Patient Description
This patient is a 68-year-old white female who was referred to us with a Pap smear of invasive cervical cancer. She had initially noticed occasional itching in her vulva and superficial dyspareunia. Her past history revealed that she had her first sexual contact at the age of 19; she has had four pregnancies, three deliveries, and a single spontaneous abortion. She reached menopause at the age of 50. She has never used contraceptives, does not smoke, and had only one sexual partner. Her last intercourse was 30 years ago after her husband died. She had the first Pap smear a month ago when she consulted her doctor after spontaneous vaginal bleeding. A Fibroepithelial polyp that was covered by squamous epithelium was discovered from a biopsy specimen that had been taken from the papillomatous area. This being the core of fibrovascular tissue, it showed that there was a slight chronic inflammatory infiltrate. There was also koilocytosis, a clear indication that the patient had HPV infection (Gonzalez-Losa et al., 2005, p. 2).
Diagnosis
Better diagnosis requires that one has knowledge of the symptoms of HPV. A very common sign of HPV is the presence of warts which has been reported to be the most common presentation of HPV. It is worth noting that the symptoms of HPV only manifest after the disease has developed. It is reported that in women warts will be visible in regions around the vulva, vagina, or anus. In men the warts are can be seen in the anus, the tip of the penis, or on the scrotum (Marshall 2009, p. 381).
Coleman and Tsongalis (2006) have shown how HPV can be detected, “human papillomavirus and its related tissue changes can be detected visually at the clinical colposcopic examination, morphologically by histopathologic examination or by DNA analysis” (p. 449).
HPV
HPV is an abbreviation for Human Papillomavirus. It is the most prevalent sexually transmitted disease with estimates showing that at least half of all sexually active people in the world have at least one HPV type. Advances in HPV mapping have made it possible to recognize about 75 HPV types with 40 of these types infecting the urogenital area. This disease equally infects men and women but, it is the women who are more likely to show the symptoms of the disease. Research has found out that HPV causes over 70% of all cervical cancer in women and in males approximately 90 percent of genital warts (Garner 2010).
Epidemiology
Transmission of HPV is mainly by sex. The group at the highest risk of contracting HPV is the young people who are sexually active. It is estimated that 75 percent of HPV infections occur among 15-24 years of age people. HPV is easily transmitted; approximately 65 percent of those who get sexually in contact with HPV infected people are contacted with HPV. Estimation shows that approximately 630 million people are annually infected around the world. The highest prevalence of the infection is witnessed in the age group between 14 to 24 years (Sweet and Gibbs, 2009, p. 81).
Diagnostic Testing
When HPV is suspected an HPV test should be carried out. The test involves the collection of cells from the cervix when the patient is being examined. This will be followed by two types of tests: the HPV DNA test and the HPV PCR test. The DNA test is used to identify thirteen of the high-risk HPV. The high-risk HPVs are most responsible for cervical cancer. The other test which is then carried out is the HVP PCR test. The HPV PCR test will identify additional HVPs apart from those identified through the DNA test. It should be noted that the Pap test should not be substituted but should be applied in addition to the other tests.
In the application of the Pap, test age should be taken into consideration as women young than 30 years of age do not have cervical cancer. Caution should be taken however for the young women as it claimed that some of them may have severe dysplasia that is likely to develop to cervical cancer if not checked out well (Almeida and Barry, 2009, p. 216).
In the event that the Pap test is positive then colposcopy will be the next step of action. This proceeds as follows:
A gynecologist applies a 3-5% acetic acid solution (like vinegar) on the cervix, then examines it and the vagina with a colposcope, a thin lighted tube painlessly inserted through the vagina into the cervix. The Vinegar solution allows abnormal areas to temporarily turn white, making them easier to locate. Sometimes iodine is used instead, which will stain normal cervical tissues and not abnormal ones. Once abnormal areas are located, treatment can be started immediately. (Almeida and Barry, 2009, p. 216)
DNA Target Amplification
In DNA target amplification, DNA fragments are duplicated from a target gene. There are many types of this technology but the commonly used one is the PCR (Polymerase Chain Reaction). It is a three-step process. The sample is heated to denature the DNA resulting in two strands. Temperatures are then decreased where HPV-specific Primers are bound to target DNA. The last step involves heating to activate catalysis by enzymes present in the mixture thereby necessitating the creation of two strands that are complementary to the targeted HPV DNA strands (Almeida & Barry, 2009, p. 216).
Patient Care
The patient’s history shows a persistent viral infection which is a precondition for cervical cancer. There is little information on the factors that facilitate persistent viruses; however, high-risk viruses persist more than those of low risk. The patient should avoid smoking and make sure that she maintains a high consumption of vegetables and high concentration series cis-lycopene which are said to reduce persistent infection. Avoid sexual partners or conclusively ascertain that they do not have HPV. Medical literature shows that the number of sexual partners relates directly to the risk of getting cervical cancer. In this case, the patient is monogamous; her risk will therefore increase when her partner has signs of HPV (Dunne 2006, p. 32).
Recommended Treatment
There is no satisfactory treatment for HPV because it has a high frequency of relapse and therefore requires retreatment. The first line of treatment combines both surgical and medical treatment. This is effective in the complete elimination of lesions and reducing relapse rate. The second line of treatment could be the topical application of trichloroacetic acid, cidofovir, and intralesional injection of antiviral agents (Williams & Wilkins, 2010, p. 62).
Khomdon and Suchitra (2000) suggested the following treatment options for HPV: LEEP, Cone biopsy, electrocautery, cryotherapy, and use of topical solutions. They have further noted that some challenges are faced when “treating cervical and anal abnormalities in positive women” (p. 406). Liquid nitrogen is used in cryotherapy. The liquid nitrogen freezes the cells which are not normal. The abnormal areas can also be removed in a process called cone biopsy. At times the friendly electrical current can be put to use in a process of LEEP. The current removes abnormal cells.
It has been noted that patient care should be taken when offering the treatment for instance pregnant women who are infected with HVP cannot sustain some of the treatment options. Cryotherapy is advisable in the course of the 2nd and 3rd trimesters. Electrocautery works well when used in small lesions in the course of pregnancy. Surgical removal is not advised to pregnant women as it increases the chances of bleeding (Daftary n.d., p. 582).
It is also recommended that when treating a patient infected with HPV he/she should be involved in the treatment process by being educated on the progress. The patient should be taken through counseling and informed of the treatment options available the one which will be used and why that one. It is also helpful to inform the patient on how to make a simple diagnosis for HPV by examining the physical symptoms. The association of Reproductive Health Professionals (ARHP) has indicated that proper patient care through counseling services will make the treatment effective (ARHP, 2009).
Conclusion
In the world today, HPV infection is a reason enough for an individual to visit a gynecologist. Many patients get anxious and stressed when diagnosed with any sexually transmitted disease. HPV diagnosis has psychological as well as emotional repercussions in women because it creates doubts in partners regarding their fidelity. This is because many people assume that an HPV infection means a recent extramarital relation causing deteriorations in relationships. This patient’s case has helped show that HPV infection does not necessarily result from a recent infection. Couples in society should therefore visit health care institutions and seek expert advice whenever in doubt so that they can avoid psychological stress and the consequences that HPV diagnosis can cause if not understood well.
References
Almeida, C., & Barry, S. (2009). Cancer: Basic Science and Clinical Aspects. New York, NY: John Wiley and Sons
ARHP. (2009). Managing HVP: A New Era in Patient Care. Web.
Coleman, W., & Tsongalis, G. (2006). Molecular Diagnostics: for the clinical laboratorian. New York, NY: Humana.
Daftary, S. (n.d.). Manual of Obstetrics, 3e. India: Elsevier.
Dunne, E. (2006). Epidemiology of HPV infection. CDC. Web.
Garner, E. (2010). A Case Study: Lessons Learned From Human Papillomavirus Vaccine Development: Approval of a Vaccine for Use in Children and Young Adolescents for Prevention of an Adult Disease. Journal of Acquired Immune Deficiency Syndromes. Web.
Gonzalez-Losa et al. (2005). Persistent infection of human Papillomavirus 18: case report. Rev Biomed, 16(4), 255-257. Web.
Khomdon, S. L and Suchitra, L. (2009). Nutrition and AIDS. New York, NY: Gyan.
Marshall, C. (2009). Sex and Society. New York, NY: Marshall.
Sweet, R., & Gibbs, R. (2009). Infectious Diseases of the Female Genital Tract. New York, NY: Lippincott Williams & Wilkins.
Williams, L., & Wilkins, L. (2010). Lippincott’s Guide to Infectious Diseases. New York, NY: Lippincott Williams & Wilkins.