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Clinical Minute: Screening the Male Patient for HPV
Most dangerous of all, misinformation may lead people to neglect a very simple procedure that saves lives. One reality is that some aspects of the virus are still poorly understood, even by medical researchers. There simply are no proven answers to many common questions. At the same time, much new information about HPV has been learned in recent years, reversing some previous assumptions about the virus. The result is that older publications may be inaccurate, when they mention HPV at all. Likewise, healthcare professionals, writers, and educators who have not kept up with recent research findings may continue to spread misconceptions. Another difficulty is that to some degree, the overall topic of genital HPV is complex and confusing to everyone, lay person and scientist alike. Myths and Misconceptions Myth: I'm the only person I know with HPV. After all, public awareness of the virus is extremely low. Those struggling with this troubling condition or strange new diagnosis rarely discuss it with others, since it would seem unlikely that they would understand. The net result is that very few people ever have the chance to place genital HPV in an accurate context, as the very common virus it really is. According to an article published in in the American Journal of Medicine, about 74 percent of Americans—nearly three out of four—have been infected with genital HPV at some point in their lives. Among those ages , only one in four Americans has not had a genital HPV infection. Far more women have abnormal Pap tests related to HPV infection, but in many cases health care providers do not explain the link between HPV and cervical infection, perpetuating the misunderstanding. Only people who have casual sex get STIs. It is true that a higher number of sexual partners over the course of a lifetime does correlate with a higher risk for STIs, including HPV. However, STIs can be passed along as readily in a loving, long-term relationship as in a one-night stand. And HPV is the virus to prove it. An HPV diagnosis means someone has cheated. This myth has been responsible for a great deal of anger, confusion, and heartache. It has led many people to tragically wrong conclusions because it fails to take into account one of the most mysterious aspects of genital HPV: The virus can remain in the body for weeks, years, or even a lifetime, giving no sign of its presence. Or a genital HPV infection may produce warts, lesions, or cervical abnormalities after a latent period of months or even years. As mentioned above, most people who are infected with genital HPV never know it; their virus does not call attention to itself in any way. In most cases, a person is diagnosed with HPV only because some troubling symptom drove him or her to a health care professional, or some abnormality was revealed in the course of a routine exam. But although careful examination can identify genital HPV infection, and laboratory tests may even narrow down the identification to a specific type among the two dozen or so that inhabit the genital tract, there is simply no way to find out how long a particular infection has been in place, or to trace it back to a particular partner. In a monogamous relationship, therefore, just as in an affair or even in an interval of no sexual relationships at all, an HPV diagnosis means only that the person contracted an HPV infection at some point in his or her life. Genital warts lead to cervical cancer. No one knows how many sleepless nights can be laid at the door of this myth. The truth, however, is that the fleshy growths we call genital warts are almost always benign. In the vast majority of cases, they do not lead to cancer, turn into cancer, or predispose a person toward developing cancer. Those most strongly associated with cancer are HPV types 16, 18, 31, 45, and, to a lesser degree, half a dozen others. Even so, it bears repeating: When not causing genital warts they may cause a transient abnormality in Pap test results, or most often produce no symptoms at all. In practical terms, a man with genital warts is no more likely than any other sexually active man to transmit cancer-causing HPV types to a partner. Experts do recommend that a woman exposed to genital warts—or any other STI—have regular Pap tests. This is because she may have been exposed to high-risk HPV types during unprotected sexual activity. Regular Pap tests are also recommended for any sexually active woman, since HPV infection is very common. It is worth keeping in mind that both men and women may be infected with, and infectious for, high-risk HPV, regardless of whether or not they have genital warts. An abnormal Pap means cervical cancer. First of all, an abnormal Pap test can be caused by factors other than the presence of a high-risk HPV type. Under the microscope, the appearance of a few cells in this sample differs in some way from the classic appearance of healthy, intact cervical cells. The difference could be due to local irritation, a non-HPV infection, a low-risk HPV type, or even a mistake in the preparation of the cell sample. Most nonsignificant reasons for an abnormal result last only a short time, and so repeating the Pap test after a few months usually weeds these out. Even if the result is again abnormal, this rarely means that cancer is imminent. In an overwhelming majority of cases, a truly abnormal Pap test is due to pre-invasive disease, not invasive disease per se. Follow-up tests such as colposcopy and biopsy can help evaluate the abnormality and remove any potentially malignant cells. If further treatment is recommended, the patient and her healthcare provider usually have several options to consider, and time in which to consider them. What if a woman with a persistently abnormal Pap test does not receive treatment? This scenario is very unlikely in the developed countries, where the follow-up measures described above are standard practice. But even supposing that a woman went untreated after repeated abnormal Pap results, she still would have the odds on her side, because only one out of four cases of cervical lesions will progress to cancer if left on its own. And treatment is almost always successful in preventing cervical cancer if the abnormal cells are found in time. But this very effective system of protection can work only when each woman takes responsibility for the first step herself, by having a Pap test at regular intervals. Warts and dysplasia do recur come back in some cases, but by no means all. When they recur, they show varying persistence: Some people experience just one more episode, and others several. The good news for most people is that with time, the immune system seems to take charge of the virus, making recurrences less frequent and often eliminating them entirely within about two years. The limiting factor here is the state of the immune system itself. However, if the immune system is weakened only temporarily, most likely the recurrence will be short-lived. The concern about life-long recurrences may be based on a misconception rather than a myth. Recent studies from the Albert Einstein College of Medicine and from the University of Washington suggest that HPV may eventually be cleared, or rooted out altogether, in most people with well-functioning immune systems. However, in at least some cases the virus apparently does remain in the body indefinitely, able to produce symptoms if the immune system weakens. Older women don't need Pap tests. Unfortunately, this myth is shared by many women and healthcare providers alike. Women who are past reproductive age may no longer visit a gynecologist, believing that they no longer need regular Paps. In many cases, no other provider recognizes the need for continued Pap screening. Data from the National Health Interview Survey indicate that one-half of all women age 60 and older have not had a Pap test in the past three years. The result can be deadly: Continued Paps may be recommended because HPV can recur even after years of latency. However, according the guidelines published by the American Cancer Society in , women age 70 and older may discontinue screening if they have 3 or more normal Pap tests, and no abnormal tests in the last 10 years. Speak with your healthcare provider to see what is recommended, given your own medical history. Warts aren't contagious after treatment. Medical opinion is not settled on this point. When considering the infectiousness of treated or untreated warts, therefore, researchers must fall back on indirect observations and on reasoning from what they do know about this virus. But since the area surrounding any visible warts is also likely to contain infectious HPV particles, removing the warts cannot eliminate the risk. A person may have good reasons for wanting his or her genital warts removed—they may be uncomfortable physically or psychologically. But removing warts cannot guarantee that the risk of transmission is removed. Lesbians don't need regular Pap tests. This myth is based on an overly simple view of how HPV can be transmitted. Certainly, penile-vaginal sex can pass the virus along from one partner to another, but HPV can be passed through other forms of skin-to-skin contact as well. The most recent evidence for this comes from a study under way at the University of Washington, which has found a number of genital HPV infections among lesbian women—even in some women who had never had sex with a man. Genital HPV in lesbians has not yet been extensively studied, but researchers suspect the prevalence rates will be lower than among heterosexuals. Even so, the rates will not be low enough to rule out the risk of cervical cancer altogether, so a regularly scheduled Pap test is a smart health measure for gay and straight women alike. If a woman has an abnormal Pap, her male partner needs to be tested for HPV. Based on our experience with other infections, this would seem like a good idea. However, thus far there is no diagnostic test that can accurately determine whether a man is carrying an HPV infection. And even if he does, there is no way to treat him for the virus. Nor is it possible to determine whether he can spread HPV to a future partner. However, if a woman has external genital warts, her partner may still consider scheduling a medical exam. It may be useful for a male partner to talk with a health care provider to gain more information. And of course, if a man starts to notice symptoms of his own, such as unexplained bumps or lesions in his genital area, he should get medical attention at once. Unfortunately, this is not always the case. Used correctly, condoms are very effective against STIs such as gonorrhea and HIV that are spread through bodily fluids. However, they are likely to be less protective against STIs that spread through skin-to-skin contact, such as HPV and herpes. The reason is simply that condoms do not cover the entire genital area of either sex. They leave the vulva, anus, perineal area, base of the penis, and scrotum uncovered, and contact between these areas can transmit HPV. That is not to say condoms are useless. In fact, studies have shown condom use can lower the risk of acquiring HPV infection and reduce the risk of HPV-related diseases, as well as help prevent other STs and unintended pregnancy.
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