[Question #410] Follow up from #392

78 months ago

Hello again. Thank you to all three of you for your work here and elsewhere. I ask for your patience. I can't believe I am now a repeat poster - but here I am. I am trying to come to grips with the likelihood that I contracted HPV in my only sexual experience outside my marriage (I am her only lifetime partner). I was previously unaware of its ease of transmission and ubiquity. I had a one time encounter with a CSW in her mid/late 30s (only my second partner); over the last six months, also five erotic massages, one involved any vaginal fluid. We had protected oral and vaginal sex, followed by prolonged hand-genital-hand contact with vaginal fluids. I know my questions are likely generated by guilt and fear - but in order to address this adequately, I need to get further clarity about whether I should expect that I contracted HPV.  HPV+ would end my relationship – this is why it is a major concern for me. I hope you can empathize. Dr. Hook was helpful in answering my questions about risk. He guessed that my risk was lower than a 10% chance that I was contracted HPV from this CSW encounter, with the caveat that this was a conservative guess and it could be much lower. Also, on MedHelp, when responding to a very similar context (including some condom slippage), Dr. Hansfield guessed the risk to be "probably under 1 in a 1000." Does the variance come from the fact that there are "guesses" – and so I should not take them as overly comforting or reassuring? 10% still *feels* high to me, not that it feels like Dr. Hook overestimated, but that 10% did not feel overly reassuring; it does not feel 'very, very low' as he suggested, but perhaps that’s because I don’t understand likelihood/probabilities when it comes to STDs. Can you explain this to me? When it comes to STIs, especially HPV, should I be encouraged by a 10% likelihood, given that this assessment has built into it all we know about HPV? Can you talk me through this a bit more?  


It's been over six weeks now and there are no visible warts. How much longer do I need to be looking for them? Is it likely for GWs to occur, but not be visible, even with very careful weekly inspection? In closing, is it safe to assume that I did not get HPV? Or, would that be too sugarcoated? I just don’t know how to proceed with the next year, waiting every week to see if my wife gets warts, or gets an abnormal pap. 

H. Hunter Handsfield, MD
77 months ago
Welcome back to the forum. But I'm sorry to see you remain so concerned and so unnecessarily.

From quick review of your previous discussion with Dr. Hook and your comments here, I see no basis for you to assume any "likelihood" you acquired HPV from your single non-marital sexual exposure. There is little chance you did, since both your vaginal and anal exposures were condom protected. I would put the risk at well below 10%. And if you were infected, over 90% of infections would not cause warts or other symptoms, i.e. you'd never know it. So I would put the chance you ever have any sort of HPV problem from this single event at no higher than 1%.

Further, I see no reason why developing HPV would end your current relationship. That's ridiculous! Everybody gets HPV, and if and when you or your partner ever had an HPV problem, there would be no way to relate it to any particular sexual exposure. New evidence of HPV (most often because of an abnormal pap smear in women) almost never is evidence that either partner has been unfaithful. If you ever develop an apparent HPV problem, or if your partner does (e.g., abnormal pap), it would be most likely from some distant past expoxure to other partners, before you were together.

How long to be on the lookout for warts? If you want brutal honesty, your entire life. Warts usually appear 2-6 months after exposure, but it can be a year and rarely a lot longer.

My advice is that you're worrying about an entirely natural event. Virtually all sexually active people get HPV at least once. Your risk is no higher on account of the extramarital event than it would be if you had not had that exposure. My advice is to just forget it and move on without worry.

Best wishes--  HHH, MD
77 months ago
Dr. Hansfield, many thanks - both for your help here and your work elsewhere. It has been very helpful as I have worked through my questions and concerns. Your responses here were reassuring and clarifying for me. It really does seem as if condoms really work - even against HPV. A few things I'd like to follow up on, while I have you here. (No tortured 'what ifs' are coming, i promise!) *Quick clarification: I did not have anal sex, only oral and vaginal, in case that matters*

1. You mention "past distant exposures to other partners" as (more) likely reasons why there might be a HPV 'event' in our lives in the future. I think part of why I am so concerned about the unlikely event that HPV shows up is that there hasn't be any past exposures to other partners - for either of us. Other than a few hand jobs to high school boyfriends, I have been the only sexual partner for her. Before this, she was my first and only -  really. And so, if HPV does show up, it feels very obvious that it had to come from this indiscretion (which I regret tremendously), with no plausible alternative explanation. I am wondering if you have thoughts about this. 

2. About the warts: I need to watch my entire life, really? Warts are quite rare in men, right, (only 1% of sexually active men have them, am I right about that?), so are you just saying that it's theoretically possible they could show up in 5, 10, 20 years, but rare enough that its not something I should not expect to happen? Or, is it really something that I need to expect past a year? 

3. Abnormal PAP tests: in women, do all HPV infections that have not yet been cleared show up on the PAP test? Or is it only those infections that linger enough to cause cervical changes? Do all HPV infections cause cervical cell changes that can show up on a Pap tests or just the ones that linger past a few year? I don't know enough about the cell biology of all this to know if this is a stupid question or not, and I am fully aware there's probably not specific data on this, but wondering if you had a perspective on it that could clarify for me, if I do have HPV now, and I pass i along to her, what the chances are it shows on a pap test? 

And - finally - (happy to be asking my last and final question!): I really appreciated hearing that over 90% of infections would not cause warts or other symptoms. I don't think I've thought 'never knowing about it' was that likely. Again, probably no data for this specific question, but does "other symptoms" include abnormal pap tests in this number? So there's a less than 10% chance that if I did get HPV (very low considering that it is a less than 10% chance I did in the first place), that it'll show up at all either in warts OR abnormal pap smears?

That's it for me. I am grateful to you - as well as to your colleague, Dr. Hook - for your patience and kindness in answering my questions and working me through this. 
H. Hunter Handsfield, MD
77 months ago
1) HPV sometimes is found in people who are true virgins. It't not certain how this occurs, but the information about you and your partner's sexual histories doesn't change my opinion or advice.

2) I do not advise you to "watch" at all, let alone your entire life. If a wart appears, just deal with it at that time. In the meantime, suck it up and stop worrying. Your fears on this are way, way off the far end of normal.

3) Most HPV in women does not cause abnormal paps. The majority of infections cause no visible abnormality and no obvious disease of any kind. I can't put a percentage on it, however.

My interpretation of this and your other thread is that you have had an unusually restrictive sexual upbringing, which probably wasn't healthy, and you still have very high anxiety about a sexual decision you regret but which is entirely natural and normal -- but you're having difficulty dealing with it. I'm not a mental health expert, but my guess is that you are transposing those anxieties to STDs in general and HPV in particular. In other words, I'm guessing the underlying issue is one of mental health in relation to sexuality. If these concerns continue to dominate your life as they seem to have done, professional counseling might be helpful. I suggest it from compassion, not criticism.

In any case, do your best to put this stuff out of your mind. Good luck with it.

77 months ago
Dr. Hansfield, thank you. You have been very kind to me. I think you are absolutely right about the underlying cause of my fear here. Something I'll need to look to in the future if my anxiety about this continues to be so high about this in the coming weeks. One thing is for sure _  I need to get off the internet.  

One very slight clarification, in an effort to clear my head of all I can before we are done here: when you say that the chance I will ever have any sort of HPV problem from this single event at no higher than 1%, this also applies my SO as well, right? I ask only b/c I know that for men, the symptomatic rates are much lower and infections shorter. I just wanted to make sure that you also think that the chances that there will be any sort of HPV sign/problem (warts, abnormal pap) for her are equally as low - IF I am even infected. I am not asking you to repeat yourself, nor do I expect you to say the same things in different words, truly, but just trying to verify that i understand you correctly and that I am not only seeing what I want to see in what you are saying. 

When one looks too much and too long at the internet these days, one can get the impression that everytime, or most times at least, sometime has sex with someone who has active HPV, they get infected. The constant qualification about how condoms reduce transmission but aren't' fully protective can make you feel as if they must not do anything, that protected sex is irrelevant when it comes to HPV. If I understand you correctly, you are making the opposite case and on that basis, I should not be considered at all about having contracted HPV here, nor shall I be concerned about transmitting it to my SO. 10% (chance of infection) of 10% (chance of warts in either of us or abnormal pap) is 1% and that's a conservatively high estimate. Do I understand you (and Dr. Hook) correctly? 

That will be it from me. I thank you, truly, for all your help. 

77 months ago
Oh, and one more quick thing: it's sometimes hard to know whether to take your point that I ought not to worry about this as either (a) an implication of your belief that HPV is ubiquitous, normal, and will happen to everyone whose sexually active at all (and so why worry about this specific encounter), or b) I really shouldn't worry b/c you really don't think I got infected in this single encounter b/c of the specifics reasons associated with it (one time, condom protected, only my second lifetime sexual partner) and b/c of what you know about HPV in the US! My guess is that it's both (but I hope its heavily weighted towards (b) !! :) ) - confirmation or correction is welcome here. All the best. 
H. Hunter Handsfield, MD
77 months ago
Yes, the 1% chance is a conservatively high estimate; and yes, it applies to any apparent health problem of any kind, i.e. warts, abnormal pap in your wife, or anything else. I would add that in the unlikely event an HPV related problem appears in either of you, there will be no reason to attribute it to the sexual exposure described above. I agree (b) is the main reason you shouldn't be worried, but (a) also applies to some extent. Finally, I certainly agree that you should stop searching online about any of this. Like many or most anxious persons, you are being drawn to information (often inaccurate) that inflames your fears and not "seeing" the reassuring bits. As the famous statistician Nate Silver wrote in his book "The Signal and the Noise", "Give an anxious person a computer with an internet connection, and he'll soon be mistaking his cold for the bubonic plague" (approximate quote, from memory).

So do your best to move on without worry. If this continues to plague you, refer back to my advice about counseling. Best wishes.