[Question #1112] HPV - more information

87 months ago
Hi, I just wanted to ask for more detailed information about HPV. I’ve only been sexually active for 2 years, and decided to get a pap done this year. My pap came back with LSIL and the high risk HPV test came back positive. I had a colposcopy done recently, and no lesions were found. All this is good news, however I have questions and hope to have them answered here. I'm 27, female, heterosexual. 

1. What are the chances of getting urethral, vaginal or vulva cancer from HPV and what is the treatment for those? Can my gynae also examine my urethra for lesions? 

2. I also had my throat and anus swabbed for HPV. Both came back negative. However, what are the chances that the HPV is on my tongue or oral cavity instead, and was missed by a throat swab? Is there another, more effective test for oral HPV?

3. Given my current negative oral and anal HPV tests, how often should I get swabbed to check? I do practice oral sex, and I try to keep it protected but like the best of us...I don't practice anal sex but was penetrated briefly once. Could HPV be dormant and resurface here? These tests are expensive and not usually covered, so I want to balance being safe with managing costs

4. My HPV test came back negative for HPV16 and HPV18. The test doesn't specify the other types, and my gynae mentioned that I could be infected with one or two of the other high risk types. What is the likelihood that HPV16 and 18 are currently dormant in my system, and will resurface?

5.My gynae vaccinated me with Gardisil. I'm 27 - is there a likelihood that the vaccine is less effective for me? Is there a way to check if your body has produced the antibodies necessary to fight off HPV?

87 months ago
I understand that most HPV infections don't lead to cancer, however I would like to address the possibility and not the probability! Just in case, I'd like to be prepared and informed. 
H. Hunter Handsfield, MD
87 months ago
Welcome to the forum. Thanks for your question.

There's a lot of attention to HPV these days, with both good and bad news. The good is that we know how harmless almost all infections are, i.e. that most infections are minor inconveniences (if they are diagnosed at all) and not serious health threats; and that most infections can be prevented with just about the most effective vaccine ever developed, against any medical conditions. (No other vaccines have true 100% effectiveness against their targets. Only this one.) The bad news, of course, is that there are occasional serious outcomes; and that its sexual transmission is better understood, which brings its own anxieties for many people. But the core fact is that everybody gets HPV at least once (well, at least 90% of all sexually active persons), and at any point in time 25% to 50% of sexually active young persons (age 15-25) are carrying the virus. (That's why it's almost unavoidable:  up to half the sex partners you might have in the next few years are infected.)

As for your particular diagnosis, the bottom line is that almost certainly your HPV infection is harmless, will clear up on its own, and will not lead to cancer or or any other important health problems. To your specific questions:

1) As you say yourself, the vast majority of HPV infections, even with the "high risk" types, do not lead to cancer. And with only LSIL by pap (the first L means "low grade", i.e. not on the road to cancer) plus negative colposcopy, your risk is even lower than average. Further, with regular follow-up as recommended by your doctor, plus your own awareness that you'll need to have any external genital bumps or sores professionally checked, any early pre-cancer changes will be diagnosed long before they become dangerous. When HPV related cancers do develop, typically it takes several years from early changes to actual cancer, i.e. easily curable. The chance you'll ever develop even an early, curable form of cancer is well under 1 chance in tens of thousands; and the odds you'll get overt, potentially dangerous cancer probably under 1 in a million. (Your chance of dying someday of breast, lung, or colon cancer is far higher than for an HPV related malignancy.)

2) I'm not sure why your anus and throat were checked. That's not normally part of the evaluation of people with genital HPV or abnormal pap smears. Perhaps you were worried and asked for these tests? In any case, the negative results are reassuring. Even if your throat or anus had HPV, just like the cervix, the vast majority of infections never progress to cancer. It isn't known whether throat swabs detect all oral HPV infections, but the chance you have an undetected oral infections is very low.

3) I recommend against any further HPV swabbing of any site, unless and until you develop an unexplained bump, sore, or another abnormal pap smear.

4,5) There are roughly 100 types of genital (i.e. sexually transmissible) HPV, of which about 40 are classified as high risk. HPV16 and 18 are the two most likely to be associated with cancer. Your immune system will reduce the risk of new infection with the same type(s) you already have had, and new HPV infections are uncommon after age 26 (which is why that's the normal age cut-off for immunization). But you remain susceptible to additional HPV infections in the future. I'm glad you've been immunized; the vaccine will protect you from new infections with the 9 types that it covers, which collectively account for 90% of HPV cancers and 90% of genital warts. So the odds are very good that you'll never have another HPV infection or problem in the future. There is no standard test method to judge how effective the vaccine is in any particular person. But also absolutely no reason to suspect it won't be fully effective against the 9 types it covers.

My final comment, even though you didn't ask:  Once your pap smears have returned to normal, at which time you can be confident your existing infection has cleared up, you need not mention any of this to future sex partners.

I hope these comments have been helpful. Let me know if anything is unclear.

Best wishes--  HHH, MD

87 months ago
Many thanks for the detailed reply Dr Hunter. I do have some follow up questions, and thank you again for the time.

1. What is the likelihood of urethral cancer? I read that this has shown up in some women due to HPV. Again I know the risk is low, but if there is a test or check, I'd love to get it done to get some peace of mind.
2. I've read about a saliva test for oral HPV. Would you have more information on it? Also, if HPV can be detected in saliva, what are my chances of getting hpv via receptive oral sex from a man who has oral HPV?
3. What is the likelihood of HPV that remains dormant and undetected, only to resurface years later?
4. I got vaccinated with the older version of Gardisil, which only covers 4 types of HPV, as I am not based in the states currently. I am however moving to the states soon and will need my two follow up shots of Gardisil in the US. Should I restart with the Gardisil 9, or finish up my course and then take another round of Gardisil 9? I've also read that it can be difficult for women over 26 to find a doctor who will vaccinate them in the US, is this true? I would absolutely prefer to get vaccinated, especially since I've been shown not to have HPV16/18 and am not in a committed relationship at present. 
5. I'm worried about spreading the virus to my anal cavity. I prefer menstrual pads to tampons - can the virus be transmitted through residual blood outside of the body? Apologies for this question. 
6. This is more of a curiosity question - I've read that studies in the UK have shown certain HIV drugs were tested on HPV positive women and shown to cure HPV. I wonder if we are on our way to an HPV cure - which together with the HPV vaccine will help eradicate this virus.  
H. Hunter Handsfield, MD
87 months ago
1) I've never heard of urethral cancer. It must be exceedingly rare.
2) There are no FDA-approved tests for oral HPV. Anything you can find online or elsewhere is unapproved. Such tests may or may not be valid. But why test at all? Whether or not HPV tests are positive, there is nothing to be done, and a positive test does not elevate the risk of future problems, and a negative result doesn't lower it. The science just isn't sufficiently advanced for such testing to be considered worthwhile. I recommend you not seek out such testing.
3) HPV sometimes resurfaces years later. But probably in only a few percent of cases; and when it does, usually there are no serious health outcomes as a result.
4) The 4 types covered by the original Gardasil still prevent 90% of genital warts and 70% of cancers. At your age of 27, I see no need for revaccination with Gardasil-9. But it wouldn't hurt anything, and would be effective protection against the 5 additional HPV types not covered by the other vaccine. If you do it,  you need the entire series of 3 Gardasil-9 doses. Be prepared to pay about $1,000; because of your age, it won't be covered by most US health insurance policies.
5) Anal HPV is often present in women with genital HPV. It rarely is harmful and not something to worry about.
6) There is no reliable research in the UK, or anywhere else, about any drugs that can eradicate HPV. Nobody can predict the distant future, but for the next 1-2 decades no treatment is likely to reliably eradicate HPV.

I would urge you to try to gain a realistic perspective on this. HPV is a normal virus in humans. Not desirable perhaps, but normal.  Imagine a football stadium with 100,000 women. 90,000 of them have had HPV, and for those age 15-25, 25-50% are currently infected. The vast majority will not have any serious health problem. All those other infected people are just living with it, without worry. That should be your plan as well.

87 months ago
Many thanks for the answers Dr H! Hearing you have a cancer causing virus is terrifying, and unfortunately there isn't a lot of information out there. I'm glad to be able to get some solid reliable information here. I have just three more questions about managing hpv going forward:

1. Are booster shots necessary for the vaccine? I haven't been able to find out much about this.

2. If my body clears the my existing HPV infection, will my immune system have produced enough antibodies to ward off future infections from the same strain? Much like chicken pox?

3. What is the thinking behind women above age 26 not needing the vaccine as much as younger women? 

Thank you very much for the information and assurances, I'm glad to know that HPV is mostly innocuous and manageable. 
87 months ago
Also forgot to ask this - but how soon would an hpv test be conclusive after exposure? 
H. Hunter Handsfield, MD
87 months ago
1) No boosters are necessary for persons who have received the recommended 3 doses of vaccine.

2) See question 3 yesterday. The immune system normally clears the virus so it never recurs. The analogy to chickenpox is pretty good; as you seem to know, shingles (herpes zoster) is localized recurrence of distant past chickenpox. The large majority of people with either HPV or chickenpox never develop recurrent problems.

3) The frequency of new HPV infections is quite low after age 26, and for that reason the vaccine manufacturers didn't study it in women over that age. It probably works, but becasue of low need or benefit, and unproved efficacy, it is not recommended nor covered my most insurance policies.

HPV testing should not be done after any particular exposure. The tests are not designed to detect all infections, and a negative result would not assure you were not infected. To the extent that some infections might be detected, it could take a year before a test would show it.

Your body is covered and filled with billions of bacteria and viruses of several hundred kinds. HPV is juse one of them. It's really not something to be concerned about. Do your best to put it out of your mind. That's what almost all people do, including those with abnormal pap smears.

That completes the two follow-up comments and replies with each question, so that ends this thread. Take care.