[Question #1547] Low risk hpv contribute to abnormal paps?

47 months ago

Hi Doctor,

I've read around the MedHelp forum extensively and have not found anything addressing a situation similar enough to mine to satisfy me, so I'm turning here.

11 years ago, at the age of 16 or 17 I had what I'm sure were genital warts. I went to an ob/gyn for the first time to consult; she did not officially diagnose me or give me any information, nor was a biopsy done. She just gave me Aldara and they went away very quickly, if I recall correctly within a month or so, and never came back. Not long afterwards I got the Gardasil vaccine.

Later, in college I began going to a new ob/gyn regularly for annual paps. Eventually one came up abnormal (maybe 7 years ago - ?) and since then its been on and off with the normal and abnormal paps, and negative and positive hpv tests. At some point I switched doctors, and my records as far back as I have with the new doctor show:

12/2011 - ascus pap HPV negative

11/2012 - colposcopy ECC negative/Surepath pap normal

03/2013 - pap LGSIL no HPV test

10/2013 - ascus pap HPV HR positive

01/2014 - pap LGSIL no HPV test

09/2015 - pap LGSIL HPV HR positive

02/2016 - colposcopy normal (2 biopsies show benign squamous metaplastic cells, 1 biopsy shows benign squamous cells)

Through all this prodding and probing and investigating by my ob/gyns, including a few paranoid visits to Planned Parenthood for full STD exams sprinkled in and my own obsessive monitoring of my downstairs, the issue of warts has not come up again since that initial incidence. It is apparent I have either persistent high risk HPV infection or reinfection with a couple different high risk strains, but I'm also wondering: what are the chances that the past wart virus in the absence of symptoms caused any of these abnormal paps, or, if it persisted beyond treatment, would it have most likely manifested in symptoms?

All the best

Edward W. Hook M.D.

47 months ago

Welcome to the forum. I'll be pleased to try to help. You are doing everything right, i.e. you got the vaccine, you are having correct follow-up in terms of repeat PAP smears and colposcopy.

In answer to your question, low risk HPV types (6 and 11) certainly can cause abnormal PAP smears as well as genital warts. This it is possible that some of your abnormal PAP smears were due to the prior infection that caused your warts. On the other hand, there is still a fair chance that your LSIL will resolve.

As far as symptoms are concerned, other than visible lesions, HPV infections tend to be asymptomatic.

Going forward I would recommend doing just what you are already doing i.e. getting regular PAP smears.

I hope these comments are helpful. EWH

---

47 months ago

Hi Dr. Hook,

Thank you very much for your reply, but I am extremely anxious and this has really got me worried sick.

I've been operating under the assumption for many years that since I hadn't had warts in so long, and not since the initial outbreak, that I had cleared the infection. This included not disclosing to partners, since I had read on forums such as MedHelp that once 6 months has passed wart-free, there is no need to say anything about them (and at that time, and until several years later, I'd not yet had abnormal paps). This made sense to me considering my timeline - warts gone at age 16, Gardasil at 17, first abnormal pap at 19-20.

I do know that the LSIL likely will resolve, but up until now I've been led to believe this was due to my high-risk HPV, not the past warts infection, especially since I had a normal pap and negative colposcopies in the interim. Am I now to understand that there is a considerable chance my immune system likely did not successfully clear that initial infection? Am I now after all these years understanding I was in the clear going to need to disclose those decade-gone warts to my partners?

Thank you again

Edward W. Hook M.D.

47 months ago

After I responded I continued to think about your question and wondered if you were assuming that your LSIL was due to thee same virus which cause your warts so many years ago. I see that you have and apologize for missing the implication in your question. While the FACT is that low risk HPV can cause LSIL, in your case this is unlikely for the following reasons:

1. Your warts did not recur

2.Your PAPs in 2011 and 2012 showed no evidence of HPV (ascus is non-specific and can certainly be caused by other, benign things rather than HPV.

3. When you have had positive HPV tests this has corresponded with HR types- many (but admittedly not all HPV tests do look for LR types as well)

4. Resolution of your original infection certainly corresponds with what we know about the natural history of HPV infections.

My advice to you is no different than what you found in our older posts on the MedHelp site- I see no reason to disclose to partners, past or future. Nearly everyone who is not vaccinated has or will have HPV and the infection will be of no consequence. Trust your immune system and do not over think this. You are doing precisely the right thing for your help by following up as you describe and you are not putting partners at undue risk by not disclosing to them. I urge you to let the past stay in the past.

Sorry for missing the implication of your earlier question. I hope that this follow-up is helpful. If not, please let me know. EWH

---

47 months ago

Hi Dr. Hook,

No need for apologies, I think my title summarizes the issue in a way that simplifies and glosses over the nuance of the question. It is not that I don't know that low risk strains CAN cause abnormal paps, rather that my anxious mind sought reassurance that there was little chance that my distant infection was the cause of my recent abnormal paps. This has eased some of my anxieties and is indeed helpful. I'm going to use my 2nd follow up to address some last things-

Q1. In regards to your points 2 and 3, I didn't realize low risk types were often tested for. That would be nice as it would be horrible to unknowingly give someone warts. My paperwork from 12/2011 and 10/2013 states, "HPV high-risk: This high-risk HPV test detects thirteen high-risk types without differentiation" then the results to the side, with no mention of low-risk testing, which I assume means it wasn't done. The testing in 2015 is different as I was living in the UK at the time and my paperwork says, "HPV Test Result: TEST FOR HIGH RISK HPV IS POSITIVE" with no mention of a low risk result. Any idea what the NHS does? I can't imagine they'd spend money on what would be routing testing with no implication for public health. Considering all this, I'm going to draw the conclusion I haven't been tested for low-risk strains. If a low risk strain that originally manifested as external warts on the vulva (with doctor confirmed absence of internal warts) did happen to persist, would it most likely continue with wart recurrences? That is, what is the chance it would switch over entirely to persistent cervical dysplasia with no warts?

Q2. Perhaps you can tell from my line of questioning, my fear is that I am going to accidentally give someone warts, despite that I am fairly confident I cleared that initial infection. To my knowledge this has not happened at any point in the last decade. I don't know where this sudden anxiety came from, as I had all but forgotten about it up until now. Perhaps because I have a couple promising new partners (both male, ages 29 & 36, both of whom have had multiple other partners). Assuming I cleared the initial infection 11 years ago (trusting my immune system), there would be a good chance I have high immunity to either type 6 or 11 as a result. Followed up with Gardasil, which would provide me protection to the other (or both if the initial infection was not one of the two). In theory, would you agree that there is a high chance I would now have immunity to both 6 and 11, and therefore warts in general? Meaning chance of acquiring and/or transmitting a wart strain would be considerably low at this point? Which leads me to the last question...

Q3. I understand there is no Gardasil boosters and that the vaccine's effects wear off after 6-10 years. Can you explain this? I don't understand how this would work if 11 year olds are given this and it wears off by the time they're all in college. If I were to, for example come into contact with HPV 16 while on the vaccine (but had no infection because I had protection), then the vaccine wore off, would I have lasting immunity to HPV 16 it because I had exposure to it while on the vaccine?

Thank you very much again and best wishes for happy holidays.

Edward W. Hook M.D.

47 months ago

1. No idea what the NHS does. it would not surprise me if they only focus on high risk HPV types. As for your how would persistence of your prior wart-related HPV, it is logical to believe that had your therapy been inadequate or the infection recurred, it would have been most likely to manifest itself as recurrence warts and not as an abnormal PAP smear later. There is little chance that you are going to spread the infection you had which was treated and has resolved to subsequent partners. I would not worry about this.

2. while your HPV infection dis generate some degree of antibody response, the response to the HPV vaccine is typically greater and does a bet job of protection. I would have confidence in your level of immunity at this time.

3. Statements regarding the duration of HPV vaccine protection are based largely on the length of study follow-up. I would presume that the protection is more long-standing.

I hope these comments are helpful. As I suspect you know, we are limited to three responses to clients and this is my 3rd response. this thread will be closed tomorrow. In the interim, I urge you not to worry about the possibility of a persisting low risk-wart associated HPV. EWH.

---