[Question #6585] Oral HPV

13 months ago
Hello Doctors,

I have been flitting between moments of anxiety and calmness over two random sexual encounters I had over a year ago. I am currently 24. Over a year ago, I engaged in hook-ups where I performed vigorous cunnilingus on each of two women (one in August 2018, she was 23 y/o, and the second in December 2018, she was 20 y/o). I was sexually inactive up until this point. What alarmed me about the second one was that she told me afterwards that she had more than 30 partners. I was thinking whether this was some bizarre sense of humor or if she was being genuine. I was alarmed because I have seen in many sources how not only the number of sexual partners but, the number of sexual partners that my partner had would increase my chances of contracting the dreaded HPV 16.  Surely after a certain number of sexual partners (I'd like to think), she must have gotten the vaccine. To the best of my memory, each cunnilingus session was 2 minutes and about 2 minutes also, respectively. My tongue was focused on the clitoral area. I have been closely looking at threads pertaining to oral HPV and cunnilingus and have noticed a slight difference between your answers. Dr Handsfield has mentioned how oral exposure via cunnilingus can indeed lead to potential infection, however Dr Hook has said recently in a thread that "experts" agree that STIs (including HPV) are poorly transmitted via cunnilingus. 
6 days after my second sexual encounter, I hastily went and got the HPV vaccine and was vaccinated a second time in February.

What I'd like to know is:

1. How worried should I be about my two episodes of cunnilingus and my ch?
2. Is cunnilingus truly a biologically inefficient way of HPV transmission and where has that information came from?
3. Do you find that your clinical experience has explained why most HPV infections are reported to clear up in good time?
4. Do you know of many ear nose and throat specialists that seem to confirm your opinions surrounding oral HPV and throat cancer>
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Welcome to the forum. Thanks for your confidence in our services.

My first reaction is to congraulate you on having safe sex. Cunnlingus is just about the lowest risk sex one can have, other than mutual masturbation, and far safer than unprotected vaginal or anal sex. The overall STD risk from orl sex very low, and that includes HPV. Further, HPV is the least worrisome or dangerous of all STDs. And for those reasons, my second response is to say your periods of calmness are appropriate and serious anxiety over these events is not. 

That one partner had 30 lifetime partners isn't a big deal. The frequency of HPV is little if any higher in people with large numbers of partners versus smaller numgers. 90% of all people get infected, and at any time about half of all sexually active persons (age 15-30) have active, potentially transmissible HPV -- no higher in people with say 50 vs 5-10 lifetime partners.

Oral HPV isn't rare, but it's a lot less common than genital infection. The chance of getting oral HPV from any single oral sex event is very low. And not all cases come from oral sex; avoiding oral sex probably makes no significant difference in the low risk of a future oral HPV infection or a serious outcome from it.

"Dreaded" is much too strong a word for HPV of any type, including HPV16. That type is more likely than most HPV types to cause cancer, but still the large majority of people with HPV16 never develop cancer. There's been a lot of media attention to throat cancer due to HPV (mostly HPV16), and rates are rising. However, it remains an uncommon cancer compared with the biggies like cancer of the lung, prostate, breast, colon, cervix, and so on.

Those comments partly address your quesitons, but to be explicit:

1. You should not be at all worried about these particular events. I can't say there was no chance of catching HPV orally, but it was very low; and if it happened, it is extremely unlikely you'll ever know it or develop any health problem from it.

2. The overall frequency of oral HPV is about 15% that of genital HPV. The large majority of people who perform oral sex frequently never develop apparent oral health problems from HPV. Probably oral tissues are inherently less susceptible than genital and anal tissues to the genital types of HPV.

3. All we can say is that the immune system usually is effective in clearing HPV, oral or genital.

4. I'm not sure what "suspicions" you are referring to. As far as I know, ENT and STD specialists have similar understandings and knowledge about oral HPV. (Most throat cancers are diagnosed and treated by ENT specialists, so even though it's not a particularly common cancer, they see most cases and are more expert than anyone else in recognizing and treating it.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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13 months ago
Thank you Dr Handsfield! Your  response is very reassuring. I have a few more questions.

1. I see that many reputable sources (sloan kettering, cdc, oral cancer foundation) are basically singing from the same hymn sheet as you guys but yet there are still some other reputable sources dental associations, NHS, Mount Sinai etc that seem to take a more alarmist approach. Is this just them being overly cautious to “cover their butts” so to speak? Or is there knowledge of HPV possibly lacking?
2. Is it possible that these HPV viruses sometimes mutate over repeated exposures to develop a wider tropism i.e. able to bind to cells in pharynx(I have a background in bio med so I have an interest in how this occurs)?
3. The mucosa of the cervix is not too dissimilar to that of the throat, would it be more plausible to become infected if I was to somehow (unrealistically) make contact with an infected cervix?

Thanks again for your time
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
1. Variable health advice is endemic, whether it's HPV, other STDs, HIV, or (currently in the news) the Wuhan coronavirus. Various agencies, physicians, etc often having differing perspectives on risk, prevention, etc. (What is NHS? Presumably not UK's National Health Service....)

2. I'm not aware that HPV has significant mutation potential. It's one of the more simple viruses with a small genome, which can translate into low mutation frequency. I'm not a virologist, but would be surprised if any particular HPV type would develop new tissue troposim.

3. I have no knowledge at all about whether there are biological reasons that explain possibly different cervix vs throat tropism.

Since you see to have some scientific understanding, I'll add that epidemiologic studies do not show a strong association of oral HPV wih oral sex. The the largest analysis so far, an ongoing project called the National Health and Nutrition Examination Survey (NHANES, usually pronouned en-hanes), the overall prevalence of oral HPV was 15% of genital infection, and the survey participants with and without oral infection reported neither more nor lesser frequency of oral sex. It is possible that direct oral exposure to the virus isn't necessary: sex is inherently messy, with genital secretions spread around and perhaps introducted into all body orifies at least some of the time. It's also possible -- but more controversial -- that once people have HPV at any anatomic site, they may auto-inoculate themselves, perhaps via their own hand-genital contact. This and other studies with similar outcomes are why avoiding oral sex, or using barriers (condoms, dental dams) is probably not a useful strategy to prevent oral HPV infection. And certainly the details of oral sex (how it is performed -- thinking about your comment about tongue-clitoris contact -- almost certainly make no useful difference in risk. A much wiser and probably far more effective strategy is HPV vaccination, which you should consider, to prevent infection with the 9 HPV types that cause ~90% of cancers and warts.
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13 months ago
Very interesting stuff. So from my interpretation of it, basically oral HPV infection is like an unavoidable consequence of sexual activity if it’s oral or penetrative? Apologies if I’m not quite getting the picture.
 I was vaccinated with Gardisil 9 in December 2018 and received the second vaccine in February 2019. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Your interpretation is right on the money, in most experts' eyes.

The vaccine is highly protective after two doses -- in fact, future recommendations may call for only two doses. But for true security on prevention, have the third dose. It can be done any time more than 6 months after dose no. 1. Probably you're aware, but official advice is that there's no protection against any HPV types with which you were infected before vaccination. Recent research is beginning to challenge that belief, i.e. that immunization may reduce the likelihood of reactivation of prior infection with the 9 types covered by the vaccine.

That completes the two follow-up exchanges include with each question and so ends this thread. I'm glad the discussion has been helpful, or so it seems. Take care and stay safe.
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