Non-sexually-transmitted HPV/cervical dysplasia?

[PabsMD]

Today I saw a 30 y/o WF who claimed she was a virgin, but had high-grade cervical dysplasia (based on her pap smear results). Her colpo results came back as low grade dysplasia.

Is it possible to contract HPV without sexual contact or was the patient lying? I've never heard of this...

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[IHeartNerds]

Yes. There are reports of transmission on towels, bedsheets, underwear from laundry, etc. They are very, very, very rare.

My guess is that she interpreted "virgin" differently from you. Or for that matter, she could be completely not sexually active in any way with a partner, but got it from a sex toy or something that she or someone else managed, who knows how, to contaminate.

 

[mjl1717]

Geez--the infectious disease world is getting rough!!....

Id like to know what serotype it is?...Maybe the vaccine would have helped?

[as stated patients lie about STD's big time, its too embarrassing]
[it scares the heck out of me NOT to have safe sex!]


Second issue:
This is important because there REALLY is a lot of cervical dysplasia out there..--Its common!!!!!!!!

 

[PabsMD]

Geez--the infectious disease world is getitng rough!!....

Id like to know what serotype it is?...Maybe the vaccine would have helped?

[as stated patients lie about STD's big time, its too embarrassing]
[it scares the heck out of me NOT to have safe sex!]

I'm not sure what the serotype was... I didn't have access to the chart as I'm just shadowing a doctor this week for a preceptorship. Does make you wonder...

 

[PabsMD]

Yes. There are reports of transmission on towels, bedsheets, underwear from laundry, etc. They are very, very, very rare.

Scary thought...

My guess is that she interpreted "virgin" differently from you. Or for that matter, she could be completely not sexually active in any way with a partner, but got it from a sex toy or something that she or someone else managed, who knows how, to contaminate.

It's entirely possible there was a "communication gap" regarding the term 'virgin.' Perhaps she contracted it via oral sex and didn't mention this as a possibility during her history.

 

[Blesbok]

If you hear hooves in the distance...


There is a chance that she got it from a non-sexual act, but there is a MUCH better chance that she is lying.

 

[mjl1717]

To me it appears that mutagenesis has an affinity and occurs often in the cervix and in the breast.








[Right now Im fighting with this medical saga as hard as I can!]

 

[GreenShirt]

HPV infects the skin of the vagine, rectum, penis, etc. She may not have had sexual intercourse but may have had contact with those areas in other ways.

 

[Habeed]

What I want to know is how she was a virgin at 30. I mean, seriously, her peak breeding years are nearly over!

What co-morbidities did the patient have?

 

[IHeartNerds]

What I want to know is how she was a virgin at 30. I mean, seriously, her peak breeding years are nearly over!

What co-morbidities did the patient have?

This is why patients lie to their doctors about embarrassing things.

Maybe she was a nun.

Totally agreeing with my prior post and that of PabsMD, many/most patients would not consider oral sex to be losing their virginity.

 

[mjl1717]

This is why patients lie to their doctors about embarrassing things.

Maybe she was a nun.

Totally agreeing with my prior post and that of PabsMD, many/most patients would not consider oral sex to be losing their virginity.

One of the important qs to ask during a history/interview could be:

seriously "what actually do mean by sex" (main point- the obvious is not always obvious). Well this is off the subject, but especially during an infertility workup..

 

[mudphudwannabe]

Also consider that she could have been raped and does not feel comfortable talking to new doctors/medical students about it.

 

[njbmd]

Today I saw a 30 y/o WF who claimed she was a virgin, but had high-grade cervical dysplasia (based on her pap smear results). Her colpo results came back as low grade dysplasia.

Is it possible to contract HPV without sexual contact or was the patient lying? I've never heard of this...

Yes. There are reports of transmission on towels, bedsheets, underwear from laundry, etc. They are very, very, very rare.

My guess is that she interpreted "virgin" differently from you. Or for that matter, she could be completely not sexually active in any way with a partner, but got it from a sex toy or something that she or someone else managed, who knows how, to contaminate.

The information given by IHeartNerds is very good here. One thing that you have to consider is that HPV is a virus and you have to thing about transmission of viruses. The other thing that you need to consider is that when you are dealing with any matters of sexual behavior or any reproductive system pathology/health, many people have different interpretations as to what they have actually engaged in. There are plenty of former prostitutes who are currently "virgins". This is not to say that your patient was lying but to say that you need to be absolutely sure that both you and the patient are on the same page when it comes to reproductive health.

I would also tell you to look for other means of acquiring cervical dysplasia besides HPV infection too. Remember the daughters of mothers who took DES? DES is an synthetic estrogen that many women were exposed to in utero. While DES was taken off the market here in the US in the 1970s, there were women exposed to this pharmaceutical in other countries. There are now granddaughters of DES exposed mothers who are currently being studied now and found to have changes in reproductive organ structures and histology.

Finally, you are not making a judgment about your patient as a person but trying to obtain the most accurate information so that you can take care of her health. This is the attitude that you want to approach any disease that can be transmitted by venereal methods. In this country, many people are ashamed (or just plain in denial) about their sexual behavior. This can be problematic but it can also be overcome with sensitivity and good questioning.

At any rate, no matter how your patient acquired cervical dysplasia (or HPV if that's the case), it has to be treated and your patient has to be educated so that she does not end up with a more potentially life-threatening problem. It's patients like the above that make medicine interesting. You put the pieces of the puzzle together and get the best outcome that you can.

 

[diosa428]

Yeah I guess the real question is - is she HPV+? Perhaps you've got a case report here of cervical dysplasia not being caused by HPV.

In terms of HPV causing cervical dyplasia and people who suggested that there are other ways to contract HPV - doesn't the HPV have to be spread by direct contact? In other words, I could see how someone could get HPV on other areas... but wouldn't something have to be put inside the vagina (either sex toy or penis) in order to get an HPV infection of the cervix?

 

[lilnoelle]

are there other causes of cervical dysplasia than HPV?
I actually know someone like this. I know her well enough that I'd believe her if she told me she had never had a sexual relationship prior to her dysplasia and I know at the time that was her story (8 years ago) but I never had any reason to have that "heart to heart."

 

[diosa428]

are there other causes of cervical dysplasia than HPV?
I actually know someone like this. I know her well enough that I'd believe her if she told me she had never had a sexual relationship prior to her dysplasia and I know at the time that was her story (8 years ago) but I never had any reason to have that "heart to heart."

I don't really know... I think I remember the stat being that the *majority* of cases of cervical dysplasia are caused by HPV, but I don't think anyone has ever shown that all cases are caused by HPV, simply because HPV testing hasn't really been routine... but I also am not sure of anything else that has been shown to be linked to cervical dyplasia in the absence of an HPV infection... I'm not sure if there have been cases where HPV testing has been done in the case of cervical dysplasia and been negative, but it would be interesting to hear if anyone knows the answers.

 

[masterofmonkeys]

Considering that other things are known to increase the risk of cervical cancer substantially (like cigarette smoking), I don't see why it wouldn't be possible to be HPV negative and have cervical dysplasia.

 

[PabsMD]

I do not know what co-morbidities she has.

She was a new patient and may indeed have felt ackward about discussing items of this nature with the doctor and a medical student. The doctor did have documentation that she is indeed HPV+. I suppose there is always the chance that this is a case of a false positive.

No, she was not a nun- she was a highly educated woman with a professional degree.

Also, I asked not to judge the patient and accuse her of being untruthful. If a patient chooses not to disclose information to her health providers it is certainly her call, but it can of course interfere with treatment. I was simply curious as to whether HPV could be transmitted via routes other than sexual contact as I've never heard of this.

The doctor I was with chose not to ask any questions about the dysplasia, HPV, or sexual history. She simply performed a pelvic exam and repeated the pap smear.

Thanks for all of the input; I definitely thought this was an interesting case.

 

[turkeyjerky]

I'm surprised to hear that HPV can be passed throught laundry (reminds me of the seinfeld episode where his girlfriend thought she got gonorrhea from riding a tractor), but it can definately be passed through manual contact with genitalia, ie: "finger-banging". (virus particles are transmitted from the partner's genitalia to their hands to the patient's vagina)

So it's entirely possible that the woman was still a virgin, but had been infected with HPV.

 

[mjl1717]

I'm surprised to hear that HPV can be passed throught laundry (reminds me of the seinfeld episode where his girlfriend thought she got gonorrhea from riding a tractor), but it can definately be passed through manual contact with genitalia, ie: "finger-banging". (virus particles are transmitted from the partner's genitalia to their hands to the patient's vagina)

So it's entirely possible that the woman was still a virgin, but had been infected with HPV.

Yes , that papilloma virus even LOOKS like it may withstand rain, snow, or sleet.
[exaggeration for a Friday night]

 

[diosa428]

Considering that other things are known to increase the risk of cervical cancer substantially (like cigarette smoking), I don't see why it wouldn't be possible to be HPV negative and have cervical dysplasia.

But don't things like cigarette smoking increase the risk of cervical cancer in the presence of HPV?

 

[Instatewaiter]

It's entirely possible there was a "communication gap" regarding the term 'virgin.' Perhaps she contracted it via oral sex and didn't mention this as a possibility during her history.

In my understanding of it, HPV's spread by direct contact so unless he was hung like a moose, I dont think it would reach all the way to her nether regions.

Yeah I guess the real question is - is she HPV+? Perhaps you've got a case report here of cervical dysplasia not being caused by HPV.

In terms of HPV causing cervical dyplasia and people who suggested that there are other ways to contract HPV - doesn't the HPV have to be spread by direct contact? In other words, I could see how someone could get HPV on other areas... but wouldn't something have to be put inside the vagina (either sex toy or penis) in order to get an HPV infection of the cervix?

At least in the south where I am, there is a segment of the population who wait to have sex until they are married but dont consider anal sex to be sex. So it could be that this girl had butt sex and then autoinocculated herself, kinda in the same way that many UTIs get started.

Or that she was too embarrassed to admit it to the doctor.

 

[SF Doc]

That's what my attending told me during my OB/GYN rotation...

 

[rhiannon777]

Don't forget you can have direct genital-to-genital contact without actual penetration, so a woman would probably still consider herself a virgin. That's also important to keep in mind as a mode of transmission among lesbians.

 

[StreamTeam]

Today I saw a 30 y/o WF who claimed she was a virgin, but had high-grade cervical dysplasia (based on her pap smear results). Her colpo results came back as low grade dysplasia.

Is it possible to contract HPV without sexual contact or was the patient lying? I've never heard of this...

The most likely answer is that she is lying. If she was truly a virgin at age 30, you wouldn't have been able to do a pelvic exam on her.

I have lost count of the number of patients I have seen who insisted that they couldn't be pregnant because they hadn't had sex in years. They even persist on lying after a postiive pregnancy test and ultrasound. My last pregnant "virgin" turned out to be having unprotected sex with two different guys each day. She burst out laughing when I first asked her if she was sexually active, like it was the most ridiculous thing I could have asked her.

 

[cpants]

There are tons of ways she could have gotten it without having a penis inserted inside of her. Or she could be lying. Also possible that she had sexual contact and doesn't remember (drunk or on drugs, molested as a child, etc.), or she was unable to discuss it due to shame. It really doesn't matter either way. Just educate, treat, move on.

 

[smq123]

The most likely answer is that she is lying. If she was truly a virgin at age 30, you wouldn't have been able to do a pelvic exam on her.

Pelvic exams don't tear open your hymen. And having an intact hymen doesn't prevent you from getting a speculum exam.

What kind of speculums are YOU using?!?!

 

[Doctor Bagel]

Pelvic exams don't tear open your hymen. And having an intact hymen doesn't prevent you from getting a speculum exam.

What kind of speculums are YOU using?!?!

Not to mention virgins don't necessarily have intact hymens.

 

[StreamTeam]

Hey I'm just trying to help you guys. I have seen three cases where patients claimed to be virgins, then sued their doctors when they had anesthesia or radiation when they were pregnant. One woman insisted that she never had sex with men, only other women. Two had false negative pregnancy tests. In the other case the pregnancy test was refused. But they sued their doctors anyway. Better document in the chart every patient who claims to be a virgin, or not be sexually active, BEFORE you order a CT scan or subject them to anesthesia. Document every refusal of a pregnanacy test. Otherwise you will be supporting her and her mentally or physically challenged child.

Not to mention virgins don't necessarily have intact hymens.

Other equally truthful statements are:

"I read it for the articles"

"I will call you in the morning"

"Of course this was my first time. I never felt comfortable enough with anyone to do that before."

 

[Depakote]

Hey, I'm just a MS2 here, but this isn't the first time I've thought Stream Team was posting something that sounded a little like BS. Caveat emptor.

 

[PabsMD]

The most likely answer is that she is lying. If she was truly a virgin at age 30, you wouldn't have been able to do a pelvic exam on her.

Agreed, patients do lie, but the hymen may be damaged by playing sports, riding a bike, tampon use, pelvic examinations, etc.

 

[themudphud]

Agreed. Patient is probably lying. HPV is responsible for essentially all known cases of cervical dysplasia/cancer. If you believe the patient, you should write a case report about it and see if it gets accepted.

 

[StreamTeam]

Hey, I'm just a MS2 here, but this isn't the first time I've thought Stream Team was posting something that sounded a little like BS. Caveat emptor.

I cant fault you for being an MS2. As someone who graduated medical school before most of the people on this forum were born, I find students idealism refreshing. I respect the time, effort, and good work you put into this forum as a moderator. But I can fault you for accusing someone of being full of BS on this board. You are a moderator, and should be trying to prevent flame wars not start them.

 

[howelljolly]

I dont see why the cervix can NOT undergo dysplastic change in the absence of HPV. In other words, a cervix that is not infected with HPV is not IMMUNE from dysplastic change.

So even thought an overwhelming number (all?) of patients with CA cervix also have HPV, -and- HPV has a causative relationship with cervical dysplastic change...
Isnt it possible, though improbable, that someone could get cervical dysplasia without having HPV infection?



Did the OP find out if this patient had an HPV infxn?

 

[OrangeA]

Lying. Duh? Are you that gullible? Good God!

 

[StreamTeam]

I dont see why the cervix can NOT undergo dysplastic change in the absence of HPV. In other words, a cervix that is not infected with HPV is not IMMUNE from dysplastic change.

So even thought an overwhelming number (all?) of patients with CA cervix also have HPV, -and- HPV has a causative relationship with cervical dysplastic change...
Isnt it possible, though improbable, that someone could get cervical dysplasia without having HPV infection?



Did the OP find out if this patient had an HPV infxn?

Yes, there are other ways of getting cervical cancer other than HPV.
The classic non HPV cause of cervical dysplasia was in utero DES exposure, associated with clear cell carcinoma of the vagina and cervix. (This is an unusual histology as most cases are squamous cell) This used to be a popular question on National Boards, and Specialty certification exams. But since they stopped giving pregnant women DES to prevent miscarriage a long time ago, I dont know if they even teach this or ask this on boards.

http://www.medscape.com/viewarticle/408885_4

 

[Doctor Bagel]

Yes, there are other ways of getting cervical cancer other than HPV.
The classic non HPV cause of cervical dysplasia was in utero DES exposure, associated with clear cell carcinoma of the vagina and cervix. (This is an unusual histology as most cases are squamous cell) This used to be a popular question on National Boards, and Specialty certification exams. But since they stopped giving pregnant women DES to prevent miscarriage a long time ago, I dont know if they even teach this or ask this on boards.

http://www.medscape.com/viewarticle/408885_4

Still taught and still on board exams.

 

[MsKrispyKreme]

I understand the small likelihood of a virgin having cervical dysplasia, but I certainly hope this doubtful attitude on SDN doesn't translate to patient interactions. The lady could be telling the truth.

It's no wonder that so many female virgins avoid gynecologists like the plague despite the need for annual exams.

If she was truly a virgin at age 30, you wouldn't have been able to do a pelvic exam on her.

This statement doesn't make any sense.

 

[mjl1717]

This statement doesn't make any sense.

You are right: From what I hear the first Pap and pelvic is done at age 18 or when patient first has sex..

 

[PabsMD]

Did the OP find out if this patient had an HPV infxn?

According to her chart, she had previously been diagnosed with HPV.

 

[howelljolly]

This statement doesn't make any sense.

It makes some sense. Some patients who are virgins even into their mid to late 20s will not get bimanual and speculum exams.

I wish people woudnt say this sort of thing to attendings that are more than twice their age. Kids these days have no manners.

 

[smq123]

It makes some sense. Some patients who are virgins even into their mid to late 20s will not get bimanual and speculum exams.

I wish people woudnt say this sort of thing to attendings that are more than twice their age. Kids these days have no manners.

It doesn't make sense because the implication is that an intact hyman somehow prevents a bimanual and speculum exam. That is emphatically not true.

You can do speculum exams on 12 year olds who have not been sexually active, if you have to. You will not break the hymen by doing a normal pelvic exam. Unless, for some reason, you are exceptionally rough or violent while doing your pelvic exam, a hymen shouldn't prevent you from doing one.

It's a flexible membrane, not a tough, fibrous piece of fascia.

 

[howelljolly]

It doesn't make sense because the implication is that an intact hyman somehow prevents a bimanual and speculum exam. That is emphatically not true.

You can do speculum exams on 12 year olds who have not been sexually active, if you have to. You will not break the hymen by doing a normal pelvic exam. Unless, for some reason, you are exceptionally rough or violent while doing your pelvic exam, a hymen shouldn't prevent you from doing one.

It's a flexible membrane, not a tough, fibrous piece of fascia.

I dunno.....? I'm not saying that you can not do it, Im saying that you may not be obligated to.... All I'm certiain about is that the doctor and patient can decide not to do it. And on second thought, I don't see why you wouldnt "be able" to do it. I really dont know.

 

[StreamTeam]

Still taught and still on board exams.

Thanks. Its good to know that at least one thing I learned in medical school isnt outdated!

 

[MsKrispyKreme]

^I've known of virgins (e.g. prone to ovarian cysts) as old as their mid-20s that get exams done in addition to young girls/children. In both cases, a smaller speculum + lube was used so I'm just curious as to what the difference is for a woman who is 30 and still a virgin?

I wish people woudnt say this sort of thing to attendings that are more than twice their age. Kids these days have no manners.

Such arrogance. I bet you're ranked last in your class, aren't you? That would explain your need to feel superior on an Internet forum.

Who gives a flying **** if he's an attending or an MS-0 like me or the homeless dude I give spare change to??? An untrue statement is an untrue statement.

Furthermore, you have no knowledge of anyone's background on here. There are PhD's, nurses, etc. who go into medicine so how do you know their level of knowledge doesn't supercede an attending -- especially if that attending probably hasn't had ob or gyn experience since his rotations 20 years ago?

 

[anon-y-mouse]

It doesn't make sense because the implication is that an intact hyman somehow prevents a bimanual and speculum exam. That is emphatically not true.

You can do speculum exams on 12 year olds who have not been sexually active, if you have to. You will not break the hymen by doing a normal pelvic exam. Unless, for some reason, you are exceptionally rough or violent while doing your pelvic exam, a hymen shouldn't prevent you from doing one.

It's a flexible membrane, not a tough, fibrous piece of fascia.

Actually, the "classic answer" for boards for the next step in the management of vaginal bleeding in a pre-menarchal girl is to do exam *under anesthesia* (then you're looking for foreign body e.g. toilet paper, trauma, signs of abuse, sarcoma botyroides, etc. etc.). I'm not sure what the age cutoff is, but if the vignette says 8 year old girl with vaginal bleeding, the answer is most definitely not 'speculum examination' if 'exam under anesthesia' is also an option.

Also, for the cigarette thing -- I always thought that it doesn't predispose, so much as ACCELERATE the rate of change of low grade => high grade... that 8-10 years for cancer may be much less in a smoker.

As for DES, I always thought that the classic pathology was cervical incompetence in addition to the clear cell adenocarcinoma, not cervical dysplasia? Well I guess it could cause an ASGUS pap, but I always thought that it was all about the multiple SAB's in the second trimester w/o contractions, leading one to suspect incompetent cervix secondary to a history of mom taking DES.

 

[howelljolly]

^I've known of virgins (e.g. prone to ovarian cysts) as old as their mid-20s that get exams done in addition to young girls/children. In both cases, a smaller speculum + lube was used so I'm just curious as to what the difference is for a woman who is 30 and still a virgin?




Such arrogance. I bet you're ranked last in your class, aren't you? That would explain your need to feel superior on an Internet forum.

Who gives a flying **** if he's an attending or an MS-0 like me or the homeless dude I give spare change to??? An untrue statement is an untrue statement.

Furthermore, you have no knowledge of anyone's background on here. There are PhD's, nurses, etc. who go into medicine so how do you know their level of knowledge doesn't supercede an attending -- especially if that attending probably hasn't had ob or gyn experience since his rotations 20 years ago?

Thanks for letting me know.

I have some questions.

1. What is StreamTeams specialty?
2. Does SteamTeam have a PhD?
3. How old am I?

 

[smq123]

Actually, the "classic answer" for boards for the next step in the management of vaginal bleeding in a pre-menarchal girl is to do exam *under anesthesia* (then you're looking for foreign body e.g. toilet paper, trauma, signs of abuse, sarcoma botyroides, etc. etc.). I'm not sure what the age cutoff is, but if the vignette says 8 year old girl with vaginal bleeding, the answer is most definitely not 'speculum examination' if 'exam under anesthesia' is also an option.

In real life, though, a 12 year old who may possibly have been sexually assaulted (without any outward signs, such as vaginal bleeding) and needs an STD test/bimanual....I may not necessarily want to do an EUA. Some parents don't want their children under anesthesia if at all possible. I'd also want to weigh the risk of anesthesia in this situation.

While I know what the board answer is, we were also discussing real life.

As for DES, I always thought that the classic pathology was cervical incompetence in addition to the clear cell adenocarcinoma, not cervical dysplasia? Well I guess it could cause an ASGUS pap, but I always thought that it was all about the multiple SAB's in the second trimester w/o contractions, leading one to suspect incompetent cervix secondary to a history of mom taking DES.

You're kind of stuck on the board answers.

- For DES exposure, the textbook pathologies are vaginal adenosis, cervical cancer (clear cell adeno), cervical atresia/incompetence, and t-shaped uterine cavities.

If they are going to develop clear cell adeno of the cervix, at some point they're going to have cervical dysplasia on pap....I'm not sure where the confusion lies.

 

[Tired]

Pelvic exams don't tear open your hymen. And having an intact hymen doesn't prevent you from getting a speculum exam.

What kind of speculums are YOU using?!?!

C'mon now, vag-doc.

They did a colpo on her. Complete visualization of the cervix with instrumentation for biopsy.

You're telling me you can do that all through an intact hymen? I think not.

 

[smq123]

C'mon now, vag-doc.

They did a colpo on her. Complete visualization of the cervix with instrumentation for biopsy.

You're telling me you can do that all through an intact hymen? I think not.

C'mon now, orthopod.

The quote that I initially was responding to was this:

If she was truly a virgin at age 30, you wouldn't have been able to do a pelvic exam on her.

That's not true, and you know it.

A colpo, I agree, is a different story. Although there are other ways of rupturing a hymen besides just sexual intercourse.