This document discusses HPV (human papillomavirus), its relationship to cervical cancer, and cervical cancer screening guidelines. It describes the different types of HPV and their risks, how HPV is transmitted, how infections typically progress, and methods of detection. The document also outlines cervical cancer screening guidelines and provides an introduction to colposcopy, using images to illustrate cervical abnormalities.

1. HPV and Cervical Cancer Screening Peter Valenzuela, MD, MBA, FAAFP Assistant Dean for Clinical Affairs Assistant Professor/Dept. of Family Medicine

2. Objectives Discuss key aspects of HPV including: Types Transmission Course Detection Vaccine Describe cervical cancer screening guidelines Provide an introduction to colposcopy using cervical images

3. Background Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. Over half of sexually active men and women are infected with HPV at some point in their lives 6.2 million people in the U.S. become infected annually

4. Economic Impact Approximately $3.5 billion spent on cervical HPV-related disease in the U.S. annually This image is Figure 13 at: http://www.merckmedicus.com/pp/us/hcp/diseasemodules/hpvd/epidemiology.jsp

5. Types There are over 100 different types of HPV Over 40 types infect mucosal surfaces of the ano-genital area High risk (cancer-associated)- 16,18 ,31,33,35,39,45,51,52,56,58,59,68,82 Low risk (non-oncogenic)- 6,11 ,40,42,43,44,54,61,72,73,81

6. Types High Risk HPV 16 most common (found in almost half of all cervical CA) HPV 18 accounts for 10%-12% of cervical CA Low Risk HPV 6 & 11 most commonly found in genital warts

7. Transmission Usually transmitted through direct skin-to-skin Can occur from mother to baby in delivery Detected on inanimate objects, but transmission via this route is unknown This image is Figure 14 at: http://www.merckmedicus.com/pp/us/hcp/diseasemodules/hpvd/epidemiology.jsp

8. Risk Factors for HPV Infection Young age (less than 25 years old) Increasing number of sex partners Early age at first intercourse (16 years old or younger) Male partner has (or has had) multiple sex partners

9. Course Typical duration of new infection is 8 months 70% of women become HPV negative within 1 year 91% become HPV negative within 2 years 10% of women infected with HPV will develop persistent HPV infections This image is Figure 19 at: http://www.merckmedicus.com/pp/us/hcp/diseasemodules/hpvd/natural-history.jsp

10. Detection HPV DNA test (Hybrid Capture II) Can be analyzed from the residual fluid of a liquid-based cytology specimen Detects high risk HPV types, but does not identify individual type Indications for use Routine adjunct to Pap in women 30 and over Management of ASCUS

11. Prevention of HPV Quadrivalent HPV vaccine (Gardasil) Protects against HPV 6,11,16,18 3 IM injections over six-month period ($360 for series) Indicated in females 9-26 years old Ideally before onset of sexual activity

12. Cervical Cancer Screening This is table 12 at: http://www.merckmedicus.com/pp/us/hcp/diseasemodules/hpvd/screening.jsp

13. Cervical Dysplasia Classification Bethesda System- developed by the CDC and NIH to standardize method CIN Grading System CIN III HGSIL Carcinoma In Situ CIN II HGSIL CIN I LGSIL Atypia ASCUS CIN GRADING BETHESDA

14. Management of an Abnormal Pap This is the first image on page 22 of the CDC brochure and may be found at: http://www.cdc.gov/std/HPV/common-infection/CDC_HPV_ClinicianBro_LR.pdf

15. Management of an Abnormal Pap This is the second image on page22 of the CDC brochure and may be found at: http://www.cdc.gov/std/HPV/common-infection/CDC_HPV_ClinicianBro_LR.pdf

16. Colposcopy This image can be found at: http://medicalimages.allrefer.com/large/colposcopy-directed-biopsy.jpg

17. Colposcopy Ectopy Nabothian Cyst This image can be found at: http://www.asccp.org/edu/practice/cervix/colposcopy/benign.shtml This image can be found at: http:// www.asccp.org/edu/practice/cervix/colposcopy/benign.shtml

18. Colposcopy Leukoplakia This image can be found at: http://www.asccp.org/edu/practice/cervix/colposcopy/benign.shtml

19. Colposcopy Punctation This is image 7.3 at: http://screening.iarc.fr/colpochap.php?lang=1&chap=7.php

20. Colposcopy Mosaicism CIN I This is image 7.16 at: http://screening.iarc.fr/colpochap.php?lang=1&chap=7.php

21. Colposcopy CIN II CIN III This is image 7.19 at: http://screening.iarc.fr/colpochap.php?lang=1&chap=7.php This is image 7.23 at: http://screening.iarc.fr/colpochap.php?lang=1&chap=7.php

22. Colposcopy Strawberry Cervix Common indicator of cervicitis Trichomoniasis is usually the culprit This image can be found at: http://www.asccp.org/edu/practice/cervix/colposcopy/benign.shtml

23. Summary Discuss key aspects of HPV including: Types Transmission Course Detection Vaccine Describe cervical cancer screening guidelines Provide an introduction to colposcopy using cervical images

24. References Centers for Disease control and Prevention http://www.cdc.gov/std/hpv/hpv-clinicians-brochure.htm American Society for Colposcopy and Cervical Pathology http:// www.asccp.org/edu/practice/cervix.shtml American College of Obstetricians and Gynecologists http:// www.acog.org /

25. References Pfenninger and Fowler’s Procedures for Primary Care, 2 nd Ed. 2003 Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner’s Mannual. Edited by Edited by J.W. Sellors and R. Sankaranarayanan HPV Disease www.merckmedicus Women’s Health Channel www.womenshealthchannel.com