Finally, for women 30 and older, HPV testing should be routinely performed and the results should indicate whether the HPV test was positive or negative. There are more than 100 different types of HPV viruses, however only a small fraction can cause cervical cancer. The majority of HPV types cause genital warts but not cervical precancer or cancer. Most gynecologists will use an HPV test that only evaluates for the strains of HPV that have been linked to precancerous and cancerous cervical lesions. These strains of HPV are also called “high-risk HPV.” HPV type 16 and 18 are the most common high-risk HPV types, causing about 70 percent of cervical cancers.

The follow-up for most abnormal Pap/HPV tests is a colposcopy. Colposcopy is a procedure that uses a special type of microscope called a colposcope, which provides a magnified view of the cervix, vagina and vulva. The gynecologist will perform a thorough evaluation with the colposcope and biopsy anything that appears abnormal. The tissue that is removed with the biopsy is then sent to a pathologist for evaluation. The pathologist will provide a diagnosis that determines who needs and who does not need additional treatment. Cervical biopsies that are high-grade (sometimes referred to as CIN2, CIN3 or ACIS) often warrant an excisional procedure, or a procedure to remove part of the cervix (for example Loop Electrosurgical Excision Procedure, also called LEEP, or cold knife cone biopsy). However, choosing the appropriate follow-up must be individualized for the specific patient and specific biopsy result.

In addition to cervical cancer screening, another way to prevent the development of cervical cancer is through the HPV vaccine. Gardasil was the first HPV vaccine available in the United States, gaining Food and Drug Administration approval in 2006. Gardasil is a quadrivalent vaccine, meaning that it provides protection against four types of HPV (HPV 6, 11, 16 and 18). In 2014 the FDA approved Gardasil 9, a 9-valent vaccine that targets the same four HPV types as Gardasil but also type 31, 33, 45, 52 and 58. Gardasil 9 is approved for women and men age 9 through 26 years old. Gardasil 9 can be given on either a two-dose or three-dose schedule as determined by the medical provider. For women who already had the quadrivalent Gardasil, repeating vaccination with Gardasil 9 is not recommended. Of note, Gardasil is also FDA approved for preventing vulvar and vaginal cancer in women and genital warts in men.

Unfortunately, women often do not develop signs or symptoms of cervical cancer until the cancer has reached an advanced stage, further emphasizing the importance of screening. The signs and symptoms that women experience vary but may include fatigue, weight loss, decreased appetite, irregular vaginal bleeding, vaginal bleeding after sexual intercourse, pain in the back, legs or pelvis or odorous vaginal discharge. When cervical cancer is diagnosed at an advanced stage the disease is generally not amenable to surgery and instead treated with a combination of chemotherapy and radiation therapy. Unfortunately, despite aggressive treatment many women will not be cured of the disease and even those who are cured often have problematic long-term sequelae from the treatment. Thankfully, it takes about 15 to 20 years for cervical cancer to develop from the initial HPV infection, giving women many opportunities for screening. However, to derive the benefits of cervical cancer screening, women must undergo screening at the recommended intervals and review the Pap and HPV test results to confirm that the testing was satisfactory and no additional follow-up was indicated. Furthermore, women age 9 to 26 can consider HPV vaccination in addition to cervical cancer screening starting at age 21 years.

Melissa Frey, M.D., is a Gynecologic Oncologist and Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medicine. Dr. Frey graduated from Duke University where she was elected into Phi Beta Kappa and earned her medical degree from Weill Cornell Medical College. She completed her residency in Obstetrics and Gynecology at Weill Cornell Medicine / New York-Presbyterian Hospital and fellowship in Gynecologic Oncology at New York University Langone Medical Center.

Dr. Frey has a busy gynecologic oncology clinical practice and is active in the Weill Cornell Medical College where she teaches medical students, residents and fellows. Dr. Frey’s research focuses on genetics and genomics in gynecologic cancer. She has presented her work at national and international meetings and has more than 30 publications in peer-reviewed scientific journals. Much of her research has explored genetic syndromes that predispose to gynecologic cancer including hereditary breast and ovarian cancer (BRCA1/BRCA2) and Lynch syndrome. Dr. Frey is also committed to providing treatment to underserved populations internationally. She has traveled to Central America, South America and Africa to provide basic health care and surgical management for gynecologic disease.