We commend Dr. David C.
Sopher for his willingness to state some very important facts regarding Human
Papillomavirus infection. He accurately
articulated that HPV is common, highly contagious, and spread through
skin-to-skin contact as well as through sexual contact. He also acknowledges that “an estimated 20 million
people, including about one-third of all sexually active teenagers, have
HPV.” More specifically, we commend him
for stating that “if you have more than three or four sexual partners, it’s
virtually impossible to avoid getting infected.” Dr. Sopher also states that individuals can still be contagious
even when warts are not visible. All
this information is important and accurate.
However, we were disappointed
that Dr. Sopher chose to make light of the potential clinical risks associated
with HPV infection, especially for adolescents. He states the warts are “generally…nothing more than a nuisance”,
and that the “biggest toll HPV takes is probably psychological.” He does acknowledge that, “in rare cases,
these strains can cause cancer of the cervix, vulva or vagina.”
Unfortunately for our
adolescents today, that is not the entire truth. We do know that over 90% of all cervical cancers are associated
with HPV infections, and the rates of cervical cancers in women younger than 50
years of age are increasing dramatically.
We also know that cancerous lesions of the cervix take at least 10 to 15
years to develop. Since there are over
80 to 100 strains of HPV, each with a different virulence and cancer causing
capability, the natural history of the virus is difficult to study. One longitudinal study of adolescents did
demonstrate that 90% of low risk type HPV infections were spontaneously
eradicated over a 30 month period of time, while only 70% of high-risk type HPV
infections were eradicated. However,
for those teens who have persistent infection, there is a 14 fold increased
risk for development of precancerous cervical lesions.
At this point in time, it is
not known which factors contribute to persistence of HPV infection – BUT we do
know that adolescents are at increased risk because of the cellular changes
which are taking place on the cervix during puberty.
1.
La Vecchia, et al,
showed that young age at first intercourse was “strongly associated with a risk
for invasive cancer.” Women who reported
having had their first intercourse before age 18 years were at a five-fold
increased risk as compared with women who waited until after age 22 years. (Cancer 1986; 58: 935-941)
2.
Wright ad Roipelle
demonstrated that for girls who had their first intercourse between 10 and 14
years of age, the mean age for developing HSIL (high grade squamous
intra-epithelial lesions) was 25 years.
In comparison, women who began sexual involvement after age 20
years did not develop HSIL until a mean age of 37 years. (Am J Obstet Gynecology 1984; 149: 824-830)
3.
In the study by
Andersson-Ellstrom, et al, NONE of the sexually inexperienced girls was found
to be seropositive for HPV infection.
(Sexually Transmitted Diseases 1996; 23: 234—238)
HPV infection has also been
associated with development of cancers of the vagina, vulva, anus, and male
urethra and penis. Young men are less
likely to have symptoms and are therefore more likely to transmit the virus
without realizing it. Most physicians
do not routinely screen partners of infected women, making the identification
of the HPV infected male even less likely.
Unfortunately, HPV has been associated with the much later development
of cancer of the penis.
In a rare instance, an HPV infected mother can transmit the
virus to her infant. The HPV virus in
the infant may cause laryngeal papillomatosis, a disorder in which polyps
develop on the vocal cords. This causes
severe respiratory distress in the infant and must be treated by repeated
surgical excision or laser therapy.
To summarize, HPV infection
is a serious public health concern because the virus is:
1.
highly contagious, being
transmitted through close skin-to-skin contact as well as sexual intercourse
2.
prevalent in our
society, and present in most individuals who have had 3-4 sexual partners
3.
caused by numerous
strains, the most serious of which do not cause symptoms (Only 1-2% of strains
cause genital warts, the remainder of infected individuals have no symptoms.)
4.
difficult to diagnose in
the asymptomatic female as there is not one easy and accurate test to check for
HPV infection
5.
difficult to diagnose in
the asymptomatic male who is most likely to transmit the infection – but for whom there is no
treatment
6.
the cause of over 90% of
cervical cancers – the rates of which are increasing, especially in women less
than 50 years of age
7.
implicated in the
development of cancers of the vagina, vulva, anus, and male urethra and penis
8.
most often diagnosed in
women by cellular changes in the Pap smear which is usually done just once a
year (Adolescents again are at an increased risk since sexually active female
teens do not always have annual Pap smears.)
9.
often undiagnosed on Pap
smear – with some studies demonstrating a 20–40% false negative rate
10.
variable in its
infectivity, with some studies demonstrating 70–90% of women becoming infection
free after 1–2 years
11.
persistent in some
women, causing cellular changes on the cervix which represent precancerous
lesions
12.
a more serious infection
in adolescent females who are more likely to have a persistent infection, with
a subsequently higher rate of precancerous and cancerous lesions
13.
often a cause of latent
disease – with clinical disease not being evident for 10–15 years after initial
infection
14.
rarely able to infect a
newborn infant
15.
not currently monitored
by the Centers for Disease Control and Prevention
16.
preventable – through
sexual abstinence
In addition, the treatment of
genital warts is often not as simple and easy as Dr. Sopher makes it
sound. Topical medications such as Podofilox
and Imiquimod must be applied repeatedly.
Podophyllin must be used weekly for up to six weeks, while Podofilox is
used twice daily for three consecutive days, and then repeated weekly for up to
4 weeks. Both topical treatments have a
cure rate of approximately 40% with a recurrence rate of 20-30%. In addition, patients often experience
adverse reactions of burning and itching.
Other treatments, such as Trichloroacetic acid (TCA) and cryotherapy can
cause ulcerations and erosions, as well as burning and pain. Many of the more expensive treatments, such
as laser therapy, may not be available to the patient or may not be covered by
the patient’s insurance.
The treatment of HPV when the
cervix is infected may require only local topical treatment, or may require
surgical excision of the affected area.
This “conization: of the cervix may cause later difficulty with carrying
a pregnancy to term.
These are all serious health
concerns, which should be presented honestly and accurately when giving medical
information to adolescents.
Given the high rates of
infection in our population, the highly contagious aspects of the HPV
infection, the inability for condoms to protect from this infection, and the
increased risk of cervical cancer associated with some forms of HPV infection,
it seems medically prudent to advise adolescents to delay sexual activity until
they are married in a monogamous relationship.
They will thus be able to live their lives free from the above concerns.
Sincerely,
R. Bob Mullins, MD
Family Medicine, Valley,
Alabama
The National Physicians
Center for Family Resources
Hal Wallis, MD
Obstetrics-Gynecology,
Dallas, Texas
Consortium of State
Physicians Resource Councils
Jane E. Anderson, MD
Pediatrics, San Francisco,
California
California Physicians
Resource Council
Glen C. Griffin, MD
Pediatrics, Mapleton, Utah
President, American Family
League
The National Physicians Center for Family Resources is a
501 (c ) (3) organization established to produce and promote family-friendly
educational resources, public policy and model legislation with the assistance
of a national network of physicians as project advisors.