Abnormal Pap Tests

What is the purpose of the Pap test?

What causes Dysplasia?

What is HPV and how do you get it?

How common is HPV?

How is HPV usually identified?

How do you get HPV?

Should partners get tested for HPV?

The bottom line...

What is the purpose of the Pap test?
The Pap is the screening test that helps us  prevent cervical cancer.  It has been a very successful screening test since its inception in the 1950's. It was named after the doctor who "invented" it, George Papanicolaou (1883-1962).  Countries where the test is done routinely have seen a 75% drop in their mortality rates from cervical cancer. The Pap test procedure identifies changes or abnormal cells on the surface of the cervix.  Because it is a screening test, it cannot be used for definitive diagnosis.  It identifies those women who need further testing and allows them to be treated (IF treatment is needed) before the abnormal cells turn into anything serious.  We usually refer to the abnormal cell growth as dysplasia ( from the Greek: "dys" means abnormal or impaired and "plasia" means cell growth).  It may also be called SIL (squamous intraepithelial lesion) or CIN (cervical intraepithelial neoplasm).  They are different terms that mean the same thing.  It is important to note that most of the time the abnormal cell growth or dysplasia  will get better by itself without any treatment.

The Pap test we do at Campus Health Services is the ThinPrep which is the newest technology in Pap tests.  We take a sample of cells that have been shed from the cervix and place it in a solution that goes to an outside lab specializing in reading Pap tests.  If the Pap is clearly normal or clearly dysplasia we get the results back in about two weeks.  If the results are equivocal or not clearly normal or abnormal, the specimen is sent out for further testing and this may take another two weeks.  Most Pap follow up and treatment of abnormal pap smears are done routinely right in the Women's Health Clinic.

What causes Dysplasia?
Cervical dysplasia is almost always the result of an infection of the cervix with a common virus call the human papillomavirus (HPV).  Dysplasia is the cellular response to this infection.  Like many viral infections, HPV usually resolves or is suppressed once the body's immune system develops antibodies to fight the virus and gets it under control.  When the infection resolves, the cells on the cervix with dysplasia repair themselves. In 5 out of 6 of our patients that is what eventually happens. Studies show that most women will clear the dysplasia in 12 - 24 months. In a few patients, probably because the virus is of a stronger type or the woman's immune system is suppressed by something like smoking, the HPV infection persists and the dysplasia becomes more severe.  When this happens, treatment is needed.  The treatment can usually be done right here in the Women's Health Clinic.  Treating the abnormal cells usually prevents the dysplasia from turning into anything serious.  But even in the worst case scenario, it can take many years for cervical cancer to develop.  It should rarely develop in someone getting regular Pap tests and the follow up that is recommended.

Having dysplasia will not prevent a woman from having children or affect the growth of the baby.  It should not  prevent her from doing anything that she ever wanted to do with her life.  She will, however, have to pay more attention to her Pap follow up for a few years and visit her gynecological clinic every six to twelve months or so.

What is HPV and how do you get it?
Human papillomavirus (HPV) is a very common virus family.  It has been found in humans since ancient times. There have been over 100 types of HPV identified so far.  Most of the types do not cause any serious problems.  All the types are numbered.   For example, HPV 2, 4, and 7 cause common warts on the hands. HPV I causes Plantar warts on the feet. HPV 6 and 11 cause genital warts.  These types do not  have the potential of causing anything serious like cancer. HPV is passed by direct skin to skin contact.  Different HPV types affect specific areas of the body and stay in that area.  For example, it would be rare for common warts to infect the genital areas, or Plantar warts to affect the hands or genital warts to affect the mouth.

Some types of HPV have no visible signs and cannot be seen with the naked eye.  These are the types that infect the cervix and are identified by the cell changes (dysplasia) sometimes  found on the Pap test. Some of these HPV types are HPV 16,  HPV 18 and HPV 31. The types of HPV that affect the genital area - genital warts and the types that cause cervical dysplasia  - are what  we are concerned with here in the Women's Health Clinic.  These types of HPV are passed by genital skin to skin contact or sexual intercourse.  The human papillomavirus and its effects are one of the most common things we deal with on a daily basis in the Women's Health Clinic.

How common is HPV?
HPV is very common  It is the most common, sexually transmitted infection in the United States and probably in the world. One study found that 43% of college women in a large East coast college tested positive to HPV.  Another recent study found that sexually active women have a 70% risk of acquiring an HPV infection in their lifetime.  Of course the studies were all done on women but men would have a similar risk.  This is an "equal opportunity" infection but since men don't have a cervix, they probably wouldn't know that they had the type of HPV that causes cervical dysplasia unless they have a partner with an abnormal pap test.

HPV is usually a "silent" infection.  Most of the time people have no signs or symptoms, especially men.  If it shows up visibly, it will be as genital warts also called condylomas.  The types of HPV that cause genital warts in men and women are usually HPV Types 6 and 11.  They are considered "Low Risk" types in that they do not cause the cell abnormalities that have the potential to turn into cancer.  About a million new cases of genital warts are reported in the United States each year.  However, most of the HPV we find at Campus Health  is not the genital wart type.   We pick up most of the HPV that we find in our patients with the Pap test.  This is a different type of HPV from the types that cause genital warts or condyloma.   The types that can affect the cervix and cause dysplasia, as we mentioned previously, are usually HPV 16, 18 and 31.  Some other types may also be involved.  These types have been  identified as "Intermediate/High Risk" because they have been found in the cells of cervical cancer samples.  Although we take every case very seriously, most of the time these types of HPV and the dysplasia they cause get better without treatment.

In the Women's Health Clinic at The U of A, as many as 10-15 percent of our patients will have an abnormal Pap test that shows the effects of HPV.

How is HPV usually identified?
Genital warts or condylomata caused by HPV 6 and 11 are detected by direct visual inspection in a clinic.  You can read more about genital warts in another section. It could take several years for HPV effects to show up on the Pap test.   Many people who have this type of HPV will have  mild effects.  The Pap may be normal one year and abnormal/dysplasia the next or vice versa.   In fact most women will have HPV  without its ever causing any cell abnormalities on the Pap.  Some women, however, will show a cell response on the Pap within a few months of acquiring the infection. It may take several years for some women to show a cell response.

We know there are cofactors which turn an HPV infection into dysplasia.  Smoking is a known cofactor.  Women who smoke are more likely to have a serious effect from  HPV.    It is difficult to predict how an individual will respond.  It should be very reassuring to know that 5 out of 6 patients who have an abnormal pap will revert back to normal within a few years without needing any treatment.

The types of HPV that cause abnormalities on the cells of the cervix, (usually Types 16,18 and 31 and several others) cannot be seen with the naked eye.   Although infection with these "Intermediate/High Risk" HPV types is common  it rarely turns into anything serious in healthy young women who don't smoke.  Most of the time the virus will either become suppressed or be made dormant by the body's immune system or perhaps, even cleared, so that it cannot be detected. Studies show that this usually occurs in 12 - 24 months. The presence of these HPV types must be picked up by looking at skin cells shed by the cervix that have been collected in the Pap test.  These cells are placed on slides and examined under a microscope by experts.  The experts look for changes in the size of the cells' nucleus and other markers that indicate  the cell effects caused by HPV.  Incidentally, the Pap is not a "direct" test for HPV (like a culture for strep throat is a direct test for the streptococcus bacteria.)  It is an "indirect" test.

If a patient has an abnormal Pap test, we usually do a follow up test to confirm or verify the results of the Pap  This test is called a colposcopy.  There is more about colposcopy in another section. There is now another test that is used to find HPV.  This is a test that looks for the DNA of the virus in vaginal and cervical secretions.  It is a direct test for the virus itself and could be positive if a woman has HPV even if the virus has not caused cell changes on the cervix that could be picked up by the Pap.  The test is made by the Digene Company and is called Hybrid Capture ll.  Our reference lab does this test on a Pap sample when the Pap test cannot be read as clearly abnormal/positive (dysplasia) or clearly normal/negative.  If this test is positive for HPV then we treat that Pap test as we would one with dysplasia and take a closer look with the colposcopy.  If the HPV test is negative, the Pap can be rechecked routinely in one year.  The Hybrid Capture II has not yet been approved for use in men.

How do you get HPV?
As you have probably realized from reading the information so far, HPV in the forms that affect the genital area is transmitted by intimate skin to skin contact.  Men have it on their skin and probably in their semen and women have it on their skin and in their vaginal and cervical secretions.  You don't have to have sexual intercourse to get the types of HPV that cause genital warts. Even condoms won't  provide complete protection.  We often see genital warts/condyloma in the areas around the vagina that the condom doesn't cover.  When the HPV is found on the cervix it mainly gets there with sexual intercourse.  Again, the condom won't completely protect the cervix although it is the best protection we have other than abstinence.

Probably the best way to protect yourself from getting HPV is to chose your partners carefully.  Any new partner, unless he or she is a virgin, puts you at a potential risk for HPV.   The more partners you have, the greater the risk of having sex with someone who has HPV.  Studies show that anyone who has had 10 partners has an 85 percent chance of having HPV!

Having sex with lots of people is dangerous to your health. Anyone who is willing to have casual sex has probably had casual sex with others, perhaps many others, and is at greater risk for HPV and other STD's.

Should partners get tested for HPV?
By the time an HPV related problem occurs, most regular sex partners are already infected.   Determining who passed the virus to whom is usually not possible unless one of the partners was a virgin.  Partners are likely to share the same virus and reinfection with the same type of HPV is thought to be unlikely.  Unless a male partner has the type of HPV that causes genital warts, and thus has visible genital warts, there is no test for a man that is equivalent to the Pap test.  Regular sex partners can continue with their usual sexual practices. Condoms should be used, of course, with new partners. As stated before, however, condoms will not always provide protection from HPV.

The bottom line...
The bottom line is that HPV is an extremely common viral infection. Many people will acquire the infection when they become sexually active. Most people never know that they have it and most will clear it or suppress it without its causing any problems. People who do have genital warts/condyloma  can be treated at Campus Health. Some people, only women in this case, will have HPV infection on their cervix that causes a cellular response in the cervical cells called dysplasia. Usually the dysplasia is mild and gets better on its own in 12-24 months. If the dysplasia is more than mild it can usually be treated right in the Women's Health Clinic. We do know that many more people have HPV than ever get dysplasia. Smoking is a known co-factor that can help turn an HPV infection into dysplasia.

HPV should never be a life threatening infection. With careful medical follow-up, it should never turn into something more serious, like cervical cancer.