Ask the Experts: HPV

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Below are some of the questions sent to ASHA about HPV. Click on the + to see the answers from our experts.

 

                

 

My daughter is at an age (she’s 14) where the nurse practitioner who sees her wants to give her the HPV vaccine. I know it’s a good thing to do, but I’m a little uneasy about the message this might send. What if she’s less likely to use protection when she does have sex (hopefully that’ll be many years from now!!). I don’t want to be a prude and deny her something of value, but wow, vaccinate my baby against something you get from sex? Can you help me feel better about this? I feel guilty for not just taking the plunge and getting her the shot.

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The important thing is that you are doing what all parents do: trying to make the best possible decisions about your child’s health and happiness, both now and for the future.

First, some background. HPV vaccines are recommended for use with all adolescents and young adults between the ages of 11 and 26. (HPV vaccines can actually be given as young as age nine). Why so young? The idea is to vaccinate and offer protection prior to the onset of sexual activity. Also, the vaccines generate a stronger response from the immune system of younger people, so the teen years are an ideal time to immunize against HPV.

As to your question, there is no evidence at all that young people who receive an HPV vaccine are more likely to have earlier or riskier sex. In fact, a recently published study (Bednarczyk, Pediatrics) that followed nearly 1,400 girls who were vaccinated against HPV at age 11 found –compared to girls of similar age who did not receive the vaccine- they were no more likely to engage in sex, become pregnant, or be diagnosed with an sexually transmitted infection. We often use the “seat belt” analogy here: just as wearing a seat belt won’t cause someone to suddenly drive faster or recklessly, neither will an HPV vaccine lead someone to become sexually active or be unprotected when they do.

Many parents also find that getting the HPV shot is a good time for discussions of sexually transmitted infections, and about sex in general. These discussions are a good way to share all that you’ve learned about HPV and other infections, as well as prepare your child to make healthy decisions about sex when she gets older.

By the way, the HPV vaccine is also recommended for boys. So, if you have a son, consider the vaccine for him as well.

We know that the HPV vaccine is safe for young people. Millions of doses of HPV vaccines have been safely given around the world. In some places, we are already seeing a reduction in HPV infections and in conditions associated with cervical cancer. If you want to read more, read ASHA’s HPV Vaccine FAQ.

--J. Dennis Fortenberry, MD, MS
Indiana University School of Medicine

I am pregnant, and have been dealing with abnormal Paps for nearly a year due to growths on my cervix I was told are due to HPV. They haven't treated me yet, and said they almost certainly won't do so while I'm pregnant. Will it hurt my baby, or me? Can I have a normal pregnancy? I just feel like I didn't handle this well!!

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First of all, congratulations on your pregnancy! And let me reassure you that in general, an abnormal Pap test in pregnancy is not dangerous to you or your baby.

Since you have had no treatment to your cervix, I assume that the abnormalities are related to high-risk HPV and are not pre-cancerous. Most all high-risk HPV cell changes are minor and are eventually cleared by your own immune system within about 2 years. The only abnormality that would require treatment in pregnancy is if you actually had cervical cancer, and I'm sure your healthcare providers have ruled that out by now. Treatment of pre-cancerous cells in pregnancy is not done because the treatment might complicate your pregnancy. There is no known risk of transmission of high-risk HPV strains in pregnancy to the baby.

There is, however, a very rare chance of transmitting low-risk HPV (the strains that cause genital warts) to the baby. If you have genital warts, also called condyloma, discuss this with the pediatrician you have chosen to care for your baby. That way, she or he will know what symptoms to look for in your baby. Talk to your pregnancy provider and make sure you are communicating well about these concerns. It is important to take good care of yourself when you are pregnant--not only for your baby, but also to help support your immune system.

If pre-cancerous cells persist after you deliver, they can usually be treated without threatening your ability to have more children in the future. Good luck to you for a healthy pregnancy!

--Beth Colvin Huff, MSN, FNP-BC


My wife was recently diagnosed with HPV and she is pregnant. She has been told that all males have it and it is a genetic STD. She has also been told that a male transmits it to a female and that a female cannot transmit it to a male. Is this true?

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HPV is perhaps the most common of STIs, with up to 80% of women estimated to have the virus by age 50 (the numbers for men are likely to be similar). Both males and females can transmit the virus to their partners, but women are more often diagnosed with an HPV-related cell changes (such as cervical cell changes detected with a PAP test). HPV is not a genetic or inherited condition, and genital HPV infections are acquired through sexual contact (vaginal, oral, and anal sex).

It can be months or even years after exposure before HPV (or a related condition) is diagnosed, making it difficult to answer the 'when' and 'from whom' questions that often arise. Sometimes pregnancy, which naturally suppresses a woman's immune system, is the catalyst that causes a latent HPV infection to emerge. In these cases, any warts or cell changes often clear naturally after the baby is delivered.

By the way, HPV is almost never a problem during pregnancy, either for the mother or baby. Most women with HPV deliver naturally and have healthy children. You and your wife should ask her health care provider if either of you have any questions about this.

--Versie Johnson-Mallard, PhD, RN, APRN, WHNP-BC


I'm a mother with two boys, ages 11 and 15. Our doctor gave me a brochure about HPV vaccines and said she thinks it's a good idea them to receive it. My questions are: 1) Is the vaccine safe? and 2) Why do boys need a vaccine to protect them against a disease (cervical cancer) that affects women?

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I applaud you for being proactive and asking questions! I also am happy your family physician initiated the important conversation about HPV vaccines. First things first: HPV vaccines are indeed safe, having been tested with thousands of boys, girls, young men and women around the world. The vaccines have been found to be well tolerated, safe and effective in both sexes. Most common side effects include mild skin irritation and redness at the site of the injection. There have been reports of some patients fainting after receiving the vaccines, but this is actually common with vaccines and adolescents in general, and can be avoided by simply sitting or laying down for 15 minutes or so after being vaccinated.

Remember that HPV is most definitely not a "female" infection only. As is the case with females, most males will contract HPV in their lifetimes. HPV can cause genital warts, penile, anal, head and neck cancers in men. Recent studies show that HPV related head and neck cancers are more common in males than females. So far Gardasil® (made by Merck) has been approved in males for prevention genital warts. Their effectiveness to prevent HPV related male cancers is currently being studied. Maybe one day research will show us that HPV vaccines are of value with these cancers, too. As men and women pass the virus among sexual partners, it makes public health sense to vaccinate men in order to reduce the viral load in the society.

--Shobha Krishnan, MD


I don't understand the difference between Pap tests and HPV tests. My Paps have ALWAYS been normal, but at my clinic they say they're starting to use HPV tests for "older" women (I'm 32!). Isn't my regular PAP good enough?

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After all these years of telling women they need a yearly Pap test, we've gone and changed the rules--no wonder you're confused! Let me start with a review of these screening tests.

The Pap test was developed about 60 years ago. A gentle scraping of the cervix accumulates cells that are sent to the lab for review under a microscope. There, the cells are examined for any characteristics that might indicate abnormal cell growth. The results are then reported in a category that corresponds to the degree of abnormality seen. This cellular test has been the cornerstone of cervical cancer screening in the United States.

The HPV test has only been available for less than 10 years. It is considered a molecular test since it tests for the presence or absence of HPV DNA. Only the "high risk" strains should be tested for since they are the ones that cause pre-cancers and cancer. It can be tested from the residual of the liquid- based PAP test, or by itself with a small collection brush. The results are reported as positive (meaning high risk DNA has been detected)or negative (meaning high risk DNA has not been detected).

New guidelines for screening now have an option for women age 30 and older by screening with both a PAPtest and an HPV test. Rates of HPV are lower in this age group, but the incidence of cervical cancer begins to go up. This may be because some women do not clear the HPV infection they acquired years before. By using a specific test (the Pap test) and a sensitive test (HPV DNA) together, you get the benefit of a highly effective screen for pre-cancers and cancer.

If both of these tests are negative, you are at the lowest risk category for developing cervical cancer and can safely lengthen the interval that you are screened to every 3 years.

--Beth Colvin Huff, MSN, FNP-BC


I've had genital warts for about a year, and have made several trips to a clinic for treatment with cryotherapy [freezing warts with liquid nitrogen spray]. I've lost my health insurance, though, and can't afford to have new warts treated. The treatment was little more than the nurse practitioner zapping the warts with the spray. Could I buy one of these units and just do it myself?

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I hear you about the difficulty of getting treatment when you don't have insurance. That has to be beyond frustrating. Please don't try and freeze the genital warts yourself, as it can be hard to control how much tissue is destroyed, both surface area and depth. Genital skin is much different from that found in other areas, and can be tricky to work with even in medical settings. The units sold online are meant to be used by trained clinical staff and are not approved by the FDA for self-care.

There are at least three prescription medicines you can apply yourself that can be effective in treating genital warts. Some are reasonably inexpensive, although they can take several weeks to show an effect. They are likely to be less costly than the $500 figure you quote above.

Have you tried either your city/county health department, or a Planned Parenthood clinic? Often they offer free or sliding scale treatment options, or can refer you to someone who offers lower cost treatment. Another tactic is to try and see if you can work out a payment plan with a provider. Is there a medical school with a teaching hospital nearby? Get in touch with them to see what they offer.

You can search for clinics in your area by zip code here (provided by the Centers for Disease Control and Prevention).

--J. Dennis Fortenberry, MD, MS



Can you get HPV from a swimming pool or hot tub?

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Great question, and you're not alone in being confused about just how HPV is transmitted. HPV is spread by skin to skin contact: with genital virus, this can involve vaginal, anal, or possibly oral sex with someone who has this infection. The virus may also be transmitted by fingers from one person's genitals to another. HPV is not transmitted through casual contact such as hugging, shaking hands, or sharing a bathroom or shower with someone. Similarly, hot tubs and swimming pools are not a risk for HPV transmission (unless a couple has sex while they're in there!).

Rest easy about hot tubs and pools, but while we're on the topic keep in mind that up to 80% of sexually active people are estimated to have one or more HPV infections in their lifetimes. Most cases of HPV are harmless and are cleared naturally by the immune system, but it's very important for women to have regular Pap tests (most experts recommend beginning Pap test at age 21, even if you've never had sex). If you're 26 or under, you can also be vaccinated against HPV (but you still need Pap tests!).

--Beth Colvin Huff, MSN, FNP-BC



About a year ago, my partner was diagnosed with high-risk HPV. She had a procedure done to remove abnormal cells from her cervix, and everything has been normal on her follow-up visits, but our lives changed completely. I am always conscious of it, and if I get sick I panic and think it's related to the HPV. My doctor told me if I do have HPV, not to worry about it and continue to live my life the same...I wish I could! What tests should we be doing now?

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I appreciate your concern about your partner's health and it sounds as if she has done the right thing by getting screened and then treated for the abnormal cells. The goal of Pap tests and in some cases, HPV testing, is to identify women at risk for developing cervical cancer. Now that she has been treated, she will need to keep up with recommended exams to make sure that her tests go back to normal.

I am concerned, however, about the emotional impact this has made in your daily lives. Although HPV has been associated with penile and anal cancers in men, these are far less common than the cellular abnormalities in women. High risk HPV causes no symptoms in men or women- no pain, discharge or bleeding. The HPV test is not approved for use in men as it is not as accurate as it is in women. The HPV vaccine is currently not approved for use in men.

We assume that men, just like most women, will clear the HPV through your immune response. In fact, you may have cleared it already, but again, we have no way of testing to know that for sure. In the meantime, the better support you can give your immune system, the better it will support you in helping to clear the virus. If you smoke, try to stop. Eat a good diet with antioxidant-rich fruits and vegetables and get adequate rest. Manage your stress in whatever way works best for you--exercise, hang out with people you care about, get involved in a cause. The benefits you get back from these healthy behaviors will pay you back in many ways!

Because HPV tends to be so common in younger age groups, it is often the first health concern that is faced and can create personal and relationship stress. If you feel that you are not getting the answers you need, talk to another provider or educate yourself through websites like this one.

--Beth Colvin Huff, MSN, FNP-BC-


I'm confused by the news that new HPV tests are available. How are these tests different and I don't understand how a test that detects certain types of the virus is helpful. Isn't my Pap good enough?

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Good for you that you are keeping up with the current news in cervical cancer prevention! You are correct that a new HPV test is available, so I will try to explain its use.

There are now 2 FDA approved HPV tests: The Hybrid Capture 2 HPV DNA test and Cervista™ HPV test. The Hybrid Capture 2 test has been available for almost 10 years. It tests for a panel of 13 high risk viral strains and if the test returns "positive" it means that one or more of those strains have been detected. This test is recommended for two uses--- with women over age 20 when a Pap test returns in a borderline category, called atypical squamous cells of undetermined significance (ASC-US); and in women over the age of 30 when doing both a Pap test and an HPV test.

Cervista™ HPV was just recently FDA-approved in March 2009. It also has a high risk panel of the same 13 viral strains as the Hybrid Capture 2 test but it adds one more strain that has been found to cause cervical disease. It is also approved for the same two indications as above: for reflex testing for an ASC-US Pap result and for primary screening of women age 30 and older.

What Cervista™ also offers is the ability to tell if either type 16 or type 18 is present; this is called genotype specific testing. We know that these two strains cause the majority of cervical cancers. If the Cervista™ high risk panel is positive, then further testing can be done from the same sample to see if either type 16 or 18 is present. Women under the age of 30 are very likely to clear their HPV infection, so genotype specific testing is not particularly helpful in this age group. However, it may be especially important for women over 30 as cervical cancer rates begin to rise.

If types 16 or 18 are present, it does not mean that you have or will get cervical cancer. It simply means that your healthcare provider has another tool to help determine the appropriate follow up for you

--Beth Colvin Huff, MSN, FNP-BC


I had my Pap test a month ago and just received a letter saying my Pap test is unclear, I MAY have changes in my cervix cells, and I need to get checked again. I'm scared because the night before I got the letter, my boyfriend and I had sex. Now I'm freaking out that I've given him HPV.

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Women can have unclear Pap tests for many different reasons. Sometimes HPV-related cell changes are the cause, but other causes such as yeast infections can also result in an abnormal Pap test. To help sort it out, it's not uncommon to repeat the Pap test in a few months or, sometimes with women over age 21, to do an HPV test. Even when HPV is involved, 90% of infections clear up on their own within 24 months, particularly in women younger than 30 years of age.

What if you do have HPV, though? Well, nearly 50%-80% of sexually active people have at least one HPV infection in their lifetimes. The virus is most often harmless and the immune system usually does clear it naturally, but it's important for women to have regular Pap tests and, when appropriate, HPV tests. Women age 26 and under should also talk with their healthcare provider about getting an HPV vaccine. If you follow-up with your clinic as they recommend, it's likely you'll be fine.

As for your partner: Most sexually active men have HPV at some point, too, and the virus is usually silent and harmless. There's no specific test recommended for men who have no symptoms. However, consistent condom use has shown to significantly reduce the risk of transmission of HPV. So, follow up on your test as recommended by your clinician and don't get over anxious!

--Shobha Krishnan, MD


I have been diagnosed with HPV and I am a lesbian. How do I protect others from getting it? Or should I not have sex at all?

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                HPV is the most common sexually transmitted virus.  It is estimated that 75-80% of people will have HPV sometime in their lifetime.  Also, 90% of HPV infections clear on their own.  It is not unlikely that any of your future partners have been with partners who had HPV or have HPV themselves.  Only a small number of women infected with HPV develop cell changes that need to be treated.  Only rarely does the presence of HPV lead to cervical cancer and when it does, it takes many, many years to develop.  Transmission can occur during direct skin-to-skin contact with the mucous membranes or the skin covering the genitals, perineum, anus, or upper thigh which can happen during genital-to genital contact.  Though it is rare, HPV can be transmitted through oral sex.  But it’s important to remember, oral sex is common, HPV-related oral diseases are not.  Manual stimulation using hands or other parts of the body does not pose any risk of transmission.

                That being said, it’s important to just have a conversation with your future partners and give them the facts and make a decision together.  If you are worried about transmission and would like to use some form of protection, dental dams (small latex sheet), a condom cut open length-wise, or saran wrap may offer some protection.  Also, abstaining from sex when or if warts are present may reduce transmission.  Though abstaining from sex would be the only 100% chance of not transmitting HPV, many people with HPV continue to have healthy sexual lives after diagnosis. 

 

Click here for an FAQ page about HPV and here for tips on how to talk to your partner about your HPV diagnosis.  Also look on the sidebar for other topics related to HPV.

-- Sexual Health Resource Center Staff

 


I have a question regarding Loop Electrosurgical Excision Procedure which is called (LEEP Surgery).  I would like to know when is this procedure necessary?  A couple of years ago I had a high-grade PAP test result, and last year my PAP was normal.  My health care provider also did an HPV test, which was negative.   Should I have had the LEEP?  

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LEEP (also known as LOOP), cuts away abnormal cervical cell using a thin wire through which electrical current is briefly passed.  It’s difficult to speak directly to your specific situation, as there are numerous factors that influence specific follow-up (depending on their medical history and other details, recommended “next steps” may be very different for women with the same Pap test results).

So in many cases, there is no one size fits all approach to follow-up care and management of women with abnormal PAPs.  Keep in mind that in addition to being a treatment option, a LEEP is also a considered a diagnostic procedure (the tissue removed can be sent to a lab for additional evaluation). There are several acceptable “next steps” for women with Pap results that indicate high-grade abnormalities (often called HSIL Pap results, or High-grade Squamous Intraepithelial Lesion), and a LEEP is one of them (whether done immediately following the abnormal Pap or later).

In general terms, then, LEEP is common as a treatment and/or diagnostic option for women with significantly abnormal PAPs, even if their colposcopy/biopsy does not indicate any cervical pre-cancer is present. The health care provider who diagnosed should be able to address any questions you might have as to why he or she chose one approach over another.

--The HPV Resource Center Staff