Human papillomavirus infection and anxiety: analyses in women with low-grade cervical cytological abnormalities unaware of their infection status

The Impact of HPV Diagnosis and the Electrosurgical Excision Procedure (LEEP) on Mental Health and Sexual Functioning: A Systematic Review

The impact of HPV diagnosis and subsequent treatment with the electrosurgical excision procedure (LEEP) on anxiety, depression, psychosocial quality of life, and sexual functioning has not been thoroughly investigated. The aim of this review was to systematically summarize the available knowledge on this topic, according to PRISMA guidelines. Data from observational and intervention studies were analyzed. A total of 60 records were included, of which 50 papers addressed the impact of HPV diagnosis on patients' psychosocial status, while 10 studies addressed the impact of the implemented LEEP procedure on patients' mental health and sexual functioning. The results indicated a negative impact of HPV diagnosis on the occurrence of depressive and anxiety symptoms, poorer quality of life, as well as on the sexual functioning of the affected women. The results of the studies to date have not confirmed the negative impact of the LEEP procedure on mental health and sexual life, although more research is needed in this area. It is necessary to implement additional procedures to minimize anxiety and distress in patients receiving a diagnosis of HPV or abnormal cytology and to improve awareness of sexually transmitted pathogens.

Effects of HPV Positivity in Women on Couples Sexual Behavior

We aimed to analyze the effect of HPV positivity in women, on women's psychology, sexual health, and male sexuality. Participants in the study were sexually active patients with high-risk HPV positivity and without any cancerous and precancerous lesions in the pathological examination. Participants and their partners' sexual health were evaluated with the FSFI questionnaire and the International Index of Erectile Function (IIEF) Score. The Beck anxiety inventory (BAI) form was used to determine participants' anxiety status. The presence of premature ejaculation was analyzed using the premature ejaculation diagnosis tool (PEDT) form. Comparison of FSFI scores at the time of diagnosis and one month later revealed a significant decrease (18.1 vs 15.1, p = 0.001). Partners' IEFF score decreased from 27.7 at diagnosis to 25.5(p = 0.001). The mean BAI score rose from 13.9 at diagnosis to 25.5 one month later (p = 0.001). Participants' partners had a significantly worse PEDT score one month after diagnosis (6.0 vs 10.8, p = 0.001). The present study demonstrated a significant deterioration in female psychological and sexual health caused by HPV positivity. Moreover, after their partner's diagnosis with HPV positivity, men were significantly more likely to suffer from erectile dysfunction and premature ejaculation.

Patterns of anxiety and distress over 12 months following participation in HPV primary screening

Objectives

Many countries are now using primary human papillomavirus (HPV) testing for cervical screening, testing for high-risk HPV and using cytology as triage. An HPV-positive result can have an adverse psychological impact, at least in the short term. In this paper, we explore the psychological impact of primary HPV screening over 12 months.

Methods

Women were surveyed soon after receiving their results (n=1133) and 6 (n=762) and 12 months (n=537) later. Primary outcomes were anxiety (Short-Form State Anxiety Inventory-6) and distress (General Health Questionnaire-12). Secondary outcomes included concern, worry about cervical cancer and reassurance. Mixed-effects regression models were used to explore differences at each time point and change over time across four groups according to their baseline result: control (HPV negative/HPV cleared/normal cytology and not tested for HPV); HPV positive with normal cytology; HPV positive with abnormal cytology; and HPV persistent (ie, second consecutive HPV-positive result).

Results

Women who were HPV positive with abnormal cytology had the highest anxiety scores at baseline (mean=42.2, SD: 15.0), but this had declined by 12 months (mean=37.0, SD: 11.7) and was closer to being within the ‘normal’ range (scores between 34 and 36 are considered ‘normal’). This group also had the highest distress at baseline (mean=3.3, SD: 3.8, scores of 3+ indicate case-level distress), but the lowest distress at 12 months (mean=1.9, SD: 3.1). At 6 and 12 months, there were no between-group differences in anxiety or distress for any HPV-positive result group when compared with the control group. The control group were less concerned and more reassured about their result at 6 and 12 months than the HPV-positive with normal cytology group.

Conclusions

Our findings suggest the initial adverse impact of an HPV-positive screening result on anxiety and distress diminishes over time. Specific concerns about the result may be longer lasting and efforts should be made to address them.

Exploring the care received by HPV-positive married women at a colposcopy clinic in Tehran, Iran: A qualitative study

Objectives

Patient experience is the focus of individual care and services to meet patient needs, but this depends on how health care providers deliver their services. The aim of this study was to explore the perceptions of human papilloma virus (HPV)-positive married women from the care they received from health professionals at a colposcopy clinic in Tehran, Iran.

Materials and Methods

Three focus group discussions were conducted between September and December 2016 with 30 women who had recently been referred to the clinic for cervical screening or colposcopy. Samples were collected by a purposeful sampling method in Tehran, the capital of Iran. The focus group discussions were carefully recorded at the same time as data collection. After ensuring the data saturation, interviews were terminated and data were categorized. Data was analyzed by direct conventional content analysis using MAXQDA-10.

Results

Two themes and three sub-themes resulted from the data analysis, including emotional responses (anxiety and fear of women), and appropriate/inappropriate behavior of the healthcare providers.

Conclusion

Healthcare providers, by identifying factors that affect patient's stress, could help reduce the negative outcomes such as patients' emotional responses to HPV positive results.

Cervical Screening and Colposcopy Management of Women Age 24 and Under

OBJECTIVES

In 2012, Ontario's cervical cancer screening program changed the age of initial screening from 18 years of age to 21 and identified women aged 21-24 years as a special population whose cervical squamous intraepithelial lesions should be managed conservatively. In order to provide insight into these changes, we sought to examine patient, provider, and clinical characteristics of cervical cancer screening and colposcopy care in women aged 12-24 years.

METHODS

We conducted a retrospective population-based cohort study of all women in Ontario, aged 12-24 years, who underwent a Pap test between 2012 and 2014. Variables measured included, patient age, cytologic result of the index Pap test; colposcopy and definitive treatment within 1.5 years of the index Pap test; and carcinoma in situ (CIS) and invasive cervical cancer (ICC) 1.5 years after the index Pap test. Descriptive statistics were calculated for variables, and incidence rates per 100 000 women screened were calculated for CIS and ICC.

RESULTS

A total of 270 391 index Pap tests were performed. The majority of patients were between 18 and 24 years of age (12-17 y: 5.5%; 18-20 y: 24.3%; 21-24 y: 70.1%). Overall, 87.0% of Pap tests were normal, 6.9% of women underwent subsequent colposcopy, and 1.1% received any treatment. Of women with a high-grade result, 86.6% (n = 1279) underwent colposcopy and 42.8% (n=632) received any treatment. Of women with a low-grade result, 42.3% (n = 13 856) underwent colposcopy, and 6.0% (n = 1955) had any treatment. Age-standardized rates of CIS and ICC in were 161.5 and 1.0 per 100 000 women, respectively.

CONCLUSIONS

Despite the change in the screening guidelines, women under the age of 21 continue to be screened. This study highlights the low risk of ICC in women under age 25 and lays groundwork for re-examining screening guidelines for women in this age group. Furthermore, colposcopy referrals for women with a low-grade result on an index Pap test, and treatment of women under 24 years of age continue to be high. Future work must address the over-utilization of population-based screening, as well as factors related to adherence to screening guidelines.

Validation of the HPV Impact Profile in Portuguese women with human papilloma virus

Objective: Human papilloma virus (HPV) is the world's most common causative agent in sexually transmitted viral infections; thus requiring clinical guidance, before and after treatment, to promote better quality of life in women diagnosed with HPV. The HPV Impact Profile (HIP) is a comprehensive instrument used to assess the psychosocial impact of HPV and related interventions in a wide range of domains. The main purpose of this study was to validate the HIP in Portuguese women, so that it can be used in this population, both in research and in clinical settings. Methods: A sample of 178 Portuguese women infected with HPV were assessed with the following instruments: Index of Sexual Satisfaction, Hospital Anxiety and Depression Scale and HPV Impact Profile. Results: The results of the confirmatory factor analysis showed some changes to the original model, which resulted in an adapted version with six domains, compared to the seven domains of the original model. The final model showed a good fit to the data. All Cronbach's alphas were higher than 0.79 indicating a high level of internal consistency of the subscales. As in the original HIP questionnaire, the exception was sexual impact, with a lower, but acceptable, Cronbach's alpha. Convergent and discriminant validities of the instrument were also assessed. Conclusions: The Portuguese version of the HIP presents good psychometric properties, allowing its use in clinical trials as well as in clinical practice in order to evaluate quality of life in women with HPV.

Sexual dysfunction in women with human papilloma virus infection in the Turkish population

Human papilloma virus infection (HPV) is the most common sexually transmitted disease. It may increase the risk of several cancers, including those of the cervix, vulva, vagina, head and neck. HPV is usually transmitted during sexual intercourse; there are limited data about sexual dysfunction (SD) after infection with this virus. We aimed to measure the incidence of SD in women with HPV. In this study, we evaluated 67 HPV-infected female patients and 66 healthy controls. The Arizona Sexual Experience Scale (ASEX), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Socio Demographic Form were used for evaluation. Gynaecologists and psychiatrists evaluated the participants. Women with HPV were found to have significantly higher Arizona Sexual Experience Scale (ASEX) total scores and ASEX sub scores than the control group in the domains of sexual desire, arousal, genital response, orgasmic experience and their satisfaction from orgasm (p ≤ .05). The study group shows a statistically significant difference in the Beck Depression Inventory (BDI), but Beck Anxiety Inventory (BAI) scores show no significant differences between the experimental and control groups. Our study shows that HPV positivity in female patients is associated with a significant impairment in sexual function and that this impairment is not related to depression or anxiety. Impact statement What is already known on this subject? There are only a few studies concerned with sexual dysfunction in HPV patients. These studies have methodological problems, as they do not rule out the effect of depression on sexual dysfunction. It is very difficult to perform studies on sexual dysfunction and sexually transmitted diseases, because both physicians and patients are reluctant to talk about sexual problems. In the present study, only 6 out of 15 physicians accepted to contribute to the study. Although the physicians gave a questionnaire to more than 400 patients, only 133 of them completed that questionnaire. The most important difficulties in this study was to find enough patients. What do the results of this study add? Depression and sexual dysfunction are frequently seen in HPV patients. Although depression is one of the most common causes of sexual dysfunction, an HPV infection may lead to sexual dysfunction even in the patients without depression. What are the implications of these findings for clinical practice and/or further research? HPV infections may be associated with mental health problems and sexual dysfunction. The gynaecologists and other clinicians working with HPV patients should also evaluate patients psychologically and refer patients to psychiatry if required. The psychiatric problems associated with an HPV infection do not only impair sexual functions, but also may lead to difficulties in social life.

Depression as a risk factor for overall and hormone-related cancer: the Korean cancer prevention study

Depression has been hypothesized to be a risk factor of cancer, especially hormone-related cancers. However, few studies have been conducted with large enough sample size and sufficient follow-up period to rigorously estimate these associations. We aim to examine the relationship between depression and risk of registry-documented overall and hormone-related cancers. In this 19 year prospective cohort study of general population, 601,775 Koreans aged 30-64 years had a biennial medical evaluation by the National Health Insurance Service in either 1992 or 1994. Major and minor depression was ascertained by a 9-item depression questionnaire. At baseline, major depression was identified in 7.4% and 10.2% and minor depression in 19.3% and 21.4% in men and women, respectively. During the follow-up, 49,744 cancers were identified in men and 7860 in women. Prostate cancer in men was positively related to minor depression (HR 1.13, 95% CI 1.05, 1.23), and cervical cancer in women was inversely related to major depression (HR 0.90, 95% CI 0.83, 0.98) after adjusting for potential confounders. Regarding overall cancer, major depression was positively related to overall cancer in men (HR 1.04, 95% CI 1.00, 1.08) and inversely related in women (HR 0.90, 95% CI 0.83, 0.98). There was no association between breast cancer and depression. Different direction and magnitude of association among gender and cancer subtypes suggest different psycho-behavioral and biological pathways in which depression may affect later cancer development. Further studies on the association of depression and cancer and the underlying mechanisms should be conducted on specific cancer subtypes.

"If you can't treat HPV, why test for it?" Women's attitudes to the changing face of cervical cancer prevention: a focus group study

Background

The relationship between infection with high-risk strains of human papillomavirus (HPV) and cervical cancer is transforming prevention through HPV vaccination and HPV oncogenic testing. In Ireland, a national cervical cancer screening programme and HPV vaccination were recently launched; HPV testing is currently being integrated into the screening programme. Women’s views on the transformation of cervical cancer prevention have been relatively little investigated.

Methods

Using qualitative focus groups, we determined women’s knowledge, attitudes towards, and acceptability of cervical cancer screening, HPV oncogenic testing and vaccination of HPV. Fifty nine women, recruited through primary care in Ireland, participated in ten focus groups. A dynamic topic guide was developed from literature reviewed. Women were provided with standardised information about HPV infection, HPV testing. Discussion transcripts were analysed thematically.

Results

The primary themes that emerged regarding HPV infection were: knowledge, emotional response and societal influences; especially those of healthcare practitioners. Knowledge, logistics, and psychological impact were the primary themes relating to HPV testing. Women’s attitudes towards HPV testing changed during discussion as issues were explored, thus demonstrating the complexity of this issue; lack of existing treatment for HPV infection influenced women’s attitudes, attachment to existing cervical cancer screening also was a significant factor.

Conclusions

Women currently have a strong attachment to cytology and any changes towards HPV primary testing will need to be managed carefully. To ensure that future cervical cancer prevention strategies will be acceptable to women, sufficient thought will have to be given to information provision and education. We identified the importance to women of healthcare practitioners’ opinions regarding HPV. Appropriate and timely information on HPV will be crucial in order to minimise possible psychological effects women may have.

Psychosocial impact of alternative management policies for low-grade cervical abnormalities: results from the TOMBOLA randomised controlled trial

Background

Large numbers of women who participate in cervical screening require follow-up for minor cytological abnormalities. Little is known about the psychological consequences of alternative management policies for these women. We compared, over 30-months, psychosocial outcomes of two policies: cytological surveillance (repeat cervical cytology tests in primary care) and a hospital-based colposcopy examination.

Methods

Women attending for a routine cytology test within the UK NHS Cervical Screening Programmes were eligible to participate. 3399 women, aged 20–59 years, with low-grade abnormal cytology, were randomised to cytological surveillance (six-monthly tests; n = 1703) or initial colposcopy with biopsies and/or subsequent treatment based on colposcopic and histological findings (n = 1696). At 12, 18, 24 and 30-months post-recruitment, women completed the Hospital Anxiety and Depression Scale (HADS). A subgroup (n = 2354) completed the Impact of Event Scale (IES) six weeks after the colposcopy episode or first surveillance cytology test. Primary outcomes were percentages over the entire follow-up period of significant depression (≥8) and significant anxiety (≥11; “30-month percentages”). Secondary outcomes were point prevalences of significant depression, significant anxiety and procedure-related distress (≥9). Outcomes were compared between arms by calculating fully-adjusted odds ratios (ORs) for initial colposcopy versus cytological surveillance.

Results

There was no significant difference in 30-month percentages of significant depression (OR = 0.99, 95% CI 0.80–1.21) or anxiety (OR = 0.97, 95% CI 0.81–1.16) between arms. At the six-week assessment, anxiety and distress, but not depression, were significantly less common in the initial colposcopy arm (anxiety: 7.9% vs 13.4%; OR = 0.55, 95% CI 0.38–0.81; distress: 30.6% vs 39.3%, OR = 0.67 95% CI 0.54–0.84). Neither anxiety nor depression differed between arms at subsequent time-points.

Conclusions

There was no difference in the longer-term psychosocial impact of management policies based on cytological surveillance or initial colposcopy. Policy-makers, clinicians, and women themselves can be reassured that neither management policy has a significantly greater psychosocial cost.

Trial Registration

Controlled-Trials.com ISRCTN 34841617

Sexual dysfunction in men suffering from genital warts

INTRODUCTION

Human papillomavirus (HPV) infection can present clinically as genital warts (GWs) in both males and females. Much less is known about the psychosexual consequences of GW, and the studies on patients in this group are still quite limited.

AIMS

The aim of this study was to test two hypotheses: (i) sexual dysfunction (SD) is likely to occur in male patients suffering from GWs; (ii) if male SD exists, it may be associated with depression or anxiety.

METHODS

This was a pilot study with a prospective cross-sectional design. Male patients with GW (N for patient group = 116) were compared with male control cases (N for control group = 71) using the Arizona Sexual Experience Scale (ASEX), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). The participants were evaluated by a dermatologist and a psychiatrist, respectively.

MAIN OUTCOME MEASURES

The associations between sexual dysfunction, depression, and anxiety among the participants were examined.

RESULTS

There was no difference between the groups in terms of sociodemographic changes. Sexual dysfunction was found to be significantly more common in the patients than controls (P = 0.000 < 0.001). When the subscores of ASEX were evaluated, they were found to be statistically significant between the two groups (P = 0.000 < 0.001). BDI and BAI scores were statistically higher in the patient group than in controls, and there was a positive correlation between BDI and BAI scores with ASEX total and subscores (P = 0.000 < 0.001).

CONCLUSIONS

Male patients with GW have higher rates of sexual dysfunction, depression, and anxiety when compared with the normal population. Men suffering from GW should be evaluated for possible sexual problems, besides depression and anxiety.

A new non-invasive approach based on polyhexamethylene biguanide increases the regression rate of HPV infection

Background

HPV infection is a worldwide problem strictly linked to the development of cervical cancer. Persistence of the infection is one of the main factors responsible for the invasive progression and women diagnosed with intraepithelial squamous lesions are referred for further assessment and surgical treatments which are prone to complications. Despite this, there are several reports on the spontaneous regression of the infection.

This study was carried out to evaluate the effectiveness of a long term polyhexamethylene biguanide (PHMB)-based local treatment in improving the viral clearance, reducing the time exposure to the infection and avoiding the complications associated with the invasive treatments currently available.

Method

100 women diagnosed with HPV infection were randomly assigned to receive six months of treatment with a PHMB-based gynecological solution (Monogin®, Lo.Li. Pharma, Rome - Italy) or to remain untreated for the same period of time.

Results

A greater number of patients, who received the treatment were cleared of the infection at the two time points of the study (three and six months) compared to that of the control group. A significant difference in the regression rate (90% Monogin group vs 70% control group) was observed at the end of the study highlighting the time-dependent ability of PHMB to interact with the infection progression.

Conclusions

The topic treatment with PHMB is a preliminary safe and promising approach for patients with detected HPV infection increasing the chance of clearance and avoiding the use of invasive treatments when not strictly necessary.

Trial registration

ClinicalTrials.gov Identifier NCT01571141

Are women ready for the new cervical screening protocol in England? A systematic review and qualitative synthesis of views about human papillomavirus testing

BACKGROUND

A new protocol for human papillomavirus (HPV) testing within the UK cervical screening programme commenced in April 2011, creating new patient experiences. This is the first review to synthesise a substantial body of international evidence of women's information needs, views and preferences regarding HPV testing. We aimed to inform the development of educational materials to promote informed choice, reduce anxiety and improve disease control.

METHODS

We searched 12 bibliographic databases. Two reviewers independently screened papers and assessed study quality; disagreements were resolved by discussion. Results were extracted verbatim and authors' findings treated as primary data. Studies were synthesised collaboratively using framework methods.

RESULTS

We synthesised findings from 17 studies. Women had overwhelmingly negative concerns; an HPV diagnosis was daunting, had associated problems of disclosure of a sexually transmitted infection (STI), impacted on relationships and provoked fear of stigmatisation. Nevertheless, many thought HPV testing could be a preferable alternative to repeat cytology. Knowledge was poor; women struggled to interpret limited information in the context of existing knowledge about STIs and cervical cancer.

CONCLUSION

Women are likely to be poorly informed, have limited understanding and many unanswered questions. This could increase anxiety and reduce ability to make informed choices, presenting a substantial challenge for those who design and provide information.