Human Papillomavirus HPV

Considerations

 

HPV is the causative agent of the common wart and nobody seems excessively worried about its presence. Genital HPV, despite being basically the same, has personal implications, especially with regard to infidelity and the stigma of a sexually transmitted disease.

In the skin related to the genitals HPV behaves like a sexually transmitted agent that produces warty lesions in the ano-genital region and asymptomatic lesions of the cervix; clinical manifestations may be absent or present late so we can not establish at what point the infection was acquired. However, we consider a period of incubation (time from infective contact to lesions becoming clinically evident) 2-3 weeks to 8 months in the case of condylomata and up to 2 years for the cervical (uterine cervix) subclinical infection.

Genital HPV infection is the main precursor of most cervical cancers and rare, infrequent cancers of the ano-genital region. Immunocompromised patients are at greater risk for developing HPV-related cancers

This article describes the genital HPV infection associated with intimate genital contact, sexual activity. Unusual and sometimes inexplicable cases are personally discussed with the patient to try to define the origin of the infection. It is not acquired by using public bathrooms or swimming pools ...

Since young college-age women are more sexually active than older women, the prevalence of HPV infection is high in this group (about 50% of college women are positive for HPV, especially 20-24 Years, and it is expected that up to 80% of women will have an HPV infection sometime in their life). Over time the prevalence of infection decreases considerably clearly indicating that the infection clears spontaneously, otherwise the older the female population the greater the prevalence of HPV infection; so, there would come a time when almost 100% of sexually active women would test positive for HPV and that is not the case.

Fact: HPV infection clears spontaneously and/or with minimal intervention but patients should not abandon their regular gynecological control.

Excellent NEWS!

OBJECTIVES: To avoid the adverse pregnancy-related complications of excisional treatment for cervical intraepithelial neoplasia (CIN), alternatives are needed. Topical treatment of anal intraepithelial neoplasia with 85% trichloroacetic acid (TCA) is known to be safe, well-tolerated and effective. The short-term efficacy and tolerability of a single topical 85% trichloroacetic acid treatment for cervical intraepithelial neoplasia (CIN) 1 – 3 was studied. METHODS: A retrospective case series including all patients with CIN treated at a private colposcopy clinic associated with the department of General Gynecology and Gynecological Oncology, Medical University of Vienna, September 2012 and January 2015 was performed. Treatment consisted of a single trichloroacetic acid application as first-line therapy. Treatment response was evaluated by colposcopy, cervical biopsy, cytology, and type-specific human papillomavirus (HPV) testing 8 weeks after a single trichloroacetic acid treatment. Regression was defined as improvement from high-grade to low-grade CIN and remission was defined as improvement from any grade of CIN to no CIN. For quantification of treatment-related pain, 107 (44.1%) patients rated their subjective perception on a visual analog scale. RESULTS: A total of 241 women were included in the study with 179 high-grade (CIN 2 – 3) and 62 low-grade (CIN 1) squamous intraepithelial lesions. For high-grade squamous intraepithelial lesions, the histologic regression rate was 87.7% (95% confidence interval [CI] 82.0 – 92.1) and the remission rate was 80.3% (95% CI 73.3 – 85.5). For low-grade squamous intraepithelial lesions, the remission rate was 82.3% (95% CI 70.5 – 90.8). Human papillomavirus types 16 and 18 were found in 53.7% and 7.3% of all women tested, respectively. Clearance rates of HPV type 16 and HPV type 18 were 73.5% (95% CI 62.5 – 81.3) and 75.0% (95% CI 46.2 – 95.0), respectively. Median pain score was 3.0 out of 10.0 (25th and 75th percentiles 2.3 and 4.3, respectively). There were no major side effects observed during treatment or follow-up. CONCLUSION: A high regression and remission rate and a high HPV clearance rate were observed 8 weeks after topical 85% trichloroacetic acid treatment for patients with CIN.

Dr. Ricardo Gómez Betancourt

Facts about HPV infection

 

1. HPV infection has no cure (as most viruses), but its infection clears spontaneously. I quote: "Studies have shown that 70% of new HPV infections clear over a period of 12 months, and as much as 91% have disappeared in two years. The average length of newly acquired infections is 8 months. HPV type 16 is more likely to persist than other serotypes; however, most infections with HPV-16 clear after two years. It is believed that the progressive development of immunity against HPV is the cause of the elimination of HPV viral DNA" Source: Atlanta´s CDC, 2015.

2. Most cases of HPV infection occur in young women and its prevalence decline as age progresses and couples become stable (mutual monogamy), suggesting that the virus tends to disappear spontaneously.

3. Genital HPV infection is a sexually transmitted condition; however, it rarely is a disease because it doesn´t affect the overall health status of the individual who has it. HPV infection rarely leads to a real disease, Cancer

4. Persistent infection could lead to progressive cellular changes over time, cell changes (dysplasia) that could lead to invasive cervical carcinoma: these are the premalignant dysplastic lesions also known as CIN-1, CIN-2 and CIN-3 (Cervival Intraepithelial Neoplasia, CIN).

5. Cervical HPV infection is the cause of 90% of cases of cervical cancer but only 1-2 of 100 women with persistent HPV infection (in 15-20 years, WHO 2015) will develop a cancer: Cervical cancer is a marker of underdeveloped countries where the health system is unavailable or unable to guarantee its female population adequate gynecological care. Women residing in the developing world continue to present in later stages of disease and have fewer options for treatment than those in developed countries.

6.-The fact that you show HPV + (HPV without advanced dysplasia) in a Pap smear or HVP DNA testing does not imply imminent cancer, not even that it will ever happen. So, do not panic and avoid mutilating interventions (Fulguration, Radio Frequency, Cervical Cone, Hysterectomy) if they are not necessary

7. The gynecological examination, Pap and colposcopy (magnification of the cervix) are the methods used to detect lesions caused by the presence of HPV. The HVP DNA testing is the modern study of viral DNA

8. The treatment of cervical lesions caused by HPV is based on resection of isolated pockets of tissue affected by the virus when these go beyond the mere presence of the virus: dysplasias, CINs

9. Every new sexual partner increases 10 times the risk of HPV infection, even with a different type of virus: there are at least 40 types of HPV that infect the genital area, the most carcinogenic types are 16, 18 , 31, 33, 35. this explains why cancer is more common in women who have had multiple sexual partners, especially those sexually active from an early age.

10. A woman can be infected by several viruses at once, this is why the multiplicity of sexual partners is not good business when it comes to the prevention of cervical cancer.

11. Smoking increases the risk of oncogenic potential of HPV infection, while Oral Contraceptives provide some protection against infection.

12. Based on the natural history of HPV infection we know that we can control the patient once or twice a year safely and avoid unnecessary treatments and costs.

13. The HPV is more stupid than it looks but disinformation and unscrupulous management by some doctors has created a feeling that HPV infection involves a deadly condition.

14. The vaccines Cervarix (2 serotypes), Gardasil (4 serotypes) and Gardasil 9 (9 serotypes) have the potential to reduce up to 70% - 90% of cases of cervical cancer worldwide, especially in developing countries. The good news is that apparently one dose is as effective as 3, this would save time and money.

The truth is I have not had a single case of cervical cancer in more than 15 years of experience and invariably 100% of patients carrying some clinical form of HPV infection have healed within weeks or months. No magic or high or unnecessary expenses.

Things are as they are because they can not be otherwise

(principle of Sufficient Reason Leibniz)

Pap smear vs HVP DNA testing, or both?

 

It is true that Pap Smear, cervicovaginal cytology, is not as sensitive (60%) to detect HPV as does the viral genome detection using HVP DNA testing (99%), but Pap detects premalignant cell changes and effectively rule out the lack of them (60 / 90%). I've seen HVP DNA testing abused as a diagnostic tool, and generating additional costs, without providing clear benefits for the patient. Fact is that in some countries the use of HVP DNA testing is a must due to certain guidelines and lower costs:

"The FDA’s Medical Devices Advisory Committee Microbiology Panel agreed by a vote of 13-0 in each of three successive votes that the cobas® viral DNA test for HPV—made by Roche Molecular Systems—was safe and effective for cervical cancer screening, and that the benefits of the tests outweighed the risks. The Panel recommended that this Roche HPV test replace the Pap smear as the first-line standard of care for cancer screening. Women 25 and older who test positive for HPV16 or 18 would proceed directly to colposcopy for further assessment. Patients who test negative for HPV16 or 18 but positive for the other high-risk strains would have a Pap test to determine the need for colposcopy. Women who have a completely negative test would be followed at their physician’s discretion"

Most US centers recommend PAP testing after 21 years of age, PAP testing every 3 years in the 21- 65 years age group or PAP + HPV DNA Testing every 5 years in the 30-65 range group and no further testing after 65 years old.

In my country, Venezuela, HVP DNA testing without PAP is not an option since Pap is quite less expensive than the HVP DNA testing. We screen women once a year (this includes full physical, Schiller, Pap and pelvic sonogram) and it is known that Pap´s sensitivity increases with repeated use. "Regular Pap screening decreases cervix cancer incidence and mortality by at least 80%". Colposcopy and biopsy is performed in case of abnormal screening results or atypical findings during the Schiller test with Lugol Iodine. In 15 years of private practice I have never had a single case of cervical cancer following this protocol.

Moreover, since 50% of women HPV + have no cytological changes, and most cases of HPV16/18 infections will clear without causing cancer giving such importance to DNA testing seems contradictory. HPV is necessary but not sufficient to generate the associated gynecologic cancer, 86.7 % of women with a positive HPV test did not develop cervical cancer or related premalignant disease after more than a decade of follow up. In any case, as long as you receive good and time tested gynecological care you won´t get a HPV related cancer

Warts and HVP DNA testing

I do not recommend DNA testing for warts since almost invariably I will get nononcogenic serotypes 6 or 11 and therapy will not change with the test results.