Myths and Facts

After being diagnosed, some people feel like they are the only person they know with HPV. It’s easy to understand why so many people hold this misunderstanding. After all, public awareness of the virus is extremely low. Most people who contact us with questions about HPV have never even heard of HPV until they were diagnosed.

Those struggling with this troubling condition or strange new diagnosis rarely discuss it with others, since it would seem unlikely that they would understand. And others–your second-best friend, your cousin, your coworker, your neighbor across the street–likewise feel constrained to keep silent about their HPV, thinking that you wouldn’t understand.

The net result is that very few people ever have the chance to place genital HPV in an accurate context, as the very common virus it really is. Current estimates are that 75-80% of all people will be infected with HPV at some point in their lives.

Among those ages 15-49, only one in four Americans has not had a genital HPV infection.

It’s true that most often genital HPV produces no symptoms or illness, and so a person who has been infected may never know about it. Experts estimate that at any given time, only about 1% of all sexually active Americans have visible genital warts. Far more women have abnormal Pap tests related to HPV infection, but in many cases health care providers do not explain the link between HPV and cervical infection, perpetuating the misunderstanding.

Even with up to 19 million Americans contracting a sexually transmitted infection (STI) each year, many people continue to believe that only “someone else”—for example, people who have multiple partners, sex outside of marriage, or a different lifestyle—are at risk.

It is true that a higher number of sexual partners over the course of a lifetime does correlate with a higher risk for STIs, including HPV. This is not because of any moral judgment concerning “casual” sex as compared with “committed” sex, but simply because the more sexual partners you have, the more likely you will have a partner who (knowingly or unknowingly) is carrying an STI.

However, STIs can be passed along as readily in a loving, long-term relationship as in a one-night stand. And HPV is the virus to prove it. At least one study of middle-class, middle-aged women, most of them married with children, found that 21% were infected with cervical HPV. In other studies, according to Nancy Kiviat, MD, a researcher at the University of Washington, about 80% of people who have had as few as four sexual partners have been infected with HPV.]

Some believe that HPV in a relationship is a sure sign of infidelity. This myth has been responsible for a great deal of anger, confusion, and heartache. It has led many people to tragically wrong conclusions because it fails to take into account one of the most mysterious aspects of genital HPV: its ability to lie latent.

The virus can remain in the body for weeks, years, or even a lifetime, giving no sign of its presence. Or a genital HPV infection may produce warts, lesions, or cervical abnormalities after a latent period of months or even years.

As mentioned above, most people who are infected with genital HPV never know it; their virus does not call attention to itself in any way. In most cases, a person is diagnosed with HPV only because some troubling symptom drove him or her to a health care professional, or some abnormality was revealed in the course of a routine exam.

But although careful examination can identify genital HPV infection, and laboratory tests may even narrow down the identification to a specific type among the two dozen or so that inhabit the genital tract, there is simply no way to find out how long a particular infection has been in place, or to trace it back to a particular partner.

In a monogamous relationship, therefore, just as in an affair or even in an interval of no sexual relationships at all, an HPV diagnosis means only that the person contracted an HPV infection at some point in his or her life.

First of all, an abnormal Pap test can be caused by factors other than the presence of a high-risk HPV type. When a Pap test comes back as “abnormal,” it means just that: Under the microscope, the appearance of a few cells in this sample differs in some way from the classic appearance of healthy, intact cervical cells. The difference could be due to local irritation, a non-HPV infection, a low-risk HPV type, or even a mistake in the preparation of the cell sample.

To help sort out the various possibilities, a woman with an abnormal Pap test is often asked to come back to the doctor’s office and have the test repeated. Most nonsignificant reasons for an abnormal result last only a short time, and so repeating the Pap test after a few months usually weeds these out. Even if the result is again abnormal, this rarely means that cancer is imminent. In an overwhelming majority of cases, a truly abnormal Pap test is due to pre-invasive disease, not invasive disease per se.

Follow-up tests such as colposcopy and biopsy can help evaluate the abnormality and remove any potentially malignant cells. If further treatment is recommended, the patient and her healthcare provider usually have several options to consider, and time in which to consider them.

What if a woman with a persistently abnormal Pap test does not receive treatment? This scenario is very unlikely in the developed countries, where the follow-up measures described above are standard practice. But even supposing that a woman went untreated after repeated abnormal Pap results, she still would have the odds on her side, because only one out of four cases of cervical lesions will progress to cancer if left on its own. And treatment is almost always successful in preventing cervical cancer if the abnormal cells are found in time.

But this very effective system of protection can work only when each woman takes responsibility for the first step herself, by having a Pap test at regular intervals. According to the National Cancer Institute, about half of women with newly diagnosed cervical cancer have never had a Pap test, and another 10% have not had a test in the past five years.

The idea that lesbians don’t need preventive screening is based on an overly simple view of how HPV can be transmitted. Certainly, penile-vaginal sex can pass the virus along from one partner to another, but HPV can be passed through other forms of skin-to-skin contact as well.

The most recent evidence for this comes from a study under way at the University of Washington, which has found a number of genital HPV infections among lesbian women–even in some women who had never had sex with a man. Genital HPV in lesbians has not yet been extensively studied, but researchers suspect the prevalence rates will be lower than among heterosexuals. Even so, the rates will not be low enough to rule out the risk of cervical cancer altogether, so a regularly scheduled Pap test is a smart health measure for gay and straight women alike.{/expand]

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Older women still need Pap testsUnfortunately, the myth that older women no longer need Pap tests is shared by many women and healthcare providers alike. Women who are past reproductive age may no longer visit a gynecologist, believing that they no longer need regular screening. In many cases, no other provider recognizes the need for continued Pap screening. Data from the 1992 National Health Interview Survey indicate that one-half of all women age 60 and older have not had a Pap test in the past three years.

The result can be deadly: One in four cases of cervical cancer, and 41% of deaths, occur in women age 65 and older. Continued Paps may be recommended because HPV can recur even after years of latency.

However, according the guidelines published by the American Cancer Society in 2002, women age 70 and older may discontinue screening if they have 3 or more normal Pap tests, and no abnormal tests in the last 10 years.

What’s best for you? Speak with your healthcare provider to see what is recommended, given your own medical history.

Based on our experience with other infections, having a partner get tested would seem like a good idea. However, thus far there is no diagnostic test that can accurately determine whether a man is carrying an HPV infection. And even if he does, there is no way to treat him for the virus.

According to recent guidelines drafted by the CDC, “examination of sex partners is not necessary” as follow-up to an abnormal Pap test. It’s certainly possible–even likely–that the partner is or has been infected with the virus, although highly unlikely that he will ever show any symptoms. Nor is it possible to determine whether he can spread HPV to a future partner.

However, if a woman has external genital warts, her partner may still consider scheduling a medical exam. It may be useful for a male partner to talk with a health care provider to gain more information. And of course, if a man starts to notice symptoms of his own, such as unexplained bumps or lesions in his genital area, he should get medical attention at once.

No one knows how many sleepless nights can be laid at the door of the myth the genital warts can lead to cervical cancer. The truth, however, is that the fleshy growths we call genital warts are almost always benign. In the vast majority of cases, they do not lead to cancer, turn into cancer, or predispose a person toward developing cancer.

According to Katherine Stone, MD, genital warts need not “raise a red flag with regard to cancer in anyone’s mind.” There are more than 100 types of human papillomavirus, and most are quite specific in the sites they can invade and the pathology they can cause. Those most strongly associated with cancer are HPV types 16, 18, 31, 45, and, to a lesser degree, half a dozen others. These are known as the “high-risk” types, not because they usually or frequently cause cancer—in fact, cervical cancer is a rare disease in the United States today, and penile cancer even more so—but because, in the infrequent event that cancer does develop, it can usually be traced back to one of these types. Even so, it bears repeating: most women with high-risk HPV on their cervix will not develop cervical cancer.

As for ordinary genital warts, says Doug Lowy, MD, chief of the Laboratory of Cellular Oncology at the National Cancer Institute, “These are caused by HPV types that are virtually never found in cancer.” These are the “low-risk” types, 6, 11, 42, 43, and 44. When not causing genital warts they may cause a transient abnormality in Pap test results, or most often produce no symptoms at all.

In practical terms, a man with genital warts is no more likely than any other sexually active man to transmit cancer-causing HPV types to a partner. Experts do recommend that a woman exposed to genital warts–or any other STI–have regular Pap tests. This is because she may have been exposed to high-risk HPV types during unprotected sexual activity. Regular Pap tests are also recommended for any sexually active woman, since HPV infection is very common. It is worth keeping in mind that both men and women may be infected with, and infectious for, high-risk HPV, regardless of whether or not they have genital warts.

Warts and dysplasia do recur (come back) in some cases, but by no means all. When they recur, they show varying persistence: Some people experience just one more episode, and others several. The good news for most people is that with time, the immune system seems to take charge of the virus, making recurrences less frequent and often eliminating them entirely within about two years.

The limiting factor here is the state of the immune system itself. According to Thomas Sedlacek, MD, adjunct professor of obstetrics and gynecology at Allegheny University, if an individual’s immune system is impaired–by the use of certain medications, by HIV infection, or by some temporary trauma such as excessive stress, serious illness, or surgery–it may be unable to prevent a recurrence. However, if the immune system is weakened only temporarily, most likely the recurrence will be short-lived.

The concern about life-long recurrences may be based on a misconception rather than a myth. It’s true that at present there is no known cure for genital human papillomavirus. As a virus, it will remain in the infected person’s cells for an indefinite time–most often in a latent state but occasionally producing symptoms or disease, as we have discussed elsewhere. Recent studies from the Albert Einstein College of Medicine and from the University of Washington suggest that HPV may eventually be cleared, or rooted out altogether, in most people with well-functioning immune systems. However, in at least some cases the virus apparently does remain in the body indefinitely, able to produce symptoms if the immune system weakens.

Despite the myth that a pregnant woman with genital warts is very likely to have a child with respiratory papillomatosis, the risk quite small, and has been associated with only two specific types of HPV: 6 and 11.

There is a possibility that, during childbirth, the baby may contract the human papillomavirus while passing through the mother’s HPV-infected birth canal. If a baby does contract HPV during birth, and if the infection persists, it may cause the child to develop lesions on the vocal cords that can interfere with breathing. This condition, known as respiratory papillomatosis, can be treated.

Delivery by cesarean section offers a baby some protection against HPV infection, but not a guarantee. Overall, the risk of respiratory papillomatosis for the baby is far smaller than the general risk of complications arising from a C-section. Pregnant women with genital warts should discuss the risks and options with their physician well before their due date and decide for themselves what they would like to do.

Used correctly, condoms are very effective against STIs such as gonorrhea and HIV that are spread through bodily fluids. However, they are likely to be less protective against STIs that spread through skin-to-skin contact, such as HPV and herpes. The reason is simply that condoms do not cover the entire genital area of either sex. They leave the vulva, anus, perineal area, base of the penis, and scrotum uncovered, and contact between these areas can transmit HPV.

That is not to say condoms are useless. In fact, studies have shown condom use can lower the risk of acquiring HPV infection and reduce the risk of HPV-related diseases, as well as help prevent other STs and unintended pregnancy. For these reasons, condoms should play an important part in any new or non-monogamous sexual relationship.