[Question #7629] Dr. Handsfield

 
20 days ago
In 2017 I had a pap smear and was diagnosed with HPV (untyped) that caused "low grade squamous Intraepithelial lesion (LSIL) encompassing: HPV/mild dysplasia/CIN 1" 

also had a lesion from vagina cultured and it came back positive for HSV-1

I have had 3 follow up pap smears since the ( 2018, 2019, 2020) all were normal. How do I know if the type I had was high risk? Is there anything I can do to prevent it from returning? unfortunately my parents did not vaccinate me for HPV so at that time I had no immunity, but I have gotten vaccinated in 2018
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
20 days ago
Welcome back to the forum; thanks for your continued confidence in our services. I reviewed your previous discussions with Ms. Warren and Dr. Hook. As you were informed then, users do not have the option of selecting the moderator who replies; it's just by chance that I'm currently up for new non-herpes questions. That said, I'm certainly happy to round out your trifecta, having now heard from all three of us! 

There is no way to know at this point whether or not a high-risk HPV type was responsible for your dysplasia -- but it doesn't matter. The important issues, and the ones predicting a virtually non-existent risk of cervical cancer, are that a) you only had CIN1 and not CIN2 or 3 and b) your follow-up paps have been normal. It is a common misunderstanding -- not only by affected patients, but among many gynecologists and other physicians -- that CIN (or LSIL, see my note on terminology below) progresses over time, i.e. that CIN1 can progress to CIN2/3. That once was the belief, but later research has shown that CIN1 almost never progresses to more serious dysplasia or to cancer. Those at risk for later cancer virtually always start out as CIN2/3 (or HSIL). And CIN1 usually clears up on its own, without treatment, as it did for you. CIN2/3 can clear up as well, but because of the higher risk of cancer, usually is treated by minor surgery or other methods to remove affected cervical tissues. Such treatment is usually unnecessary and not done for CIN1.

CIN1 can be caused by either low or high risk HPV types. But as I said, that doesn't really matter. The important information is that you only had CIN1. I'm very glad to hear you've been vaccinated against HPV:  that means you are no longer susceptible to the 9 types of HPV that cause 90% of cancers (and 90% of genital warts). You still could have a future Pap smear abnormality, and be at slight risk for cervical cancer, if unlucky enough to have another HPV infection with a type not covered by the vaccine. But whatever HPV you had in 2017 is not likely to ever be a problem for you again. 

Here's my note on terminology, in case you're interested and not aware -- maybe also helpful for other readers. Consider it a blog-like entry that I can refer to (or copy and paste) in response to future questions as well as this one.

Low- and high-grade squamous intraepithelial lesion (LSIL, HSIL) is the main terminology used in interpreting Pap smears. Cervical intraepithelial neoplasia (CIN) stages 1, 2 and 3 are similar and this is the routine terminology used in biopsied cervical tissue -- although some labs may use the CIN terminology for Pap smears as well, i.e. in absence of biopsy. CIN is essentially the same as "dysplasia", which is classified as mild, moderate or severe. LSIL usually implies CIN1 and mild dysplasia, as in your case, and HSIL corresponds to CIN2/3 or moderate or severe dysplasia. CIN2 and 3 are not much different from one another:  technically, CIN3 is carcinoma in situ, i.e. the earliest stage of cervical cancer (several years before invasion and serious health risk). The risk of later invasive cancer is identical for both and treatment no different, which is why cervical cancer experts often refer to them together as CIN2/3. Finally, as noted above, when HPV causes these abnormalities, it's usually either CIN1 or CIN2/3 from the start; there usually is no progression (or regression) from one to the other. This can occur, but probably is most often due to variable interpretation by the microscopist examining the tissue or Pap smear, more than true change in stage.

In summary, it sounds like your dysplasia was managed in standard, textbook fashion -- i.e. follow-up paps, without cervical surgery, cryotherapy, etc -- and that, as expected, it cleared up. No further worries about it.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD
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3 days ago
Thank you for your prompt and thorough reply! And yes! 3 or so years ago I got to speak with Dr. Hook so Its awesome to hear from both of you. Reading your work on the medhelp forum helped me tremendously when I was first diagnosed. And what is your opinion of a diagnosis of genital HSV-1? Do you think it's necessary to disclose? and should precautions for transmission be used (e.g condoms and antiviral meds)? I have had this for over 4 years now, no outbreak other than the primary one.

As for HPV I guess it became hard to move forward from as I had a family friend diagnosed with throat cancer that I believe stemmed from HPV, so I am always wondering will I develop throat or cervical cancer, or both. It is scary knowing that what I had could even have the potential of forming cancer or effecting me long term. (I was also treated for Chlamydia in 2017 which I always wonder how that will effect my fertility as I know it can lead to infertility). I just want to do everything I can to prevent it or catch it early *if* it does happen. How does one screen for HPV related throat cancer?


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 days ago
Disclosure of genital HSV1 is optional in my opinion -- but I stress that's an opinion only; not all affected persons will agree. Your situation is typical, i.e. few or no recurrent outbreaks, and your transmission risk for a partner undoubtedly is extremely low for any one sexual encounter. For an ongoing relationship, that small risk would rise in proportion to sexual frequency and total number of sexual episodes -- but you still likely would never transmit. If I were in your situation, and if dating but not (yet) in a committed relationship, I probably would not disclose, but would do so if and when a relationship moved toward commitment. A small minority of GHSV1 infections do recur more frequently; those persons probably should disclose to all partners. But as I said, this is an ethical gray area, and not all would agree. (I'm pretty sure Terri, our herpes expert, would agree:  I'll ask her to take a look at these comments.)

Your reaction to knowing someone with pharyngeal cancer due to HPV is entirely human and very understandable. But that doesn't make it more common or risky for you -- any more than your risk of someone you know being struck by lightning, which would not elevate your near zero risk (assuming you weren't golfing together when it happened!). Pharyngeal cancer due to HPV is rising in frequency, but it remains uncommon compared with major cancers like breast, colon, prostate, lymphoma, etc, etc. Even if people with known oral HPV16 -- almost the only HPV type causing throat cancer -- probably fewer than 1 in a thousand develop cancer. For cervical cancer, following standard Pap smear guidelines is nearly 100% effective in preventing invasive cancer. There are no recommended screening procedures to prevent throat cancer. It's conceivable that someday there will be a recommendation to test for oral HPV16 (at what age? how often?), and if HPV16-positive maybe followed by regular professional inspection of the throat (by what specialists? how often?) for early cancer. But at this point, there is zero evidence that such steps would be effective in reducing risk of overt cancer or improving survival. At this point in time, all I do personally (having had my day as a single person with a very active dating life, including all expected sexual practices) is rely on my dentist letting me know if he sees anything funny during my routine visits. I see no need for anything more. I don't actually say anything at all to my dentist about it.

If you didn't have symptomatic PID (pelvic pain, fever, etc) when your chlamydia was diagnosed, there is little chance you are infertile as a result. In addition, with modern infertility management, tubal factor infertility (the sort caused by chlamydia) usually can be successfully managed with IVF. So this really should't be a big worry for you.
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