HPV vaccination

I had a request from a dear friend who has a daughter the same age as mine to discuss HPV vaccination.  This is a great topic for discussion, and there has been a lot of controversy surrounding the issue of mandatory vaccination by some states and schools.

First off, what is HPV?  It stands for Human Papillomavirus, which is rampant.  It's the virus that can cause you to get warts, but some types can cause cells to divide abnormally and then become invasive (cancer).  There are about 150 subtypes of HPV, and about 40 subtypes are sexually transmitted. Some types do not cause any symptoms, some cause warts (genital or otherwise), and others can cause cancer.  We call these subtypes "high risk".  When someone gets infected with HPV, very frequently the infection is cleared by his/her immune system, but sometimes the infection is persistent.  When someone has a persistent high-risk type of HPV, they are at risk for cancer.

Most genital warts are caused by two specific subtypes of HPV, namely HPV-6 and -11.

Almost all cervical cancer is caused by persistent high-risk HPV infection, and 70% of those cancers are caused by the subtypes HPV-16 and -18.  Many other cancers can be caused by HPV infection.  90% of anal cancer, 65% of vaginal cancer, 60% of oropharyngeal cancer, 50% of vulvar cancer, and 35% of penile cancers are thought to be caused by HPV.  Thankfully, these diseases are not very common, but for those who are affected, the treatment (as you can imagine) is horrific.

In 2007 (the most recent year with available data), about 12,000 women were diagnosed with cervical cancer, and over 4,000 women died of it.  I have participated in the care of women with cervical, vulvar, and vaginal cancers, and although no cancer is easy to deal with, these are among the most terrible.

In 2005, the Gardasil vaccine was FDA-approved after extensive testing.  It is a quadrivalent vaccine, meaning that it covers against 4 subtypes of HPV, the aforementioned types 6, 11 (which cause genital warts), and 16 and 18 (which cause 70% of cervical cancers).  It is given in 3 separate shots, initially and then 2 months and 6 months later.  Immunity has been documented at over 97% after the series is complete.  It is recommended for those aged 9-26 (boys and girls).

Another vaccine, called Cervarix, is also available.  It, however, is bivalent and protects only against subtypes 16 and 18, so no protection against genital warts.  It is used much less frequently than Gardasil.

There are many anecdotal reports of serious adverse effects to Gardasil, such as stroke, mental retardation, and muscle weakness.  This is one topic you may remember that presidential hopeful Michele Bachman brought up a few months ago, when making the point that Texas governor Rick Perry (also running for president) mandated that girls in Texas be vaccinated.  Many parents are scared to vaccinate their children because of these reports.  Several studies, though, have shown the safety of Gardasil, and there is an ongoing registry to report adverse events.  A link to the CDC's report is here:  http://www.cdc.gov/vaccinesafety/vaccines/hpv/gardasil.html.  In short, approximately 40 million doses of vaccine have been administered in the U.S.,  and about 20,000 adverse events have been reported.  That's about 0.05%.  Of those, 8% were considered serious, so about 0.004% of the total number vaccinated.  Serious events included anything that required hospitalization, or that caused permanent disability, life-threatening illness, congenital anomaly, or death.  It is not known whether these events were caused by the vaccine, or were just coincidence.

The CDC (Centers for Disease Control) and FDA (Federal Drug Administration) continue to recommend these vaccinations to prevent HPV-associated cancers.  Here's a link to the information sheet provided by the CDC:  http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hpv-gardasil.pdf

I do not think this vaccine should be mandatory, but rather a decision made by individuals based on the facts that are known.  I do intend to have my children vaccinated, but wholeheartedly respect the decision of others to decline the vaccine.  As with nearly all medical treatments, the risks and benefits should be carefully weighed before making the decision that's right for you.

Emergency Contraception

OK, now I think it's time to approach a more sensitive topic, but one that I think the public really needs more education about.  Yesterday in the news there was a lot of hubbub about Plan B, one available emergency contraceptive pill, and its failure to become truly over the counter.  For several years, Plan B has been available to women ages 17 and over without a prescription, although it is still kept "behind the counter" and you have to ask the pharmacist for it.  For those 16 and under, a prescription is still necessary.  The FDA made a recommendation to make this medication available to anyone without a prescription, but yesterday it was announced that this would not be happening.

Definitely a controversy-stirring topic...

First, I think it's important to explain what the "morning-after pill" is and how it works.  The most widely-used emergency contraceptive is levonorgestrel, or brand-name "Plan B".  It is a progestin hormone that acts to delay or inhibit ovulation.  If taken within 72 hours of unprotected intercourse, it prevents around 75% of unintended pregnancies.  Levonorgestrel has not shown any harmful effects on an already established pregnancy, and does not cause an abortion.  All it does is decrease the chance that an egg is released while there are live sperm in the reproductive tract.  There is some speculation that emergency contraception may also inhibit sperm transport through the reproductive tract, or make for a "hostile" environment for sperm, as well as make the endometrium (the uterine lining) less receptive to an already fertilized egg.  These theories have not been scientifically proven.

It is not difficult to take, and side effects are minimal.  The most common side effect is irregular bleeding.  Because ovulation is inhibited, cycle length is also altered.  Some women may experience nausea and vomiting and/or breast tenderness.  Because it does not contain estrogens, the woman's risk for blood clots is not increased.  It's also important to remember that emergency contraceptives do not always prevent pregnancy. 

While not every woman is comfortable using emergency contraception, I think that it's an important part of family planning.  If unintended pregnancies are prevented, there will be fewer elective abortions.  I personally believe that the morning-after pill should be available to all women without a prescription.  Numerous studies have shown its safety, and the 16-and-under population is most likely to benefit from prevention of an unintended pregnancy. 

Here's a link to the American College of Obstetricians and Gynecologists patient education sheet regarding emergency contraception...http://www.acog.org/~/media/For%20Patients/faq114.ashx

Obviously, this topic will spark a lot of debate...I welcome your comments.

The Flu Shot

This week is National Influenza Immunization week.  If you're pregnant, and have not already received your flu shot...now would be a good time to get it done.

Why?  The flu shot is recommended for everyone over 6 months of age, but especially for those in high-risk groups.  Pregnant women and caretakers of infants are among those at high risk. 

When you're pregnant, your immune system is compromised.  The body's ability to fight off infections is weaker.  This was especially evident during the H1N1 outbreak in 2009, when pregnant women DIED and were commonly on the ventilator in the intensive care units with influenza.  We should do all we can to prevent influenza infection during pregnancy.

Another big reason to get vaccinated is to protect your baby.  Antibodies that your body makes in response to the influenza vaccine can cross the placenta and are present in breast milk.  Since infants can't receive the vaccine until 6 months of age, these antibodies can help your baby fight off the influenza virus, and avoid illness.

I get a lot of questions in my office about the safety of the flu vaccine.  Studies have never shown that the flu vaccine causes the flu.  Some people do complain of flu-like symptoms after they receive the vaccine, but they are never the same as actual influenza.   This may even be another virus that the person just happened to get after the flu shot, a coincidental event. 

There has also been a lot of discussion about thimerosal, a preservative used in multi-dose influenza vaccine vials.  Thimerosal is an organic mercury-containing compound, and is a derivative of ethyl mercury.  Much controversy has been stirred up over whether ethyl mercury (thimerosal) is neurotoxic (i.e. causes damage to the nervous system).  Another mercury compound, methyl mercury, is a known neurotoxin...that is another blog topic altogether.  Some groups have expressed concern that mercury exposure is associated with the development of autism, but no studies have consistently found an association.  There has, though, been a push to eliminate thimerosal from vaccines.  A thimerosal-free influenza vaccination is available, although I do not think the evidence exists to recommend only thimerosal-free vaccines.

Pregnant women should not get the intranasal inhaled vaccine (FluMist).  This vaccine contains a live attenuated virus and could cause the flu.

In the end, I do feel strongly that all women who are pregnant during flu season (October-May) should receive the vaccine.  All caregivers of pregnant women and their infants should also receive the flu vaccine.  I do every year, and most hospitals now require their employees to receive the flu vaccine.

See the attached link for more information:
http://www.cdc.gov/Features/PregnancyAndFlu/