HPV
What You Need to Know

An Article Submitted by Dr. Mary E. Geldernick

Gov. Rick Perry recently issued an executive order directing the Health and Human Services Commission to adopt rules requiring all girls age 11 and 12 to receive the Human Papillomavirus (HPV) vaccine prior to entering sixth grade, effective September 2008. Public concerns expressed over the vaccine where the young age of the patient and the effect the vaccine may have on increasing effect on promiscuity.
Texas has ranked number one in the country for incidence of teenage pregnancy for most of the past twenty-five years. Promiscuity will not become a problem: it already is one. Given that ten percent of thirteen-year-olds and fifty percent of sixteen-year-olds are sexually active in the U.S., the vaccine is ideally given before that age. Even for the girl who plans to remain a virgin until marriage, the vaccine is indicated: twenty percent of women who were virgins at marriage acquire HPV. It is estimated that up to 44 percent of women will be victims of date rape or other sexual assault.
Though parents can choose to opt out of mandatory vaccinations, here is some information to help make the choice that is right for your Daughter.
HPV – What is it?
Genital human papillomavirus (HPV) is the most common sexually transmitted infection in America. It is also the first virus shown to be necessary “present” for the development of cervical cancer. The CDC (Centers for Disease Control) reports that twenty million Americans currently have HPV, and over six million new cases occur each year. Eighty percent of sexually active individuals will contract the virus at some point in their lives. The highest infection rate is seen in girls under twenty-five years old, when the cervical lining is more delicate and easily infected by the virus.
HPV is acquired by any skin-to-skin contact in the genital area. It does not require intercourse for transmission and has been reported in both virgins and lesbians. Because condoms do not cover all areas of the genitals, they do not prevent infection with HPV. Infected skin usually appears normal -- less than five percent of HPV infected individuals have genital warts.
Another mode of transmission, although extremely rare, is from mother-to-child at birth. The genitals of the baby may develop warts. Alternatively, the virus may attack the respiratory tract, lining it with warts. More recently, HPV has been isolated in oral cancers, and oral sex may soon be shown to be another mode of transmission.
About one hundred strains of HPV exist. Some are associated with the common warts found on hands and feet - these do not infect the genitals or cause cancer. About thirty-five types of genital HPV exist. They are divided into “high-risk” (HR-HPV) and “low risk” (LR-HPV) categories based on their likelihood of causing cancer.
HR-HPV types are responsible for 99.7 percent of cervical cancer. Other cancers associated with them include penile, vulvar, vaginal, anal and, recently, also oral cancer. The most common types, 16 and 18, account for 70 percent of cervical cancer and precancerous changes. Over 25 percent of women infected with either of these strains will show precancerous changes on Pap smear within two and a half years. Twenty percent of women over 30 years old who are infected with HPV-16 develop severe dysplasia or cancer within ten years. The vaccine was, therefore, developed against these two most frequent high risk strains.
There is no cure for HPV. Thankfully, 75 percent of the time, the immune system of an infected individual will clear the virus from the body. This usually occurs within eight months, but may take two and a half years. For women with prolonged HPV infections, treatment is aimed keeping the effects of the virus in check.
While most women never even know they have been exposed to the virus, two manifestations of HPV infection may occur: genital warts or precancerous changes, most often seen in the cervix.
The most common medical problem resulting from HPV infection is an abnormal Pap smear test. Dr. George Papanicolauo developed the test to detect precancerous changes of the cervix before they progressed to cancer. Although he did not know it at the time, the changes the Pap smear identifies are caused by HPV.
Prior to the introduction of the Pap test, cervical cancer was the second most common cancer in women.
In taking a Pap smear, a physician gently swabs the cervix, which is the portion of the uterus that protrudes into the upper vagina. The specimen is then sent to a lab where they are read and a report is given to the patient’s doctor. At times, Pap smears are difficult to interpret.
Evaluations and treatment of the HPV related changes varies depending on the severity of the dysplasia, as well as patient history and age.
Moderate and severe dysplasia are considered high grade lesions because, although rare, they have more potential to progress to cancer.

Mild dysplasia (CIN I) -- changes consistent with HPV infection are found in one-third of the cervical lining. Considered a low grade lesion, it will progress to moderate or severe dysplasia less than 50 percent of the time. CIN I and ASCUS (atypical cells of undetermined significance) comprise the low grade changes seen on Pap smear.
Moderate dysplasia (CIN II) -- two thirds of the cervical lining shows changes associated with HPV.
Severe dysplasia (CIN III) -- the entire thickness of the cervical lining is affected by HPV. It is seen in seven percent of all HPV positive women. Only one in one thousand women will progress from CIN III to cancer.
Squamous Cell Carcinoma -- the HPV infection has become cancer. The changes seen have broken past the barrier between the cervical lining and inner tissues of the cervix.

Infection most likely is acquired in their twenties and failed to clear the virus. The progression to cancer takes about ten years, so these ladies are at risk and require treatment. Thus, positive HPV tests and abnormal Pap smears in women who are married do not indicate infidelity. These women may have been exposed to the virus years prior to meeting their husbands.

The Vaccine
Last year, the FDA approved the Gardasil vaccine for HPV. It is given in three parts, at 0, 2 and 6 months. The vaccine consists of certain HPV proteins, not the entire virus, so it cannot cause disease. Its safety profile is similar to the flu vaccine with inflammation at the injection site and fever being the most common side effects. Efficacy at four years is 100 percent.
Gardasil protects against HPV types 6, 11, 16, and 18, the ones most frequently causing condyloma, dysplasia and cancer. Because the vaccine only protects against the two most common high and low risk strains, vaccinated women will still need Pap and/or HPV testing. As with all vaccines, it is meant to prevent, not treat, its target. It may not have any effect on the natural course of an HPV infections acquired before the vaccine was given. Thus, virgins are ideal candidates for immunization.
Currently, the vaccine is recommended for females aged nine to twenty-six years: most girls will be exposed to at least one strain of HPV during that time. Initial studies show that somewhat better immunity is conferred when girls are immunized at a younger age. At present, it is “off-label” for women older than twenty-six years. However, research is ongoing as to how well the vaccine works on males and in women over twenty-six. One could make a case that a thirty-year-old woman whose husband is having an affair or is recently divorced could be a candidate for the vaccine. Most likely, the vaccine will be recommended for adolescent boys at some time in the future. While males less commonly develop significant problems with HPV, they do act as the vector in infecting women.
The real issue is whether or not we want to protect our daughters against a virus they are more likely than not to be exposed to, a virus whose treatment is painful, potentially disfiguring, and may cause problems in future pregnancies, a virus whose presence is emotionally disturbing and potentially lethal. A virus with no cure.

Mary E. Geldernick MD is an obstetrician-gynecologist practicing in New Braunfels since 1994. She did her specialty training at the University of Texas Health Sciences Center in San Antonio after she graduated from Texas Tech Health Sciences Center medical school. Her undergraduate alma mater is Northwestern University in Evanston, IL.