Ask the Doctor: July 2008

Question: I am 23 years old and my pap smear came back positive for HPV and had some abnormal cells. I am very worried about this. Can I still get the vaccine for HPV?

Answer: The vaccine for HPV (human papilloma virus) is marketed under the name Gardasil. When they studied the effectiveness of Gardasil before it was approved by the FDA, they studied women who were already infected with one strain of HPV. Gardasil contains the 4 strains of HPV most likely to cause cervical cancer and genital warts. The women who had previously been diagnosed with one strain of HPV were still protected from the other three strains, and the FDA has approved Gardasil for women who have already been infected with one strain. Make sure you talk to your gynecologist about getting the vaccine series. Also, make sure you are getting treated for the abnormal cells on your pap and you follow through with your repeat pap smears, as they will have to be more frequent than once a year of a while.

Question: Last month when you talked about screening for breast and ovarian cancer, you mentioned the CA-125 test. I have read about this in my women’s magazines, which say I should have it done, but my gynecologist has never ordered that test for me. Do I need this test done?

Answer: This is a great question and my patients ask about this test all the time. Ovarian cancer is a rare cancer, with most women only carrying a 1.7% lifetime risk (compared to 13.2% lifetime risk for breast cancer). Unfortunately, due to the location of the ovaries deep within the pelvis, it is difficult to screen for ovarian cancer, thus ovarian cancer is not usually found until it is at a later stage and is harder to cure. Many studies have been done, and no effective screening test has been found for ovarian cancer. The CA-125 blood test is supposed to be used after a woman is diagnosed with ovarian cancer, to follow to see if the cancer has come back. Not all women with ovarian cancer have a positive CA-125 before surgery, so this does not help all patients. In addition, not all patients with a high CA-125 have ovarian cancer, so the false positive rate is quite high; too high for a screening test. As an example, a patient of mine had severe pelvic pain, an ultrasound was done showing an ovarian mass and the CA-125 was very high, around 1700 (normal is less than 25). However, when she went into surgery the results showed that she did NOT have ovarian cancer, and she had endometriosis instead. She is a very lucky woman, but this just illustrates why we don’t use the CA-125 as a screening test for all women. All of that being said, for the women who are at very high risk for ovarian cancer, we have to screen somehow. For my patients with a first degree relative (mother, sister, or daughter) with ovarian cancer, I recommend a pelvic ultrasound every year to look at the ovaries and the CA-125 blood test. This however is not standard of care and generally not covered by insurance for screening purposes. With women that are such high risk, usually the expense is worth the possibly of early diagnosis and a chance at a cure. I would discuss your personal risk with your gynecologist and determine if the CA-125 is right for you.

Dr. Karen Lockwood is a graduate of University of Oklahoma College of Medicine.  She completed her residency in Internal Medicine at Henry Ford Hospital in Detroit.  She is board-certified in Internal Medicine and is currently in private practice in Troy, MI.

If you would like to submit a medical question to Dr. Lockwood, Please email your question to askthedoc@healthandleisureonline.com.

*Advice found within this article is for informational purposes only and should not replace the advice or recommendations of your physician.

What You Need to Know About HPV

By Faris Ahmad, MD

For the past couple of months, many of us have read about a new vaccine available to prevent infection with the genital human papilloma virus, or HPV. This has caused both excitement and confusion, in trying to determine who are the best candidates for this new product, which has the potential to eradicate cancer of the cervix.

Genital HPV infection is currently the most common sexually transmitted infection in the United States, with over 6 million people being infected each year. At least 50% of all sexually active people will get HPV at some time in their lives, and it can affect up to 75% of all men and women in the U.S. between the ages of 15 and 30.

About 40 types of HPV can infect the genital tract. While some types cause no symptoms and go away on their own, some types cause genital warts, and others can cause cancer of the genital tract, most commonly of the cervix. The American Cancer Society estimates that in 2006, over 9700 women will be diagnosed with cervical cancer and approximately 3700 women will die from this type of cancer in the U.S. Genital warts are present in up to 1% of all sexually active people in the U.S at any given time, or about 1 million people.

In June 2006, the Advisory Committee on Immunization Practices (ACIP) voted to recommend the first vaccine developed to prevent infection with HPV. In clinical trials, the vaccine was found to protect against 4 subtypes of HPV, which together cause approximately 70% of all “cases of cervical cancer, and 90% of genital warts.

The FDA recently licensed the vaccine as safe and effective for use in females ages 9-26 years. Although this seems like a very young age, because this is a vaccine, its effectiveness is dependent on being administered prior to the onset of exposure, and should be administered prior to the onset of sexual activity. With the age of onset of sexual activity in this country decreasing to the early teen years, the vaccine was studied in females as young as 9 years of age and found effective. Research on the vaccine’s effects in women over the age of 26 is ongoing. Studies are also being conducted on the effectiveness of using this vaccine in men.

The vaccine is still recommended for those women who are already sexually active, even those with HPV. This is because even if they have already been infected with one of the four vaccine-related HPV types, it will still protect them from the other types not yet acquired. Unfortunately, there is not yet a widely used test available to tell if someone has any or all of these HPV types.

The vaccine is administered in a series of three intramuscular injections: the second dose is given two months after the first dose, and the third six months after the first dose. The retail cost of the vaccine is around $120 per dose, and although not always covered by medical insurance, more carriers are reimbursing the vaccine as the information and demand spreads.

The vaccine has been endorsed by the American College of Obstetricians and Gynecologists (ACOG) and has been heralded as one of the greatest contributions to women’s health care in decades. All women of the appropriate ages are encouraged to contact their gynecologist for further consultation regarding the vaccine. Due to its effectiveness in children as young as nine years of age, some pediatrician’s offices are carrying it as well.

As always, it is important to be proactive in your health. Practicing safe sex is one way to reduce your risk of getting HPV, but also, be sure to have regular check ups with your gynecologist.

Faris Ahmad, M.D., is certified by the American Board of Obstetrics and Gynecology, and has been in practice 12 years. He is a graduate of Wayne State University School of Medicine. His private practice is located in Troy and he has privileges at Troy Beaumont and Royal Oak Beaumont hospitals.