Howard Kraft, M.D.

Cancer of the cervix is the most preventable female cancer. The Human Papilloma Virus [HPV] is a sexually transmitted virus that significantly increases the risk of cancer of the cervix. The October 2011 issue of National Geographic Magazine reports that cervical cancer is most lethal in countries where the human papilloma virus is common and cervical cancer screening is rare, principally in Africa and Southeast Asia.

As the USA has the resources to provide women with routine screening for this disease, all women who meet criteria should regularly obtain a gynecologic exam and pap smear [a sampling of the cells of cervix which is the “mouth” of the uterus (womb) with a small brush, swab or spatula].  A Pap smear tests for pre-cancer and cancer of the cervix.

Development of the Pap smear and HPV testing

Dr. George Papanicolau, a Greek immigrant physician with an interest in zoology, evaluated genital tract cells in guinea pigs and thereafter in adult women. He developed the pap smear test as a means by which cervical cancer could be detected in the 1940’s. He lived in Douglaston, Queens, New York, and was a member of the Cornell University Medical School in New York City. Pap smear cells are analyzed at a laboratory by a cytologist [a person who is an expert at studying cells].

Years later others discovered that DNA testing for high-risk Human Papilloma Virus [HPV] may be performed simultaneously with the pap smear. There are high and low risk types of HPV. Each may be transferred to a sexual partner with intercourse or even by mere external genital skin-to-skin contact.

Risk Factors for Cervical Cancer

The presence of Human Papilloma Virus [HPV].

These factors increase the chance of getting HPV:

     – Early age at first intercourse.

     – If persons or their partners have sex with multiple partners.

Cigarette smoking.

Having a weakened immune system such as having HIV (the virus that causes AIDS). This creates difficulty in fighting off health problems.

Lack of regular pap tests.

Personal exposure to Diethystilbesterol [DES] before your own birth; that is, when you were a fetus in your mother. This estrogen was prescribed until 1971 to prevent pregnancy complications.

Pap Smear Screening

The American Cancer Society (ACS) advises that pap smear screening should start about three years after the onset of sexual intercourse or no later than age 21.

Author’s comment: Despite the above ACS recommendation, one should begin visits to the doctor before the onset of sexual activity, for HPV vaccinations, and contraception and sexually transmitted disease (STD) counseling.

Newer recommendations specify that a pap test might not be necessary every year, but rather every few years, as long as one has had normal pap test results in the recent past.  The presence of high-risk HPV may influence the advised frequency of pap testing.

It is felt that pap tests may not be necessary when one is over age 65 or if one has had one’s uterus removed for benign disease reasons. Each person must discuss the frequency with which pap smears should be obtained with their doctor.

Symptoms of Cervix Cancer Most persons with these symptoms do not have cervix cancer, but should be evaluated by a gynecologist: Bleeding in between menstrual periods, heavy or prolonged menstrual periods, bleeding in menopause. Also: Excess vaginal discharge and pain or bleeding during intercourse. Most cervix pre-cancers have no symptoms.

High-risk Human Papilloma Virus

The presence of the high-risk HPV increases the chance of abnormal cervix cells, which can lead to cervix cancer. Most sexually active women will have HPV infection during their lifetime. Most persons who harbor high-risk HPV do not develop cervix cancer. HPV often disappears after a few years, provided a person is not exposed to it again and provided the person has no immunologic deficiencies.  There is currently no known treatment for the high-risk HPV.  The high-risk type of HPV produces no early visible signs of its existence and therefore the male carriers of high risk HPV do not know that they have or that they can transmit this disease. Females will know that they have and can transmit the disease only if they have been tested for it.

Low-risk Human Papilloma Virus

Causes genital warts in men and women. Warts may be treated by a gynecologist or dermatologist depending upon their location.

Plays little to no role in cervical cancer prevention.

Has less of a propensity to result in cervical cell abnormalities compared to the high risk HPV.

Human Papilloma Virus Prevention

Condoms may serve a role in spread of HPV but they do not always perform a very good job in doing so because they do not cover all areas of HPV skin infection. Condoms are greatly effective in prevention of other sexually transmitted diseases such as HIV, gonorrhea and Chlamydia compared to their prevention of HPV.

The best preventative for acquisition of HPV is abstinence or to minimize the number of partners in one’s lifetime. Each partner may have different kinds of HPV, each of which may have varied propensities to act as carcinogens [factors that increase the chance of cancer]. Candidates for the HPV vaccine should strongly consider undergoing the vaccine series.

Human Papilloma Virus Vaccination

HPV vaccine became available in 2006 for women between age 9 and 26. It is recommended that women in this age zone be vaccinated. The vaccine is most effective if given prior to the onset of any sexual activity, and therefore the American Academy of Pediatrics recommends vaccination between age 11 and 12. Pediatric and OBGYN physicians administer the vaccine.  

The vaccine serves to prevent HPV infection, not to treat it. The vaccine should be administered even after a woman is sexually active and/or if she already has HPV because it will assist in protecting against acquisition of any other kinds of HPV that she does not have.

The vaccine does not negate the need to have pap smears and to use condoms to prevent acquiring STDs [sexually transmitted diseases]. One of the two currently available brands of vaccine protects against the two most concerning of the many types of high risk HPV and two of the most concerning low risk HPVs. The same brand of HPV vaccine was FDA approved in late 2009 for males age 9-26.   

It is important for persons who are at risk to acquire any sexually transmitted diseases other than or in addition to HPV and be tested and treated for such diseases because the HPV vaccine will only protect against HPV. Examples: One can also be tested for the Human Immunodeficiency Virus (HIV), syphilis, gonorrhea, chlamydia, and sexually transmitted hepatitis.

Persons vaccinated for HPV starting in 2006 are currently maintaining a very high level of HPV immunity. The vaccine contains virus-like substances, not live virus or live weakened virus, and therefore, one cannot acquire HPV from the vaccine. The vaccines will protect only against acquisition of any of the kinds of HPV for which each has been designed; that is, the vaccines will not protect against all kinds of HPV.

The effectiveness of the vaccines decreases with the older the age of the person to whom it is administered as well as with an increasing number of sexual partners. Vaccine side effects should be discussed with the doctor.

To maximize its effectiveness, the most commonly used brand of vaccine requires three doses administered over the course of six months. If a person has delayed receiving all three doses of the vaccine on time, the person may resume and finish the series at any time.

Administration of the vaccine to persons younger than 18 years of age requires parental consent. College health services are usually able to continue the vaccine series begun at the person’s Pediatric or OBGYN doctor.

Additional Cervix Cancer, HPV and Pap Smear Facts

Although there is currently no known treatment for HPV, moderate to severe precancerous changes of the cervix can be treated to reduce the chance of development of cervix cancer.

The appearance of cervical cancer is rarely sudden; that is, it usually is preceded by various forms of pre-cancer of the cervix.  

Most persons with pre-cancer of the cervix do not develop cervix cancer.

Pap smears are a screening method only for cervix cancer, not for other cancers. Only very infrequently might a pap smear indicate the possibility of another female genital cancer.

HPV can remain hidden [not be detectable] for many years after contact with a positive partner.

Persons often immunologically “fight off” HPV with the passage of time as long as they are not re-exposed to HPV from their partner(s).

Each male and female may have different subtypes (varieties) of the high-risk HPV.

If a male states that he has been tested “for all the STDs,” he likely has not been tested for high risk HPV because there is no commercially available test for this at the time of this writing.

Heterosexual and homosexual transmission of HPV easily occurs.

HPV may cause cancers of the vagina, vulva, penis and perianal and anal skin.

There is currently no available blood test for HPV.

Methods for Further Evaluation

When the degree of pap cell abnormality and/or the presence or absence of high-risk HPV are collectively considered, some women may need to undergo a very common in-office procedure known as “colposcopy.”  At colposcopy the physician views the cervix with a floor-standing microscope (which remains outside the body) and obtains cervix biopsies or other biopsies of any areas that have concerning appearances.  

These cervix tissue biopsies are analyzed at a laboratory by a pathologist [a doctor who studies the various tissues from the body].

Based upon the results of the colposcopy biopsies, a person may simply be required to follow up with additional pap smears with or without HPV testing and with or without colposcopies, or may require more extensive surgical procedures. These procedures include a LEEP [Loop Electrosurgical Excision Procedure], a Cervical Conization, cryosurgery or laser surgery, all of which require a more detailed discussion than space permits here. The need for hysterectomy [surgical removal of the uterus] is infrequent.