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.