Ask an Expert: Abnormal pap & HPV

Women's Health

Abnormal pap & HPV
07/23/2007

Question:

I am 43 years old and just had my first abnormal Pap ever and am religious about annual screening. Results came back LSIL and HPV positive. I have been unfaithful outside my marriage - one partner, also married, assumed we were in an exclusive situation - for 2.5 years. This is the first time anything abnormal has come up on a Pap.
Had colposcopy procedure and am awaiting results. Dr. found only one small lesion on the cervix, which she commented was fairly unremarkable. No warts were detected.
I am an emotional wreck and sick over what I consider to be a horrendously bad decision I have made in my life. If any good has come from this, it has put me back on track with the 18 year marriage I have. Stupid move on my part...
While waiting for the biopsy results, I`m reading all the shameful and scary information on the internet about HPV. So, I have a few questions:
1. If this has just shown up on my Pap now, is it likely that my partner (for the sake of argument, let`s assume this is the partner that`s not my husband, because I`m fairly certain my husband did not introduce this to us)contracted it recently? I ask this because we have been sexually active 2.5 years and I have had 2 normal Pap test since we started. Would this not have shown up on a Pap test earlier if I was infected early in the 2.5 year relationship? 2. What is the relevance of me being 43 years old and this just showing up? I read all kinds of information about over 30 women - if I have just been exposed and am just now positive, is there any way to tell when I was exposed (even a rough time range). And, does my age have any bearing on whether or not this virus will be "transient" or "persistent"? I read with some optimism the fact that a large percentage of people get this and "clear" it. Obviously, I didn`t before my Pap was done. Is this just timing? How can I know? 3. Since I suspect I have been infected recently (may be wrong) and already have a small LSIL, is there any significance to that? 4. What are the chances a woman my age will "clear" the infection? I know it never goes away, but I`m referring to references to it spontaneously resolving itself. If I have multiple "strains" of the virus (I think I saw that on the lab report - honestly, I was so shaken, it was hard to focus in the Dr. office), do some clear and others not? 5. Is it essential that I tell my husband this immediately? If I have decided that what caused this was a gross error in judgment and intend to never stray again and be with this individual ongoing, is it better for me to wait to see if any symptoms present? The reason I ask this is that children are involved and if there is a chance symptoms will not present themselves with him (or only a small chance), the pain this news would cause numerous people might be best deferred until the time it needs to be dealt with. I would certainly not want to do this at the expense of getting appropriate medical treatment, though. (But, I understand in males, this treatment is given if and when warts appear.) 6. Given that my partner ouside the marriage is married, what is the liklihood that he knows he is infected - assuming his wife is getting routine gynological care? I know this is a judgment call and you may not be able to answer it. Obviously, the discussion I intend to have surrounds his knowledge of if he was placing me at risk.
I have lots of questions, as you can see. I`m sure I haven`t asked them all and would welcome you opining on anything else you can help with. All the literature that tries to take the shame out of this being a "common" STD is not helping... I`ve been married for 18 years and had 20 years of clear Pap tests. No one can convince me that my bad recent behavior is not the cause of this. All the commentary on this being able to lay latent in people for months, years, decades, whatever, is not the case with me, I`m certain. Now, I`m just trying to clean up my mess without unnecessarily hurting my husband and children as much as I possibly can.
Thank you.

Answer:

I am sorry about how you are feeling right now. These notes are from patient information of a well-researched medical website (UpToDate). I hope these will help answer some of the questions you have.

Human papillomavirus — Infection of the cervix with certain types of human papillomavirus (HPV) is the most significant risk factor for cervical abnormalities and cancer. Over 100 different types of HPV have been identified, however not all types infect the cervix or cause cancer. Researchers have labeled the HPV types as being high or low risk for causing cervical cancer. HPV types 6 and 11 can cause warts and are low-risk types because they rarely cause cervical cancer; types 16 and 18 are considered high-risk types because they may cause cervical cancer in some women. (See "Patient information: Condyloma (genital warts) in women").

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching an object, such as a toilet seat.

Most persons who are infected with HPV have no signs or symptoms. Most HPV infections are temporary and resolve within two years. When the virus persists (in 10 to 20 percent of cases), there is a higher likelihood of developing cervical cell abnormalities and cancer. However, it usually takes several years for HPV infection to cause cervical cancer.

LOW-GRADE SQUAMOUS LESION (LSIL) — These are mild cellular changes. Further testing is almost always recommended for women with LSIL because 15 percent of women with LSIL have a precancerous lesion that was not detected by the Pap smear.

A small number of women with low-grade changes will develop cancer over a period of several years if no treatment is performed. A large percentage (50 to 90 percent) of women with low-grade changes do not require treatment because the abnormality resolves on its own.

Low-grade abnormalities may be described with other names, including low-grade squamous intraepithelial lesions (LSIL), cervical intraepithelial neoplasia, grade 1 (CIN 1), and mild dysplasia.

Follow up of LSIL — Colposcopy is recommended for women with low-grade lesions (LSIL) (see "Colposcopy" above).

    * Determining the size and location of the lesion with colposcopy can help to decide whether to treat the lesion or follow it over time. Large lesions are less likely to heal without treatment.

    * Observing the extent and severity of the lesion with colposcopy is useful for establishing a baseline in women who are not treated.

However, LSIL in postmenopausal or adolescent women may be approached differently. A repeat Pap smear or HPV test may be recommended for adolescents; if the HPV is positive or the Pap smear continues to be abnormal, the adolescent is usually referred for colposcopy. Postmenopausal women may be treated with a course of estrogen cream, as described above (see "Atypical squamous cells (ASC)" above).

Treatment of LSIL — There are three options for management of LSIL:

    * Close follow-up with HPV testing after 12 months or repeat Pap smear at six and 12 months. Colposcopy is performed if abnormalities persist or worsen (see "Follow up testing" abovesee "Follow up testing" above). HPV testing is preferred because it is as effective as Pap smear but requires fewer visits and less need for colposcopy.

    * Treatment to remove or destroy the abnormal cells (See "Patient information: Treatment of abnormal Pap smears").

    * Repeat colposcopy and Pap smear at 12 months.

Since many of these lesions will heal without treatment, some women prefer to delay treatment and have close monitoring. Treatment is the best option if LSIL persists, if the woman would have difficulty remembering to follow-up every six months, if the lesion is large (large lesions usually persist), if the lesion extends into the inner cervix (where it is difficult to see), or if the patient prefers treatment.

I hope your dilemma gets resolved soon. Take care.

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Response by:

Riza T Conroy, MD
Clinical Assistant Professor of Family Medicine
Department of Family Medicine
College of Medicine
The Ohio State University