Gardasil also provides protection against HPV types 6 and 11, which cause anogenital warts, and has been approved for use in both females and males between 9 and 26 years old. Gardasil is ideally given before the start of sexual activity and before exposure to HPV. So it is commonly administered prepubertally when children are between 11 and 12 years old.

Even if you are already sexually active, vaccination is recommended. And even if you plan to abstain from sex or become monogamous for life, you could still be at risk for acquiring HPV if your partner has ever had another sexual partner. Furthermore, HPV can be transmitted by genital contact besides intercourse. Vaccination should be considered for all young people, because everyone who will eventually become sexually active will most likely be exposed to this ubiquitous virus.

Because vaccination doesn’t cover all strains of HPV, annual Pap smears are recommended for women over the age of 21 years old, regardless of vaccination status. With a Pap smear, your doctor can collect a sample of cells from the cervix and upper vagina to analyze under the microscope. This test can detect precancerous cells, prompting further intervention in order to diagnose dysplasia and prevent the progression to cancer.

If, after taking appropriate precautions, you find yourself with an HPV-related concern, as did the patient I described, remember that you are not alone. In fact, you are in the majority. The volume of patients seeking care for HPV-related concerns is quite large. Also, about 90 percent of infections become undetectable without further intervention. Therefore, you will most likely not develop an HPV-related cancer. Make healthy choices for your body and mind, and live your life.

Alexandra Villasante is a fourth-year M.D. candidate at Weill Cornell Medical College in New York City. He may be reached at acv2004@med.cornell.edu. What’s Up, Doc? appears alternate Fridays this semester.