The saying that politics makes for strange bedfellows took on a new low when Michelle Bachman came out with her ridiculous statement against HPV vaccination. (In case you didn’t get the pun…HPV infection is most frequently transferred in a bed … or for that matter in any place that allows for sexual contact.) So I’ll skip the part where we ask why a responsible parent would not want to help diminish the chance that her daughter would get cervical cancer or genital warts. (Yes, their may be parents out there who think that their daughter will not be sexually active with anyone but the man she marries, but what guarantees do they have that the young man she commits to did not have partners before or after he proposed to and married her.) Long-term large studies have shown negligible side effects from HPV vaccination. Sudden “mental retardation” which of course is a truly nonmedical and impolitic term, cannot suddenly occur from a vaccine given to an adolescent girl! (I have given hundreds of shots in my office and at most have seen a few “ouches” at the site of injection.) Okay, I have to stop now and become scientific. Here are the facts I promised in the heading of this week’s newsletter:
There are more than 40 types of human papilloma viruses or HPV’s that infect the general tract; approximately 15 types have been linked with cancers and are classified as carcinogenic or high risk. We now know (or at least the scientists who do the testing know) that 99.7%of cervical cancer specimens, as well as their precancerous predecessors, test positive for at least one of these high risk HPV’s. (Just in case you want to complete your viral numerical knowledge…they are HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 72.) The most common onset of infection occurs in the first years of sexually activity. Thankfully most of the infections in young women and men resolve within 2 years. In a small proportion of women however, HPV infection persists. If this happens, the virus may enter the DNA of cervical cells and cause mutations, which over time can result in precancerous lesions that progress to cancer. HPV viral infections are extremely contagious. (Put bluntly, a touch of a penis harboring the virus will pass it on.) And there are usually no lesions that signify viral presence. It’s a “down there” scenario akin to that portrayed in the movie Contagion; but with HPV, the consequences of the viral infection occur years later. If a woman has sex with someone, she essentially has a viral contact with everyone he or she has had sex with and everyone those individuals have had sex with… etc., etc.
So it’s not surprising that at least 80% of women will, at some time in their lives, have an HPV infection…most commonly when they are young or when they are exposed to the virus through new or non monogamous partners. In most young women, the virus will clear. In the few in whom infection persists, it takes at least 2 to 3 years for potential progression to a precancerous lesion and more time until it can cause cancer. So adolescents and young adults have a very low risk of developing cervical cancer.
Obviously many young women will initially harbor one of the HPV viruses and as a result may also have some mild changes in a Pap smear screening. If these changes are found and pronounced abnormal, they (and their moms) will go through a lot of unnecessary anxiety over something that usually clears up… and even worse they may go through unwarranted surgical procedures that can scar the cervix and impact their future ability to conceive or have a normal vaginal delivery.
To help avoid unwarranted concern and cut down on unnecessary procedures, the American College of Obstetricians and Gynecologists (ACOG) has released guidelines that should make us all relax with regards to screening. They state that Pap smears should begin no earlier than age 21. And from 21 to 29 women should be screened every 2 years. (But this does not negate the need for annual pelvic exams and, if necessary Chlamydia and other STD testing should be done more frequently.) It’s recommended that by age 30 all women should undergo screening with HPV testing as well as a Pap smear. If both tests are negative and the woman has no new partners, she can then be tested every 3 years. (But again a yearly pelvis exam should be done, and if a woman has a new partner or if she is not sure of the monogamy of her current partner, testing should be more frequent.) All women in high-risk groups (women with HIV, those on immunosuppressive medications, women exposed to DES in utero and women who test positive for high risk HPV or who have been treated for cervical precancerous or cancer) should be screened frequently.
The current vaccines protect against 2 types of high-risk HPV infections that cause 70% of cervical cancers. These vaccines will not cure or get rid of HPV infections that are already present. Hence the best way to help prevent cervical cancer is to vaccinate young women (and ideally young men) before sexual activity occurs. In medical parlance this is when the young person is “sexually naïve”. Because other high-risk HPV’s, which are not covered by the vaccines, can still cause 30% of cervical cancers, young women who receive the vaccine will still need to begin cervical cancer screening when they reach the age of 21. But when administered at the right time the vaccine will insure that the majority of cervical cancers won’t occur. What’s political about that!