1. Gynaecological Implications of HPV Infection
Dr. P. Reddi Rani
Professor of Obstetrics & Gynaecology
MGMC & RI, Puducherry

2. Introduction Genital HPV is one of the most common STDs
More than 120 HPV types exist
More than 40 HPV types can infect the anogenital tract

3. Virology
Double-stranded DNA virus that belongs to the Papilloma viridae family
Genital types have specific affinity for genital skin and mucosa
Infection identified by the detection of HPV DNA

4. HPV Oncogenic Potential
HPV types are divided into two groups based on their association with cancer.
Low-risk types (non-oncogenic) associated with genital warts and mild Pap test abnormalities
High-risk types (oncogenic) associated with moderate to severe Pap test abnormalities, cervical dysplasia and cervical cancer, and other cancers like Vulva, Vagina and Anus
Most genital HPV infections are transient, asymptomatic, and have no clinical consequences.

5. Risk with different types of viruses
High risk types 16 and 18 Less common risk 30, 31, 33, 35, 39, 45, 51 and 53 Low risk types 6, 11, 40, 42 – 44, 54, 61,70, 72 and 81

6. INDIAN SCENARIO OF HPV INFECTION
Cervical cancer is ranked as the most frequent cancer in women in India.
India has a population of approximately 366 million women above 15 years of age, who are at risk of developing cervical cancer.
The current estimates indicate approximately 132,000 new cases diagnosed and 74,000 deaths annually in India, accounting to nearly 1/3rd of the global cervical cancer deaths.

7. Indian women face a 2. 5% cumulative lifetime risk and 1
Indian women face a 2.5% cumulative lifetime risk and 1.4% cumulative death risk from cervical cancer.
At any given time, about 6.6% of women in the general population are estimated to harbor cervical HPV infection.
HPV serotypes 16 and 18 account for nearly 76.7% of cervical cancer in India.
Warts have been reported in 2–25% of sexually transmitted disease clinic attendees in India
WHO-2008

8. Sexually – vaginal , oral and anal intercourse Toilet seats
Transmission
Sexually – vaginal , oral and anal intercourse
Toilet seats
Prenatal
- can be transmitted during child birth
( especially with genital warts)
- cause JORRP
( juvenile onset recurrent respiratory
papillomatosis)
- Very rare 2/ children
Hugging and holding hands
Swimming
Heredity
Sharing food and utensils
Sharing of contaminated objects
Surgery

9. Risk factors Women Men Multiple sexual partners
Partner with multiple partners
Not being circumscribed
Early age of first sexual intercourse
Smoking
Not circumscribed male partner
Long term use of OC Pills
Immuno suppression
Presence of other STDs

10. Pathogenesis Incubation period usually 3 to 4 months
Range is from 1 month to 2 years
Can clear spontaneously or can progress to pre-cancerous or cancerous cervical abnormalities

11. Cervical Carcinogenesis

12. Natural History of HPV
Most genital HPV infections are transient, asymptomatic (subclinical), and have no clinical consequences in immunocompetent individuals.
Time to development of clinical manifestations is variable.
Median duration of new cervical infections is 8 months, but varies.
90% of infections clear within 2 years
Gradual development of an effective immune response is the likely mechanism for HPV DNA clearance.

13. Natural History of HPV-continued
Persistent HPV infection
Not cleared by the immune system
Characterized by persistently detectable type-specific HPV DNA
Persistent oncogenic HPV infection is most important risk factor for precancerous cervical cellular changes and cervical cancer.

14. Natural History of HPV & Cervical Cancer
80%
HPV
Infection
Spontaneous Clearance
Persistence
Viral Integration
20%
Intra Epithelial
Neoplasia
20%
Invasive Cancer

16. Molecular Mechanism of HPV Infection
HPV infection produces two oncoproteins E-6, E-7
E-6 reacts with P-53 protein
E-7 interacts with PRb protein
Inactivation of P-53 & PRb causes proliferation & genomic instability, DNA damage leading to precancerous and cancerous lesions
(P-53 & PRb are tumor suppressor proteins)

17. Pathology
HPV infects the basal cell layer of stratified squamous epithelium and stimulates cellular proliferation.
It requires mild aberration or micro trauma of epidermis
Once inside the host cell HPV DNA replicates to surface epithelium
Affected cells display a broad spectrum of changes, ranging from benign hyperplasia, to dysplasia, to invasive carcinoma.

18. Genital lesions associated with HPV infection
CONDITION
HPV SUBTYPE
Condyloma acuminatum
6, 11
Verrucous carcinoma
Bowenoid papulosis
16 31, 32, 34, 35, 37,42
Intraepithelial neoplasia, invasive carcinoma
(cervix, vulva, vagina, anus, penis)
16, 18, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56

19. Clinical manifestations & Sequelae
Depends on
Viral subtype
Immune status of the patient
Environmental co-carcinogen (smoking)
In most cases, genital HPV infection is transient and has no clinical manifestations or sequelae.

21. Genital Warts-Appearance
Condylomata acuminata
Cauliflower-like appearance
Skin-colored, pink, or hyperpigmented
May be keratotic on skin; generally
nonkeratinized on mucosal surfaces
Smooth papules
Usually dome-shaped and skin-colored
Flat papules
Macular to slightly raised
Flesh-colored, with smooth surface
More commonly found on internal structures (i.e., cervix), but also occur on external genitalia
Keratotic warts
Thick horny layer that can resemble common warts or seborrheic keratosis

22. Genital Warts-Location
Most commonly occur in areas of coital friction
Perianal warts do not necessarily imply anal intercourse.
May be secondary to autoinoculation, sexual activity other than intercourse, or spread from nearby genital wart site
Intra-anal warts are seen predominantly in patients who have had receptive anal intercourse.
HPV types causing genital warts can occasionally cause lesions on oral, upper respiratory, upper GI, and ocular locations.
Patients with visible warts are frequently simultaneously infected with multiple HPV types.

23. Genital Warts-Symptoms
Genital warts usually cause no symptoms. Symptoms that can occur include:
Vulvar warts-dyspareunia, pruritis, burning discomfort;
Penile warts-occasional itching;
Urethral meatal warts-hematuria or impairment of urinary stream;
Vaginal warts-discharge/bleeding, obstruction of birth canal (secondary to increased wart growth during pregnancy); and
Perianal and intra-anal warts-pain, bleeding on defecation, itching
Most patients have fewer than ten genital warts, with total wart area of 0.5–1.0 cm2.

24. Genital Warts-Duration and Transmission
May regress spontaneously, or persist with or without proliferation.
Frequency of spontaneous regression is unclear, but estimated at 10–30% within three months.
Persistence of infection occurs, but frequency and duration are unknown.
Recurrences after treatment are common.

25. Genital Warts and High-Risk HPV
High-risk HPV types occasionally can be found in visible warts and have been associated with squamous intrepithelial lesions (squamous cell carcinoma in situ, Bowenoid papulosis, Erythroplasia of Queyrat, or Bowen’ s disease of the genitalia).
The lesions can resemble genital warts.
Unusual appearing genital warts should be biopsied.

26. Diagnosis of Genital Warts and Cervical Cellular Abnormalities

27. Diagnosis of Genital Warts
Diagnosis is usually made by visual inspection with bright light.
Consider biopsy when
Diagnosis is uncertain;
Patient is immunocompromised;
Warts are pigmented, indurated, or fixed;
Lesions do not respond or worsen with standard treatment; or
There is persistent ulceration or bleeding.

28. Differential Diagnosis of Genital Warts
Other infections
Condylomata lata
Tend to be smoother, moist, more rounded, and darkfield-positive for Treponema pallidum
Molluscum contagiosum
Papules with central dimple, caused by a pox virus; rarely involves mucosal surfaces
Acquired dermatologic conditions
Seborrheic keratosis
Lichen planus
Fibroepithelial polyp, adenoma
Melanocytic nevus
Neoplastic lesions

29. Condylomata Accuminata
Condylomata lata
Molluscum Contagiosum
Seborrheic keratitis

30. Diagnosis of Cervical Cellular Abnormalities
Cytology (Pap test)
Useful screening test to detect cervical cell changes
Provides indirect evidence of HPV because it detects squamous epithelial cell changes that are almost always due to HPV

31. Cervical / Vaginal / Vulvar / Anal / Penile
Abnormal PAP Smear Nomenclature
Cervical / Vaginal / Vulvar / Anal / Penile
Dysplasia
Mild Dysplasia
Moderate Dysplasia
Severe Dysplasia Carcinoma in-situ
Intraepithelial Neoplasia
CIN I
VIN 1
VAIN 1
CIN 2
VIN 2
VAIN 2
CIN 3
VIN 3
VAIN 3
Squamous Intraepithelial Lesion
(SIL)
Low Grade SIL (LSIL)
High Grade SIL (HSIL)

32. HPV Infection-Koilocytes

33. Diagnosis of Cervical Cellular Abnormalities-continued
HPV DNA tests
FDA-approved:
To triage women with ASC-US Pap test results, and
As an adjunct to Pap test screening for cervical cancer in women 30 years or older.
HPV DNA tests should not be used
In men,
In adolescents <21 years,
To screen partners of women with Pap test abnormalities,
To determine who will receive HPV vaccine, or
STD screening for HPV.

34. HPV DNA Detection Hybrid capture II assay by Digene Diagnostics
Only pos. or neg. for Hi Risk HPV: not type specific
Research techniques
In-situ hybridization
Polymerase chain reaction
Dot blot
Filter hybridization
Southern transfer hybridization

35. Management of HPV associated lesions
Depends upon
Clinical manifestations & symptoms
Location & extent of warts
Potential for malignancy
Pregnancy status
Immuno compromised state
Likelihood of complications
Cost effectiveness

36. General Treatment of Genital Warts
Primary goal is removal of warts.
If left untreated, genital warts may regress spontaneously or persist with or without proliferation.
In most patients, treatment can induce wart-free periods.
Currently available therapies may reduce, but probably do not eliminate infectivity.
Effect of current treatment on future transmission is unclear.

37. General Treatment of Genital Warts-continued
No evidence that presence of genital warts or their treatment is associated with development of cervical cancer.
Some patients may choose to forgo treatment and await spontaneous resolution.
Consider screening persons with newly diagnosed genital warts for other STDs (e.g., chlamydia, gonorrhea, HIV, syphilis).

38. Treatment Regimens-continued
Factors influencing treatment selection include
Wart size,
Number of warts,
Anatomic site of wart,
Wart morphology,
Patient preference,
Cost of treatment,
Convenience, and
Adverse effects.

39. Treatment NO specific treatment Resolves spontaneously
Before treatment of EGW, pap smear should be done to rule out cervical lesions.
Spontaneous regression = 10 to 30% ( within 6 months)
In atypical lesion , biopsy done to rule out VIN

40. Treatment of warts Modality MOA Dosage Advantages Disadvantages
Podoph- yllin
Antimi-totic
0.5% solution
Every 12 hrs,
3 days / week for 6 weeks
Low cost , low toxicity
Contraindicated in pregnancy , ulceration , variable penetration and difficulty in application
Imiqui-mod
Immunomod --ulator
5% cream
3 times /week for 16 weeks
Easier to use, low recurrence rate , efficacious
High cost , delayed response , contraindicated in pregnancy
Trichloroacetic acid
Coagulation of proteins
85 %
Every 4-6 weeks
Low cost, safe in pregnancy easy to use , low systemic reactions
Pain , ulceration , use of petroleum to prevent surrounding skin

41. Modality
Material used
Advantages
Disadvantages
Cryotherapy
Liquid nitrogen , CO2, N2O
Safe in pregnancy, easy to use, no systemic reaction , for exophytic lesion
Pain and ulceration
Surgical excision
Scalpel or electrosurgical loop (LEEP) -
Electro-cautery
Heated probe opposed to electric current
More tissue damage and avoided
Laser vaporisation
Efficacious , precise , no systemic reactions
High cost , training , long healing time
Interferon
Antiviral , antiproliferative , immunostimulant
High cost , questionable efficacy , pain and systemic reactions

42. Recurrence After Treatment
As many as two-thirds of patients will experience recurrences of warts within 6–12 weeks of therapy; after 6 months most patients have clearance.
If persistent after 3 months, or if there is poor response to treatment, consider biopsy to exclude a premalignant or neoplastic condition, especially in an immunocompromised person.
Treatment modality should be changed if patient has not improved substantially after 3 provider-administered treatments or if warts do not completely clear after 6 treatments

43. Management in Pregnancy
Genital warts can proliferate and become more friable during pregnancy.
Cytotoxic agents (podophyllin, podofilox, imiquimod) should not be used.
Cryotherapy, TCA, BCA, and surgical removal may be used.
HPV types 6 and 11 can cause recurrent respiratory papillomatosis in children. The route of transmission is not completely understood.
Prevention value of cesarean delivery is unknown; thus, C-section should not be performed solely to prevent transmission to neonate.

44. Impact of HIV infection on the manifestations of HPV infection
With immunosuppression Increased risk of
HPV infection of genital tract
Development of condylomata acuminata
Increased severity of HPV disease
Anal & cervical intraepithelial neoplasia
Increased relative risk of developing in situ or
invasive genital cancers
HPV is more difficult to treat / more likely to recur with increased immunosuppression

45. Squamous Cell Carcinoma in situ
Patients in whom squamous cell carcinoma in situ of the genitalia is diagnosed should be referred to a specialist for treatment.
Ablative modalities
usually are effective,
but careful follow-up
is essential.

46. Genital Wart Follow-Up
Counsel patients to
Watch for recurrences,
Continue regular Pap screening at same intervals as recommended for women without genital warts, and
Communicate to current sex partners about genital warts and the risk of transmission. Patients should have no sexual activity until warts are gone.
After visible warts have cleared, follow-up evaluation is not mandatory, but provides an opportunity to
Monitor or treat complications of therapy,
Document absence of warts, and
Reinforce patient education and counseling messages.
Offer patients concerned about recurrences a follow-up evaluation 3 months after treatment.

47. Treatment of Cervical Dysplasia
1.Treatment is not usually necessary in Low grade lesions(infections regress quickly) 2. Necessary to avoid progression to malignancy in High grade lesions 3. Cryotherapy 4. Laser Ablation Therapy 5. LEEP (loop electrical excision procedure) 6. Conization 7. Hysterectomy

48. Patient Counseling and Education

49. Counselling
HPV infection is associated with strong emotional responses
5 R’s of counselling
Reach out
Review
Resourceful
Reassure
Reiterate
Inform about transmission, characteristics of infection, treatment options, prevention and risk of cervical cancer
90% cases , EGW and cervical regress in 2 years
Focus on smoking cessation and consistent use of condoms

50. Prevention Safe sex practices Screening HPV vaccine
Develop individualized risk-reduction plans with the patient for lasting results.
Discuss prevention strategies such as abstinence, mutual monogamy, condoms, limiting number of sex partners, etc.
Consistent and correct male condom use reduces risk for genital HPV acquisition and HPV-associated diseases (e.g., genital warts and cervical cancer).
HPV infections can occur in areas that are not covered or protected by a condom(e.g., scrotum, vulva, or perinanus).

51. Screening methods Cytology : conventional ( pap smear )
: liquid base cytology ( LBC)
Visual inspection after acetic acid ( VIA)
Visual inspection after acetic acid with magnification ( VIAM)
Visual inspection after lugol’s iodine ( VILI)
Cervicography
HPV DNA testing

52. Cytology
Abnormal cells of cervical neoplasia exfoliate which can be collected by scraping the cervix and staining the smear.
It is the gold standard screening procedure
Introduced by Papanicolaou and known as pap smear or pap test .
Methods of cytology :
Pap smear
Liquid base cytology

53. PAP SMEAR ACOG cervical cancer screening guidelines ( September 2013)
Should start at the age of 21 years
Women aged years have a pap test every 3 years
Women aged 30 – 65 years should have a pap test and HPV test ( co testing ) every 5 years ( preferred) It is acceptable to have a pap test alone every 3 years

54. Women should stop having cervical cancer screening after age 65 years if they do not have a history of moderate or severe dysplasia or cancer and they have had either 3 negative pap test results in a row or 2 negative co test in a row within the past 10 years , with the most recent test performed within 5 years
Women who have a history of cervical cancer , are infected with human immunodeficiency virus ( HIV) , have a weakened immune system , or who were exposed to diethylstilboestrol (des) before birth should not follow theses routine regimens
If patient have had hysterectomy , need for screening tests depends on why hysterectomy done , whether cervix removed or not and whether any history of moderate or severe dysplasia

55. Colposcopy Visualisation of lower genital tract under
magnification through a colposcope
Magnification system with a light source
mounted on a stand
Satisfactory colposcopy :
SCJ, columnar epithelium , TZ
Indications – abnormal cytology
- unhealthy cervix

56. Method
After positioning , colposcope placed
1 foot from vulva
Cervix focused under magnification
Cleaned with saline and examined
under white light
3% acetic acid
Green filter used
Lugol’s iodine
Colposcopic directed biopsy
Additional, endocervical curettage

57. Manufactured by Qiagene / Digene
Detects 13 high risk HPV affecting cervix but not specify type
Used either in conjugation with pap or follow upto pap
Cells are collected like liquid based cytology
Differs from pap : pap looks for abnormal cells while it looks for virus Causing infection

58. Pap abnormal + HPV DNA normal = wait for 3 years for co testing
Pap normal + HPV DNA abnormal = co testing within one year
ADVANTAGES :
More sensitive ( 40% more )
Non invasive and DNA based
Faster result
Not done before
30 years

59. Three vaccines available GARDASIL GARDASIIL 9 CERVARIX
HPV vaccine
HPV virus infects at least 50 % of all people who have sex sometime in their lifetime.
Three vaccines available
GARDASIL
GARDASIIL 9
CERVARIX

60. Characteristics of HPV vaccines
Bivalent (2V-HPV)
Quadrivalent (4V-HPV)
Nine valent (9V-HPV)
Brand name
Cervarix
Gardacil
Gardacil-9
Manufacturer
Glaxo-Smith Kline
Merck & Co
VLPs
16, 18
6,11,16,18
6,11,16,18,31,33,
45,52,58
Vol. per dose
0.5 ml
Mode of adm. IM
No.of doses & interval
0, 2, 6
(months)
0, 2, 6 (months)
Second dose two months after first dose, third dose 6 months after first dose.

61. Age of vaccination :
female
For Gardasil and - ideal b/w years or Cervarix before sexual activity
- can be age of 9
- can be given b/w yrs
( If not vaccinated previously or not completed course before sexual intercourse )
For Gardasil can be given b/w 9 – 25 years

62. H/o hypersensitivity to latex ( cap tip of prefilled syringe )
Contraindications :
H/o immediate hypersensitivity to vaccine components ( yeast hypersensitivity)
H/o hypersensitivity to latex ( cap tip of prefilled syringe )
Moderate to severe acute illness
Pregnancy ( category B)
Bleeding disorders
Storage : Refrigerated at 2- 8 ºC , not frozen and protected from light

63. Efficacy Protective up to 6 years and probably beyond
No booster dose required
30 % cervical cancer not prevented by 3 vaccines
10% genital warts not prevented by Gardasil
Neither of them prevent from STD nor treat existing HPV infection or cervical cancer
Offers 100% protection against CIN and genital warts caused by strain in vaccine
with few or no effects
Effective when given prophylactically
Immune defence is type specific

64. Safety
Extensive clinical trial and safety surveillance documented all 3 vaccines to be safe
Side effects :
Local – pain , redness , induration , swelling at injection site
Non serious – syncope , dizziness , nausea , vomiting , headache , fever
Serious – Stroke , VTE , seizures , anaphylactic reaction – Very rare
Fainting spells most common
CDC recommends all patients to be seated or lying down during vaccination and to be monitored for 15 minutes post vaccination
VAERS – vaccine adverse event reporting system

65. Mechanism of action
HPV vaccine based on hollow virus like particles ( VLP’s) assembled from recombinant HPV capsid proteins with out viral DNA core
Produces neutralising antibodies
Non infectious and Non oncogenic
Highly immunogenic
Seroconversion rate of 99.5 % within one month after completion of 3rd dose
Duration of protection > 6 years

66. Special circumstances :
Pregnancy
- During pregnancy : avoided
- If pregnant during 3 dose series : postponed
2) Inadequate dose or vaccine doses received after shorter than recommended interval : re administered
3) If vaccine schedule interrupted after 1st dose , 2nd dose given and interval of 12 weeks maintained b/w 2nd & 3rd dose
4) Can be given concomitant with other vaccines using separate syringe at different anatomic sites
5) Can be given if abnormal pap , known HPV infection or presence of warts
( to be counselled regarding therapeutic effect )

67. 6) No need for HPV DNA testing before vaccination
Lactating mother can take vaccine
8) Can be given to HIV +ve and immunocompromised
9) Cervical screening guidelines to be continued in vaccinated females
Does not protect against all types
May not receive all 3 doses or not received at the right time
Women already infected with HPV type present in vaccine

68. Advantages of HPV vaccine
Cost effective
Delays screening initiation& interval without affecting the reduction of life time risk of cancer cervix
Therapeutic effect is being explored

69. Summary
Vaccines generate a broad spectrum of antibodies, only neutralizing antibodies are important.
The major basis of protection against infection is neutralizing antibody
Quadrivalent HPV vaccine has in addition to cervical cancer, demonstrable efficacy against vaginal & vulvar pre cancers, anogenital warts and RRP attributable to HPV 6,11,16 & 18.
Screening is not mandatory prior to vaccination & should be continued after vaccination.
HPV vaccine can be given to lactating women.
HPV vaccine is not recommended during pregnancy

70. Take Home Message HPV is one of the most common STDs
Two types-Oncogenic & Non-Oncogenic
Oncogenic (16,18) - 70% of Cervix cancer & HSIL and also vulvar, vaginal & anal cancer
Non-Oncogenic (6,11) – 90% warts & LSIL
Most infections are asymptomatic and spontaneous clearance occurs
Persistent infection with high risk is responsible for cancer
Diagnosis is by clinical exam, PAP, Colposcopy and HPV DNA test

71. Treatment depends on type of lesion
Prevention is possible
Safe sex practices
HPV Vaccine
PAP smear
Counseling and Health Education will go a long way in Prevention