Ellen (name changed by request) was just 19 years old when she was rushed to the emergency room. The problem? Excruciating pain during sex. The diagnosis was human papillomavirus (HPV), which had created abnormalities in Ellen’s vagina, resulting in pain—and later a diagnosis of cancer. “I was young. I felt this awful fear,” Ellen tells HealthyWay. “Who would want to be with me? How do you tell someone that you are a carrier for an STD? I had a lot of guilt and disgust.” It’s true that HPV is a sexually transmitted infection or STI (a term that’s replaced the phrase sexually transmitted disease or STD in medical circles in recent years), and with it has come an unfortunate stigma for the women and men who are diagnosed. But while cancer and other complications from HPV are real, the truth is, being sexually active in America means your chances of coming in contact with HPV are sky high. It’s almost guaranteed that sexually active Americans will encounter this common STI at some time in their lives. Sounds like an exaggeration, right? One virus can’t possibly be so prevalent that nearly everyone will be exposed to it at one point or another. Guess again. The Centers for Disease Control and Prevention (CDC) has labeled HPV as the “most common sexually transmitted infection in the United States.” CDC literature even goes so far as to state that “HPV is so common that nearly all sexually active men and women get the virus at some point in their lives.” Every day, approximately 14,000 individuals ages 13 to 24 are infected with HPV, and every year, more than 30,000 cases of cancer are tied to human papillomavirus. With 40 distinct types, human papillomavirus isn’t just prevalent. This STI is also wildly contagious, which is why at any given time an estimated 42.5 percent of Americans in the 18 to 59 age range are walking around with a case of HPV. “Other than abstinence, there is no reliable way to prevent transmission,” says Steven Vasilev, MD, a gynecologic oncologist and medical director of integrative gynecologic oncology at John Wayne Cancer Institute at Providence Saint John’s Health Center in Santa Monica, California. He tells HealthyWay that “A condom will not help prevent transmission, because the virus can be present on multiple genital areas, not just the penis. Other than vaccination at an early age, before exposure to the virus, there is no reliable medical way to prevent spread.” For Ellen, HPV came with a sexual assault when she was just a tween. For hundreds of thousands more Americans, HPV can come at any time as a result of a sexual encounter, be it one that’s consensual or not. Because it’s so contagious, the risk is high. But with warnings that some types of HPV (although not all) can cause cancer and it’s nearly impossible to avoid, how worried should you be about HPV? And is there anything you can do to protect yourself or your family? We asked the experts to weigh in on the real deal with this STI.
What is HPV, anyway?
Short for human papillomavirus, HPV is a virus, just as its name would imply. That means it’s a microscopic organism that replicates inside the cells of a host organism. According to Amesh A. Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, human papillomavirus chooses mucosal surfaces as host and tends to live in or on the vagina, penis, anus, and/or mouth, which is where it spreads from person to person via sexual contact. That means HPV infection can be genital, anal, or oral, depending on the mode of sexual contact, Adalja says. In other words? Oral sex, anal sex, and any other form of genital-to-genital contact can spread HPV. So unlike with pregnancy, simply avoiding sex that puts a cisgender male’s penis in contact with that of a cisgender female will not keep someone safe. Even the use of condoms in those cases can still do little to prevent transmission, as HPV lives in the area around the vagina and anus, not just inside. Because there are 40 different types of HPV, what happens next depends on what kind you’ve contracted. Most types will cure themselves, passing through the body in six to 12 months without ever showing any symptoms, Vasilev says. But it’s not always that simple. “Sexual activity timing could be such that the infection is passed back and forth between a monogamous couple for a prolonged period of time,” Vasilev says. What’s more, certain types of HPV can cause complications—some as serious as cancer.
Most types of HPV are what’s termed “low risk” by doctors. That doesn’t mean it won’t cause problems in your life, but it does mean it’s unlikely to cause cancer. Low-risk HPV includes the types that cause warts or, as they’re known in medical circles, papillomas (hence the name), says Gerald J. Botko, DMD, a master of the Academy of General Dentistry and dentist chief of service at VA Miami Healthcare System. These warts typically crop up in the genitals and anus of men and women, although women may also have small cauliflower-type growths on the cervix and/or vagina, and oral warts are a possibility. The warts are usually painless but cause some irritation, itching, or burning, Botko continues. Low-risk genital HPV typically goes away on its own without treatment. “In oral HPV infections, the warts colonize in the back of the mouth (throat), including the tongue, base, and tonsils,” Botko explains. In those cases, contagious lesions found in the gingiva (gums) and palate typically have to be excised surgically for a cure, although sometimes oral HPV can go away on its own as well. Low-risk HPV can also cause wart-like lesions called condylomas. Again, these can be found on the genitals or in the mouth (the latter from oral–genital contact). Condylomas can cause disfigurement and are difficult to treat, Botko says. Although low-risk HPV types 6 and 11 cause 90 percent of genital warts, they are still termed low risk because they rarely cause cancer, Botko says.
About a dozen of the 40 types of HPV are considered high risk, but there are just a few that have been linked to cancer. Despite that bit of good news, it turns out that 79 percent of the cancers of the vaginal region, anal region, and mouth are caused by HPV. Researchers have tied most of those back to human papillomavirus types 16 and 18. According to the National Cancer Institute, the most common types are:
- Cervical cancer: Types 16 and 18 are responsible for about 70 percent of all cases of cervical cancer.
- Anal cancer: Approximately 95 percent of anal cancers are caused by HPV, most by type 16.
- Oropharyngeal cancers (which includes cancers of the middle part of the throat, including the soft palate, the base of the tongue, and the tonsils): Approximately 70 percent of oropharyngeal cancers are caused by HPV, more than half by type 16.
- Vaginal cancer: About 65 percent of cases are caused by HPV, most by type 16.
- Vulvar cancer: Approximately half of all vulvar cancers are linked to HPV, most caused by type 16.
- Penile cancer: More than a third of all penile cancers are caused by HPV, most by type 16.
Unfortunately, high-risk HPV tends to be silent, says Renée Volny Darko, DO, an OB-GYN and founder and CEO of Pre-med Strategies, Inc. That means there aren’t signs that scream “I have HPV,” such as pain or itching. Typically, the first sign of infection will be a precancerous lesion—or cancer itself.
Finding HPV Before It Turns to Cancer
Because HPV doesn’t have symptoms until it causes a disease such as genital warts or cancer, most people don’t show up in a doctor’s office complaining that they have an issue. Men can’t currently be tested for HPV, as no such test exists. With women, however, testing can be done at your annual exam to determine if you have HPV. Although it can’t be picked up via a regular Pap smear, Darko says HPV can be tested from the same sample collected for your Pap smear. Confused? “A Pap smear is looking at cells of the cervix under a microscope to determine if they are normal or abnormal,” Darko explains. “HPV can be hiding in cervical cells. Another test can be done on that same sample of cervical cells to determine if HPV is present in the cells.” If HPV types that are considered low or high risk are noted, your doctor will advise you on the next steps. For example, those tied to cancer may indicate you should have more frequent screenings to ensure that no such cancer has developed.
Preventing HPV Before It Starts
So nothing prevents HPV, right? Sticking to oral or anal sex, condoms—none of that will keep you safe? Yes and no. Some HPV cases simply can’t be avoided, save for complete abstinence, but Darko says, “HPV vaccine is the next best line of prevention against several types of HPV.” For children and women under the age of 26, there is now a trio of options out there to prevent the highest-risk forms of human papillomavirus. Gardasil and Cervarix have both been found to help prevent HPV type 16 and 18 infection. Gardasil 9, a more recent vaccine, prevents types 6, 11, 16, 18, 31, 33, 45, 52, and 58. The vaccine can be given up until age 26, even if you’ve already been sexually active. If you’re pregnant, it’s best to put off the vaccination, says Lara Millar, MD, a radiation oncologist with the Eastern Virginia Medical School, as there’s not enough research on the safety of the vaccine for pregnant women. If you’re afraid you may contract HPV in the meantime and put your baby at risk, Millar says transmission from mother to child can happen but is extremely uncommon. If at all possible, it’s recommended that you get the HPV vaccine well before pregnancy—and even before having sex. Darko advocates that parents in particular talk to their children’s pediatrician about it earlier rather than later, no matter how uncomfortable it is to think of their child one day encountering an STI. “The vaccine is most protective when it is given before the first sexual encounter. So it is recommended for males and females as early as age 11 years,” she says. Kids who get a dose of the vaccine typically only need one follow-up shot, whereas older women and men who opt for vaccination may require three doses to be fully vaccinated.
Is it worth it?
Consider this: Since the U.S. Food and Drug Administration’s approval of vaccination for human papillomavirus more than a decade ago, doctors have seen a reduction in infection rates. Six years after the vaccine’s approval, a study of infection rates for the four most common high-risk types of HPV showed a 64 percent decrease among females age 14 to 19 years and a 34 percent decrease among those age 20 to 24 years. It’s also worth using condoms and dental dams regardless of whether you’ve gotten the shot, Darko says. Although they are not 100 percent effective in preventing HPV, contraceptives like these can prevent other STIs (and pregnancy). And if the HPV infection is living inside the vagina or anus or on the penis (rather than outside on labial tissue or near the penis), that coverage may indeed make a difference. One final note of relief? Although the internet is rife with myths on how HPV is spread, the American Cancer Society assures women and men both that they cannot contract human papillomavirus via a dirty toilet seat, by swimming in a pool or hot tub, or by simply being unclean.