HPV: The Unspoken Truth

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Dr. Jessica Kahn is an HPV expert from the Cincinnati Children's Hospital Medical Center says HPV is most prevalent during your adolescence and young adulthood.

By Amelia Carpenter

Lauren Jones* scheduled her annual gynecology appointment at Miami University Student Health Services (SHS) for April 1, 2010 like she had done the year before when she was a freshman. She was one of the first appointments that day and was called into an office where her blood pressure was taken, general health and medications were entered into the system and then something that had never happened to her before.

"The woman pleaded with me not to have a PAP smear done at my annual appointment," Jones said. "I felt confused — I started getting PAP smears when I was 16."

Jones said the woman cited new guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) suggesting women have their first cancer screening at 21 and less frequent rescreening than previously recommended as of November 2009. 

"She urged me to wait a year until I turned 21," Jones said. "I didn’t mean to be the weird patient who actually wanted a PAP smear done, but I insisted. She complied and sent me to the waiting room."

The nurse practitioner, Sarah Skolnick, did the PAP smear that day and afterward asked Jones if she had been vaccinated for HPV. 

"I had all three doses of Gardasil before college from my gynecologist at home," Jones said. "Then (Skolnick) said she would contact me if the results came back positive for any STDs or anything looked abnormal."

On April 9, Jones received a voicemail from Skolnick.

"She told me my PAP came back abnormal and that I should come in to review my results, and try not to worry. I was sitting in her office at 8:45 a.m. the next day. I was really worried."

Skolnick told Jones she had HPV, a high-risk strain that could potentially lead to cervical cancer. She told her it was very common, and it was likely to resolve itself over time. She recommended Jones have a colposcopy done to examine her cervix for potential pre-cancerous or cancerous cells. A colposcopy is a procedure where a lighted microscope allows gynecologists to examine the vagina and cervix. Jones left Skolnick’s office a year ago almost in tears, terrified of what having high-risk HPV meant for her.

"I was livid at that point. The fact that they tried to make me forego the PAP smear and then it was abnormal?" Jones said. "I immediately called my mom and we were both on the phone with my doctors from home."

The Unspoken Truth

HPV is the most prevalent sexually transmitted disease (STD) in the U.S. among men and women, most commonly know as causing cervical cancer in women. HPV may cause genital or oral warts, recurrent respiratory papillomatosis, abnormal PAP tests and cervical intraepithelial neoplasia in addition to cervical cancer. There are more than 40 types of HPV, and each is labeled as low-risk or high-risk. Low-risk types typically come with genital warts while high-risk types have no symptoms until a PAP test comes back abnormal.

According to the Center for Disease Control and Prevention (CDC), about 20 million people are currently infected with HPV. Another 6 million are diagnosed each year, and at least 50 percent of sexually active people have HPV in their lifetime. About 1 in 100 sexually active adults have genital warts at any one time.

A number of risk factors can cause HPV including early age of sexual initiation, multiple sexual partners, inconsistent condom use and cigarette smoking. Kahn’s research also suggests oral contraceptive use is a cofactor in adults, but inversely associated with HPV in adolescents.

HPV prevalence is highest during adolescence and young adulthood. In a sample of U.S. women, 20 percent of 14 to 17-year-olds, 38 percent of 18 to 21-year-olds and 42 percent of 22 to 25-year-olds were HPV-positive, according to research by Dr. Jessica Kahn, HPV expert from Cincinnati Children’s Hospital Medical Center.

Last year, Skolnick diagnosed 28 female Miami students and 4 male students with HPV. Since 2001, SHS has seen 268 total cases of HPV, 196 being women, according to SHS data. Skolnick said many young women panic when they hear HPV because they don’t understand, and she has spoken with students who come to her office crying.

“We spend more of our time reassuring young women that likely this is something because it’s very transient in your age group you all have very strong immune systems, it’s virally based and it’ll resolve itself over time,” she said, recommending the CDC website for more information on HPV.

Skolnick had told Jones the same thing a year ago.

“Fifty percent or greater people walking around have probably had HPV at one time or another and they just didn’t know it because it’s virally based,” she said, adding that it’s especially transient in college-aged students mostly due to increased number of partners. “There’s a lot of hype in the college age group because of the misunderstanding of HPV.”

Skolnick said SHS does not type results because it’s expensive to do. She said SHS was seeing so many women with low-grade dysplasia, or low-risk types that typically resolve themselves, so typing the results may have been overkill. Most cases of HPV are resolved by the immune system within 18 months, and gynecologists will typically recommend repeat PAP tests every 6 months after the patient’s first abnormal PAP. If abnormal PAP tests continue for more than 24 months, colposcopy is recommended, according to Kahn’s research.

Skolnick said she is required to refer patients with high-risk HPV for colposcopy at a gynecologist as a nurse practitioner.

“Because it’s in the very lowest category of abnormality, we see a ton of it,” she said. “(Referring patients for colposcopy) is just one of those things that you have to follow,” she said.

Skolnick brought up the ACOG guidelines for PAP testing.

“The gynecology world has way backed off of screening because what we were getting back were all these abnormal pap smears that were low grade abnormalities that over time the cells generally resolve back to normal and so that’s why they changed the guidelines to not ‘papping’ young women until they’re 21,” she said.

Dr. Daniel Stein is a gynecologist at the Oxford OB GYN practice located inside McCullough-Hyde Memorial Hospital, and has been practicing gynecology for 23 years. Stein has a more conservative take on gynecology and the presence of HPV.

“I still go with the old rule (of PAP smears),” Stein said. “I see too much (HPV) over 18 (years-old) or sexual activity — whichever comes first.”

Stein has never missed an invasive cancer when it turns to something bad in his years of practice. Part of the reason why is because he does a colposcopy on any woman with any type of dysplasia, which refers to low-risk or high-risk HPV detection in a patient. The precursor to dysplasia is the atypical results with ASC-US cells, which Stein said requires the patient to have a repeat PAP smear as well. If ASC-US cells return results of high-risk HPV, a colposcopy is done.

“There are those that argue colposcopy is a lot to ask when you’re thinking about how many you have to do. Personally, I’m going to err on the side of conservatism I don’t care who it costs money as long as it keeps me out of court because if you miss a diagnosis nowadays … you’ll be more likely to get criticized and potentially sued,” he said.

Some patients consult with their gynecologist and decide to continue with repeat PAPs until they absolutely must do a colposcopy because the procedure causes discomfort, according to Stein.

“You wait and it usually goes away the vast majority of times. There is a subset of people that it just never goes away,” Stein said. Those people’s health is not affected otherwise.

Jones' PAP results showed ASC-US cells with high-risk HPV. She made an appointment for a colposcopy at her home gynecologist in summer 2010, but ended up having a repeat PAP instead of the procedure.

"My doctor just said it was unnecessary for the type I have and that repeat PAPs every four to six months would be fine to do unless something changed," Jones said.

Jones said she was relieved because she had heard a colposcopy can be painful.

If it were Stein, he would have done the colposcopy, but recognized the argument not to have the procedure done.

Jones most recent PAP was in March 2011, which returned ASC-US cells with high-risk HPV, with no change in dysplasia. She said her gynecologist recommends continuing with repeat PAP smears, and if they continue to stay abnormal, Jones will go ahead with a colposcopy.

Vaccination

The Gardasil vaccine was approved by the U.S. Food and Drug Administration (FDA) in July 2006 and began being offered to women ages 9 to 26. Gardasil protects against four types of HPV (6, 11, 16 and 18). The Gardasil vaccine was approved for males ages 9 to 26 in October 2009, right as Cervarix, a vaccine that protects against two types (16 and 18) of HPV, was approved for women ages 10 to 25 by the FDA. Both vaccines are shots given in three doses.

Student Health Services (SHS) carries both Gardasil and Cervarix vaccines, according to Skolnick, and 1,254 females alone have had HPV vaccines at SHS between 2006 and 2011. No males have been vaccinated at SHS.

Like all new vaccines, people speculate the long-term effects it could have and wait to find out, while others go ahead and get vaccinated.

“My mom recommended that I get it after I saw the commercials on TV,” one sophomore Miami female said. “It was a good thing to get and I feel better that I had the vaccine and I’m protected in the future.”

A female Miami senior agreed.

"I was told to by my mom it was a good idea," she said. "My family has a history of cancer problems so that was a good option for me."

Miami junior Rob Burns’ mother is a public health nurse in the STD and Vaccines Clinic in Oakland County, Michigan. Burns is well versed in sexual education and STD prevention and — per his mother’s orders — has received the Gardasil vaccine, which was approved in 2010 for males. Burns said his mother is an advocate for all vaccines and he has had so many he can’t remember which was which. A conversation came up one day amongst Burns and his friends that led to Burns saying he had had the vaccine for HPV.

“We were talking about it one day — and it isn’t like we talk about it all the time — but the guys made fun of me (for having the vaccine),” Burns said.

When his mom told him he was getting vaccinated against HPV, he said he was hesitant. “I was just like, ‘Mom do you think I’m a promiscuous person?’” Burns said, laughing.

Prevention

Aside from vaccination and abstinence, how do you prevent transmission of HPV? Condoms?

“Not a damn thing … not a thing,” Stein said.

Okay, well now what? Do people with HPV have to tell people they’re sexually involved with?

“That’s the golden question. Quite honestly what I tell people — and this is going to sound bad to you — I tell people, ‘You know what everybody has this anyway,’” he said. “It’s probably your moral obligation to bring it up, but the problem is what transmits it is so asymptomatic that’s how viruses really explore they get transmitted before they cause disease (and) before they cause symptoms.”

Stein said if every male and female at Miami were tested for HPV, almost everyone would have it. According to CDC data, some people go their whole life not knowing they ever had HPV because it so often resolves itself over a period of time.

Stein has seen the rare cases of HPV that progress rapidly. “I can count them on one hand the number of cases I’ve seen in my life… I’ve only seen one person die in 23 years of practice and she was someone that never got PAPs,” Stein said. 

He said in the rare case that someone has a rapidly moving case of high-risk HPV, it could be too far gone when a doctor begins treatment. The young woman who died was in her mid-twenties and went through radiation, but was unable to fight the virus.

Stein said he has detected a drastic change in HPV in the last five years.

“We saw a whole bunch of venereal warts. Bad ones. Ugly ones that required treatment,” he said. “You don’t see that as much anymore. Mostly what we’re seeing is a more subtle version of an abnormal PAP smear.”

SHS diagnosing males with HPV are likely due to symptoms of genital warts. Males otherwise have no symptoms unless swabbed and tested for HPV, which is unlikely according to Stein.

Although there is likely no correlation to Stein's observation, the Food and Drug Administration approved first vaccine for HPV around the same time he began seeing the change.

Stein and Skolnick agree that as long as HPV-positive women follow up with repeat PAPs and colposcopy, the health risks are minimal, and usually the virus resolves by itself.

*Name has been changed to protect the source.

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