HPV and Arthritis

You hear HPV and think STD. Or maybe you associate the virus with cancer. Both are valid associations: Human papillomavirus, or HPV, is the most common sexually transmitted infection in the U.S.; and some types of HPV may cause health problems, including cervical and other cancers.

Now here is some news about HPV you may not have yet heard: Some preliminary research suggests that having a systemic inflammatory disease, like rheumatoid arthritis (RA) or lupus (SLE), may impact HPV infection and your risk of developing cervical cancer. Here’s what you need to know.

What Is HPV, Anyway?

HPV is a virus that can be spread through genital or intimate skin-to-skin contact. It is very common — so common that anyone who’s ever had sex ever may have been exposed to HPV. Nearly 80 million Americans are infected with the virus. Often, those infected don’t know they have HPV, so they don’t realize they’re passing it to other people.

There are more than 100 different types of HPV. Some strains do not cause any symptoms or health issues; others are low-risk and cause genital warts. Some high-risk types have been linked to cancer of the cervix, vagina, vulva, anus, penis, and throat.

Most HPV infections resolve on their own — and about 90 percent clear up with two years. But sometimes, certain HPV infections can persist and progress to cancer.

How Does HPV Lead to Cervical Cancer?

Of the 100 strains of HPV, about a dozen are considered high-risk and associated with cancer. Two types in particular — HPV 16 and HPV 18 — cause 70 percent of cervical cancers and pre-cancerous cervical lesions.

HPV is the primary cause of cervical dysplasia, a precancerous condition where healthy cells in the cervix undergo abnormal changes. The abnormal cells (or lesions) aren’t cancerous, but can develop into cancer if not caught early and treated. Cervical dysplasia can range from mild to severe. Low-grade lesions — where changes are only mildly abnormal — often resolve on their own. High-grade lesions, on the other hand, are considered pre-cancerous, and left untreated may develop into cervical cancer.

It takes 15 to 20 years for cervical cancer to develop in women with normal immune systems, according to the World Health Organization. However, it can take only five to 10 years in women with weakened immune systems. That’s because people who have compromised immune systems are less able to fight off the virus, and therefore more likely to have persistent HPV infections and a quicker progression to pre-cancer and cancer.

How Could Inflammatory Arthritis Affect HPV Infection?

Some data suggests that women with autoimmune diseases, like rheumatoid arthritis and lupus, may be more vulnerable to the effects of HPV infection and the development of cervical disease. It’s not that these patients are more likely to contract HPV in the first place, but that if they are infected with HPV, they are less able to fight off the virus so it can progress more easily.

Several studies have shown an increased risk of cervical lesions and HPV infection in patients with lupus. Another small study found that HPV infection is more common in women with RA as well, compared to those women without rheumatic disease. Results from a U.S. population-based cohort study reported women with RA and lupus had a 1.5 times increased risk of high-grade cervical dysplasia or cervical cancer, compared to those without systemic inflammatory disease.

In a study published in the journal Rheumatology, scientists hypothesize that these observed increased risks may be related, in part, to immune dysfunction associated with these rheumatic diseases, as well to immunosuppressive medications used to treat them.

Research has shown in patients with lupus, for example, the risk for cervical lesions or cervical cancer is higher among those treated with immunosuppressive drugs versus antimalarial medication. And a study found that women taking TNF inhibitor biologics for RA had a 1.4-fold greater risk for high-grade lesions and a doubled risk for invasive cervical cancer, when compared to patients who never took biologics.

“HPV is sexually transmitted, so the drugs are not necessarily increasing the risk of transmission,” explains study author Seoyoung C. Kim, MD, ScD. “But they could increase the risk of not clearing HPV spontaneously, which would lead to persistent HPV infection and higher grade of [cervical dysplasia] in some patients.”

Longer duration of HPV infection is a risk factor for cervical cancer, adds Dr. Kim, who is the director of the Program in Rheumatologic, Immunologic, and Musculoskeletal Pharmacoepidemiology at Brigham and Women’s Hospital in Boston.

More research on the connection between inflammatory diseases and HPV is needed. But if you’re an inflammatory arthritis patient and you know you’ve had an HPV infection in the past, ask your doctor about what kind of ongoing monitoring may be appropriate for you.

How Do Doctors Test for HPV and Cervical Cancer?

For women, doctors use two separate tests, which are often done at the same time, in the same way. (Currently, there is no approved HPV test for men.)

The HPV DNA test checks for the presence and type of the virus. Knowing whether you have a type of HPV that puts you at high risk of cervical cancer may help determine next steps in your health care. A Pap test (or Pap smear) is used to screen for cervical cancer; it detects the presence of cancer cells and abnormal cells that may become cancer. For both tests, doctors use an instrument called a speculum to hold the walls of your vagina apart to see the cervix. Then, a sample of cells from your cervix is collected using a small brush and a tiny plastic spatula, and sent for lab testing.

Current guidelines recommend:

  • Women between ages 21 and 29 should get a Pap test every 3 years.
  • Women between ages 30 and 64 have three options for screening:
    • A Pap test every 3 years
    • An HPV test every 5 years
    • A Pap and HPV test together (called co-testing) every 5 years
  • Women 65 or older need a Pap test if they have never been tested, or if they have not been tested after age 60.

Some women may need Pap or HPV testing more often, including those who have weakened immune systems or who have a history of HPV infection or precancerous cells.

Talk to your doctor to determine the best screening plan for you, given your medical history and current conditions.

What About the HPV Vaccine?

The HPV vaccine is a safe and effective series of vaccines that can prevent some strains of HPV infection and may reduce your risk of cervical cancer and other HPV-related cancers. For the HPV vaccine to be most effective, the series should be given prior to exposure to HPV, which is why it is recommended for adolescents.

Current guidelines recommend the vaccine for preteens at ages 11 or 12; as well as everyone through age 26 who has not been vaccinated already.

Adults age 27 through 45 years who are not adequately vaccinated may decide to get the HPV vaccine after speaking with their health care provider about their risk for new HPV infections and the possible benefits of vaccination.

HPV vaccine rates in the U.S. are low — only about half of adolescents are up to date on the HPV vaccine. A study using U.S. commercial insurance claims data from 2006 to 2012 showed that only 23 percent of healthy people and 21 percent of people with rheumatic disease aged 9 to 26 years started an HPV vaccine series, and only half of these completed the cycle.

There is no contraindication to HPV vaccination for immunocompromised patients. The American College of Rheumatology recommends HPV vaccination for people with RA before starting or currently receiving disease-modifying antirheumatic drugs or biologics, if indicated.

Ask your doctor whether an HPV vaccine is appropriate for you.

Keep Reading

Abnormal Cervical Cancer Screening Test Results. The American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Abnormal-Cervical-Cancer-Screening-Test-Results. Published January 2016.

Feldman CH, et al. Risk of high-grade cervical dysplasia and cervical cancer in women with systemic lupus erythematosus receiving immunosuppressive drugs. Lupus. 2016. doi: 10.1177/0961203316672928.

HPV Infection. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hpv-infection/symptoms-causes/syc-20351596. Published August 30, 2019.

Human Papillomavirus (HPV) and Cervical Cancer. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer.

Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a3.htm. Published August 15, 2019.

Interview with Seoyoung C. Kim, MD, ScD, Brigham and Women’s Hospital, Division of Rheumatology, Immunology and Allergy

Flores ADE, et al. Human papilloma virus (HPV) infection in women with rheumatoid arthritis. Medicina Universitaria. 2008. https://www.medigraphic.com/pdfs/meduni/mu-2008/mu084f.pdf

Kim SC, et al. Risk of high-grade cervical dysplasia and cervical cancer in women with systemic inflammatory diseases: a population-based cohort study. Annals of the Rheumatic Diseases. 2015. doi: 10.1136/annrheumdis-2013-204993.

 

Klumb E, et al. Is Higher Prevalence of Cervical Intraepithelial Neoplasia in Women With Lupus Due to Immunosuppression? Journal of Clinical Rheumatology. 2010. doi: 10.1097/RHU.0b013e3181df5261.

Pap and HPV tests. Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/pap-hpv-tests. Published January 31, 2019.

Singh JA, et al. 2012 Update of the 2008 American College of Rheumatology (ACR) Recommendations for the use of Disease-Modifying Anti-Rheumatic Drugs and Biologics in the treatment of Rheumatoid Arthritis (RA). Arthritis Care & Research. doi: 10.1002/acr.21641.

STD Facts – Human papillomavirus (HPV). Centers for Disease Control and Prevention. https://www.cdc.gov/std/hpv/stdfact-hpv.htm. Published August 20, 2019.

Understanding HPV Coverage. Centers for Disease Control and Prevention. https://www.cdc.gov/hpv/partners/outreach-hcp/hpv-coverage.html. Published August 23, 2018.

Wadström H, et al. Cervical neoplasia in systemic lupus erythematosus: a nationwide study. Rheumatology. doi: 10.1093/rheumatology/kew459.

What Is Cervical Dysplasia? Treatment & Prevention. Familydoctor.org. https://familydoctor.org/condition/cervical-dysplasia. Published November 13, 2018.