HPV Detected or Suspected: What Now?

As to this file/page, you have been directed to & are now @ Dr. Shaw's personal website

YOU JUST GOT YOUR DIAGNOSIS: On hearing that your Pap smear or HPV test is positive, you need to avoid any angry confrontations with your doctor! The ancient Greeks were known to kill the messenger who brought negative news. True, your doctor may be giving you some upsetting news; but, he/she did not cause your situation! Calm down! If you blew up at your doctor because of this news, send him/her a note of apology. He/she is there to HELP you!!

The Screening Test:

The tests done along with the Pap smear is so sensitive that it has a high "false positive" rate. You may actually not have HPV! The Qiagen digene test is one type of test. About false positive & false negative tests, HERE.

What is HPV?

This DNA virus tends to cause skin or mucous membrane (cervix and vagina, vulva, penis, anus or groin) growths which:

•  can either be seen with the naked eye (as with skin warts or "venereal" warts)
   
• or are present as much more microscopic (most of the cervix/vaginal cases) growths.
  

Some Pap Smear Report Terminology:

Because this virus is linked to over 90% of cases of cervix cancer or high-grade cervix pre-cancer (moderate or severe dysplasia), detection of cellular clues as to the infection is a goal in the technical screening process of Pap smears by cytotechnologists. But, keep in mind that the Pap smear "cytology" finding of HPV change is only 20-60% sensitive in the detection of HPV. When the Pap smear report contains one or more of the following wordings, the diagnosing pathologist is probably trying to convey suspicions about an HPV infection to your doctor: "perinuclear haloes", "wrinkled nuclei", "raisinoid nuclei", "koilocytes", "koilocytotic atypia", and "warty change" or "warty atypia".

HPV Types & Associations:

By molecular lab techniques, it has been shown that there are over 120³ (more than 200¹) varieties of HPV, about 85 having been now well characterized¹. HPV 1 causes plantar warts, & HPV 2 causes the common hand wart³. Over 30 types are genital types; some (16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 and 70)...maybe only 13 of these⁴...are more highly associated with cervical precancer and cancer ("bad"...high risk...oncogenic varieties). Others are less associated (6, 11, 42, 43, and 44). About half of women with cervical cancer are positive for HPV 16; HPV 18 is second most common cervical cancer-associated HPV and one strongly associated with endocervical adenocarcinoma, either AIS or invasive³. But, were you to be diagnosed from a Pap smear as "HPV positive," and further tested to show infection by a "bad" variety, it only means that your risk of future pre-cancer or cancer is increased (and significantly so³)...it does not guarantee that you have, or will get, pre-cancer or cancer in the future. So, there are mucosal (mucous membrane) types of HPV and skin types of HPV.

After the Diagnosis...What Now?

So, what now? Your safety comes from regular check-up or follow-up by your good doctor plus your use of safe sex practices. Knowing the exact HPV variety does not give a physician any real medical management advantage in your behalf. Aside from personal curiosity...or some dramatically unusual, rare circumstance..., there is no as-yet-widely-agreed-upon medical reason to pay physician and test fees which altogether might exceed $300-500 to get HPV tests for your exact HPV type. Screening "panels" (groups) are less expensive and are readily available with the liquid-based Pap smears. But, if strongly desired, our lab is more than willing to expertly cooperate with your treating doctor & obtain the specific tests.

THE NEW HPV TESTS

However, there is current interest in using ancillary virus testing...in addition to the Pap smear findings...by such as the CISH method.Pro or the Digene Hybrid Capture 2 (HC2) test results (methods compared). A fundamental truism of laboratory testing is that the test sample is most optimal when it is specifically and carefully collected for the HC2 test, keeping a particular goal in mind. But, your doctor can come very close (perfectly acceptably close) to this ideal with his/her routine of obtaining your Pap smear sample...keeping all goals in mind. The idea is to use HC2 results to help in "risk-stratification" of patients who have some type of cellular abnormality of their Pap smear short of the precancerous diagnosis. Using HC2 results AND all other case info (history of family tendency for cervix cancer, history of risky sex practices, estimates of patient reliability in follow-up co-operation [compliance reliability], financial situations, transportation situations, other factors which might favor tests or procedures, and what a given health plan might allow), doctors might be able to tell who (1) can be safely "followed" by regular Pap smears without further procedures and (2) who ought to be more quickly evaluated by regular random biopsies, colposcopy-directed biopsies, and/or by conization surgery after colposcopic biopsies.

You Are HPV Negative With the Pap Smear Associated HPV Test:

Women age 30 or older who have a Pap smear (deemed "adequate") plus HPV test and both are negative, retest is said to not be needed for 3 years⁴.

But, I was positive once & then negative & then positive again!

Persons infected (their test is positive) by HPV have been shown to be periodically molecular-test-negative and, later, again positive. This suggests cycles of either repeated re-infection (most likely) or waxing and waning of HPV infection above and below levels of test detectibilty (or possibly the presence of PCR-test inhibitors periodically in the patient samples). This is common in younger age groups...groups known to frequently "clear" themselves of the virus.

CISH or HC2 test: what if both "hi risk" and "low risk" HC2 tests are positive?

The vagina normally contains numerous types of bacteria in large numbers. When the HPV virus was passed to this patient, there may have been two types in the transfer inoculum; or one type was passed in one episode and another in another episode. It is not so unusual to see both HC2 screening panels positive.

HPV "positive" Pap or biopsy & HC 2 or CISH test negative:

Because the sampling techniques for Pap smears and cervical biopsies are less-than-total samplings, it is possible that (1) the HC2 specimen simply failed to contain HPV antigen (see above). Or, (2) the morphological changes may reflect one of the 60+ HPV serotypes not in the HC2 test screening battery. Lastly, (3) in our earnestness to detect this important infection, it is possible to over-diagnose the morphological changes in tissues and smears (the spectrum from normal cells to absolutely unequivocal HPV-altered cells is not defined sufficiently clearly so that even experts can replicate diagnoses with 100% accuracy when...the experts themselves...even checking the same case slides on different days or weeks). Cytology medical practice...as with all human efforts...is imperfect!

Person-to-person, "fomite", and STD  infectious spread

If you are positive for HPV, it is NOT 100% certain that you caught it by sexual contact (not 100% an STD)!! HPV has been detected in virgins and can be passed from (1) an infected mother to an infant during the birth process and (2) by way of any type of sexual contact. AND, though an ineffective method of transfer, (3) nonsexual "fomite transfer" [because HPVs are highly resistant to lethal effects of heat & drying¹] occurs, by such as:

• moist-towel sharing
  


• unclean-device (even seats of exer-cycles)
   
• unclean-underwear sharing
   
• nakedly trying on bathing suits in a store
   
• hot tub parties
  

The above represent so-called "fomite transfer" between venereal warts or infected genitals and a non-infected person's genitals (through water, sweat, or body moisture). By the 1990s and later, any woman who is genitally sexually active has most likely had HPV exposure. The most effective...most infectious...method of transfer is genital-to-genital in sex acts. So, HPV is considered to be the most widespread STD (sexually transmitted disease). Condoms are not a dependable protective against virus transfer, in general, and because foreplay touching is probably just as effective as sexual intercourse. After over 30 years as a professor of virology at MUSC, Charleston, SC (during which time he prepared autologous HPV vaccines from a person's own HPV genital warts in severe cases), John P. Manos, M. D. recently (5/2000) agreed with me about generalities of HPV fomite transfer. He notes that proving it is impossible, so far, because the virus can't be cultured. Moist-towel or other non-sexual transfer between mother-daughter, sister-sister, and roommate-roommate or other partners are very low-risk, ineffective, BUT POSSIBLE routes of transfer. In the late 1960s and at least up until maybe 1990, Dr. Manos used to take parts of surgically removed warts (as well as some bacteria from patients who had recurrent eyelid abscesses) & create concentrated antigen to be re-injected into the donor patient (we sent a few specimens to him over the years).

HPV is the "wart" virus

Be aware that this virus is the same (differing only by serotype number) as the one causing warts on the fingers, hands, and feet (and we know that these transfer by fomite transfer...especially in athletic locker-rooms). Even if you knew (via the above tests) your HPV variety, the variety could change if you engage in unsafe practices and acquire re-infection with other varieties of HPV or even other STDs.

Talking to your doctor about HPV

A Pap smear finding of HPV changes without precancerous cell changes (without "dysplasia") is still considered to be a low-grade precancerous situation (LGSIL). If a Pap smear contains clear-cut  findings of dysplasia, pathologists may or may not bother to comment upon the presence or absence of co-existing HPV changes, (1) because we generally presume HPV infection or effect as causing the dysplasia, (2) it frequently unexpectedly (your doctor's office schedule had no way to plan a proper allotment of discussion time) generates inordinately time-consuming and emotionally intense discussion between the patient and doctor which have very little to do with actual medical matters, and (3) presence or absence of HPV is not known to have any "hard and fast" bearing on the medical management of the patient with pre-cancer or cancer of the uterine cervix. Such discussions tend to be focused on unanswerable questions such as: (1) "how did I get this?" [note the above sexual implications] and (2) "Does this mean that my husband/boyfriend has been running around on me?" It is actually better for you to read a file like this web page file at home, get more info at your hospital or community library (if you want to), get more internet info if you want to, and THEN reschedule an appointment with your doctor if you REALLY feel the need for "how-did-I-get-this" discussions.

Pap smear or HPV test or both?

One of the long-time giants in the field of cytology (Pap smears being only one thing in that field), Leopold G. Koss, M. D., in his 4th edition text page 382, states, "The data summarized above clearly document that testing a large population for the presence of and typing of HPV virus, as advocated by some commercial interests, is counterproductive, particularly because this knowledge has no bearing on the treatment of lesions. The presence of the viral DNA in an asymptomatic, lesion-free person is meaningless, since there is no known treatment for this infection." And, page 383, "Cytologic abnormalities as observed in cervical smears [Pap smears] are still the most important factor in the detection and diagnosis of these lesions." Yet, the knowledge of at least the "hi risk HPV panel" status is now strongly thought by many to help in the management of patients with less-than-dysplasia cell changes such as ASCUS and AGUS.

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(posted 5 Oct., and 1st updated 16 Oct. 1999; 2nd update, 17 June; 3rd update 25 July 2000; 4th, 30 April 2001;
latest addition 17 August 2009; 20 March 2017)