Taken from the March/April 2007 issue of the Women's Health Activist Newsletter.
In addition to its marketing campaign, Merck, Gardasil’s manufacturer, aggressively pushed for legislation to require mandatory vaccination of school-aged girls. In the wake of the resulting major public outcry, Merck abandoned this tactic, but its political faux pas further complicated the murky issues surrounding HPV’s link to cervical cancer. (See the March 2007 issue of the Women’s Health Activist for Adriane Fugh-Berman’s column on the campaign.)
The HPV discussion currently focuses largely on young, school-aged girls -- because Merck’s controversial push for mandatory vaccination in this population caused a general knee-jerk, parental freak-out. Many parents are probably uncomfortable with the HPV vaccine because it makes them think of their children one day having sex, which they almost certainly will (an issue they don’t have to consider with other childhood vaccinations!). Eventually, the dust will settle and public health authorities will promote a stronger, more cohesive and (I hope) less biased public message on the HPV vaccine. But, in the meantime, where does this leave women who are past the age of school vaccinations? Women over 18, like me, must decide whether to get vaccinated on our own.
Gardasil has been approved for use in females between the ages of 9 and 26, so there are many young adult women who will have to deal with pressure to get the vaccine. Doctors are allowed to prescribe a therapy for any purpose in any population after its approval by the Food and Drug Administration (FDA), so it’s possible that doctors will advise women over 26 to receive the vaccination. It is also possible that women over 26 may demand vaccination because, “Hey, it can’t hurt.” One’s level of sexual activity is, however, the important determinant in whether to get vaccinated. The HPV vaccine makes the most sense for women who have never had sex or had very few sex partners. Although Gardasil isn’t approved for use in men, men are most often the carriers who infect their female partners. If the vaccine is shown to be effective in men, then vaccinating males might be good for women, too. Currently, there are lots of questions about the choices that can be made to prevent cervical cancer -- questions that are unlikely to be answered in the politically charged climate.
I first heard about HPV several years ago while in college, where I learned that it is sexually transmitted, that people may not have symptoms when infected, and that it causes the majority of cervical cancers. At least 80 percent of women will have had an HPV infection by the time they are 50.1 At first, I was angry. You always hear about HIV, gonorrhea, syphilis, and herpes — so why hadn’t I heard about this virus before? Then I saw a television episode of "Law and Order: Special Victims’ Unit" in which a woman who had been sexually assaulted was diagnosed with HPV. The fictional detectives wanted to find the young woman quickly so that she could get treated for the infection immediately, since HPV can cause cancer. Although this was just a TV show, I wondered about this: was HPV an emergency? What treatment could the woman get? I thought there was no treatment for HPV!
I learned about treating HPV first-hand some time later. Over a year ago, a doctor nonchalantly informed me that I had genital warts caused by HPV, and that I could treat them with a cream or she could burn the warts off. It really bothered me that she acted like it was no big deal, and I was a bit taken aback because I worried that my chances of getting cervical cancer later in life had automatically increased with the HPV infection. My next emotional reaction was guilt that I had been sexually irresponsible. I wondered if I should tell my past partners that I had HPV. I worried about how long I had been infected. I felt really confused; was HPV something I should stay up nights worrying about, or was it as normal a part of women’s life as yeast infections?
It turns out that HPV is quite common — so common that a gynecologist told me women could think of it as normal flora. HPV infection often goes unrecognized because there may be no symptoms, but it can be diagnosed through an abnormal Pap test or from the presence of genital warts. The genital warts caused by certain types of HPV (including types 6 and 11) can be removed with gels, creams, cryotherapy (literally burning them off), or surgery, but there is no cure for HPV.2 Luckily, this is generally not a problem because the infection almost always goes away on its own: 90 percent of women with cervical HPV infection have no detectable virus within two years.1 Additionally, the types of HPV that cause genital warts are not the same types that can lead to cervical cancer. Therefore, HPV is only a cancer risk for women who have persistent infection with high-risk HPV, such as types 16 and 18.2
After I learned that HPV is very common, most people clear the virus, and that genital warts are not caused by the type of HPV associated with cervical cancer, I was no longer worried. Condom use dramatically reduces the risk for HPV infection, but it is not fully protective; HPV can be transmitted through skin that isn’t covered by a condom (such as the vulva, scrotum, or perianal region).2 Wow -- I wish I had known this before the doctor told me that I had HPV.
Considering all this, should sexually active young women run out and get the HPV vaccine? Maybe not. The vaccine is not very effective in those who have already been exposed to one of the types of HPV it targets.3 If you have never had sex (or had very few sex partners), you may benefit from the vaccine. If you have had multiple sex partners, you are unlikely to benefit from the vaccine because your level of sexual activity is a more important determinant than age for getting HPV. Also, HPV exposure usually occurs within the first few years after a person becomes sexually active – that’s why it’s recommended that women get the vaccine before having sex (or very soon thereafter). Nearly one-quarter of U.S. teens have had sex by age 15, and 70 percent have had sex by the time they are 18 – that’s why vaccination at a much younger age is the most effective public health intervention.3
A general sense of dread surrounds HPV and cervical cancer, and I think most women are relieved there is a vaccine. But I worry that the public is getting an oversimplified view of HPV and its relation to cervical cancer. From a public health perspective, it makes sense to vaccinate all girls before they’ve had sex. But for women who have had sex, the number of sexual partners—not age—should be the most important factor in the decision to get vaccinated. I fear that many women will be subjected to unnecessary vaccinations, or stop seeking regular cervical cancer screening. It is possible that confusion surrounding the vaccine could lead to a misuse of resources and could become a barrier to achieving the best possible health outcomes for women.
Cervical cancer screening through regular Pap tests is still crucial, especially since the currently available HPV vaccine does not protect against all types of high-risk HPV strains. The Pap test has truly been the first line of defense against developing cervical cancer and U.S. screening programs have greatly reduced deaths from cervical cancer in this country. The single most important factor associated with developing invasive cervical cancer is never (or rarely) getting screened.4 The American Cancer Society estimates that in 2007, 11,150 women will develop invasive cervical cancer in the U.S. and 3,670 would die.3 Even in the U.S., most of the women who die of cervical cancer never had regular Pap tests.1
The World Health Organization (WHO) estimates that there are 250,000 annual cervical cancer deaths worldwide, making it the second most common cause of female cancer deaths.5 The vast majority of these deaths are in countries where women do not have access to regular screening, and the HPV vaccine has amazing potential to save many lives in these countries. Despite the hype now surrounding HPV, regular Pap tests and condom use are still key to reducing risk for genital HPV infection and the HPV-associated problems of genital warts and cervical cancer — even if you do decide to get the HPV vaccine.
Alicia M. Bell, M.S. is Project Manager of PharmedOut at the Georgetown University School of Medicine Department of Physiology and Biophysics.
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1. Centers for Disease Control and Prevention (CDC). Genital HPV infection - CDC fact sheet. Available at http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed March 14, 2007.
2. CDC. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55(No. RR-11); 62-66 Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm.
3. American Cancer Society. ACS recommends HPV vaccine but cervical cancer screening still necessary. 2007 Jan 19. Available at http://www.cancer.org/docroot/NWS/newsletterarticles/NWS_1_1x_ACS_Recommends_HPV_Vaccine.asp.
4. CDC. Human papillomavirus; HPV information for clinicians. 2006 Nov. Available at http://www.cdc.gov/std/hpv/common-infection/CDC_HPV_ClinicianBro_LR.pdf.
5. World Heatlh Organization (WHO). Report of the consultation on human papillomavirus vaccines. WHO, Geneva. 2005 April. Recent estimate available at http://www.who.int/immunization/topics/hpv/en (accessed Mar 14, 2007), full report at http://www.who.int/vaccine_research/documents/816%20%20HPV%20meeting.pdf.