Cervical Cancer, HPV and Pap Smear

What is Human Papilloma Virus?

Viruses are causes of infection which are smaller than bacteria and we can not be successful in the treatment of them as much as bacteria. HPV (Human Papilloma Virus) is a virus popularly known to make wart in the skin and reproductive organs. Recently, this virus has been proven to have much important and serious implications on human health. Currently, studies about the virüs known to have more than 100 subtypes and the diseases it causes are intensely continuing.

What’s Cervical Cancer?

Cervical cancer is a type of cancer that develops from opening portion of the uterus (cervix) which is one of the female reproductive organs. This type of cancer has bad consequences on women's health. Despite the fact that it’s such a bad type of cancer, it should be remembered that it has precancerous diseases which turns to cancer and has stages (CIN I, CIN II, CIN III) while the detection and treatment of them before they turn to cancer, are possible. Cervical cancer are seen in more than 500,000 women every year. It is the most common 3rd type of cancer after breast and endometrial cancer among women worldwide. Every year 250,000 women pass away due to this disease every year. This shows that one woman dies due to cervical cancer in every two minutes.

How is the detection and treatment of Cervical Cancer?

Early detection is possible with the pap-smear tests before it turns into cancer. Therefore, all women are recommended to have smear test annually. Surgical treatment of these precancerous diseases are known and applied.

What is the relationship between cervical cancer and the Human Papilloma virus?

In recent years, it is shown that some types of high risk HPV are the main cause of cervical cancer and its precancerous diseases and that the virus initiates the transformation of cancer in the cells. The fact that preventing the spread of this virus and being protected from other diseases are possible is a remarkable issue in recent years.

It is known by everyone that smoking causes cancer. In the studies, it is estimated that smoking 10 folds increases the risk of lung cancer than non-smokers. It estimated that a woman's chance of developing cervical cancer 300 and 400 times higher in women who faced High-risk types of HPV than women are protected from HPV.

How is the virus transmitted?

HPV is transmitted in adult life from spouses to each other. While previously transmitted virus don’t cause any disease in one of the spouse, particularly being more common in women, hat can turn into warts and diseases of cervix, external genital region and reproductive tracts which may turn to cancer and precancerous diseases such. When the body is infected with the HPV virus, it is cleared by the body within 2 years in about 90% of people. However, post-infection precancerous lesions may develop and turn into cancer in approximately 10-15 years in the rest of the people.

Low-risk HPV types are responsible for the formation of genital warts: They are benign, however, HPV types 6 and 11 are responsible for 90% of genital warts.
High risk HPV types hat can cause cancer of female reproductive tract may initiate the transformation of cancer after being sexually transmitted. Especially HPV types 16 and 18 cause approximately 70% of the cervical cancers.

Is there a relationship between the virus and another disease except cervical cancer?

Other cancer and non-cancer diseases known to be associated with HPV are present. These include diseases of the respiratory tract in children caused by the transition of HPV from the mother and genital warts. Knowing only that genital warts are seen in 30 million women worldwide every year explains the prevalence and magnitude of the problem. In addition it is known that HPV plays an important role in cancers of anus, penis, vagina, vulva, head-neck and finger.

Who does the cervical cancer threaten?

Cervical cancer is more common in middle aged women as its incidence and age. However, this incidence shows the years that cancer comes out and begins to give symptom. The onset of the disease is in previous years and its development takes long years.

How can we be protected from HPV?

Since the most important cause in the prevalence and transmittance of HPV infection is sexual intercourse, monogamy plays a very important role in protection.

Modern "preventive medicine" approach is to prevent the virus infection by destroying it in our defense system via our immune system even if the virus enters into the body like diseases such as measles, varicella and influenza. This approach is possible with the vaccine. HPV vaccine is the leading attempt among the last decade's most important issues of public health and fight against cancer.

When should this vaccine be done in order to effect and how much protective it is?

Currently, there are two HPV vaccines in use in our country and in the world. Double and quadruple vaccine. The quadruple vaccine provide protection from the two types of HPV that cause cervical cancer (types 16 and 18) and the two types that cause genital warts (type 6 and 11). Double vaccine provide protection from the HPV 16 and HPV 18 which are most common cause of cervical cancer.

When should the vaccination be done?

According to data obtained from the first studies, while HPV vaccine could be done for the girls and young women between the ages of 9-26, currently the upper limit has been lifted up and now children, young girls and women can be vaccinated from the age of 9 until 50s. The reason why it is started to be vaccinated at an early age is not only because immune system is more active in the pediatric age group, our children are intended to be immunized against the virus before marriage and protected from the risk of disease.

What should be done against HPV?

Second step should be done: Initially vaccination should be done and the second step is regular pap-smear scan once a year.

Is there any test required before vaccination?

No. Vaccine can be performed for anyone without making any test the moment they are firstly seen.

Is there a therapeutic effect of the vaccine?

No. Vaccines only have protective effect only. Currently it’s treatment is only for the damage that HPV causes. A treatment which destroys the virus from the body entirely has not been available yet but there are ongoing studies. Currently we know that the virus can only be beaten by the person’s own immune system.

Should smear test still be continued after vaccination?

Yes. First of all, viruses can already be present in the patient when the vaccination is done and since the vaccine doesn’t have therapeutic effects, this virus can continue to make cellular changes. Secondly, the scanning should be continued for the types of diseases which the vaccine doesn’t cover.

The majority of HPV infection appears within 3 years after initial contact. The reason why HPV infections are more common in young people is because HPV is effective in immature metaplasia of the epithelium and perhaps the immune response in this period is low.

HPV infection is the most common sexually transmitted disease in the United States. Approximately 15% of the population is infected with HPV. Lifelong possibility of contamination is around 70%.

The most important risk factor for the transmission of HPV infection is sexual activity. Other factors necessary for the formation of disease after HPV infection include birth control pill usage for long time (> 15 years), presence of other sexually transmitted diseases, smoking, nutrition, status of people's immune system, the type of virus. Although the time between Exposure to HPV and development of condyloma in the genital area (warts) is approximately 3 months, this condition may also take years depending on the immunologic status of the patient. 64.70% ratio of penile HPV infection was detected in spouses of women with CIN diagnosis. 1/3 of them are clinical lesions (warts), 2/3 of them are subclinical (non-invisible, the infection is at microscopic level, can be detected only with examination). In women with sexually transmitted HPV infection, even if the infection in the partner is treated, HPV infection determines its course depending on the immune response at the next stage. While recurrences with the same type of HPV are seen in hosts with a poor immune response, infection with other types of HPV and lesion are seen in hosts with well immune response depending on contact with other partners.

HPV infection is passed through the skin and mucous membranes and body fluids and begins with clinically non-specific lesions. The most effective route of transmission is sexual contact. Environmental surfaces, clothing, shared toilets, towel-like surfaces have been also suggested, but the hypothesis has not been proven. Transitions are possibly in the form of oral-genital (oral-sex zone), manual-genital (hand-to-genital area) and genital-genital (sex region in the genital area). Genital-oral switch is also possible although there is no consensus that HPVis transmitted orally yet. Vertical transmission. Laryngeal papillamatosis is a dangerous situation in which the respiratory system of the baby is affected by HPV virus following to normal vaginal delivery of a woman with active genital warts. It is controversial whether cesarean section could prevent this dangerous condition or not. Fortunately, this condition is seen only in seven babies born from 1000 women with HPV.

The most important factor in the infection transmitted through sexual intercourse is being infected at an early age and multiple partners. Most commonly seen during the age period of 20-24. Frequency decreases as age progresses. If men contact with various female partners, risk of cervical cancer will increase in their wives as well.

HPV virus must enter the basal epithelial cells for the visualization of infection. Virus enters from the outer skin of the genital area or microscopic cracks in mucosa and from thin epithelium in the anus or transformation zone of the cervix. Thus, the presence of visible or invisible cracks in the outer genital area or presence of lesions such as erosion defined as “wound” at cervical region in the public, are among the facilitating factors.

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