HPV - question not asked or mentioned???

[Please Help Me - Really Depressed]

Hi Doc,

Quick question, I have read here and learned lots about HPV. But have a question  based on what I have read on the internet, that hasn't been asked. I was reading  on the internet about HPV and its related cancers.

1. Is there any reason why SOME doctors are recommending anal pap tests for  gay/bisexual men, or women who practice anal sex especially if they are HIV  positive?

2. Since there are so many men and women that have never had anal sex, but have  anal warts, I have yet to read or hear about doctors recommending that they also  have a anal pap test?

3. I hear that in the general population that the risk of anal cancer is somewhere like 7-9 people per 1,000,000. Is this the main reason why there is no testing for the general population, even with so many people who have anal warts.

Thanks so much doc.

[H. Hunter Handsfield, M.D.]

Good questions.  Paps in gay men have been addressed on this forum, although not for some months.

1) Although some researchers and other experts have recommended routine anal paps in gay men, there are no recommendations on it from any authoratative source (CDC, etc).  There are too many questions about exactly how to do the procedure, the meaning of cellular abnormalities that may (or may not) lead to cancer, treatment (not nearly as straightforward as for women with cervical infection), and costs.  Most authorities--including the most productive researchers on anal HPV and paps in gay men--agree that anal paps remain a research procedure and that routine use by health care providers is not yet ready for prime time.  CDC's new STD treatment guidelines--which probably will be released later this week--specifically say that anal paps should not be routine until such qeustions are resolved.  There are articulate voices on the other side of the question, but the weight of expert opinion is clear.  It has nothing to do with homophobia, in my opinion--although some people undoubtedly will make that charge.

2) The anus and rectum appear to be equally susceptible as genital tissues to the genital HPV types (more accurately called "anogenital" types).  The answer is obvious in women; genital secretions are regularly in contact with the anus.  Indeed it is true that anal warts occur fairly frequently in straight men and in non-bottom gay men, but to my knowledge no studies have looked at anorectal infection with high-risk (non-wart-causing) HPV types in such persons.  Autoinoculation or other anal area contact during sex is assumed to be the explanation

3) I don't know the rate of anal cancer in the general population; your figures may be correct.  But that's not the reason anal paps are not recommended.  In gay men, the rate of anal cancer is 30-40 cases per 100,000, i.e. 30-40 times the rate in the general population.  That is a high rate, about the same as cervical cancer back in the days before routine pap smears in women.

Regards--  HHH, MD

[Please Help Me - Really Depressed]

1. So hetrosexual men and women that do have anal warts, don't really need to worry about anything other than treating them if they bother them (whether it be physical or psychological?

2. Also in general for hetrosexual men this would put them at no higher risk of contracting anal cancer then the average sexually active hetrosexual man with no visible warts?

Thanks a bunch doc.

[H. Hunter Handsfield, M.D.]

1) Most people with symptomatic anal warts should have them treated.  2) Not known.  No obvious increased risk for anal cancer, but to my knowledge never studied.

HHH, MD

[Please Help Me - Really Depressed]

Last question on this i promise, since most doctors say that warts in normal people with healthy immune systems will go away, is there any change that anal warts can spread into the rectum or colon. If so, then why do most people say just leave them for the body to clear them out?

Like in my case, all my external warts went away on their own, but i have a few internal ones, and the doc said just to leave them, any reason that these won't grow bigger or spread, they have been there for a year now and haven't changed?

Again, last question i promise after this i will speak to my health care provider on this, its just that you're probably way more knowledgeable on these questions than they are.

Thanks so much.

[H. Hunter Handsfield, M.D.]

There always is conflicting advice from providers, including defferences between qualified experts, when data are lacking and only clinical judgment is available for guidance.  That's the situation here.  To my knowledge, there are no data to show that getting rid of anal warts reduces the likelihood of internal infection.  By the time anal warts appear, probably most people already have internal HPV infection anyway.  And eradicating internal rectal HPV infection probably is impossible.  It's hard even to identify all individual warts, and the HPV infection always involves normal looking tissue where warts are absent.  So treatment often is not effective in resolving warts and probably is never effective in eradicating the virus.  And it can be painful, inconvenient, and expensive.  Thus most experts agree that watchful waiting is the best strategy.  For all these reasons, in my STD clinic we usually do not even do an internal exam in people with anal warts, because it doesn't change our management or our advice to the patients.

HHH, MD

[Please Help Me - Really Depressed]

Thanks so much doctor.

[H. Hunter Handsfield, M.D.]

I deleted your attempt at at third (!!) new thread on the same topic.  See my reply in your 7/25 thread.  See MedHelp rules, maximum 2 questions in 6 months.

HHH, MD