Table of Contents
| Author's Note: A Word on the Setup of this Book | xi |
| Part 1 | What You Need to Know First | 1 |
| Chapter 1 | HPV 101 | 3 |
| Chapter 2 | Pap Smears 101 | 51 |
| Part 2 | Cervical HPV | 77 |
| Chapter 3 | Unsatisfactory, Normal, and Benign Pap Smears | 79 |
| Chapter 4 | Abnormal Paps: An ASCUS Diagnosis | 95 |
| Chapter 5 | Abnormal Paps: An LSIL Diagnosis | 115 |
| Chapter 6 | Abnormal Paps: An HSIL Diagnosis | 129 |
| Chapter 7 | Cervical Cancer | 146 |
| Part 3 | Anogenital Dysplasias in Areas Other Than the Cervix: Vagina, Vulva, and Anus | 183 |
| Chapter 8 | Vaginal Dysplasia and Cancer | 185 |
| Chapter 9 | Vulvar Dysplasia and Cancer | 203 |
| Chapter 10 | Anal Dysplasia and Cancer | 215 |
| Part 4 | Benign HPV Infection | 251 |
| Chapter 11 | Genital Warts | 253 |
| Chapter 12 | Methods of Treatment for Genital Warts | 266 |
| Chapter 13 | Recurrent Respiratory Papillomatosis | 279 |
| Part 5 | Anal and Penile HPV Infections in Men | 287 |
| Chapter 14 | Men and HPV | 289 |
| Part 6 | Taking Control | 319 |
| Chapter 15 | Living with HPV and Talking with Your Partner | 321 |
| Part 7 | Hope for the Future | 341 |
| Chapter 16 | Looking Ahead | 343 |
| Glossary | 351 |
| Appendix A | Choosing Your Gynecologist | 363 |
| Appendix B | Pelvic Self-Examination | 365 |
| Appendix C | Penile Self-Examination | 368 |
| Appendix D | Resources | 370 |
| References | 373 |
| Index | 385 |
Read a Sample Chapter
What Your Doctor May Not Tell You About HPV and Abnormal PAP Smears
By Joel Palefsky and Jody Handley Warner Books
Copyright © 2002 Dr. Joel Palefsky
All right reserved. ISBN: 0-446-67787-6
Chapter One
HPV 101
The Facts
An estimated 75 percent of sexually active adults have or will have transmitted human papillomavirus (HPV) at some point in their lifetimes.
Over 75 percent of women have never even heard of HPV. It's important to understand that HPV should not be confused with HIV, which stands for "human immunodeficiency virus." These two viruses are very different and affect women differently. That said, HPV and HIV can both infect women, and the interaction between these two viruses is discussed later in the book.
If it were up to me, the moment a woman came in for an annual gynecologic exam, she'd be told about HPV: the risk factors, the frequency, the consequences. Knowledge is power, says "Schoolhouse Rock," and I believe that knowledge leads to wiser, more informed choices. That's why I'm starting off this book with a crash course.
Why should you care about HPV? Because HPV is the most common sexually transmitted virus. HPV can be frightening, since not only do most women acquire it at some point, but it contributes to the development of precancerous cervical disease (also known as cervical dysplasia, or cervical intraepithelial neoplasia) and cervical cancer. HPV, along with other factors, is the cause of dysplasia. But wait-there's more! HPV is versatile and also causes warts!
Your doctor may talk to you about Pap smears, warts, and dysplasia. So why don't doctors tell their patients about HPV? Probably a bunch of reasons. Perhaps they're embarrassed to talk about sexually transmitted diseases (STDs), like many people are from time to time. A few doctors don't know much about HPV themselves. Maybe they don't even know the risks involved with HPV. Others don't bother saying anything about HPV because there's no treatment for the virus itself, only treatment for the diseases the virus causes (such as warts, precancerous lesions of the cervix, and cervical cancer). They're all reasons why you may have to bring up the subject with your doctor if he or she doesn't. (You'll notice that I use the word doctor in this book. However, a wide range of health professionals actually provide many of the services referred to in the book, including nurses, nurse practitioners, and physician's assistants. So if one of these other health professionals is involved in your care, you can substitute them for doctor as appropriate.)
From your perspective, discussing STDs could be difficult as well. Many health professionals have difficulty leaving their own personal prejudices and judgments at the door, so you may feel as though Dr. Smith is condemning you when she says the risk of HPV increases with the number of sexual partners. Indeed, though she's telling the truth-your sexual behavior does affect the chances of getting any STD-her tone may suggest condemnation, disappointment, arrogance, or condescension.
The real issue, after all, is not your past behavior. You can't change that and Dr. Smith can't change that. What you can control is your health and practices in the present and future, and even there, I've heard horror stories from patients.
"I had a friend with HPV, so when my doctor told me I had it, I knew how to handle it and what it meant," said Karen, twenty-seven. "Then he told me that everyone on the street probably had it, so I didn't have to tell my partner!"
Why would you tell your patient that her partner doesn't need to know she has a sexually transmitted virus? Especially when he might have been the one who gave it to her?
Your past choices, whether or not you regret them now, are unchangeable. If you didn't know your partner had HPV-indeed, maybe he didn't know-then that's unfortunate ... and also in the past. Now, you have the power to monitor your health, keep the HPV under control, make more educated choices about your sexual practices, and inform your partners so they can make more educated choices. With the knowledge in this book, you're armed with information that can save your life and other people's lives. You have the power.
Now that you know why I think you need to know this information, let's get started.
HPV: Bare-Bones Basics
First and foremost, I want you to understand that HPV only infects the skin, and the term in medicalese for skin is epithelium. The skin, or epithelium, lines not only our whole body, but also inside some of our internal organs.
Because of this particular trait, the only diseases caused by HPV are those of the skin. The skin is our coat of armor; it protects us from the environment and keeps us healthy. We have two kinds of skin: cutaneous and mucosal.
Cutaneous skin surfaces are what you usually think of as "skin": the dry, occasionally hairy skin on your arms and legs. This kind of skin has a thick protective coating called keratin.
Mucosal skin surfaces, known as mucous membranes, are the wet ones: your mouth, vagina, and anus. These also contain keratin, but the protective coating is much thinner.
More than one hundred types of HPV infect humans. Like the skin, they're divided into two subgroups: those that infect cutaneous skin and those that infect mucosal skin. (HPVs are numbered 1, 2, 3, etc., much like hepatitis is lettered A, B, C, and so on.) Both types of HPV, cutaneous and mucosal, are spread through surface contact: from skin to skin, or mucous membrane to mucous membrane, or skin to mucous membrane, or mucous membrane to skin.... Imagine the possibilities! But since HPVs infect only the skin, they do not cause disease in other organs like the blood, bones, liver, heart (unless the skin cells infected with HPV spread to those organs in a process called metastasis, which I'll talk about later). Also, HPVs can't be acquired through a blood transfusion.
Cutaneous HPVs mostly cause warts on your skin-they're infectious and tenacious. (By the way, you don't get warts from toads! Lots of animals have their own papilloma viruses-rabbits, cows, dogs, to name a few. All papilloma viruses are extremely species specific and cannot be passed between species. So you can't get them by touching animals.)
HPV is particular in other ways. Not only does it only hang out in its own species (humans), but each of the more than one hundred HPV types has its own favorite hangout in the skin of the human body. Some HPV types prefer the cutaneous skin, and some prefer the mucosal skin. Some like the hands and feet, and some like the genital region. They rarely, if ever, cross over!
The most common skin HPV types are HPV 1, 2, and 4, and these cause warts on the hands (palmar warts) and feet (plantar warts). Almost all of us have had warts on the hands or feet at some time. Fortunately, HPV 1, 2, and 4 don't like to live in the skin of the genital tract, so these HPV types rarely-if ever-cause genital warts, precancerous genital lesions, or cancer. This means that you cannot get these lesions by touching the hands or feet of another person.
On the other hand, a group of HPV types do prefer the cutaneous and mucosal skin of the genital region. These HPV types can cause warts, precancerous lesions, or cancer in your genital area. As I mentioned earlier, the HPV types that are associated with cancer are called oncogenic. They're sometimes also called intermediate-risk or highrisk HPV types. The HPV types not associated with cancer-typically the ones that cause warts-are called nononcogenic, benign, or low-risk HPV types. The most common cancer-causing genital HPV types are HPV 16 and HPV 18, while the most common low-risk HPV types are HPV 6 and 11. While most of the thirty to forty known types of mucosal HPVs typically infect your genital tract, a few, such as HPV 13 and HPV 32, prefer the mucous membranes of the mouth.
Here's an important point about the skin-site preferences of the various HPV types. Since the genital HPV types live only in the genital skin, and since HPV is spread by skin-to-skin contact, then it seems as though most, if not all, genital HPV infection is sexually transmitted: It spreads by one person's genitalia touching another person's genitalia. Remember-the genital HPV types live only in the genital skin, and not in the other parts of your skin, such as your hands, face, and so on. So you can't get a genital HPV infection by touching the hand or foot of someone with warts in those places. To acquire a genital HPV infection, there usually needs to be genital-to-genital skin contact. Having said that, there are some other methods of sexual transmission, and I'll talk about them later.
Not all mucosal HPV types cause cancer, though. The chart above displays the cervical cancer risk of genital HPV types. Keep in mind, though, that "intermediate" risk doesn't mean those types won't cause cancer; it only means that they're found in fewer cancers. If you have an intermediate type, your risk of developing cancer may be similar to high-risk types.
Genital warts are caused by HPV types 6 and 11. These are the cauliflowerlike lesions, similar to other warts on your body, that can be found anywhere in the genital tract, including the anus, vulva, vagina, or penis. They're also nononcogenic-they won't cause cancer. But they're a pain, to be sure! I'll cover HPV 6 and 11 in great detail in part 4 of this book.
High or intermediate risk, or oncogenic, types don't always cause visible lesions, but they do cause cancer. In fact, 99 Percent of cervical cancers have been linked to oncogenic HPV types.
(Continues...)
Excerpted from What Your Doctor May Not Tell You About HPV and Abnormal PAP Smears by Joel Palefsky and Jody Handley Copyright © 2002 by Dr. Joel Palefsky . Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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