[Question #334] hpv

35 months ago
Hello. I did a pap smear today and it's been a day since my period ended. Usually I have brown discharge for two days after my period and I had some today whenever I did the pap. Will this affect the results? Also, I'm getting a urine trich test tomorrow. Is this test good for females or is it only for males? I'm pretty sure I have trich, I just want to get the most accurate result. And last question, where can I get an HPV test done? I'm 22 and I read online that I can get an HPV test without a pap. I want to be tested for all high risk HPVs. Can I do that at an doctors office? I tried planned parenthood but they only do it for abnormal pap.
Thanks so much. I appologize for the lengthy email.
35 months ago
Also, I forgot to mention that whenever she was taking samples and when she inserted the speculum it was really painful. I have a constant vaginal and vulvar stinging pain. There was also pain when she took a sample from the cervix. Is this something serious? I'm really concerned . Thanks again.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Greetings. Welcome to the forum.

Presumably you asked these questions of the doctor or clinician who you saw today for your pap and STD testing. What is it that makes you "pretty sure" you have trichomonas? It would have been normal for them to evaluate your discharge, including tests for STDs, bacterial vaginosis (BV), and trichomonas by microscopic exam of discharge. Presumably you told the examiner about the pain during speculum exam and cervical sampling. What did they say about all this? Also, can you say more about your "brown discharge"? Dark or light brown? Does it look like old blood? Is there any odor? How long has it been going on? How old are you? Are you at risk for STD, i.e. new, multiple, or recent chance in sex partners? Sex with men, women, or both? Condom use? The answers to all this would help me give useful advice.

In the meantime, here are my preliminary thoughts. First, "brown discharge" usually present for only a couple days after most menstrual periods may not be abnormal, just residual menstrual blood. However, reappearance of discharge between periods, or discharge continuing more than 2-3 days, would be of greater concern.

Second, the preferred trich test for women is a PCR done on a vaginal swab, not urine. Testing urine would pick up most infection, but probably not as good as vaginal swab. Why is this being done tomorrow and not included during your pap smear visit? Also, was routine STD testing done at that time, i.e. gonorrhea, chlamydia, and syphilis and HIV blood tests? As for trichomonas, the best gonorrhea/chlamydia test in women is on a vaginal swab, not urine.

As for HPV, most STD experts would recommend against being tested in the way you suggest -- i.e. like Planned Parenthood, HPV testing in women normally is done only in conjunction with pap smears. The tests offered on line are not necessarily approved by regulatory agencies like the US Food and Drug Administraiton, and the results cannot be considered conclusive. Most important, they probably miss some infections -- so if negative, it won't prove you don't have HPV. Or if some type(s) are found, you could still have others not detected. In addition, what will you do with a positive result? On average, 20-50% of sexually active women age 15-30 are carrying at least one HPV strain. Nothing can be done for positives, unless there is an abnormal pap, warts, or other abnormalities needing treatment. And knowing that particular types are present, even the highest risk types in terms of future cancer risk, is not considered a valid basis further tests, paps, or sexual behavior changes. So my advice is to think carefully before you decide whether in fact to go ahead with HPV testing.

Finally, I really can't speculate further about the painful speculum exam. If you had overt genital sores or ulcers at the time, it would suggest herpes, but no other STD is a likely explanation. A yeast infection could cause this sort of symptom,.

I hope this information helps -- but perhaps I can do better if you fill in some of the missing information implied by my questions. Best wishes in the meantime.

HHH, MD
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35 months ago
Hi Dr. Handsfield,
Thanks so much for the reply. Well I haven't been sexually active since 2011 and I've only had sex with one guy. We did have unprotected intercourse couple of time and I know my ex had sex with two other girls but I'm not aware of their status. The brown discharge it's just dry blood from my period, I only have it after my period I don't have brown discharge between periods. Well the NP just tested me for chlamydia, gonorrhea and we did a Pap smear. She took a sample for BV but I don't think it was a microscopic examination. she mentioned something about PTOC or something, Ill ask her tomorrow. it only took ten minutes for the result.Well in the past I've tested negative for gonorrhea, chlamydia and pap were normal. I'm 22 now. I've never been tested for trich, that's why I ordered the urine test. I think I have trich because I sometimes have a milky discharge with strong odor especially after the gym. I have the odor pretty much every day. The discharge is not always milky but it appears yellow on my underwear. I've always had brown discharge after my period. Just for two days. I'm just worried cause of the pain in the cervix and vagina. I told her that but she said the pain could be due to my period since I just finished it. But I do have a constant vulvar vaginal stinging pain associated with itchiness. Would you recommend HPV test?
Thanks so much. I appreciate it.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Thanks for the clarifications.

I agree it isn't unreasonable to test for trichomonas, but my bet is you don't have it. In any case, arrange for a vaginal swab DNA test, not urine.

POTC = point of care test, and such rapid tests are available for BV, such as BV Blue® and others. The negative result is reassuring but doesn't entirely exclude. There is a spectrum of vaginal bacteria between normal and BV, with a 10 point scale. Some women fluctuate between, say, 2-3 (slighly abnormal) to 6-7 (more abnormal, but not florid). Intermittent symptoms can reflect fluctuation iin this range -- and at the lower end, most POTC tests would be normal. You might arrange with your doctor to be seen promply (within 1-2 days) so you can be checked on short notice next time you have increased discharge with odor. In theory, yellow discharge doesn't quite fit with BV but does go with trich and other STDs -- but this is highly variable and nothing that can be relied on as a strong indicator either way.

And as noted above, stinging and itchiness fits most closely with yeast. Having a period could temporarily make such symptoms more prominent. Further, yeast and BV (and maybe trich) can interact -- either one probably increases the risk of having the other as well. And yeast can be difficult to detect either on direct exam or microscopically. If you were my patient, I would probably prescribe a course of anti-yeast treatment; or you could try one of the many effective OTC treatments. Select a product with active ingredient ending in "azole" (clotrimazole, miconazole, and others). Choose the cheapest; they're all equally effective. If the stinging and itching clear up in a few days, that will confirm a probable yeast infection.

Finally, if I understand correctly, you were tested in the past but not recently for gonorrhea and chlamydia. You should do it again if it wasn't done at your most recent visit. Have a vaginal swab DNA test. It is unlikely but not inconceivable your past tests missed one or the other. It would be very unusual for either of these to persist 4 years, but stranger things have happened and such testing is routine in evaluating unexplained vaginal discharge. Better safe than sorry!

If all this fails to explain your discharges, odor, etc, I would recommend you ask for referral to an ObG who subspecilizes (or has special interest) in infectious diseases. But to close the loop started above, I don't think HPV testing has any place in any of this. HPV for sure has nothing to do with any of these symptoms.

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35 months ago
Hello Dr. Handsfield,
Thanks so much again. This is my last post. Well yesterday she did take a swab from the vagina to test for chlamydia and gonorrhea, but I'm not aware what kind of tests they used. So you think the urine test Wil be useless for me? I would go to see a doc but I currently don't have insurance. I did one chlamydia and gonorrhea test in December 2015 and another one in February 2015. I haven't done any std testing prior to that. I did have herpselect 1 and 2 IGG ordered but they were both negative and they were done three years post exposure. Is milky discharge usually associated with trich or chlamydia or gonorrhea? Thanks so much for the help. I really appreciate it.
35 months ago
I apologize. I want to clarify in the last post I did chlamydia and gonorrhea tests in December 2014, February 2015 and December 2015
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Glad to hear you were tested recently. From your previous comments I had the impression you had a single gonorrhea/chlamydia test some time ago.

Also glad to hear your HSV IgG test is negative for both viruses. Genital herpes is a possible cause of intermittent vaginal discharge -- not highly likely, but good to know that's not an
issue.

In general, discharge from inflammatory STDs like gonorrhea, chlamydia, or trich would not be milky but colored -- creamy, yellow, etc. Milky is most typical for BV, or for normal vaginal fluid. However, this varies widely and there are many exceptions. That said, your multiple tests prove it isn't gonorrhea or chlamydia, and as noted above, I'm guessing trich testing also will be negative.

Normal fluid amount varies widely from one woman to the next. You're in the best position to know whether the current discharge is normal for you. All things considered, I am most suspicious of BV, or fluctuation along the spectrum toward BV, as discussed above. if you cannot arrange to see a doctor, ideally an ObG with ID expertise. then it probably would be safe to first try the anti-yeast treatment suggested above; then arrange for another clinic visit if/when odor and discharge are both present.

You also might further explore health insurance options under Medicaid or the Affordable Care Act. Good luck!

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35 months ago
So to sum up, your advice for me is to get a DNA test so I can be tested for trich, chlamydia and gonorrhea? I assume those can only be ordered through a doctor. Do you happen to know if planned parenthood uses DNA tests? I know you said a swab is better for females to get tested for trich but do you think the urine test is not good enough? It's an RNA test, so I assume it should be accurate. Were you saying earlier that the HPV tests ordered online are not approved or any test that they sell online? I've ordered the herpselect online and it was through Quest diagnostics. And last question is the amount of the sample collected important for getting more accurate results? I'm not sure if she got enough sample because I was experiencing pain during the exam. The NP said she didn't see anything unusual on the cervix or vagina but I guess that doesn't mean anything. Thanks so much Dr. Handsfield. I don't mean to bother you but I've been dealing with this for over a year now (itchiness, pain, discharge with odor), and I still don't know what it is. I guess it's an STD, I just have to find a better test to prove that. Thanks again! I appreciate your help.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
First, a bit more clarity on terminology. The proper term for the kind of tests we're talking about is NAAT, which stands for nucleic acid amplification test. NAATs test for DNA or RNA. All NAATs are equivalent -- it doesn't matter if DNA or RNA.

You do not need another test for gonorrhea and chlamydia; you already had those NAATs. Just a trichomonas NAAT, which I suspect will be negative. I cannot say whether your planned parenthood clinic routinely does that test, but they probably can request it from whatever lab they routinely use.

HerpeSelect is a standard herpes blood test. The amount of blood collected makes no difference in test accuracy.

Finally, I disagree with your statement that you "guess" your itchiness, pain and vaginal odor are an STD. As noted repeatedly above, yeast or BV are the best bets, and neither of these is an STD.

That will end this thread; we're already passed the limit of 2 follow-up comments and replies. If you have further questions, my advice would be to first carefully read all your own questions and my replies above. Most additional thoughts that might come to mind probably have already been addressed.

Best wishes and stay safe. Happy holiday.


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