My patient, an outgoing young woman, didn't consider herself promiscuous. She'd had only two sexual partners -- her current boyfriend and one in high school several years earlier. She and her partner had been monogamous for more than a year, she said, and they were eager to give up the inconvenience of their not-always-consistent use of condoms for a birth control pill.
I reminded her that she would no longer be as protected against sexually transmitted diseases as she had been with a condom. But feeling secure in her relationship, she was not too concerned about the potential risk. Neither she nor her partner had ever been diagnosed with an STD, and she didn't believe that her previous boyfriend had had an infection either.
After talking with her about her choices, I started her women's health physical, which included collecting tissue samples from her cervix to send for routine gonorrhea, chlamydia and Pap test screening. I discovered no obvious abnormalities during her examination, so, pending the laboratory test results, I wrote her a prescription for a popular low-dose estrogen-progesterone pill and asked her to return in a few weeks so we could see how well she tolerated the hormones and review the test results we both expected to be normal.
That follow-up discussion would last longer than either of us anticipated. Her tests for chlamydia and gonorrhea had proved to be negative, i.e., free of disease, but her Pap test had shown abnormalities consistent with another sexually transmitted disease -- the often silent but potentially lethal human papilloma virus. Further study of the test sample had identified the virus type as being a high-risk strain, which can cause precancerous tissue changes that could turn into cervical cancer if left untreated.
HPV infection is very common -- there are more than 100 strains of the virus, some of which cause the annoying but benign warts seen on the skin. Four strains, however, are of significant concern: Types 6 and 11, which cause genital and anal warts, and Types 16 and 18, which infect women's (and men's) genital organs and are considered to be the cause of 70% of cervical cancer.
The news of her HPV infection was deeply upsetting to my patient. Was there a chance she might already have the seeds of cervical cancer? And how -- and from whom -- was she infected? She'd been faithful in her relationships -- but had her boyfriends? Even worse, if she had been infected by her first partner, had she put her current boyfriend at risk too?
The medical adage regarding sexual partners was an unwelcome truth -- that when you have unprotected sex with someone, you are sleeping with everyone he or she has had unprotected sex with, and everyone that those people have had unprotected sex with, and so on. With HPV, even using condoms does not guarantee protection from infection. The virus can be spread from one partner to another via skin surfaces not covered by the condom.
The Centers for Disease Control and Prevention reports that at least 50% of people who are sexually active will be infected with HPV at some point in their lives. Each year in the United States, 6.2 million people, most in their teens and 20s, will get the virus. Many will never show signs of infection, and others' symptoms will resolve via their bodies' immune system function. But, according to the American Cancer Society, almost 10,000 women will be diagnosed with cervical cancer in 2006 and 3,700 women will die of the disease.
With the recent FDA approval of a new vaccine against these four dangerous strains of HPV, we now have the ability to lower those numbers dramatically by vaccinating women before they become infected with one or more of the strains.
In June, the Advisory Committee on Immunization Practices of the CDC recommended that the vaccine be administered to 11- and 12-year-old females and to females ages 13 to 26 who have not previously been vaccinated, and to 9- and 10-year-old females at the discretion of their doctors. No women's exam or Pap smear is necessary before getting the injections.
Some parents fear that administering the vaccine will encourage girls to become sexually active at younger ages or before marriage.
But fear of catching HPV has not to date been shown to discourage teens from choosing to be sexually active, and concerns that the HPV vaccine will promote adolescent sexual activity have been proven unfounded by research.
Even those who opt to "wait until marriage" could benefit from the vaccine's protection. A spouse's previous -- or ongoing -- sexual activities could put their marriage partner at risk of a sexually transmitted infection such as HPV and of future cervical cancer.
My patient was fortunate that her diagnostic evaluation had identified the high-risk HPV strain before cervical cancer had developed. I referred her to a gynecologist for a colposcopy (a microscopic examination of the cervix and surrounding tissues). Microscopic examination and biopsy identified precancerous tissue that was then fully removed by her gynecologist with a minor surgical procedure.
After treatment, her Pap smears returned to normal, and her follow-up evaluations have been free of abnormalities. Her risk of cervical cancer in the future has been greatly reduced.
We did not have a quick "cure" for the worry and distress she suffered -- an ordeal that could have been prevented if the HPV vaccine had been available. Fortunately, she will now be able to get the HPV vaccine to protect her from infection with the other high-risk strains -- and avoid a repeat of the trauma she recently experienced in the years to come. Although it's best to get the vaccine before becoming sexually active, the vaccine can still protect women infected with one strain of HPV from infection with other high-risk strains.
Trials have shown the HPV vaccine to be a safe and wise investment for all young women who are or will be sexually active. The $360 cost, which may be partially or fully covered by health insurance, may seem expensive, but the benefits in health and peace of mind are priceless.
Dr. Yolanda "Linda" Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.