Why is HPV So Confusing? - Kamm McKenzie OBGYN

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Why is HPV So Confusing?

Originally published in July 2013

I previously wrote a blog on herpes (HSV) with the thought that it may be the most confusing sexually transmitted infection.  Then I got to thinking… man, this HPV is probably pretty confusing to our patients too.  And for those of you over 30 years old, for whom we now routinely check for high risk strands of HPV with your routine pap smear, there are many “new” diagnosis of being HPV positive.  Let’s see if we can make this hot-topic a little more digestible. 

What is HPV?

It stands for Human Papillomavirus… but that is a mouthful, so we stick with HPV.  There are many, many different types, or strains of HPV; estimated at over 100, with at least 30 leading to genital infections.   We typically group types of HPV into two categories, “Low Risk” and “High Risk”.  Low risk types of HPV commonly cause genital warts, and high risk types of HPV more commonly cause abnormal pap smears, precancerous changes of the cervix, and even cervical cancers.   I try to explain that the virus types that cause warts are like “distant cousins” to the types that cause cervical changes.  When we test for HPV on a routine pap smear, we are only testing for the high risk strains of the virus.  So if you have a history of an abnormal pap smear or one that tests positive for HPV,  it does not necessarily mean you have a type of HPV that will lead to warts for you or your partner – that is unless you carry both types.

Is HPV common?

Ummmm… yes.  It is estimated that at least 75% of people who have sex will get some sort of genital HPV in their lifetime.  Even those who have only one sexual partner have up to a 20% chance of encountering HPV.  The way I look at it is like this… if you have had sexual relations in your life with several partners, then you most likely have encountered HPV. 

How is this virus spread?

It is considered a sexually transmitted infection, but intercourse itself is not required for infection to occur.  It is spread from direct contact; and thus, vaginal, oral or anal sex can lead to spread of HPV.

Do you ever get rid of HPV?

Fortunately most women clear their HPV infection within 8 to 24 months.  This is particularly true for adolescents and women in their early to mid 20’s.  By clearing the infection, I mean that it would be undetectable on a lab test, and thus clinically insignificant.  Like most viruses, HPV is something a woman can contract years before she ever was to have a detectable level because it may never go away 100%. 

If you have HPV, does that mean you will have cervical cancer?

Most likely you will never get cervical cancer.  As mentioned above, 75% of people probably have some form of genital HPV.  In the entire United States, there are just over 13,000 new cases of cervical cancer diagnosed on an annual basis.  In fact, many women with HPV will never have an abnormal pap smear.  That being said, routine screening with your provider is the only way to follow any changes to the cervix that could lead to cervical cancer. 

Do we routinely check our patients for HPV and what do the results mean?

For women over 30 years old, who have not had a high grade abnormal pap in the last 2 years, the standard of care is to check a pap smear AND high risk HPV.  The HPV is checked from the same sample as the pap itself, so you will not notice a difference in your exam.  If both tests are negative, no pap smear or HPV testing is done for at least 3 years.  Annual exams with a pelvic exam are still recommended for these patients, but no pap smear needs to be done. 

Some women for whom we test for HPV will have a normal pap smear, but have a positive high risk HPV result.  This is particularly confusing because they may have never had an abnormal pap smear, and they may never even develop one.  If a patient has a normal pap smear that tests positive for high risk HPV, we can then specifically check for 2 types of high risk HPV that are most associated with precancerous cervical changes, types 16 and 18.  If the pap is negative for these 2 types, then we simply repeat the pap and retest the high risk HPV in one year.  If the pap is positive for the type 16 or 18, we take a closer look at the cervix with a procedure called a colposcopy. 

This scenario of a normal pap smear that is unexpectedly positive for high risk HPV seems to be the most confusing and upsetting to our patients.  They are confused about how they could have possibly contracted HPV when they have never had an abnormal pap smear, and often times have been with the same partner in a monogamous relationship for many years.   As mentioned above, 75% of people have likely been exposed at some point in their lives, so it is incredibly common.  And, again, as mentioned above, the virus can be cleared by your immune system, but that does not mean you will never test positive in the future.  So a negative test one time, or having a history of normal pap smears your entire life, does not mean you are in the clear forever.

Can you prevent HPV infections?

There are two vaccines available to protect against some of the more common types of HPV.  The goal of the vaccine is to boost immunity towards these common strains and hopefully decrease abnormal pap smears and eventually decrease cervical cancer.  If you are 26 years old or younger and have not been vaccinated, you should talk to your provider about it.  Currently the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the Centers for Disease Control all recommend that all young women AND men ages 11-26 are vaccinated against HPV.  The vaccine is not approved for those over 26.

Condom use when having oral, anal, or vaginal sex helps decrease the spread of HPV, but any skin-skin contact outside the surface area of the condom can spread HPV. 

Limiting the number of partners you have in your lifetime can also decrease your exposure.

Lastly, smoking increases the activity of HPV so quitting will ultimately lead to fewer abnormal pap smears.   Women who smoke have also been shown to have a higher rate of progression of mild abnormal pap smears to more severe ones.

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