HPV in Menopause – Old Infections or New Relations?

Menopausal couple cropped
New love comes at all ages.
So can HPV.

When HPV occurs in the menopause, is it due to reactivation of a previous HPV infection or a newly acquired infection?  That’s the question asked, but not properly answered in this doc’s opinion, by a new study published this week in the Journal of Infectious Diseases.

Researchers performed HPV testing in 843 women age 30-60, and found an increased prevalence of HPV infections among women in the peri-menopausal age group who also reported having had >5 lifetime partners, but not necessarily a new partner within the past 6 months. They concluded that this second lifetime peak of HPV infections (the first peak occurs in the second decade) was due, not to new HPV infections, but to infections acquired in the earlier years that were now re-emerging with older age and waning immunity.

The fact that we have not seen this peri-menopausal HPV peak in prior population-based studies, they say, is because most women in this age group until now have not had so many sexual partners.

The study’s findings contradicts what we are now telling women, which is that most HPV infections permanently clear within two years of an initial infection that occurs primarily during the second and third decades.

Erroneous conclusions based on a flawed study design

I take strong issue with the study’s conclusions, based on over two decades taking care of peri-menopausal women in a country where 50% of marriages end in divorce.

The flawed conclusions of this study stem from what I believe to be a flawed methodology – namely using 6 months as a cut off for defining women as having had a recent new partner, an artificial categorization that makes no sense socially or biologically. As a result, the researchers may have missed much of the important new sexual activity in their cohort that could explain an increase in HPV infection around the age of menopause.

Sex, HPV and the Middle-Aged Woman

Many women in their middle years have new relationships through divorce, dating and often, remarriage. HPV infection can occur at any time in a recent relationship, not just in the first 6 months (a part of which time many couples use condoms). These infections can persist up to 2-3 years before they clear and be diagnosed any point in that time frame.

In my own clinical practice, the overwhelming majority of HPV infections in this age group occur in women who have had a clear change in partnership within the past 1-5 years. Not surprisingly, theses HPV infections clear in the same 12-36 month time frame as the infections I’m diagnosing in the younger crowd.

Remember too, that it is at middle age that some of the husbands will start to wander – bringing home a new infection to a woman who has not had a new sexual partner in decades. The study does nothing to address this possibility. Not that any study can, of course, but you get my point.

A better study design would have been to ask how long the subject has been in her current relationship , and correlate that with HPV prevalence.

Bottom Line –

The study raises interesting questions, but unfortunately its design limits its conclusions, which to this clinician don’t make sense given what we know about HPV infection and the social lives of women.

While we cannot completely discount the possibility of reactivation of dormant HPV, this study, in my opinion, does little to answer the question it raises.

Unfortunately, the publicity around this study is sure to drive anxiety among every menopausal woman out there, especially as we are now telling them that they can back off on pap smears if theirs have been normal up till now. (I myself am not 100% comfortable with the new pap recommendations, by the way...)

What if you have a positive HPV and have not had a new partner?

I see two possible ways that a women can have HPV and not have a new HPV infection.

One is a longstanding persistent HPV infection that is only now causing precancerous changes, which as we know can take decades to appear. Is this reactivation of a dormant HPV infection or just delayed detection? After all, we only recently began testing for HPV, so unless we have a prior negative test, it’s hard to say, isn’t it?

The second is that menopause itself can lead to low grade pap abnormalities related to estrogen deficiency rather than true pre-neoplastic changes.  In women without HPV, these are so called false positives. But in women who may have a persistent HPV infection, this estrogen-deficient pap may be the first time she has ever had an HPV test.

The important point with these two scenarios is that not every HPV infection necessarily comes from a new partner (or a wayward husband).

Which is good to know.

14 Responses to HPV in Menopause – Old Infections or New Relations?

  1. I’ve heard that people can have HPV come back. I realize you are not giving medical advice on here so I won’t consider any response as such. Can the HPV that is coming back actually be the result of some cells not completely clearing the virus? Can some DNA actually be integrated? Can those people who do clear it possibly not have integrated DNA or do some cells just die? I wonder if it is due to the intensity of the initial infection.

  2. Hello Dr. Peggy: I have recently undergone treatment for a squamous cell carcinoma on the base of tongue, just aside tonsil. As you probably know this is a prime target for HPV 16 & 18 cancers. I call it the “Woodstock Cancer” because so many of my generation seem to be coming down with this weird throat cancer. Treatment was a bitch!!

    Here’s the thing: I have not had sex with anyone but my own husband in 27 years. I have enjoyed excellent health throughout my life, aside from having delicate skin — blond, freckly and blue-eyed. As a child I as plagued with poison ivy, poison sumac, and sunburn. Then, at age 59, this tumor. So it seems my HPV was dormant until the stress of my mother’s incredibly horrible illness, care, and death, I think, brought my immunity down to dangerous depths. which is when the HPV jumped in.

    Now my gyno is wondering whether or not I need HPV screening. If the answer is yes, if a cervical screen does show HPV, what then? More surgery? Just in case? I’m almost 63, healthy again, and sort of fatalistic about the whole thing at this point.

    27 years?? I am certain my husband has not brought any disease into our marriage by the way.

    Many people I know are now very concerned about HPV. A radiologist doctor friend told me that we are just seeing the tip of the iceburg of cases yet to come. I started treatment around the same time as 3 men. so far, I’m the only survivor 3 years later . . .

    • June –

      SO sorry to hear what you have been through, but it’s great news that you are three years out and doing well. As you probably already know, HPV related oral cancers tend to respond very well to treatment, better than non-HPV related cancers.

      As you also probably know, I cannot give out personal medical advice on this blog. I would discuss your questions with your doctor and your oncologist. If your gyno is not sure what to do, you can ask for a referral to see a Gyn oncologist for another opinion regarding screening.

      All the best –

      Peggy

  3. Appreciating the commitment you put into your site and detailed
    information you offer. It’s awesome to come across a blog every once in a while that isn’t the same
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  4. This is very scary as I am 33 years old woman with High rise HPV. It’s 50% chance this will pop again in my elderly years. I don’t want to have cancer.

  5. Dr. Polaneczky,

    Thanks for your blog and also for the critique of the study on this thread. I agree with you, the study gives confusing, conflicting information which is exactly what we don’t need—as you point out. We DO need information, though, and what we tend to get seems vague and obtuse to me.

    As an older female who was monogamous for decades as was my then husband, I think the HPV issue does need to be discussed more directly with older women so we can make better decisions. I know that is what you are doing on this blog and I commend you for it.

    There is a large contingent that is going unaddressed however—the DES exposed-in-utero daughters, of which I am one. I have seen a gyn-oncologist for decades for close monitoring for DES exposure in utero. At this point, at mid-life, I find myself now with high risk HPV. I was tested several times in past years (while with my husband and no one else…and he with no one else) and my HPV tests: negative.

    After 8 months with new partner—HPV test…high risk positive. It does appear I can know where I got this. No, I cannot blame the man—very decent. We even had panel of testing done prior. HPV was not discussed as I think it should have been. It was treated as if it is, well, just nothing much.

    Yes, this is scary to me, and it should be. I have been through a lifetime (it seems) already with all the DES exams, routine colposcopies twice a year with my gyn oncologist.

    I do wish now that I had better informed (I am well-educated with a Masters degree). After the negative HPV tests over the years since the testing has been available, perhaps it would have been helpful to have the vaccine, I do not know. It was not discussed.

    The number of DES daughters my age (as we are aging) is considerable. Adding HPV onto a cervix that is already damaged via DES in utero exposure is truly (I think) an issue that is not being addressed. It is a serious issue for us and I doubt the HPV will “clear” so well from us.

    I do realize I am lucky that I have a doctor who already does twice yearly colposcopies and smears on me and I will now be monitored all the more closely and more often.

    Please though don’t say, don’t be scared, etc. This information is scary, depressing and surprising. To say the least. Even if it shouldn’t have been. I wish I had had more direct concise information. It would have helped me in making certain decisions.

    Obviously, a test for men is critical and should be available already. I know it’s not. Men can’t know they have it unless a woman tells them they most likely do, so the men can’t know. They are spreading this and certainly don’t intend to.

    As for me, the DES situation has been stressful enough (high risk pregnancy, etc, etc.) but now this. Clear information and solid research on HPV (with good funding) for women and men is critical.

    Thank you and the best to you.

  6. Dr. P,

    It’s estimated that around 3 million pregnant women were given DES when they were pregnant from the years 1941-1971.
    The DES daughters of these mothers (depending on the time the DES was given) are, yes, at risk for Clear Cell Carcinoma. I have known this since I was 19 and have been faithfully checked every 6 months for decades. Yes, as an older female now, who has acquired HPV in past year (negative HPV tests always prior to this)…I do think that older women are not being talked with about this and it is not a good thing—as I have found out. Why is this not worth posting? Seriously?
    Again, thanks for your consideration of a very important women’s health issue and HPV.

      • Dr. P,

        Thank you. Do you have any thoughts on why
        this contingent of women have been forgotten and
        for the reasons you discuss in this article, are often turning up in mid life with new or either
        recurring high risk HPV (on top of DES-exposed)?
        There is no information anywhere re: the conjunction of these two issues. Is truly scary and depressing to me. And gyn-oncologists have no answers really but to say…”we will follow you as we have been.” Only now…more so. This can be really a devastating feeling. And all the more reason older women who are divorcing, or widowed, etc., need to be aware of high risk HPV and that men cannot be tested for it. It is truly a mess in my opinion.
        Thanks. I’d appreciate your thoughts (not medical advice) when you have the time.
        Best!

  7. Excellent article calling out flaws to erroneous logic by other doctors and researchers about latent virus reactivation. It seems far more likely that new infections come about from new partners. I know a few women of middle age who contracted HPV and not because it “reactivated.”
    Two of them were divorced and sleeping with men known to be playboys. Both men slept with multiple other women to get closer to their bank accounts. No surprise there about HPV when it comes to sleeping with very promiscuous men. Unfortunately, middle aged women often feel lonely and desperate and cave in when seduced by lotharios who make them throw caution to the wind.
    The other woman had a husband that went through a typical mid life crisis who slept with other women including prostitutes.
    Accordingly, I wholly agree with you that a lot of these middle age HPV cases are due to new partners or the horny old goat husband stepping out. Celibate menopausal women are likelu the only people who can rest assured of not having HPV. Thanks for a great article!

  8. So if I have been married for 23 years, I have never has any other sexual partners, tested negative for HPV in 2013 and recently tested positive hor HR-HPV with am abnormal pap smear would you conclude this is a latent infection or newly acquired?

    • Please address specific questions regarding your health or test results to your health care provider. (See disclaimer)

      HPV testing, like any test, has both false positive and false negative results. Using these test results to pin down where and when an HPV infection was acquired, especially given the implications of this, is an exercise in uncertainty. We do not know for certain if HPV becomes latent, and there is no way to tell a latent from a new infection. HPV test results are best used to triage uncertain paps and to screen for cervical cancer, but are not useful, in my opinion, as an std screen or as a marker of fidelity.

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