HPV Incidence and Pap Smears 

Hi everybody. Thanks for coming back to read my blog again.

Today someone in my office had read my blog and suggested that I write about HPV. HPV is very common and is responsible for a lot of pap smear issues. It has been in the news a lot lately because of the Gardasil vaccine and the newer vaccination protocols. There has even been some effort to vaccinate the young boys. Gardasil is approved for young girls from 9 to 27 years of age, and similar ages for the boys. Gardasil has new competition now, the Cervarix vaccine. The HPV vaccines are nearly 100 percent effective at preventing infection with the two pre-cancerous HPV viruses, type 16 and 18. Their effectiveness against the other precancerous viruses is much lower, if at all. We don't yet have data that these vaccines actually prevent cancer. That data will take at least a few more years to come out.

First of all, everyone needs to know that HPV is unbelievably common and prevalent. About 90 to 95 percent of humans carry HPV in our cells somewhere in our body. People catch HPV commonly when they are young. Little children get HPV, also known as warts or condyloma, on their hands, their feet, their elbows, and all over the place. It is extremely easy for HPV to go from one person to another. HPV can be caught in any manner that includes skin contact. HPV is easy to transmit with sex. But HPV can be transmitted non-sexually just as easily. HPV is very common in the vagina, and on the penis and scrotum. HPV, at least some variants, seem to like it in there and grow quite a bit. It is in there that it stirs up pre-cancerous activity of the cervix, vagina, vulva, and anus. HPV, in a human, becomes dormant after the immune system starts fighting it. There is controversy about whether some people eradicate it completely from their systems, but most Gyn's believe that once you get, you don't completely get rid of it. It just stays dormant. When women get HPV on their pap smear report, many women assume that it is clear evidence of a Sexually Transmitted Disease. Many times, this conclusion is false. HPV is easy to get without sex. Little kids get it all the time. It is common that some if not many cases are non sexual. Try not to let women's lives be wrecked over this possibly incorrect interpretation.

HPV affects all women because women need to get their pap smears, and a modern pap smear should include HPV testing, at least for women over 30 years of age. Younger women are at less risk for cancer, so we don't test them for HPV on a routine basis.  Why do we test for HPV?  This is because the prolonged presence of a high risk HPV requires an examination for precancerous cells. In my practice about 30 percent of the time, when  there is prolonged HPV, there will be precancerous cells as well. 

HPV has about 115 different variants. Of course, the variants are more similar than they are different. Of the differences, though, some are more likely to be in the vagina, especially when we look for the higher risk variants. Of the 115 variants, about 13 of them are commonly found in precancerous conditions of the vagina and cervix. Two of those, type 16 and 18, seem to be the highest risk type, and are very common. Only recently have Gynecologists started separately testing for type 16 and 18. When we find type 16 or 18, we should move to testing for pre-cancer sooner rather than later. I find these types all the time in my practice.

About 1 in 4 women will eventually get an abnormal pap smear. I can almost guarantee that you personally know someone who has had an abnormal pap smear. You may not know it, because women don't like to talk about it. But, in my experience, if you share your abnormal pap smear experience with women, then the ones who have had it will come out with it and talk about it. It can be very supportive, talking with your friends about this. But be careful and only speak with your closest friends. Other people can get mean about it.

To do the workup for precancerous cells, we will need to look in the vagina with a microscope. This procedure is called a colposcopy (remember the procedures are named in the Greek right? From a prior blog article. Greek for vagina is colpos). Generally, in my office I do several colposcopies a day. A colposcopy requires a special microscope, some vinegar to wash out the vagina fluids, a green light, and special training and experience that almost all Gynecologists have. The vinegar makes the precancerous cells turn white under the green light. They also swell up a bit. I presume that the precancerous cells absorb more vinegar, get thicker and more opaque, and are therefore easier to see. Without the vinegar, the abnormal cells are almost impossible to see, even with the microscope. I don't think anyone knows for sure how the vinegar really works.

Sometimes when we do a colposcopy, we see absolutely nothing wrong. If that is true, then we may do a scraping inside the cervix and finish. But usually, we see some bits of whiteness here and there, or an abnormal looking blood vessel. If we see any abnormality we tell the patient and then take a small biopsy under local spray on anesthesia. Then, after the biopsies, we'll have a discussion with the patient about what we've seen. But for the final diagnosis we willl have to wait for the official diagnosis from the pathologist.

Commonly there will be mild dysplasia, or pre-cancer. This is also called CIN-1, SIL-1, Class-1, or some other names. Mild dysplasia, depending on where it is, will need to be either followed or removed. More serious dysplasias, will definitely need to be removed.

Removing pre-cancerous cells is easy but not guaranteed. Unfortunately, we have no technology to remove the HPV. Removing the precancerous cells can be done with the laser, they can be frozen off in some places, they can be burned off with electricity or heat, they can be surgically removed, or chemotherapy can be used in some cases (that is my least favorite method, and in my opinion requires a visit to a gyn oncologist). Most of the removal methods leave behind about a 20 percent risk of persistent pre-cancerous cells. Therefore careful followup is necessary.

For that followup we will do more paps and likely more colpos.

In my practice, preventing cervical cancer is easy. I cannot remember having a patient proceed from abnormal pap smear to cervical cancer. All of the known pre-cancerous lesions have been sufficiently removed to prevent cancer.

But there are still women who get cervical cancer. Generally it is mostly women who don't get pap smears. They are at risk of cervical cancer. I can also remember one women who had three negative pap smears over 8 months, and then a biopsy showed cervical cancer. The cervical cancer must have been below the surface, where the pap smear couldn't detect it. Either that, or it advanced so fast that there was no chance to prevent it. But generally, cervical cancer is preventable in the pre-cancerous stage. The pre-cancerous stage usually takes years to progress, giving us a very long time to stop it.

All of the areas near the pap smear source are at risk. I have diagnosed pre-cancer from the mons to the cervix, to the anus.

Talking about pap smears and HPV and pre-cancer can be long winded. But, I can assure you, it is important to the women who have had to go through with these tests and things.

Thanks again for reading. More good blogs are coming up.

Next time, breast lumps and the basic rules about how to deal with them. Are they cancer?

Sincerely,

Dr John Marcus MD
89 North Maple Ave
Ridgewood NJ 07450

Second paragraph edited on 5/15.