HPV: Current Evidence & Common (Plus a Few Less Common) Questions
This is the first in a series of posts about issues I encounter commonly with patients and are prone to causing stress and confusion (especially when misinformation abounds!). My goal is to provide accessible information about sensitive and scary subjects, as well as to provide scripts for providers who want to learn more about talking to patients about sexual health. These are not intended to be a substitute for medical advice.
In 2006, the CDC began recommending HPV vaccination in girls and young women, shining a spotlight on an extremely common and often misunderstood STI. The push to vaccinate female patients was driven by an increased understanding of the role of HPV in the development of cervical cancer. Certain strains of HPV (what we call “high-risk” types) have been found to be the culprit in nearly all cases of cervical cancer, and the vaccine has dramatically reduced rates of both HPV infection and cervical cancer in the years since its emergence.
The HPV vaccine has made a tremendous impact on reducing transmission of higher-risk types of HPV and related cancer rates. Since 2006, the CDC has begun to recommend the vaccine for males as well, and has broadened the age range at which a person can be vaccinated (it is currently ages 9-45). While it is obviously ideal to be vaccinated prior to onset of sexual activity, anyone can be vaccinated, as the vaccine now protects against 9 different HPV strains; it is thus beneficial even for those who have been diagnosed with HPV already.
Although the focus on HPV is relatively new, we’ve understood for decades the value of screening for cervical cancer through Pap testing. However, starting in 2012, the guidelines around Pap smears have been changing pretty dramatically in order to account for the increasingly better-understood role of HPV, as well as the realization amongst gynecologic providers that we were overtesting and utilizing too many invasive procedures on low-risk individuals. In a significant shift from the former trend, providers were now being advised to start pap testing at age 21 (regardless of the age of onset of sexual activity) and continue it every 3-5 years alongside HPV reflex testing or co-testing depending on the patient’s age, up until age 65 (for most patients). Then, in 2021, the guidelines changed again, now recommending the start of screening at age 25 in conjunction with HPV screening (or just standalone HPV screening), and continuing every five years. Standalone, or what’s called “primary,” HPV screening appears to be the most evidence-based method of screening for cervical cancer at this time, but it is not readily available in most clinical settings yet. We are likely to see a shift in this direction, but for now providers are largely utilizing the pap test plus HPV screen (hence “cotesting”).
Note that unlike testing for other common (and much less common) STIs, HPV testing is not recommended yearly, or with each new partner or exposure. This can cause some confusion for patients who are requesting STI screening and expect to be tested for HPV. It is only done as a component of cervical cancer screening as described above. Therefore, it’s only done on people who have a cervix (or in specific, higher-risk cases, people who used to have a cervix). Additionally, it’s important to note that the HPV test done for cervical cancer screening only picks up certain, higher-risk types. The strains that cause benign conditions (i.e., genital warts) are not going to be picked up on a pap, and warts are diagnosed on physical assessment only (so you only know you “have” this strain of the virus if you develop symptoms). Another helpful way to understand this: while the appearance of warts can be upsetting, they do not turn into cancer and do not suggest a risk of cancer. Furthermore, they can be treated, and while they sometimes recur, they often do not.
Frequently Asked Questions about HPV
Who can get the HPV vaccine? Is it just one dose?
Anyone, regardless of gender identity, can get the HPV vaccine starting at 9 years of age and continuing up to age 45. If the series is given prior to age 15, it is given in 2 doses. After age 15, it’s given in 3 doses. The series is only given one time in the lifespan based on current evidence.
Does the HPV vaccine prevent all types of HPV?
No. The current vaccine that is most commonly given, Gardasil 9, protects against 9 types of high-risk (i.e., cancer-causing) strains.
I do not and have never had a cervix. Why would I want the vaccine?
For two reasons! First, to protect partners from cervical cancer. Second, we are learning more and more that HPV is implicated in many oral and anal cancers in addition to cervical and vaginal cancers.
If I give my 9-year-old this vaccine, aren’t they more likely to have sex early?
No. Current evidence suggests no relationship between the HPV vaccine and precocious sexual activity. In other words, giving your child the vaccine makes them no more likely to engage in risky behaviors that could expose them anymore than vaccinating them for something like measles does.
I became sexually active prior to age 21. Doesn’t this mean I should start cervical cancer and HPV screening sooner?
No, for the general population (i.e., persons who are not severely immunocompromised by something like HIV) cervical cancer and HPV screening are not recommended before age 25 according to the most current evidence. This is because young people, while frequently exposed, will clear the virus on their own before it can cause problems.
I’ve had the HPV vaccine in childhood. Do I really need a pap smear?
Yes. Current evidence based guidelines continue to recommend regular pap and HPV testing at least every 5 years (some providers are still doing it every 3 years) regardless of vaccination status.
My pap smear came back positive for HPV. What can I expect now?
Depending on the result of your cytology test (i.e., what the actual cervical cells look like under a microscope) and the results of your previous test (if you had HPV last year, for example), you may qualify for additional testing. Typically, this is going to be a colposcopy, a procedure in which a specially-trained provider will look at the cervix with a device that looks like binoculars and take 2-4 tiny biopsies. This can feel crampy and may cause spotting, but is typically very well-tolerated without pain medication (though taking ibuprofen beforehand can be a help).
I already tested positive for HPV in the past. Why should I bother with the vaccine?
If you tested positive for HPV on a pap, you probably only had 1 strain at the time. The vaccine prevents against the transmission of 9 high-risk types, and having had one does not mean you’re protected against others (or even against picking up the same one again).
I just found out I have HPV on my pap test. I’m freaking out! What about my partner?
HPV is sexually transmitted via vaginal, oral, and anal routes. Condom use can help prevent transmission of all types if condoms are used consistently and correctly. This is definitely something that is worth discussing with a partner and determining both parties’ comfort levels. It is entirely possible that your partner has already been exposed, by you or someone else. However, there is no additional indicated testing. In other words, partners who do not have a cervix/vagina will not get HPV testing, as there is no currently available HPV testing for them. Partners who do have a cervix/vagina should continue their age-based HPV testing; having a partner with known HPV is not an indication to get a pap/HPV test any sooner than indicated by your age and the timing/results of your last test.
Will I have HPV forever?
This is a great question. Based on what we can tell, most people will clear HPV on their own in 1-2 years. A small proportion of people do not; this is why some people end up with HPV-related cancers. These cancers take a long time to develop, which is why we don’t get too worried when people have HPV positive results on pap tests for 1 or 2 years. However, there is some anecdotal evidence to suggest that some people may continue to carry dormant HPV for many years, and experience a newly positive result again much later in life– for example, after experiencing an immune-compromising event like chemotherapy. We don’t know much about this phenomenon, and it does not change the guidelines on testing and treatment.
How can I help my body clear HPV?
HPV, like all viruses, can thrive when we don’t take great care of our bodies. On the contrary, eating a healthy and balanced diet, and especially avoiding tobacco use can really help us clear this virus (like others).
I have genital warts. I understand that they don’t cause cancer, but I hate the way they look. What can I do?
See a provider trained in sexual health. They can offer one of three kinds of treatment. If the warts are relatively small, few in number, and easy to reach, and if you feel comfortable, they can offer at-home treatment with a cream that you apply topically three times a week for several weeks (imiquimod). If the warts are more extensive or you’d rather have someone else treat them, you can come into the clinic for weekly treatments with cryotherapy or acid until their appearance has improved sufficiently. They may recur after removal, but they also may not– remember, most people clear this virus in 1-2 years.
Less Frequently Asked (But Important) Questions
I’ve had a hysterectomy. Do I still need pap smears/HPV testing?
For the majority of people, the answer is going to be no. However, you need to make sure of a few things. First, was the cervix left behind? If you had a “partial” or “supracervical” hysterectomy, it may well still be there– check with your surgeon. If you still have a cervix, even if you don’t have the rest of your uterus, you need to continue pap testing based on the guidelines. Second, did you have normal/HPV negative pap tests up until your hysterectomy? If you had an abnormal pap result and/or HPV prior to your hysterectomy, you may need to continue to have vaginal pap smears for now. Finally, if your uterus was removed because of a malignancy (either cervical or uterine cancer), you should continue to have vaginal pap smears. In all of these cases, shared decision making with your provider is key. However, generally speaking, if you’ve had normal pap smears and negative HPV tests, your cervix was removed, and you had a hysterectomy for benign reasons (such as uterine fibroids), you won’t need to continue pap testing.
I was exposed to diethylstilbestrol (DES) when I was a fetus. What special recommendations apply only to me as a “DES daughter”?
DES is a synthetic estrogen that was given to some pregnant women between 1940 and 1971 to prevent pregnancy loss and preterm labor. It was found to cause an increased risk of clear cell adenocarcinoma of the vagina and cervix. Make sure your gynecologic/sexual health provider is aware if your mom took DES in pregnancy. People in this category need more frequent paps, and their paps must include a sample of vaginal cells as well as cervical cells.
I am immunocompromised. Do basic guidelines still apply?
People with some immunosupressive conditions, including HIV, should follow different screening and management guidelines. Talk to your provider about your specific condition. The guidelines for screening in people with HIV and certain other immunocompromised states tell us that: pap testing should start within 1 year of insertional sexual activity regardless of age, should be continued every year for 3 years, and then (as long as it’s normal) can be continued every three years (without concomitant HPV testing) up to age 30. Then pap testing plus HPV testing should be done every 3 years for the rest of the person’s life.
References
Fontham, E, Wolf, A. et al. (2020). “Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society.” CA: A Cancer Journal for Clinicians 70 (2020): 321-346.
Marcus, J., Cason, P., et al. (2021). “The ASCCP Cervical Cancer Screening Task Force Endorsement and Opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines.” Journal of Lower Genital Tract Disease 25: 3 (July 2021): 187-191.
