Human Papilloma Virus

Genital Warts and Cervical Cancers

Considering the infections of the female genital system, perhaps we should take a very serious approach to the infections related to wart viruses that affect women socially, economically and psychologically. Because the most important aspect of the work is that it is possible to protect and scan.

Perhaps it is appropriate to emphasize that we should not frighten our patients while starting to speak. It is necessary to save our patients from the feeling of anxiety that the wart virus is equal to the idea of cancer. Not every wart virus can cause cancer, we should always remember to rely on our body’s extraordinary immune system. Women’s consciousness is becoming more and more mature and women’s efforts to obtain information and it is the most important factor in collaboration with the physician in protection and screening. Taking a pap smear from every woman whose sexual activity has started is a protocol that has been established for many years in the world for cervical cancer screening.


When Should We Start to Have a Smear Test?

The age of onset for Pap smear is definitely related to the age of onset of sexuality. Although some sources report it as 18 years old, child brides or in cases where early sexuality is concerned, the age of smear may be taken earlier. The frequency of taking for smears is limited to once a year if there is no problem in the results. The smear results determined by the problem are guided by the physician according to the degree of the problem. Statistics in developed countries show that cervical cancer is reduced by 75% with regular PAP smear.


How Does the Wart Virus Transmitted?

The most frightening question is: “How is this virus transmitted?” The only way of transmission of papilloma virus is sexual contact. Contamination with articles is not possible according to the literature. In countries with poor medical conditions or healthcare facilities, if disposable material is not used, contamination from infected gloves and examination equipment may occur. Complete sexual intercourse is not necessary for the transmission of the virus. If sexuality is experienced through double friction, virgins can also be seen. There is also an equivalent risk of transmission in oral or anal sex. Because the virus is not only associated with warts and cervical cancer; It is also related to vaginal and vulvar cancers, anal and oropharyngeal cancers, and persistent laryngeal papillomatosis (the virus that the baby receives in the vaginal canal at vaginal delivery).

Meanwhile, the woman who is infected with papilloma virus may have a wart lesion or history in her partner, as well as there is often no wart history or there may not be a wart at the moment around her penis. Because mostly virus is transmitted and transmitted without lesions. The incubation period can vary from 2 months to 2 years, but this period may vary depending on the immune system and the type of virus.

When talking about risk factors in virus transmission, the most important risk factor is the number of partners. However, the number of ex-partners of the woman’s spouse or partner becomes equally important. Up to 90% are given for a woman who has two or more partners to have a lifetime risk of papilloma virus. However, the extraordinary mechanism called immunity ensures 80-85% destruction of this virus. Immunity provided by mucosal natural transmission does not bring permanent immunity and the risk of re-transmission does not continue.

Starting sexuality at an early age also increases the risk of virus infection and cervical cancer. Considering the number of child brides and the age of onset of sexuality shifting to an early age, the statistics stating that the risk of cervical cancer of the woman who started sexual activity before 16 years may increase 29 times should be given importance to the protection and screening programs of these women. The risk of cervical cancer gradually decreases as the virus gets older and older.

We know very well that papilloma virus is the only cause of cervical cancer. However, it is well known that smoking facilitates cancer. This mechanism is related to the fact that nicotine increases the effect of the virus on the cervical mucosa. It is known that birth control pills increase cancer load in the cervix by increasing virus load since the barrier method is not used in the relationship.

A facilitating effect of chlamydia, another sexually transmitted disease, in this process is also suggested.


Types of Wart Virus

There are over 100 types of HPV. About 60 of these are cutaneous (skin related) types that form simple warts on the hands and feet. About 40 of them concern mucosa, which is exactly our subject. Some of this sexually transmitted group, especially types 6 and 11, are low-risk virus types. It is mostly related to wart formation, low-grade genital precancerous lesions and airway papilomatosis. High-risk types, primarily types 16 and 18, are also related to high-grade genital precancerous lesions and cervical cancer. 75-80% of cervical cancer occurs with types 16 and 18.


Treatment of Wart

The wart lesions most common in types 6 and 11 actually bring a socially, economically and psychologically challenging process for the woman. 20% of the lesions regress spontaneously, but 80% tend to continue and spread more. These lesions vary from a few millimetres warts to a few centimetres lesions in the genital area. In therapy, cryotherapy, carbon dioxide laser application, trichloroacetic acid, Aldara application, cauterization or excision can be made in large lesions. If Aldara has relapsed again, using Aldara a second time would be useless. Although personal treatment models vary according to lesion localizations and sizes, electro cauterization seems to be the most successful model. While the total recurrence rates are given as 30%, this rate is much lower after electro cauterization. In the wart treatment process, besides women’s aesthetic concerns, it requires a very important resource in terms of time and economy. It should not be forgotten that effective cooperation in treatment selection will bring effective treatment, since the psychological component gets heavier during relapse.

If a risk factor for cervical cancer is detected as a result of Pap smear, colposcopy, biopsy and endocervical curettage or LEEP (conization) can be performed depending on what the lesion is. Follow-up model and frequency will be determined and determined after all these procedures. In the natural course of HPV infection and cervical cancer, HPV infection occurs for the first 1 year and CIN 1 (low grade lesion) in the next 5 years, and ongoing HPV infection and CIN 2-3 (high grade lesions in a period of time up to 20 years if it will be at high risk) and cervical cancer is predicted to occur. The length of time period in between; It is very important for us to understand the importance of protection in patients caught during screening tests and risk factors.


Should The HPV Typing Be Done?

HPV typing is no longer a contradictory issue and has become widely used in practical practice. Determining typing in diagnosis can be meaningful in terms of determining low or high risk, and follow-up can be tailored accordingly, but this should not mean that follow-up in low-risk types will be disrupted.

Although infection is very likely between the ages of 20-30, the immune mechanisms will be strong in general, and HPV typing is generally recommended according to the patient and conditions in this age range. However, after 30 years of age, HPV typing must be done at least once. HPV screening and typing can be repeated every 3 years by taking into consideration many issues such as the life conditions of the woman or couple, relationship choices, personal immunity and hygiene measures, and smoking methods. In the presence of high-risk viruses such as Type 16 and Type 18 and type 31, 33, 45, it can be re-examined every year, if necessary, considering the results of pap smears.


Is PAP Smear + HPV Screening (Co-testing) useful?

Adding HPV DNA test to PAP smear during routine follow-up increases the scanning capacity during follow-up. Application of HPV DNA test with PAP smear is called “co-testing”. The sample taken from the vagina or cervix is ​​based on determining the presence and type of HPV DNA. In the case of co-testing, women aged 25-45 can be screened every 3 years. Of course, co-testing application is an application that increases the cost in routine follow-up, but makes the routine follow-up less frequent in terms of PAP smear and makes it equivalent in cost in the long run. HPV DNA test is a very important application in determining the high-risk patient group that cannot be detected from time to time in Pap smear application. In PAP smear applications alone, cervical cancer precancerous diagnosis value may be insufficient from time to time especially in the pre-diagnosis of adenocarcinoma. Patients with HPV DNA positive but PAP smear normal are actually the group that should be followed more frequently with high risk. HPV screening and typing at the beginning of the wide time interval starting with the presence of the wart virus in the tissue and extending to the development of atypical lesion, cancer precursor lesion or cervical cancer, may change the fate of the process from the beginning.


Protection From HPV: HPV Vaccine + PAP Smear

The main target in health is to develop health policies for disease prevention, rather than developing methods to treat diseases. As in all areas of preventive medicine, the ways to eliminate the risk should be explained in detail to each person as a right to health.

DNA recombinant vaccines have been developed for the protection of human papilloma virus, which is the DNA virus for warts, latent infections, active infections and precancerous lesions and cancers they cause.

There are three different HPV vaccines currently used in the world. One is a quadrivalent vaccine with protection against types 6, 11, 16 and 18, and the other is a bivalent vaccine that protects against types 16 and 18. Bivalent vaccine has not been produced in recent years (since the type of virus it is immunizing is less) is not produced. The nanovalent vaccine, which was licensed in the USA in 2014 and used in many countries (provides immunity against 9 main types), is not yet licensed and available in our country. In our country, quadrivalent vaccine, which provides 100% immunity, is used safely for years for the most common warts, types 6 and 11, and the most common for cervical cancer types 16 and 18.

The ideal application age of the vaccines is between the ages of 9-26 and the group of women who have not yet started sexuality. However, with the new data, it has become clear that vaccines are effective and can be made until the age of 46. Vaccination can also be done in the sexually explicit group. In this group, it is necessary to share the protection principles and rates of the vaccine, to determine the patient’s expectations correctly and to recommend the vaccine. Vaccination is also strongly recommended for women who have previously been infected with HPV. If it has not developed immunity to the HPV type it received before, it may not be protective against that type, but it will prevent the removal of other viral types. Apart from the main types mentioned, the types with which the vaccines cross protect have also extended the protection range considerably.

Quadrivalent vaccine; Available in 0.5 ml disposable syringes. Quadrivalent vaccine is over the age of 12 years 0.-2. and 6 months, 3 doses, and under 12 years, two doses, 0 and 2 months.

Care must be taken when the vaccine is delivered. However, if the dose has been forgotten after the first dose, if the doses are completed within one year, the vaccine protocol does not need to start over and can be resumed.

Vaccination is not recommended in pregnancy, although any inconvenience is not detected during pregnancy, but puerperant vaccination is recommended and applied. The vaccine is not a live virus vaccine but it is produced by DNA recombinant technology such as hepatitis vaccines and the area used as antigen is not live virus, but HPV L1 major capsid protein.

The vaccine does not interact with medications such as painkillers, vitamins, birth control pills, antibiotics, and antidepressants and can be taken together.

They can be made simultaneously with the hepatitis vaccine, but should be applied to separate arms.

There have been no major side effects reported worldwide since the vaccine was first introduced. Side effects other than 10% mild fever, mild swelling and pain at the injection site are not expected.

In the vaccinated group, PAP smear applications are continued and routine screening programs are not changed.

Vaccine administration reaches effective antibody levels 1 month after the last dose, ie 7 months, and 99% seroconversion is detected. After the 7th month, it can now be shared clearly with the patient from whom protection began.

The vaccine does not need dose repetition later, just as with hepatitis vaccines. Because immune memory ensures that antibodies reach a sufficient level when the virus, that is antigen, is encountered.

The only basic fact that should not be forgotten is that it is always easier to prevent the disease than to face the disease and to treat it. It is necessary to proceed without forgetting this fact, whose psychological and socioeconomic aspects are very important. Treatment is always troublesome and difficult when the disease is diagnosed, especially in the diagnosis of cancer, the journey will always be more difficult. Please, in diseases where it is possible to protect, especially if it is a huge risk like cancer, vaccinate yourself and your children and do not take risks.