Can HPV really lead to cervical cancer?

Human papilloma virus, or HPV, affects nearly all sexually active men and women at some point in their lives. Many people “clear” or fight off their infections without ever knowing that they had an infection at all. However, a percentage of people with the virus do not clear their infections and may develop genital warts, cervical cancer, or other types of cancer.

We spoke to Dr. Terez Yonan, an adolescent medicine specialist at CHOC Children’s, to get the facts on HPV and how it can indeed lead to cervical cancer.

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Dr. Terez Yonan, an adolescent medicine specialist at CHOC Children’s.

How common is HPV?

There are nearly 80 million people currently infected with HPV in the United States, according to the Centers for Disease Control, and nearly 14 million people, including teenagers, become infected with HPV each year.

How does HPV lead to cervical cancer?

The most common way to contract HPV is through sexual contact, from a direct transmission from one person’s genitals to the other. When transmitted vaginally, the HPV cells will integrate into cells of the vaginal wall and cervix. This changes the composition of the normal, healthy cells and you end up with dysplasia, also known as abnormal and pre-cancerous cells. This can worsen and turn into cervical cancer.

For people with a normal immune system, it could take years for HPV to turn into cervical cancer, but for someone who is immune-compromised, that process could take just a few months.

HPV does not always lead to cervical cancer. There are what we call high-grade infections and low-grade infections. Low-grade infections are easily cleared by the body on its own. It takes about two years for a healthy person to clear HPV. High-grade infections can last longer in the body and put you at risk for cervical cancer or genital warts. Although not considered dangerous, genital warts are unsightly and can cause irritation depending on where they are. If not treated, warts can grow into different types of cancer, including oral and anal and penile cancer.

What are the warning signs of cervical cancer?

Most of the time, people don’t know they have HPV because there are no warning signs. In some cases, genital warts may appear. Abnormal vaginal bleeding can be a sign of cervical cancer. If you notice abnormal bleeding, consult your primary care provider, gynecologist, or adolescent medicine specialist.

Can I get tested for HPV?

A Pap smear, also called a Pap test, is a pelvic exam designed to test for cervical cancer in women. An HPV test can be done using the same sample of cells collected during a Pap smear.

When should I get my first Pap smear?

A Pap smear is intended for healthy, sexually-active people. They are generally not recommended before 21 years of age. For people who are immunocompromised, Pap smears are recommended when you become sexually active regardless of age because of the increased risk for picking up infections , and for those infections to more quickly develop into cancer.

How often should I get a Pap smear?

Someone who is immunocompromised needs two Pap smears within the first year of becoming sexually active. If those are normal, the exam can be done annually. Healthy women in their 20s need a Pap smear every three years. Beginning at age 30, Pap smears can usually be done every five years.

Who can do my Pap smear?

You can get a Pap smear from your adolescent medicine specialist, family medicine provider, internal medicine provider, or gynecologist. Nurse practitioners and physician assistants  in each of these offices can perform the exam as well.

What does an abnormal Pap smear mean?

If your results are abnormal, you will undergo more frequent Pap smears for monitoring, until your results are in the normal range. The frequency of these Pap smears will be determined by your doctor, but it could range from every three months to every year. Since many people’s bodies clear HPV on their own, when the results are clear again, you will return to an every three- or five-year schedule for Pap smears, depending on your age.

Your doctor may suggest a colposcopy, another type of cervical cancer test. This gives them a better view of your cervix. If they identify cells that may be abnormal, they will perform a biopsy and remove a tiny sample of tissue from either the inside or outside of your cervix. If the biopsy confirms the presence of abnormal cells, your doctor will discuss specific treatment options.

How can I prevent cervical cancer?

Receiving the HPV vaccine is the only way to protect against cervical cancer. Each year in the U.S., 13,200 women are diagnosed with cervical cancer. This number has decreased since the introduction of the HPV vaccine.

What happens if I get cervical cancer?

If you are diagnosed with cervical cancer, you will be referred to a gynecologic oncologist—a doctor who specializes in cancers of the female reproductive system. Most cases require chemotherapy, and some require radiation as well. Surgery may be a treatment option.

Get more facts about HPV

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Ask a CHOC Doc: How can I safely gain weight?

Question: I am underweight, and don’t feel like eating sometimes. I am tired of not being able to gain weight. I tried talking to my doctor about it, but she didn’t give me a chance to explain; all she said was to eat more. When I was diagnosed with depression I wouldn’t eat as much and a part of that stayed with me I suppose. I don’t get hungry even when I want to eat. There is this supplement called Apetemin that helps people gain weight by making you feel hungry and slowing down your metabolism. Would you recommend it? -Anonymous

Answer:

Identifying and maintaining a healthy weight is an important discussion, and a common one I have with teen patients. Here’s what I usually discuss with my patients:

  1. How to determine a healthy weight

To determine whether someone is medically underweight, doctors use a tool called Body Mass Index, or BMI. This is a calculation that uses height and weight to estimate how much body fat someone has. Doctors use it to determine how appropriate a someone’s weight is for a certain height and age. There are online tools to help you calculate your BMI at home.

BMI is the most common measure about what weight is appropriate for someone’s height—but there are exceptions to this guideline. BMI is not always the best measurement for everyone. To determine a healthy weight for you, have a conservation with your doctor. Work with them to identify a healthy weight.

  1. How to know when skipping meals is a cause for concern

It’s ok if you skip a meal every now and then because you’re stressed or sick. That’s normal. Some days our bodies are hungrier than others, and that’s ok. If skipping meals becomes a regular thing, or if you’re unable to complete meals on a regular basis, talk to your doctor. If you’re also experiencing stomach problems like vomiting or diarrhea, see your doctor.

  1. How appetite plays into mental health

If this feeling of not being able to eat accompanies sadness, worry or sadness, speak to your doctor. You can also speak to a trusted adult like a school counselor who can help you find a psychologist or other mental health professional. Depression and anxiety are common problems that can cause changes in appetite and eating. These are chronic problems that can have times where they’re pretty severe, and other times where symptoms are not present, but they can still affect your appetite or mood. It’s important to have an ongoing conversation with your physician about your mental health. They can help you find the resources you need, including a psychologist.

  1. Be cautious with supplements

If you are underweight and having trouble eating, your doctor may recommend seeing a nutritionist for recommendations on food and supplements. Always discuss supplements with a provider, as they are not well regulated and need to be taken under the supervision of a doctor or nutritionist.

Appetite stimulants may be prescribed, but can come with adverse effects, including abnormal changes to the immune system, nausea, stomach problems and fatigue.

terez-yonan-do

-Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

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HIV Symptoms and HIV Prevention

By Dr. Sora Song, pediatric resident at CHOC Children’s and Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

HIV (Human Immunodeficiency Virus) is a virus that can spread through certain body fluids eventually attacking the body’s immune system and because of its potential severity, everyone who is sexually active should be aware of HIV symptoms and how to prevent HIV. HIV is a life-long illness, but people living with HIV have many different treatment options. Anyone who is HIV-negative and at risk of contracting the virus should know what they can do to decrease their chances of becoming infected PrEP and PEP, in addition to practicing safe sex, are options available for preventing HIV infection.

HIV symptoms in men and HIV symptoms in women

How long it takes for HIV/AIDS symptoms to appear can vary from person to person. Some people could look and feel healthy for years while they are infected. It is possible to infect others with HIV even if you have no symptoms. This means that getting tested regularly is important, even if you feel fine.

When a person’s immune system is overwhelmed by AIDS, they might notice:

  • Extreme weakness or fatigue
  • Rapid weight loss
  • Frequent fevers that last for weeks with no explanation
  • Heavy sweating at night
  • Swollen lymph glands
  • Minor infections that cause skin rashes and mouth, genital and anal sores
  • White spots in the mouth or throat
  • Chronic diarrhea
  • A cough that won’t go away
  • Trouble remembering things
  • Severe vaginal yeast infections that don’t respond to usual treatment
HIV prevention: PrEP

PrEP stands for pre-exposure prophylaxis. PrEP can stop HIV from infecting your body and spreading throughout your body. It is not a vaccine. PrEP is a pill that is actually a combination of two HIV medicines (tenofovir and emtricitabine) under the trade name Truvada®. This medicine has been approved for daily use. PrEP can cause side effects like nausea in some people but these generally improve over time. These side effects are not serious or life-threatening.

PrEP is taken before HIV exposure. It is taken every day. This is for people who don’t have HIV and are at very high risk for infection. It is recommended for those who:

  • have a sex partner who is HIV positive
  • have sex with a partner whose HIV status is unknown
  • are not in a mutually monogamous relationship with a partner who tested HIV-negative
  • have injected drugs or have shared needles in the past six months

For those at very high risk for HIV infection, PrEP can greatly lower your risk of infection if taken daily.

When used as directed, daily PrEP pills can reduce the risk of getting HIV from sex by more than 90 percent and from injection drug use by more than 70 percent. PrEP can be very effective if used as directed but is much less effective if not taken consistently. PrEP can only be prescribed by a health care provider. Your risk of getting HIV from sex can be even lower if you combine PrEP with condoms and other methods of prevention. PrEP should be used daily and for as long as there is risk for HIV infection.

HIV prevention: PEP

PEP stands for post-exposure prophylaxis. It is a method of HIV prevention after possible exposure. It should be started within 72 hours (three days) after possible exposure to HIV. PEP has little or no effect in preventing HIV infection if it is started later than 72 hours after HIV exposure.

Someone using PEP will take a combination of medicines, usually all in one pill, that fights HIV infection. This pill can cause some side effects like nausea, in some people. These side effects are not serious or life threatening. PEP is only used for 28 days after possible HIV exposure. It is not a substitute for other HIV prevention methods, such as pre-exposure prophylaxis (PrEP). Someone can switch to PrEP right away after completing PEP for continued HIV prevention.

PEP is for people who are HIV-negative or don’t know their status and, in the last 72 hours, may have been exposed to HIV:

  • during sex
  • at work through a needlestick or other injury
  • by sharing needles
  • during a sexual assault

PEP can help prevent HIV infection when taken correctly, but it is not 100 percent effective. If you may have been exposed to HIV in the last three days, or if you aren’t sure if you have been exposed to HIV or not, talk to your healthcare provider immediately. Start PEP as soon as possible to give it the best chance of working. Individuals should continue to use condoms with sex partners and practice safe drug injection practices (for example, using your own sterile needles) while taking PEP. These different methods can reduce the chances of transmitting HIV to others if you do become infected while you’re on PEP.

Testing while Preventing HIV

Anyone who uses PrEP or PEP needs to have close follow-up with their medical provider to get testing for HIV and other sexually transmitted infections. PrEP users should have repeat testing done on a routine basis because if someone becomes HIV positive, they need additional blood tests as well as different medications for HIV treatment. PEP users need to see their providers more often to ensure the medication is working.

Talk to your health care provider about whether PrEP or PEP is right for you.

Learn more about adolescent medicine at CHOC.

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Teen Marijuana Use on The Rise: What Parents Should Know

By Dr. Jennie Gary, pediatric resident at CHOC Children’s, and Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s

Did you know that 45 percent of all high school seniors have tried marijuana? Marijuana use now exceeds cigarette use among high schoolers, according to a recent study by the National Institute on Drug Abuse. Despite the recent legalization of recreational marijuana use in California, parents and teens should be aware that recreational use of marijuana is still illegal for ALL minors under 21 years old.

What does the legalization of marijuana mean for our children and teens? Youth will now have easier access to marijuana, possibly through relatives, friends, or the use of fake IDs. With these new laws now in effect, how your child or teenager views marijuana may change as well. As advertising for and usage of legal marijuana becomes more widespread in our communities, adolescents may be less likely to understand the real dangers of marijuana use.

Many people feel that using marijuana is safe, but there are serious concerns. Parents should be aware of signs of acute marijuana intoxication in teenagers. These include slurred speech, red eyes, dry mouth, increased appetite, and changes in mood such as euphoria or anxiety. Other problematic effects that can come with even occasional use include impaired judgment and slowed reaction time, which can lead to unintentional injury or motor vehicle accidents. Frequent use of marijuana can cause long-lasting effects including learning difficulties, impaired brain development, lower IQ, lung disease, addiction and mental health disorders. As medical providers, we worry about marijuana as even one time use of marijuana can trigger a psychotic break in someone with a genetic predisposition for mental illness.

Medical marijuana refers to the use of the marijuana plant or its extracts (called cannabinoids) to treat symptoms of certain illnesses, such as nausea in chemotherapy patients. The U.S. Food and Drug Administration (FDA) has not approved marijuana itself as a medicine. However, there are currently two FDA-approved cannabinoid medications. For parents who use marijuana for medical or other purposes, it is important to always keep all marijuana and marijuana-containing products hidden in child-proof containers that are out of reach to help prevent accidental ingestions.

Talk with your middle school and high school-aged children about marijuana and other drugs. We encourage open and honest discussions between you and your child. In general, it is best to discuss general drug use scenarios and not to share your own experiences with drug use with your children. Be sure to speak to your child’s provider about screening for substance use if you have any concerns about your child.

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What Parents Need to Know about Teens and Emergency Contraception

By Dr. Terez Yonan, adolescent medicine specialist at CHOC Children’s and Razleen Brar, pediatric resident at CHOC Children’s

Compared to other industrialized nations, the U.S. still has one of the highest teen birth rates in the world. Fortunately, these rates have decreased significantly in the last 20 years – this is largely due to the increased availability and ease of prescription birth control.

Another resource available to help prevent unintended pregnancy, emergency contraception (EC) is clouded in misinformation and myths. EC comes in three different forms, all of which help prevent pregnancy when used correctly. The most important things to know about EC are that these methods do not harm an existing pregnancy, do not cause abortion, and do not protect against sexually transmitted diseases.

There are many reasons why one may need EC to prevent unintended pregnancy:

  • after unprotected vaginal sex
  • condom slippage or breakage that leads to semen exposure
  • contraceptive failure
    • in the first week of starting a new birth control method if a backup method (condoms) is not used
    • missing three consecutive doses of active birth control pills (not placebo or “sugar” pills)
    • replacing birth control patch late or patch falling off for more than 24 hours
    • forgetting to replace the vaginal birth control ring or leaving it out for more than three hours
    • delayed or missed birth control injection
    • IUD or hormonal implant (Nexplanon ®) dysfunction
  • sexual assault

With each of these instances, EC should be used as soon as possible or within 72-120 hours (3-5 days). EC can also be safely used by transgender men while on testosterone, as testosterone can decrease ovulation but does not work as a birth control method; EC should not alter treatment with testosterone.

Emergency Contraceptive Options:

Medications

The levonorgestrel pill (1.5mg oral pill: Plan B ®, Plan B One Step ®, Next Choice ®, commonly referred to as “the morning after pill”) is very effective in preventing pregnancy. This method carries limited side effects. This EC is available in most medical offices and by prescription at any age. It is also available over-the-counter without a prescription at any pharmacy to females 17 years or older or males 18 years or older (with proof of age provided). Over-the-counter costs range from $30-60. A pregnancy test is not needed before the use of levonorgestrel.

This pill is about 89 percent effective at preventing pregnancy. It is most effective in the first 72 hours (3 days), but can be used up to 120 hours (5 days) after sex to prevent pregnancy. Its effectiveness is also decreased in those who are overweight or obese. Alternative methods, listed below, are recommended for those whose BMI is over 25.

The effectiveness of levonorgestrel also decreases when someone has had multiple episodes of unprotected intercourse and has used  the pill multiple times in the past. EC is not a good option for birth control. Talk to your medical provider about finding an effective method of birth control that meets your needs.

Ulipristal (Ella ®)  is more effective than the levonogestrel pill for preventing pregnancy and is an option for those who are overweight or obese (BMI over 25). This EC requires a pregnancy test and a prescription. Ulipristal has increased potential adverse side effect including nausea, vomiting andabdominal pain compared to the levonorgestrel method. If you’re taking this form of EC because your primary method of birth control has failed, the pill, patch, or vaginal ring has to be paused (not taken or used) for five days, as these methods can interfere with this EC’s effectiveness in preventing pregnancy. On day six, birth control can be restarted with condoms as a backup method.

Before the levonogestrel pill or ulipristal were perfected, people were encouraged to use their prescribed oral birth control pills to prevent pregnancy when they needed EC. This was called the Yuzpe method. Medical providers no longer recommend increasing doses of the birth control pill as an EC as this was found to cause uncomfortable side effects, and there are now more effective methods.

Intra-uterine Device

The copper intra-uterine device (Paragard ®) is the best option for EC as it is over 99 percent effective at preventing pregnancy when EC is needed, and it provides long-term pregnancy prevention for up to 12 years. It can be used as EC when placed within five days of unprotected sexual intercourse. This IUD is placed by a trained medical provider during an outpatient procedure. Close follow up with your medical provider is a must.

The side effects of this method are few, but include: uterine cramping (which feels like bad menstrual cramps) during and up to 24-48 hours after the IUD is placed, and heavier menstrual bleeding and menstrual cramps for the first two or three menstrual periods after placement. Ibuprofen and heating pads are recommended at-home treatments for these side effects.

Talk to your doctor for more information and for any questions regarding safe sex practices, sexually transmitted infection testing, birth control options, and emergency contraception. See your medical provider immediately after under protected or unprotected sexual activity for emergency contraception. Your medical doctor may also provide a prescription for emergency contraception to use as instructed in the future.





Learn more about Adolescent Medicine




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  • Can HPV really lead to cervical cancer?
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