[Question #2588] HPV risk assessment

43 months ago
I'm a 45-year-old single woman with 7 past vaginal sexual partners...all cleared for STD's /STI's.  With 2, condoms always used.  I've never had an abnormal pap.   I've been on the BC pill for 15 years.    I'm currently seeing a man my age (smoker) whose sexual history included threesomes, anal sex with men (with condoms), a lap dance from a CSW, and I would imagine thirty partners would be conservative, and I doubt STD testing was a prerequisite.   His last long-term relationship was with an HSV2-positive woman that ended four months ago.    He recently has tested clear with an STD panel and two HSV 1 / 2 tests.  

I'm a healthy adult, attracted to this guy, trying to protect myself yet not be overly paranoid.  I'm aware of HPV risks (higher with BC pill use, higher for smokers,  higher with multiple partners, higher with partners who have had multiple partners, higher if someone has GW at the time), and I'm aware that condoms offer minimal protection.   Given his extensive history, how risky would you say I should regard oral and vaginal sex with him?    

Edward W. Hook M.D.
Edward W. Hook M.D.
43 months ago
Welcome to our Forum.  Your question is a good one.  Before I comment on risk for HPV, I need to congratulate both you and your (potential?) partner on your approach to your sexual health.  It appears that you have done an outstanding job of sharing information about your sexual histories and your partner (and perhaps you) have done well to get evaluated for STIs in anticipation of unprotected sexual contact.  I wish more persons would take these steps.  I think that his relatively extensive history is offset by his recent (I presume) testing and do not see unprotected oral or vaginal sex with him to be particularly risk for you.

As far as HPV is concerned,  were I you, I would presume that you have or have had HPV infection in the past and likely still have it.  You mention normal PAP smears but not specific tests for HPV.  If this is correct, on a statistical basis, you likely have HPV but that it is not a big deal.  There are numerous other threads on this site in which both Dr. Handsfield and I go into some detail about why we do not believe that HPV infection concern should not be a concern or barrier to a fulfilling sexual relationship - I would suggest you review some of them for this purpose.  Careful studies show that, even in 100% monogamous persons, they acquire HPV at a rate of about 15% or more per year and within 3 years well over half of persons have HPV. (parenthetically, with normal PAP smears, I do not think you need specific testing for HPV).  As long as you continue to have regular sexual health check-ups, including PAP smears, and neither you or your partner have other partners I think you are likely to be fine and would not worry about unprotected sexual intercourse at any site of exposure. 

I hope this comment is helpful. If parts of this are unclear or raise new questions, please feel free to follow-up.  EWH
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43 months ago
Thank you, Dr. Hook (and other doctors), for this excellent online resource.   To answer your question, I have received HPV testing along with annual PAP smears;  all have been negative.  I've had some unrelated but serious surgeries in the last year (cancer caught early), so I'm quite protective of my health and am extremely healthy.  To clarify, for the past eight years I've had annual blood tests for STD's and herpes 1/2, and I've always tested clear.  

Now I have new questions about herpes, perhaps better answered by expert Terri Warren?  I've learned my potential partner's test results for HSV1 are actually positive (a little unsettling since his first explanation to me was that everything was clear), although I'm not sure his HSV1 is oral or genital.  To be conservative, I'm assuming genital.   For perspective, I'm not convinced this would be a life-long relationship.   If he has oral HSV1 and is not taking suppressive therapy but we use condoms, what is risk of HSV1 transmission to me from vaginal intercourse only?  If I receive oral?  


Edward W. Hook M.D.
Edward W. Hook M.D.
43 months ago
Your questions are thought provoking and well directed.  Since you started the thread with me, I will provide my reflections on the issues of HSV infections as well, no need to go to Terri.  Let's start with some statistics and then go to how to use the knowledge that I hope will be helpful to you.  Statistically, with 7 prior partners, at least one of those folks had genital HSV-2 infection and half of the people you have ever kissed on the lips (not just traditional sexual partners) had HSV-1 and thus placed you "at risk".  In both groups, 80-90% of those with infection did not know it.  Currently, among persons of your general age, about 60% have HSV-1 and over 20% have HSV-2 infections.  These are all facts.  You've made it this far without an STI, I suspect through good decision making and undeniably a bit of luck.  On the other hand, at the risk of being philosophical, you also mention having caught cancer early so you are not invulnerable.  My sense as well is that you are committed to your own health maintenance, thorough regular check ups including sexual health evaluations.  Good job! 

With respect to your (potential?) partner, statistically he is more likely to have oral HSV-1 than genital infection although, curiously, your risk for acquiring infection if his HSV-1 is genital would be lower than if his HSV-1 were oral.  Genital transmission of genital HSV-1 is extraordinarily rare and virtually all genital HSV-1 is acquired through receipt of oral, not genital sex.  Further, with oral HSV-1, shedding of the virus tends to go down over time so if your partner has had HSV-1 for years (most is still acquired in childhood) the likelihood of transmission goes down, thereby reducing the chance of transmission.

Finally, were you to acquire a viral STI (i.e. HPV or HSV) from the person you have asked about, it would not, by any means, be the end of the world. These infections are entirely manageable.  None of us can ever know where relationships are going to take us and I hope concern or fear about STIs will not be an impediment to your exploration of future relationships.  From the sound of things in this post, I don't think it will.  I hope not.  EWH

p.s.   Given your detailed past history, one thing you might consider, is getting the HPV vaccine.  It would cost you $400-500 but would virtually eliminate your risk for future HPV infection with the 9 most common HPV infections.  You are beyond the age where insurance would pay for it but your history suggest it might both provide you with some benefit and a degree of peace of mind.  Just a suggestion.  EWH
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43 months ago
Thank you so much.  I'm seeing my doctor today and will ask about the HPV vaccine, and if I hear back from you soon, I could ask any additional questions your might recommend.

The man I'm dating has HSV1 but isn't sure whether it's genital or oral.   He doesn't recall any outbreaks, cold sores or GW, and we know he tested positive to HSV1 in the past, so is there any way to know for sure?   His IgG testing three months after his 3+ year relationship with an HSV2-positive partner who took suppressive therapy, shows he did not acquire HSV2.  Hopefully, testing 14 weeks after exposure is adequate. 

Since we don't know whether his HSV1 is genital or oral, would it be advisable for him to take suppressive therapy for HSV1 -- primarily to reduce oral-to-genital transmission and/or possibly reduce oral-to-oral transmission?  Am I correct that oral to genital transmission of HSV1 is more likely than genital-to-genital transmission of HSV1?




Edward W. Hook M.D.
Edward W. Hook M.D.
43 months ago
Your doctor may be surprised to have a woman in her 40's asking about the HPV vaccine but, given you negative tests and concerns, if you are willing to accept the costs, he should be OK with it.  Insurance will not pay for it and  you may need to review your (my) thinking on the matter with him/her.  There are no other specific questions I would suggest.

There is no way to tell where is HSV-1 infection is.  His 14 week HSV-2 data are reliable.  As I mentioned, statistically it is more likely to be oral but those are statistics and have limited applicability to any single person.  There are also no data on the utility of suppressive therapy for HSV-1.  Genital t- genital transmission of HSV-1 is very, very rare.  Logic says it might be beneficial and there are few side effects to the suppressive therapy.  You might want to query Terri Warren on our site about that- she typically answers most of our HSV-related questions.

I hope this helps.. Typically threads are closed after three replies but I will keep this thread open a bit longer as I am interested to hear how your interaction with your doctor comes out, if you are willing to share it.  EWH

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43 months ago
To follow up and answer your questions, I can offer the following:

I asked my doctor about getting the HPV test, and she agrees that it's advisable; however, the clinic will not approve use of the vaccine on someone over age 26.  She said if I could find CDC.gov evidence that it is safe for those over 26, she could make an argument, but I cannot find any such language online through the CDC or state health authority, so I'm afraid we are at a standstill.  I would be willing to pay for the vaccine, but we cannot find anyone to order it.  I called Planned Parenthood, but that was a dead end too.   Do you have a strong source to validate the vaccination's appropriateness for someone like me?

I am curious to hear Terri Warren's thoughts about suppressive therapy for HSV1. 


Edward W. Hook M.D.
Edward W. Hook M.D.
43 months ago
Ugh!!!!  Your doctor is being overly conservative.  The studies of the vaccine were done in younger groups and the official approval is for persons up to age 26.  That said, doctors regularly prescribe medications for reasons that are not FDA approved. I do not have a source for you and would suggest you reach out to more reasonable clinicians. 

Regarding Terri, you will have to start a new thread with the word herpes or HSV-1 in it.  She will answer. 

I share your frustration and wish there were more I could do to address this.  For better or worse, this thread will have to now be closed and if there are further questions you will need to start a new question.  Take care.  EWH
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