Obgyn · Year 3 · from Obgyn

Case 3: HPV Vaccination Counseling and Cervical Cancer Screening

Patient Demographics

• Age: 24 years
• Sex: Female
• Occupation: Graduate student

Chief Complaint

"I'm here for my first Pap smear, and I want to know if I should get the HPV vaccine."

History of Present Illness

The patient presents for her first gynecologic examination and cervical cancer screening. She has never had a Pap smear before. She recently became sexually active with her first partner 6 months ago and is using combined oral contraceptive pills for contraception. She has heard about the HPV vaccine but was not vaccinated as a child and wants to know if it's too late.

Gynecologic History

• Menarche: Age 12
• Cycles: Regular, 28 days (on OCPs)
• LMP: 3 weeks ago
• Sexual history: One lifetime partner (current boyfriend x 6 months)
• Contraception: Combined oral contraceptive pills
• Prior pregnancies: None
• STI history: None known
• HPV vaccination: None

Past Medical History

• No chronic conditions
• No medications other than OCPs
• No allergies

Family History

• No family history of cervical cancer
• Mother had abnormal Pap smear treated with cryotherapy in her 30s

Social History

• Non-smoker
• Social alcohol (weekends)
• Graduate student in biology
• In monogamous relationship

Physical Examination

• General: Healthy-appearing young woman
• External genitalia: Normal
• Speculum: Cervix appears normal, nulliparous os, small physiologic ectropion
• Bimanual: Uterus normal size, anteverted, no adnexal masses

Cervical Cancer Screening Discussion

Current Guidelines (ASCCP/ACOG):

For This Patient (Age 24):

• Pap smear (cytology) alone
• No HPV testing recommended at this age (high rates of transient HPV infection)
• Repeat in 3 years if normal

Cervical Cancer Screening Performed

• Pap smear collected
• No HPV co-test (per guidelines for age 21-24)

HPV Vaccination Counseling

Patient Questions:

Q: "Is it too late for me to get the HPV vaccine since I'm already sexually active?"

A: No, it's not too late. The vaccine is FDA-approved for individuals ages 9-45. For those who begin vaccination before age 15, only 2 doses are needed. For those starting at age 15 or older, 3 doses are required. The vaccine is most effective before any HPV exposure, but it still provides protection against HPV types you haven't been exposed to.

Q: "What does the vaccine protect against?"

A: The current vaccine (Gardasil 9) protects against 9 HPV types:

• Types 16 and 18: Cause ~70% of cervical cancers
• Types 31, 33, 45, 52, 58: Cause additional ~20% of cervical cancers
• Types 6 and 11: Cause 90% of genital warts

The vaccine prevents:

• ~90% of cervical cancers
• ~90% of anal cancers
• Vulvar and vaginal cancers
• Oropharyngeal cancers
• Genital warts

Q: "Since I already have a partner, have I already been exposed?"

A: You may have been exposed to some HPV types, but likely not all 9 types covered by the vaccine. The vaccine will still protect against types you haven't encountered. Studies show catch-up vaccination still reduces cancer risk.

HPV Vaccination Plan

Recommendation: HPV Vaccination (Gardasil 9)

Schedule for patients age 15+ (3-dose series):

• Dose 1: Today
• Dose 2: 1-2 months after Dose 1
• Dose 3: 6 months after Dose 1

Administered:

• Gardasil 9 0.5 mL IM (deltoid)
• Dose 1 given today
• Return appointments scheduled for doses 2 and 3

Counseling on HPV and Cervical Cancer Prevention

Key Points Discussed:

1. HPV is extremely common:

• 80% of sexually active individuals will acquire HPV at some point
• Most infections clear spontaneously within 1-2 years
• Only persistent high-risk HPV causes cancer

1. Cervical cancer is preventable:

• Regular screening detects precancerous changes
• HPV vaccination prevents most cervical cancers
• Smoking cessation reduces risk

1. What to do with abnormal results:

• ASCUS or LSIL at her age: Usually observation
• Most low-grade abnormalities resolve spontaneously
• Will not overtreat young patients

1. Partner considerations:

• Male partners can also be vaccinated (reduces their cancer risk and transmission)
• No need for partner to be tested or treated for HPV

Pap Smear Result (1 week later)

• Result: Negative for intraepithelial lesion or malignancy (NILM)
• Interpretation: Normal
• Next screening: 3 years (age 27)

Follow-up Visit (1 month - Dose 2)

• HPV vaccine dose 2 administered
• Tolerated well, mild injection site soreness

Follow-up Visit (6 months - Dose 3)

• HPV vaccine dose 3 administered
• Series complete
• Counseled that protection develops over several months
• Still needs regular cervical cancer screening despite vaccination

Vaccine Side Effects Discussed

• Common: Injection site pain, redness, swelling (most common)
• Less common: Headache, fever, nausea, fatigue
• Rare: Syncope (observe 15 minutes post-injection)
• No increased risk of autoimmune disease, infertility, or serious adverse events

Teaching Points

• Cervical cancer screening begins at age 21 regardless of sexual history
• HPV testing is not recommended in ages 21-24 due to high transient infection rates
• HPV vaccination is recommended for all individuals ages 9-26 (catch-up to age 45)
• Vaccination is beneficial even after sexual debut
• The 9-valent vaccine prevents ~90% of cervical cancers
• Vaccination does not replace the need for cervical cancer screening
• Both males and females benefit from vaccination

Clinical Image

Image Description: Illustration depicting the HPV vaccination schedule and the types of cancers prevented by the nonavalent HPV vaccine (Gardasil 9). The image shows the dosing schedule (2 doses if started before age 15, 3 doses if started at age 15 or older) and highlights protection against cervical, vulvar, vaginal, anal, and oropharyngeal cancers.

Attribution: Educational illustration adapted from CDC immunization resources. Public domain.

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