Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

Melanie Cole, MS: I'm Melanie Cole. And joining me today is Dr. Suzanne Pastore. She's an assistant attending obstetrician-gynecologist at New York Presbyterian Hospital Weill Cornell Medical Center, and she's an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College Cornell University. And she is here today to talk to us about human papillomavirus, HPV, helping patients understand this sexually transmitted infection.

Dr. Pastore, thank you so much for joining us today. You know, this HPV has been all over the news for years now, with the vaccine and questions about it. So, I'd like you to jump right in with what it is. What is HPV? How common is this infection?

Suzanne Pastore, MD: Sure. First, I'd like to say thank you for having me, Melanie. HPV is a topic that needs discussion, so I'm happy to be doing this podcast for you and for our patients. So, HPV is human papilloma virus, and it is very common. In fact, it is the most common sexually transmitted infection in the United States, and 80% of sexually active women will have HPV at some point in their lives. Thankfully, most women clear it before it can cause cancer.

Melanie Cole, MS: Wow, that's really common. Those are some astounding statistics. So, you mentioned cancer. What kind of problems or cancer can the HPV infection cause?

Suzanne Pastore, MD: So in women, HPV causes genital warts, which are benign growths most commonly on the vulva, but it is also associated with certain cancers and pre-cancerous lesions. Virtually, all cervical cancer is caused by HPV and HPV can also cause vulvar, vaginal, anal and oropharyngeal cancers in women.

Melanie Cole, MS: Wow. So, how do people get this infection? How is it transmitted, Dr. Pastore?

Suzanne Pastore, MD: HPV is transmitted by skin to skin contact, also, vaginal, anal or oral sex. And typically, it has no symptoms, that's why we do a Pap and HPV tests to screen for pre-cancerous changes on the cervix before it ever gets to cancer.

Melanie Cole, MS: Dr. Pastore, if a woman is engaging in sexual activity or a man, would they see those warts? Would they see it and know and say, "Oh, yikes"? Or is it something that doesn't really show itself?

Suzanne Pastore, MD: Genital warts can be seen on the vulva. But usually, we don't see warts on the cervix, sometimes you can see it. But majority of the time, HPV is just picked up on the Pap smear in routine screening.

Melanie Cole, MS: So if a woman is engaged in sexual intercourse with a man, would she see it on his penis?

Suzanne Pastore, MD: Not always. Some men can have genital warts, but the majority of men are transmitting HPV to a female unknowingly. There's no FDA approved test in men, so they're not being screened.

Melanie Cole, MS: That's so interesting that men aren't screened. And before we discuss the vaccine, are there treatments for existing HPV? So if a woman tests positive for this at her gynecologist, what then?

Suzanne Pastore, MD: This is a good question. Unfortunately, there is no treatment for HPV itself. So, most women with a competent immune system will clear the virus in 12 to 18 months. However, a certain percentage can have a latent infection that can show up again later in life. There are no oral medications to treat the virus. So, genital warts can be treated with topical medications or cryotherapy, which is freezing, or they can be removed surgically. Cervical dysplasia, which is a pre-cancerous condition of the cervix, is treated surgically as well.

Melanie Cole, MS: Do condoms work to protect from HPV?

Suzanne Pastore, MD: Unfortunately, they're not fully protective because it can be transmitted skin to skin. It may decrease transmission, but it does not eliminate the possibility of getting HPV.

Melanie Cole, MS: Which is why we are here now to discuss this vaccination, which is really a game changer in this world of cervical cancer and HPV transmission. So, I'd like you to tell us, Dr. Pastore, about Gardasil. When was this developed? What do we know about the efficacy of it?

Suzanne Pastore, MD: Gardasil was initially approved in 2006. The initial Gardasil vaccine was a quadrivalent vaccine, meaning it covered four strains of the virus. The two most common that cause cervical cancer, which are 16 and 18, and the two most common that cause genital warts, which are 6 and 11. In 2014, the FDA approved Gardasil 9, which covers nine strains of the virus. The two most common strains that cause genital warts and seven other strains, which can cause cervical, vulvar, vaginal, anal, oropharyngeal and other head and neck cancers. As for efficacy, it is 99% effective when administered to women before HPV exposure, so that's why we need to be vaccinating our children.

Melanie Cole, MS: That's incredible. What do we know about the safety of the vaccine? You know, people have so many questions about vaccines today. And I trust the experts and people really that are much smarter than I came up with this. Tell us a little bit about the safety.

Suzanne Pastore, MD: The HPV vaccine is safe. It's not a live virus. All HPV vaccines use virus-like particles, which like mimic the viral capsid and don't contain any genetic material. Millions of people around the world have gotten the HPV vaccine without serious side effects. I'd say the most common side effects are like any vaccine, soreness or redness at the injection site. In adolescence, there's a small risk of fainting, so we usually observe them for 15 minutes after administration to make sure there's not any problems.

Melanie Cole, MS: Well then, who does need to be vaccinated? You mentioned briefly that women need to be vaccinated before they become sexually active or before they acquire the HPV virus. Tell us a little bit about the age, when should kids get vaccinated and the rationale again for starting that early.

Suzanne Pastore, MD: The HPV vaccine was recommended for women age nine through 26. Then, it was approved for boys. And now, the HPV vaccine is approved for women and men age nine to 45. So, the target age is age 11 to 12 to vaccinate children prior to exposure, so prior to sexual contact basically. But you can give it later to try to play catchup.

Melanie Cole, MS: Okay. So, this is both boys and girls now at this age, and why are two doses recommended for nine to 14-year-olds while an older adolescent needs three doses? Do they have the rationale for that?

Suzanne Pastore, MD: Yes. So when you're younger, you have a more robust immune response. So, the immune response in this age range provides antibody levels that are equivalent to or greater than those who received three doses at the age of 15 and older. So, another reason to vaccinate early, two shots instead of three.

Melanie Cole, MS: Absolutely makes a lot of sense. Now, do women who've been vaccinated still need to have a Pap smear? Because now this is really, as I said at the beginning, a game changer for cervical cancer, but now it's also changing recommendations from ACOG and such for Pap smear recommendations. I know that mine are fewer and further between than they used to be. And so as far as screening for cervical cancer, and Dr. Pastore, while you're telling us about this, one thing that we should note is that the pap smear was actually developed at Weill Cornell university.

Suzanne Pastore, MD: That's true. So, Dr. Papanicolaou by inventing the Pap smear decreased cervical cancer deaths worldwide. Vaccination status has not changed the Pap screening guidelines. It may someday, but it has not yet. They're age-based and the Pap screening guidelines keep changing, I feel like every few years. Although Gardasil covers nine strains of the HPV virus, there are other strains that can still cause cervical cancer. And in women in this older age range, age 30 to 65, most gynecologists do co-testing, which is Pap testing plus the HPV test. The other options are to do Pap alone every three years or HPV testing alone every five years. But the new PAP guidelines, most of us are doing co-testing, which is looking for the HPV, high-risk HPV strains plus cytology every five years, because it's the best detection.

Melanie Cole, MS: That's what I get. I got that co-testing just a couple years ago, so now I wait another year or something to get my Pap smear. So, it can be a little confusing and thank you so much for clearing that up. Now, what should young men or women do if they didn't receive the vaccination or if they didn't finish their series? So, are they considered not protected? Can they finish it? Up to what age can you get vaccinated?

Suzanne Pastore, MD: Obviously, they should see their healthcare provider and get vaccinated. If they didn't finish the series, they can complete it. They don't need to restart it. In the United States, we're not doing a great job of vaccinating against HPV unfortunately. The vaccination rate is around 50% among women, so we need to do a better job.

Melanie Cole, MS: We certainly do. Now, pediatricians are talking to their patients every day about this, and I know that you are an obstetrician gynecologist. But for the pediatricians that are looking at these kids and saying to the parents, to their 11 and 12-year-old kids and even younger, "This is the vaccine I want to give," they're getting a lot of questions from parents. How can they help parents? And explain the importance of this vaccine to their patients. Tell us a little bit about that conversation.

Suzanne Pastore, MD: Okay. So, pediatricians are used to giving vaccines to prevent disease, so they are very good at having these conversations. They need to explain that HPV is a serious disease and it is important to protect your children from HPV before they are at risk of exposure. The HPV vaccine reduces the risk of genital warts and cancer up to 99%. I think I said that before, I'm just emphasizing it.

Melanie Cole, MS: No, it's good to emphasize it. We need to reinforce these things. And now, my last question to you, and I'd like you to offer your best advice, but as parents are explaining this vaccine to their children, again, this is something that's been a little controversial because some parents think that it's going to give their kids this, you know, way forward. But speak to parents now, Dr. Pastore. What would you like them to know about the importance of this vaccine? Discussing it with their children and discussing any questions that they have with their family physician.

Suzanne Pastore, MD: I would say to the parents, I would start the conversation in this way, we are so lucky in this country to have access to a vaccine that can help prevent cancer. This vaccine is proven to be safe and effective, but it needs to be given before exposure. So, not all children are going to be forthcoming with their parents as to when they're becoming sexually active. It's the most effective way to protect your child from getting the disease, but also prevent them from spreading it to others.

Melanie Cole, MS: That's so important and it's actually a vaccine that can prevent cancer. That's what really amazes me about this. And Dr. Pastore, thank you so much for joining us today and telling us about this. It was really an important episode and so informative. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify and Google Podcasts. And for more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out Kids Health Cast. So many great interviews there. I'm Melanie Cole. Thanks so much for joining us today.

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