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Home: The Toast

This is the first in a three-part series.

Name: Human papilloma virus, HPV

Science Facts:

Prevalence: Verbatim, from the CDC: “Human papillomavirus (pap-ah-LO-mah-VYE-rus) (HPV) is the most common sexually transmitted virus in the United States. Almost every sexually active person will acquire HPV at some point in their lives.”

Symptoms: usually none.

What’s The Worst Case Scenario?: Cervical cancer.

Yes, I said cancer. Hang on a second and let’s talk about cancer!

HPV is a virus that can invade your cervix epithelium. Your cervix is a special type of place, speaking science-wise, because the tissue there changes from the type of tissue that’s in your vagina (squamous epithelium) to the type that’s in your uterus (columnar). Any area in the body where two different types of cells come together is more vulnerable, because they’re already not really sure what’s going on. “What type of cell am I supposed to be? Is this uterus or vagina?” is the normal state of cells in your cervix. Now imagine that same identity-crisis cell infected with a virus.

The reason we do pap smears every three years, and used to do them annually, is that the cervix goes through a predictable series of changes before you have all-out cancer. You can get ASCUS, which is atypical squamous cells of undetermined significance, which means these are cervical cells that are extra-confused, probably because they have HPV in them. ASCUS can progress to LSIL, which stands for low-grade squamous intraepithelial lesion, which means these cells are really confused and starting to act funky about it. LSIL can progress to HSIL, high-grade squamous intraepithelial lesion, which is where we start to get worried. Only after HSIL progresses outside of its local site do we call it carcinoma-in-situ, a type of cancer. We can treat all of these at every stage if your gynecologist catches it!

Hey, something less scary than cancer but still scary: genital warts. Many strains of HPV cause genital warts. In fact, if you’re a cis dude, since you don’t have a cervix, that’s probably the only reason you care about HPV. Also, HPV causes regular, non-genital warts. We freeze ‘em or burn ‘em off and that’s usually that. Cool.

What’s the Treatment For Cervical HPV?

Dear Every Single Cervix-Owning Person Reading This: Get Your Pap Smear. Do not skip annual gynecologist visits. Even though we don’t do pap smears every year, the best way to keep yourself safe is to be honest with your doctor about your sexual behaviors. We’re not here to judge—I promise doctors have heard a lot weirder stories. We’re just here to let you know about any risks you have and do what we need to make sure you’re healthy.

Management of cervical changes with HPV can be complicated, which is why I have a special app on my phone that tells me what to do with your pap results, and why the American Society for Colposcopy and Cervical Pathology has a complicated set of guidelines. In short, we can watch & see if you clear it (many people do! See “Nicole, Please Reassure Me”, below) with a repeat pap in a year, we can look at the cervix with a special camera (colposcopy), and we can take out part of the cervix that has the weird changes, with either a little loop of heated wire (LEEP), cryotherapy (old-school, still works), or conization (removing a little cone of the infected cervix, a more extensive procedure). 

“But Nicole, I Got Gardasil! I Got Vaccinated Against HPV!” AND I AM PROUD OF YOU AND YOU DID THE RIGHT THING. However, much like there are many different types of milk in the world (chocolate, soy, almond, etc), there are many types of HPV, called different viral strains, each with slightly different DNA makeup. Unfortunately, the Gardasil you got (if you got it more than one year ago) only covered four strains of HPV (strains 16, 18, 6, and 11, if you wanna know). Strains 16 and 18 cause the majority of cervical cancer (70% and 20%, respectively, for the two strains), while the other two strains (6 and 11) cause warts. We now have vaccines that cover nine strains of HPV, and vaccines that cover even more are in the works. But there are a lot of strains of HPV out there, and our vaccines don’t work against all of them. You can still get infected by HPV even if you’ve gotten the vaccine. However, if you contract HPV and you haven’t received the vaccine, you can still get vaccinated for exactly the same reason! In fact, studies have shown that infection with multiple subtypes of HPV simultaneously puts you at much higher risk for developing cervical dysplasia, the precursor to cervical cancer.

Use condoms! Here is some good and bad news: condoms are only 70% effective at preventing HPV transmission, because it’s shared via skin-to-skin contact. That means anything that isn’t covered by the condom isn’t protected.

Nicole, Please Reassure Me, I Feel Horrible: okay okay okay okay! I know I said the big C-word and I’m so sorry. I know I used a lot of caps and bold up there, and it was very upsetting, and I am so sorry. I feel very strongly about HPV because WE CAN DO THINGS ABOUT IT! The first thing I will tell you is that HPV is INCREDIBLY common. In case you want me to say it again, ALL sexually active people will come into contact with HPV. That’s according to the Center for Disease Control, I am not making this up. Basically, you have HPV. Also, have you ever had warts anywhere on your skin ever? That’s also HPV. This isn’t really even a bug where you can call your recent partners & be like “YO, HPV, GET ON THAT” because HPV can take a while to show up; it can take years from infection to progression of symptoms, so partner-blaming “you gave me this STD” is not so clear-cut with HPV. You should definitely still tell your partners, though, I am not giving you a free pass here.

That being said, here is the most reassuring fact I can tell you: Studies have shown that more than 90% of new HPV infections, including those with high-risk types, clear or become undetectable within two years, and clearance usually occurs in the first 6 months after infection.

This is why our first-line management is just watchful waiting, even if you have cervical changes that could be due to HPV. 90% of the time, the immune system clears HPV on its own. This is true even for genital warts—most warts will spontaneously regress in six months as your immune system clears the virus. Why would it be harder to clear HPV? Since it’s the most common sexually transmitted virus, it’s very easy to become coinfected with multiple strains of HPV (why you should get vaccinated even if you’ve received a diagnosis of HPV). It’s so common that we don’t even test for most types of HPV, because then everyone would be positive—our HPV testing only detects high-risk subtypes that cause cervical cancer. In short: everyone has it, 90+% of people get rid of it on their own, and even if you don’t we have very good treatments for it.

If you want to buy a stuffed HPV toy, you can do so here.

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Nicole Nolan is in medical school. Someday she will be a gynecologist, and then her entire job will be NSFW.

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