E85: The Environmental Domain of Pap Smears

Kirtly: Welcome back to the 7 Domains of Pap Smears, or Pap Tests. And if you're just starting on the "7 Domains of Women's Health," welcome. We are working our way into the environmental domain of pap smears. And in the case of the virus that causes pre-cancerous changes of the cervix and cervical cancer, we're talking about the environment that it meets, this virus, when it meets you.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. And with me today is my co-host, Dr. Katie Ward. Katie is a women's health nurse practitioner with a Doctorate in Nursing Practice, and she's done a lot of Pap smears and talked to a lot of women about cervical cancer screening. Katie and I have been friends and colleagues in women's health for almost 40 years.

So let's start by reminding listeners that cervical cancer is almost always caused by the human papillomavirus. There are many families of this virus, but the ones we are talking about today like to grow and multiply and change the growth habits of cervical tissues, and some other tissues, but that's for another day.

The HPV viruses that infect the cervix are passed by intimate partner contact.

The cervix has several kinds of cells. It has squamous cells, cells that are kind of like the cells of the vagina, and glandular cells that make mucus, the ones that line the cervical canal. Where these two types of cells meet, there's a lot of activity and cell division, and that is where HPV likes to grow.

Teenage girls, girls soon after puberty, and pregnant and postpartum women have a lot of these cells. There's a lot of activity in this junction between the skin cells and the gland cells.

Now, estrogen hormones make these cervical cells more active. All of these are reasons why the environment is more favorable for HPV to grow in women of reproductive age.

Now, the environment in which the virus finds itself partly will determine whether the virus can do its thing, or whether the person infected can fight it off. And a healthy immune system is really important.

I'm going to take you back, we're going to take you back together, to the COVID-19 virus. Most of us think about it easily, the COVID-19 virus, as we just spent 5 years living and learning about this virus. You know people who got this airborne virus, and you probably know people who got sick, really sick, in-the-hospital kind of sick. And the risk factors for getting really sick include other factors in people's health, including preexisting conditions and suppressed immune systems.

People who didn't have the immune system to fight it off got much sicker. People with good immune systems and people who got their immune systems against the virus boosted by the vaccine got much less sick.

Now, Katie spent the second part of the COVID pandemic . . . I divide the COVID pandemic into pre-vaccine and post-vaccine. So Katie spent the second part of the COVID pandemic being a volunteer vaccine shot-giver, and she gave thousands of shots and knows a lot about viruses.

Katie: I did. I mean, as a healthcare worker, I got my vaccine really early on, and my immediate impulse when I got mine was like, "I can't wait to help other people have this immunity." And so I signed right up to be a volunteer vaccinator. I kind of gave up everything else in my life and spent my weekends in the freezing cold out at the Maverik Center giving vaccines in the snow, in people's car windows.

Kirtly: Yeah, I was there. I saw Katie there.

Katie: It was so much fun to be a part of that effort. But yeah, we have had a crash course in viruses over the last five years. So I feel like everybody now knows a little something about viruses, and maybe that's made my job a little easier talking about HPV, so bear with me. I'm going to nerd out a little bit on virology and HPV specifically.

One of the interesting things about viruses, and this is true for the common cold and COVID-19 and HPV, is that they actually don't have the ability to replicate themselves on their own.

So viruses are essentially genetic material wrapped in a protein coat. It's kind of like a bad M&M.

Kirtly: I love that. I love M&Ms.

Katie: I'm going to come back to that analogy.

Kirtly: I like certain colors.

Katie: So this is the M&M color you don't like.

Kirtly: That I don't like.

Katie: But the thing about these viruses is they can't make copies. So basically, what they're doing is they're using our cells' Xerox machine that's built into our cells' ability to make a copy. And that's really all they want to do, is insert themselves into human cells, or whatever animal they live on, and borrow that copying mechanism so that they can reproduce and get transported to the next environment that they need to live in.

It's the reason antibiotics don't treat viruses, because they're not alive in the same way that bacteria or our cells are. So the only way that our bodies can get rid of them is by making antibodies that neutralize them. And that is something our immune systems know how to do, and they're really, usually, pretty good at.

So COVID was a big deal because it was brand new, and our immune system had never seen it before. It didn't have any prior information about it, and it's taken us a while to figure it out. So vaccines and the fact that people have had the infection, our immune systems are getting better at detecting COVID and responding to it. And as a result, COVID is adapting and evolving to the different environment it finds itself in.

HPV is different because it's been living on humans maybe forever. And the reason I say that is that all animals have their own special kind of papillomavirus, but the ones that live on humans are kind of specifically designed for humans. So that virus has evolved for our environment.

Our immune system deals with viruses with kind of two different responses. The first is inflammatory, and that's designed to neutralize the virus and give the body time for this slower, secondary immunity, which we call adaptive immunity, to develop. The adaptive immunity is long-term, and the body remembers that virus. So the next time you encounter it, you're ready to get rid of it in a hurry.

It's the inflammatory reaction that makes you feel sick. It's not really the virus that's making you sick. It's the fight that your body is putting up, and that buys some time for those long-term antibodies to develop.

So since we're on the environmental domain, I want to think about the world from the virus's point of view. As I said, HPV has been living on us for eons, and it's adapted to different places. We've talked about different animals. You were talking about the part of the skin where this virus likes to cause cervical cancer.

If you had a wart on your foot, for example, which you might get from walking across a swimming pool barefoot, that virus on your foot, even if you touch it and pick at it with your fingers, you're not going to transport it to your genitals because that foot virus, the strain of HPV, is specific for the foot, where the strain for the genital tissue is specific to that area. So environmentally, the virus needs its own unique environment to grow.

Since HPV has been being passed down from human to human for thousands of generations, it's figured out this kind of clever strategy. It wants to stay under the radar where our immune system doesn't notice it, so it usually only uses the outermost layer of skin, the one that we're kind of done with. It's about dead anyway. It's only going to reproduce a few more times and then shed, and so your immune system doesn't know it.

So that's what HPV has done that's super sneaky. It doesn't trigger that inflammatory reaction, you don't really feel it when you get it, and it stays on those surface cells just long enough to make copies and moves on. So if you've got antibodies and your body is able to recognize it, it can clear that infection pretty quickly.

Most of us encounter papillomaviruses regularly. Our immune system recognizes them, and that preexisting reaction means that it doesn't stay on you for very long.

And it's why vaccination is so important, whether it's the HPV vaccine or the COVID vaccine. Then you have those antibodies before you ever meet the virus.

So back to my M&M analogy . . .

Kirtly: I'm getting hungry. I shouldn't get hungry on this topic, but I'm getting hungry.

Katie: I told you I was going to nerd out for a minute. I'm not done.

But the reason the vaccine is safe is that the vaccine is made for the hard protein candy shell on the outside. The vaccine doesn't contain any of the virus on the inside. So I just want to make that point. Getting the vaccine never actually exposes you to the actual virus, but it does teach your immune system to recognize it the next time it sees it.

Kirtly: And that's the way for many, many vaccines, including the new way of making vaccines with COVID. So vaccines are great things to help you, and I'm a total fan.

The HPV virus is more likely to infect the cervix and make cells progress toward cancer in people with suppressed immune systems. This includes people who have HIV, human immunodeficiency virus. Right there in the name of HIV is immunodeficiency, meaning suppressed immune system. Or people with AIDS.

It also includes people with suppressed immune systems from cancer and cancer chemotherapy. And I've seen people who have the hardest times being treated for pre-cancerous conditions of the cervix, who actually were immunosuppressed. They were really hard to treat because you'd try to get rid of the cells and you'd just really struggle because they just keep growing and growing.

Katie: So right now, they have a specific sort of direction for people who are immunocompromised. For a lot of people, being immunocompromised is temporary. Pregnancy, chemotherapy, hopefully those are things that don't last forever. HIV is maybe a little bit different circumstances.

But we do have specific guidelines for immunocompromised women. So we do slightly more frequent Pap testing or HPV testing. So currently, the guideline is every three years instead of every five.

But if your HPV is positive or the Pap is abnormal, the threshold for doing that next test, the colposcopy and the biopsy . . . which we talked a lot about in the financial domain. If you haven't listened to that one, you might want to go back and take a deep dive into colposcopies and biopsies. But the threshold for doing that is a little bit lower for people who are immunocompromised than people who have normal immune systems.

And we also know that people who are immunocompromised might not have as strong an immune reaction to the vaccine. So we always recommend the full three-dose series in immunocompromised individuals.

If you have a normal immune system and you get the vaccine when you're young, before age 14, you actually only need 2 doses. But if you were 14 and, for some reason, were immunocompromised, we would make sure you got 3 doses. And the same with anybody getting vaccinated at a later stage, there are three doses. And sometimes we change that schedule just a little bit.

Kirtly: That's actually true for a lot of vaccines. They change the guidelines for people who are older, they get a higher dose. And so thinking about the individual, we try to individualize a lot of vaccines.

Katie: But getting vaccinated is still strongly recommended, especially if you're immunocompromised, because the immune system is also going to have a harder time fighting off the actual infection. So the idea of getting the immunity in advance of the infection is still your better strategy.

Kirtly: Yeah. And the HPV virus is more likely to infect the cervix and make cells progress toward cancer in women who smoke cigarettes. So when we're thinking about the environment in which this virus might find you, smoking cigarettes causes DNA damage in the cells of the cervix, so they're more likely to change and progress toward cancer when infected with HPV.

Smoking cigarettes also suppresses your immune system so much. And women who smoke are two to three times more likely to get cervical cancer and pre-cancer.

The risk increases with the number of cigarettes smoked each day, and the number of years of smoking, and when smoking began, if you started in the teen years. All those increase your risk. And even passive exposure to cigarette smoke, living with a heavy smoker, increases the risk a little.

Now, the risk goes down when women stop smoking, and returns to average risk when women have stopped smoking for 10 years. And that's like the risk of lung cancer in smokers. It goes down to average when people have stopped smoking for 10 years.

So how can women who smoke protect themselves? Make sure you get a Pap and HPV test, try to pick up the problem early, get the HPV vaccine, and stop smoking.

Young women are more likely to get infected with HPV if they're exposed, probably because the young cervix has a lot more of these maturing cells that grow after puberty. These cells are more likely to get infected with HPV.

And women who've had their first pregnancy before the age of 20 also have a slightly increased risk.

Women who were exposed to the hormone DES, this is Diethylstilbestrol, when they were fetuses in their mom, when their mom took DES during pregnancy, are at increased risk. And thank goodness that was a long time ago.

Women took it to prevent premature labor from 1938 to 1971. Women who were exposed in utero are over 50 years old now and hopefully have been screened for cervical and vaginal cancer throughout their young lives.

And women who've had multiple pregnancies are at a slightly increased risk, probably because the cervix has changed after every pregnancy, and with more cells likely to be infected, or because the hormones of pregnancy suppress the immune system a bit.

And some birth control methods may make a small difference in risk for cervical cancer. Birth control pills are associated with a small increase in cervical cancer and pre-cancer for reasons that aren't really clear. The copper IUD is associated with a decreased risk of cervical cancer, again for reasons that aren't clear.

But in the cases of women who are at increased risk for HPV infection causing cancer and precancer should probably be screened more frequently so that early changes can be treated before they become cancer.

Katie: Yeah, those are such . . . I mean, they're interesting data. The studies on the oral contraception and cervical cancer and pre-cancer were done in populations that didn't have widespread HPV vaccination.

I mean, I think we'll get more data, it's always coming out all the time, but I think as we start to see more widespread use of the HPV vaccine, maybe that's going to be something that we stop seeing, is the increase in cervical cancer or pre-cancer with oral contraception.

And I want to reiterate that the increased risk is small. But it's one more reason to get vaccinated because you can't always predict what contraceptive you might need in the future, and we know the vaccine provides protection.

Kirtly: So these are the current screening guidelines. Number one, women under 21 years of age do not need to be screened. Number two, women 21 to 29 should have a Pap smear every 3 years. Number three, women 30 to 65 should have either a Pap smear every 3 years or HPV testing every 5 years, or you can do both a Pap and HPV test every 5 years, and this is called co-testing. Many of us really like that one.

Now, women over 65 don't need to be screened if they had normal testing by Pap or HPV in the past 10 years.

And women who've had a hysterectomy and had their cervix removed and have never had pre-cancerous cells or cancer cells, they don't need to have any more cervical cancer screening.

Now, these recommendations do not apply to women who've already had pre-cancerous cells or cancer cells of the cervix. They do not apply to women who've had suppressed immune system, and they don't apply to women who've been DES-exposed before they were born.

So women who are at increased risk for HPV infection causing cancer probably should be screened more frequently so that changes can be treated before they become cancer.

And women who are at increased risk for HPV infection causing cancer and precancerous cells should be probably extra careful about getting vaccinated and be extra careful about partners.

So if you're a smoker, for goodness's sake, please stop smoking. There are so many reasons to stop smoking, and the increased risk of cancers is only one of them. Maybe you just don't skip your cancer screening, just as we outlined.

So please, if you're a smoker, stop smoking. Don't skip your cervical cancer screening. And if you're eligible, get the HPV vaccine. If you're a young person or the mother of a young person, make sure you get vaccinated.

Katie: I want to talk about one other environment we find ourselves in. People ask me all the time if there is something they can take. Usually, these are people who have had an abnormal Pap or positive HPV, and they're coming in for a colposcopy. And so at that point, they're asking if there's something they can do to help get rid of this virus faster.

Of course, if they're smokers, we talk about that. But often, people are asking me if there's a supplement that they can take to boost their immune system, and I want to talk about this just a little bit.

I think of it as an environment because we're in this environment of wellness, influencing, and misinformation. But here's the truth about this. Boost is not a scientific term when it comes to immunity. There's no credible study showing that a particular vitamin or supplement benefits your immune system in a way that we can measure. We don't even know what boosting actually means.

So your immune system isn't really something you can improve. As we've talked about, there are some things that compromise it, but there's not anything you can take that just suddenly makes it temporarily stronger.

So if you're dealing with an abnormal Pap smear or a positive HPV test, and you've Googled that, you are likely to get targeted with people that want to sell you something that promises to do a thing that isn't really real.

All that you can do is focus on the basics. Get a good night's sleep, get outside for walks, eat a balanced diet. You can take a multivitamin if you're concerned about nutritional gaps, but don't spend a fortune on it.

Your immune system is largely hardwired into your DNA. Certain conditions, as we've discussed, can suppress it, but no supplement is going to make you reprogram it to grow antibodies faster or better.

So the best science-backed approach is straightforward: Get vaccinated, don't smoke, follow the screening guidelines. And anything that's claiming to supercharge your immune system is just emptying your wallet.

Kirtly: But we're always hopeful.

Katie: Sure.

Kirtly: And I think that being hopeful improves my immune system. I mean, when I get sad and depressed, I get more colds. So I try to be hopeful.

Katie: So boot up this podcast and listen to it and get some hope. We're here for free, we're not sponsored by anybody, and it doesn't cost you anything.

Kirtly: So we have deepened our dive into Pap smears. And by the way, the guys' team at "Who Cares About Men's Health" cannot wrap their heads around the word Pap smear. I think the smear word freaks them out. And so for the guys listening, we'll just call it a Pap test, if the other word freaks you out.

Anyway, we've talked about the HPV virus and the environment where they like to grow. Katie and I want you to be more informed about the test and the vaccines so that you can take better care of yourself, and you can pass the words on to the women in your life.

Thanks so much for joining us. If this is the first of your Pap smear/Pap test domains, or you want to check out any of the other "7 Domains of Women's Health," you can find us at womens7.com, or wherever you get your podcasts.

Take care of yourself. We are thinking about you.