Human Papillomavirus, HPV

What is it?

Overview

What Is It?
Human papillomavirus (HPV) is a virus that often causes no symptoms but can cause cervical cancer.

Chances are you have been exposed to the human papillomavirus (HPV) and didn't even know it. In fact, it is estimated that at least 50 percent of the reproductive-age population has been infected with one or more types of genital HPV, and an estimated 6 million new infections occur each year. As many as 20 million Americans are infected with the genital form of the virus.

The good news: In the vast majority of cases, the virus causes no symptoms or health problems and will go away on its own when a healthy immune system clears the infection. The bad news: A persistent infection with high-risk strains of HPV occurs in about 5 percent of women and causes nearly all cases of cervical cancer, which the American Cancer Society estimates affected an estimated 12,170 women in 2012, killing about 4,220.

HPV can also lead to anal cancer in both men and women, a cancer that affects about 4,430 women and 2,630 men per year and causes 550 deaths in women and 330 in men. Other health problems can result from HPV infection as well, including: genital warts; recurrent respiratory papillomatosis (RRP), a rare condition where warts grow in the throat; and other less common but potentially serious cancers, including cancer of the vulva, vagina and penis, and oropharyngeal cancer, a type of head and neck cancer that affects the back of the throat, base of the tongue and the tonsils.

In many ways, the issues raised by infection with high-risk strains of HPV are similar to those raised by genital herpes. Both often have no symptoms; both can cause medical problems in some women; and both have become widespread in this country. Like herpes, persistent HPV is incurable, though some forms of HPV disappear, and it is not yet known whether they completely go away or merely enter a dormant stage, like herpes. Unlike herpes, however, HPV can cause cancer.

There are more than 150 strains of HPV and at least 40 HPV types that can infect the genital and anal areas. The HPV family of viruses is called papillomavirus because they tend to cause warts, or papillomas—benign (noncancerous) tumors. Warts may appear on the hands and feet or on the genital and anal areas. The strains of HPV that cause warts to grow on hands and feet, however, are rarely the same type that causes warts in the genital and anal areas.

The U.S. Food and Drug Administration (FDA) has approved two HPV vaccines, called Gardasil and Ceravix, which can protect women against the HPV types that cause most cervical cancers. Gardasil also protects women against vaginal and vulvar cancers and protects both men and women against most genital warts and anal cancers. (See Prevention section for more information.)

In addition to the HPV vaccine, the Pap test and the HPV test are important screening tests to prevent cervical cancer in women. When combined with a Pap test in women age 30 and older, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone. (See Diagnosis section for more information.) There is no FDA-approved HPV screening test for men.

Because of early detection and treatment of cell changes, the number of invasive cervical cancer cases and deaths in the United States has steadily decreased over the past several decades. The cervical cancer death rate declined by 74 percent between 1955 and 1992, and the incidence of cervical cancer dropped significantly by 2.3 percent per year between 1999 and 2008.

Conversely, the number of new anal cancer cases has been increasing for a number of years, with most cases occurring in adults, with the average age being in the early 60s. Anal cancer affects women more often than men.

How is HPV spread?

HPV is spread by skin-to-skin contact with an HPV-infected area. Infections can be subclinical, meaning the virus lives in the skin without causing symptoms. This is why many people with HPV do not know they have it or that they could spread it. For a person exposed to a partner who has a low-risk genital wart-causing strain of HPV such as HPV 6 or 11, it usually takes about six weeks to three months for genital warts to appear. However, infections with high-risk strains of HPV cause no symptoms and can only be detected on Pap or HPV tests.

Researchers already know that condoms don't always protect against the virus because the virus can grow on areas of the genitals not covered by a latex barrier.

Researchers don't know whether people infected with genital HPV but who don't have symptoms are as contagious as people with symptoms. They also don't know how much HPV is transmitted through sexual contact versus skin-to-skin contact.

Diagnosis

Diagnosis

Because human papillomavirus (HPV) infections often cause no symptoms in men or women and are hard to identify, you must rely on your health care professional for diagnosis.

Genital warts can be flesh-colored and hidden inside the cervix, vagina, penis, scrotum or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth.

Genital warts come in two forms—growths that can be seen with the naked eye and are on the surface of the skin and smaller, less visible growths called squamous intraepithelial lesions (SILs) that cover the cervix and require a special instrument, called a colposcope, to see.

Studies find that specific HPV types are responsible for the development of genital warts, previously known as "condyloma acuminata." Each HPV type has been numbered and divided into "high risk" or "low risk" categories depending on whether the virus is associated with the development of cancer.

For example, HPV types 6 and 11, which are usually associated with genital warts, are considered "low risk." HPV types 16, 18, 31, 33 and 45, found on the genitals and in the anus, have been linked to most HPV-related cancers in both men and women and are therefore considered "high risk."

If you notice warts, see your health care professional. You should also seek an examination if:

• You see any unusual growths, bumps or skin changes on or near the penis, vagina, vulva or anus.

• You experience unusual itching, pain or bleeding in the genital or anal area.

• You have a sexual partner who tells you that he or she has genital HPV or genital warts.

During your examination, your health care professional may use a colposcope, a lighted magnifying lens, to find small warts or abnormal areas. Your health care professional may also apply a vinegar solution to the genitals, which causes abnormal tissue to turn white. This doesn't hurt, but it does make it easier to see warts or precancerous lesions.

You may also have a Pap test, which was designed to identify cervical cancer in its earliest stage but can also find abnormal precancerous cells and active HPV infections.

The Pap test is a simple procedure. In the Pap test, a health care professional uses a special brush and/or spatula to collect cells from the cervix and places them on a glass slide or in a liquid preservative, which is sent to a laboratory for evaluation.

There is also an anal Pap test that is much like the Pap test for cervical cancer. It involves swabbing the anal lining and looking at the swabbed cells under a microscope. The anal Pap test is relatively new and hasn't been studied well enough to determine when, how often and on whom it should be performed or if it actually reduces risk of anal cancer. Some experts recommend it be done regularly in men who have sex with men.

There are different classifications for abnormal results for the cervical Pap test, but the most common is called atypical squamous cells of undetermined significance (ASCUS).

In conjunction with the Pap test, which screens for abnormal cells once cell changes have taken place, there are also tests that look specifically for HPV. These tests can detect HPV infection early on, before cell changes have occurred. The most common test looks for DNA from several high-risk types of HPV, but it doesn't indentify which types are present. Another test looks specifically for DNA from HPV types 16 and 18, the HPV types that cause most cancers associated with HPV. A third test can detect DNA from several high-risk HPV types and can distinguish whether HPV-16 or HPV-18 is present, and a fourth test looks for RNA from the most common types of high-risk HPV.

At this point, these HPV tests are FDA-approved for two indications only—for follow-up testing for women whose Pap tests reveal abnormal cells and for cervical cancer screening in combination with a Pap test in women over age 30.

There are currently no recommended screenings or FDA-approved tests that detect HPV infection in men, but research is continuing.

Along with medical history and evaluation of other risk factors, the HPV test helps physicians determine what follow-up might be necessary if there is an abnormal result from a Pap test.

Pap Test Screening Guidelines

The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force recommend the following guidelines for Pap tests and early detection of cervical cancer:

• All women should begin screening at age 21.

• Women ages 21 to 29 should have a Pap test no more than once every three years to five years. They should not have an HPV test unless it is needed because of an abnormal Pap test result.

• Women ages 30 to 65 should have both a Pap test and an HPV test every five years or a Pap test alone every three years. (The ACS and ACOG recommend the two tests together every five years; the USPSTF recommends either schedule. The organizations agree that a Pap test alone once every three years is acceptable if HPV testing is not available.)

• Women over age 65 who have been screened previously with normal results and are not at high risk for cervical cancer should stop getting screened. Women with cervical precancer should continue to be screened.

• Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened.

• Women who have received the HPV vaccine should still follow the screening guidelines for their age group.

• Women who are at high risk for cervical cancer may need more frequent screening. Talk to your health care professional about what's right for you.

If your health care professional identifies any unusual cell changes, he or she will recommend a plan of action, depending on the result and your health history. That may include a waiting period, a repeat Pap test, a DNA-based HPV test, a colposcopy or a more thorough examination and biopsy of the abnormal area. If the Pap reveals ASCUS and the HPV test is positive, a colposcopy will be required. Colposcopy also is needed if any other more serious changes are shown by the Pap results. Further screening and treatments will depend on the results of the colposcopy. Mild dysplasia (CIN 1) should not be treated, but the Pap will be repeated in six to 12 months. For CIN 2 or CIN 3, further treatment is needed to remove the abnormal cells.

Regular Pap tests are equally important for lesbians and bisexual women who, studies find, may be less likely to seek routine health care because of the discomfort they feel discussing or revealing their sexual orientation to health care professionals. They also may not want to be screened because they feel that they are not at risk. Lesbian and bisexual women are also at risk for HPV infection and cervical cancer (for example, through prior male partners, vibrators and other sexual aids or skin-to-skin contact with an infected partner).

Treatment

Treatment

There is no cure for HPV, but there are treatments for genital warts. In addition, young women may be vaccinated against four common strains of HPV, as well as the types that cause most HPV-related cervical cancers. (See Prevention section for details.) For women over 26, the best defense against HPV is to learn as much as possible about the disease to try to minimize your risk. Using condoms, limiting your number of sexual contacts and continuing to have regular Pap tests are important steps to reducing risk.

Most people with HPV infections don't require treatment. Your body's immune system simply gets rid of the virus on its own. Only a small portion of women develop problems, ranging from warts to cervical cancer, that require treatment.

Most genital warts are treated because you may not like the way they look or because of symptoms—not because treatment prevents them from reforming or from you transmitting the infection to someone else. In fact, genital wart recurrence is common, especially within the first three months. Studies also find that small warts of short duration (less than one year) respond better to therapy than large warts of long duration. All wart treatments may cause mild local irritation.

Experts reviewing current genital wart treatment practices find that no single treatment is ideal for all women. They recommend that you be involved in making any treatment decisions with your health care professional. So it's important that you understand your options.

You may not even need treatment. There is no treatment available for subclinical genital HPV infection (i.e., no visible warts diagnosed by colposcopy, biopsy, acetic acid application or HPV laboratory tests). That's because there's no certain way to diagnosis subclinical genital HPV infection and no effective therapy. The infection with these low-risk strains will eventually go away on its own.

In the past, treatments for genital warts were administered by health care professionals and often caused more damage than the disease itself. Traditional treatments ranged from cryotherapy, which froze the warts with liquid nitrogen, to electrocautery, which burned off the warts. Today, there are a wide variety of treatments that can be administered by you or your health care professional.

The goal of treatment should be to remove visible genital warts and relieve annoying symptoms. No available treatment is any better than another, and no single treatment is ideal for all cases. Thus, the CDC has developed the following guidelines:

Self-applied treatments:

• Podofilox (Condylox). This 0.5 or 0.15 percent solution or gel is a relatively cheap, safe, easy-to-use treatment. It is applied directly to the warts every day for three weeks or twice a day for three days, followed by four days of no therapy, for a total of three to four weeks. Warts may return after treatment.

• Imiquimod (Aldara). This 5 percent cream is used to treat external genital warts and perianal warts, which appear around the anus. It is safe, effective and easy to use. The cream works by stimulating the immune system to target the warts. Apply three times a week at bedtime for up to 16 weeks. Warts may recur after treatment.

• Sinecatechin (Veregen). This is a 5 percent ointment made from a green tea extract. The active ingredients in sinecatechin are components in green tea called catechins. Apply the ointment three times a day until the warts disappear.

People tolerate these three therapies differently, so podofilox may work better for you while imiquimod or sinecatechin works better for someone else. Discuss with your doctor which therapy you should try. Side effects of all three drugs may include tenderness, irritation and localized burning. None has been deemed safe to use during pregnancy.

Treatments applied by health care professionals:

• Cryotherapy (freezing off the wart with liquid nitrogen). This treatment is relatively inexpensive. It is usually performed without an anesthesia, and you may experience some discomfort. You may require several treatments a week for up to six weeks to remove all warts.

• Podophyllin resin 10 percent to 25 percent. This solution is applied once a week, typically for up to four weeks and must be washed off within one to four hours after application to reduce local irritation. It is more likely to cause side effects than the less-toxic, over-the-counter podofilox. There's no evidence that it's safe for use during pregnancy.

• Trichloracetic acid (TCA) (10-25 percent) or bichloracetic acid (BCA) (80-90 percent). These are two other chemicals that are applied to the surface of the wart once a week for up to four consecutive weeks. These chemicals are stronger forms of the over-the-counter acids used to remove external warts. Because the procedure can be painful, most health care professionals use a topical anesthetic.

• Laser therapy (using an intense light to destroy the warts) or surgery (cutting off the warts) gets rid of warts in a single office visit. However, treatment can be expensive and the health care provider must be well trained in these methods. A local or general anesthetic may be used. If not performed correctly, laser therapy can cause burning and scarring.

Because HPV is a virus, your immune system plays a role in whether your warts return or not. The virus travels to a deeper level of tissue where it can remain indefinitely. You should watch for recurrences, which occur most frequently during the first three months after treatment.

Eating a balanced diet, exercising regularly and avoiding illegal drugs, tobacco and alcohol are simple ways to help maintain a strong immune system.

Prevention

Prevention

At least 50 percent of sexually active adults by the time they reach age 50 will have acquired an infection with one of the genital HPV strains at some point.

The U.S. Food and Drug Administration (FDA) has approved two HPV vaccines, called Gardasil and Ceravix, which can protect women against the HPV types that cause most cervical cancers. Gardasil also protects against most strains of genital warts, as well as anal, vaginal and vulvar cancers. Vaccination should be given before an infection occurs, ideally, before a girl becomes sexually active. The vaccines are given in three doses, and it is important for females to get all three doses for the best protection. Either vaccine is recommended for girls ages 11 and 12, as well as for females ages 13 to 26 who did not receive any or all of the shots when they were younger. The vaccines can also be given to girls as young as age nine.

Gardasil also protects males against most genital warts and anal cancers. Therefore, it is recommended for 11- and 12-year-old boys and males ages 13 through 26 who did not get any or all of the shots when they were younger.

It's important to note that vaccination doesn't protect against all HPV strains. Therefore, continued lifelong screening with Pap tests and the HPV test if appropriate is necessary. The vaccines are not effective for a particular strain of the virus if a woman is already infected with this HPV type. For this reason, vaccinating before a woman is sexually active and exposed to the virus is optimal to provide the greatest protection.

Women age 30 and older who test positive for HPV are more likely to have a persistent infection that was not cleared by the immune system. And only women with persistent infections with HPV are at risk for developing cellular changes that can lead to cervical cancer. Therefore, when combined with a Pap test in women 30 and older, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone. In addition, four tests have been approved by the FDA to look for high-risk strains of HPV. (See Diagnosis section for guidelines on Pap tests and HPV tests.)

Health experts advise women to use one or more of the following options to reduce contact with the virus, which is transmitted via skin-to-skin contact:

• Use condoms whenever you are intimate with a new or casual sexual partner. Latex condoms, when used correctly and consistently from start to finish each time you have sex, can provide some protection if they cover the area of HPV infection. Note, however, that while condom use will decrease the risk of HPV infection, it can't prevent it entirely because HPV can infect cells anywhere on the skin in the genital area.

• Be aware that spermicidal foams, creams or jellies are not effective against any sexually transmitted disease (STD), including HPV. The FDA has advised consumers that using vaginal contraceptives containing nonoxynol-9 can increase vaginal irritation, which may increase the risk of infection.

• If you're having oral sex, use a dental dam, plastic wrap or a split and flattened unlubricated condom. These materials provide a moisture barrier between the mouth and the vagina or anus during oral sex. Avoid brushing or flossing your teeth right before having oral sex, which may tear the lining of your mouth, increasing your exposure to viruses.

• Be careful about sharing sexual toys. It's possible that HPV could be transmitted via sexual toys that are inserted in the vagina but aren't thoroughly cleaned before being used on your partner.

Facts to Know

Facts to Know

1. If you have HPV, you are not alone. It is estimated that as many as 50 percent of the reproductive-age population has been infected with one or more types of sexually transmitted human papillomavirus (HPV), and an estimated 6 million new infections occur each year.

2. Most HPV infections have no symptoms and are hard to identify. Warts are caused by low-risk strains of the virus and can be flesh-colored and hidden inside the cervix, vagina or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth. High- risk cancer-causing strains of HPV cause no symptoms and are detected by an abnormal Pap test or the HPV test.

3. HPV infection is a direct cause of cervical cancer. Cervical cancer was once one of the most common causes of cancer death for American women but is now one of the most preventable, with fatality rates dropping because of early detection and treatment.

4. In addition to cervical cancer, other health problems can result from HPV infection as well, including recurrent respiratory papillomatosis (RRP), a rare condition where warts grow in the throat, and other less common but potentially serious cancers, including cancer of the vulva, vagina, anus and penis, and oropharyngeal cancer, a type of head and neck cancer that affects the back of the throat, base of the tongue and the tonsils.

5. In the vast majority of cases, the body's immune system clears the infection within two years. Because the virus travels to lower-level tissues where it may remain indefinitely, researchers don't know if the virus is completely eliminated or just suppressed to such a low level that it's hard to detect with routine screening. However, women who test negative for the high-risk strains of HPV using the HPV test have almost no chance of developing serious cell changes in the near future. This can provide tremendous peace of mind.

6. Women who are 30 and older who have persistent HPV infection are more likely to have the cancer-causing, or high-risk, types of HPV, and if they test positive for HPV two times in a row, will require further testing even if their Pap test is normal.

7. In conjunction with the Pap test, the HPV test can be used in women age 30 and older to help detect HPV infection. When combined with a Pap test in women of this age group, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone.

8. It is important that you work with your health care professional to determine which HPV treatment (whether for low-risk HPV causing genital warts or for high-risk HPV causing dysplasia) is most appropriate for you.

9. Because HPV is so common, and it is impossible to determine when someone was infected, notifying a partner of a prior HPV infection is not considered mandatory. A patient with an active infection with genital warts, however, should use protection and notify a partner, who may choose to forego sex because the condom isn't completely protective, and the genital wart virus is highly infectious.

10. Genital warts are uncommon in children. When they occur, they are most often the result of sexual abuse.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about human papillomavirus (HPV) so you're prepared to discuss this important health issue with your health care professional:

1. How can I tell whether or not I have HPV? How does it affect my risk for developing cervical cancer and other diseases?

2. Am I a good candidate for the HPV test?

3. What procedures can you do if I have an abnormal Pap test? Does that mean I have cancer? Which follow-up tests should I have?

4. Please explain the treatment you recommend. Given the wide variety of treatment options available, why is one better for me than the others?

5. How much will each treatment cost, and how many treatments will it take to permanently remove my warts?

6. What are the side effects of this treatment?

7. What should I do if my symptoms or treatments become painful?

8. Can I have sex during the treatment period?

9. If I'm pregnant, or plan to get pregnant, how will HPV affect me and my baby?

Key Q&A

Key Q&A

1. How can I tell if I'm infected with human papillomavirus (HPV) if I don't have genital warts?

   If you or your partner do not have warts, it is virtually impossible for you to determine whether you have HPV. An estimated 20 million Americans are infected with the virus, but many people are unaware they have it.
   
   Occasionally, people may notice itching or skin changes, but more often HPV is a silent infection. For this reason, women are strongly encouraged to see their health care professional for regular pelvic examinations and Pap tests. Men should also see their health care professional to learn as much as possible about this disease.
   
   Because HPV can be a predictor of the presence or future development of cervical cancer, many medical professionals now also test for the virus as an adjunct to the Pap test. There are now four tests available that look for high-risk HPV types that can lead to cervical cancer. These tests can detect HPV infection early on, before cell changes have occurred.

2. Can I get HPV from someone performing oral sex on me?

   Yes. HPV is spread by skin-to-skin contact, primarily during sexual relations, even if a wart is not visible. HPV infections are most commonly found in the genital area, anus and mouth. An increasing number of oral and tonsillar cancers are caused by high-risk strains of HPV thought to be related to an increase in oral sex.

3. If I have a wart removed, will it come back?

   Because HPV is a virus, your immune system plays a role in whether your warts recur. In some cases they do return; however, in the majority of cases, the infection clears within two years. However, because the virus hides in lower-level tissue, it is impossible to know if the virus is completely eliminated or just suppressed to such a low level that it's hard to detect.

4. If I use a condom, can I still get (or spread) HPV?

   Yes. Unfortunately, condoms do not provide complete protection against HPV because they do not cover all the possible infection sites, which include the genital area, anus and mouth. This does not mean you should not use them. While condoms are not foolproof, they provide the best available protection, especially for those who have several sexual partners. Studies have shown that condoms do reduce the risk of HPV infections but are not completely protective.

5. If I have HPV, does that mean I am at risk for other sexually transmitted infections or cervical cancer?

   Yes. Having HPV increases the likelihood that a woman may have other sexually transmitted diseases or cervical cancer. Although only certain types of HPV cause cervical cancer, it is important that women of all ages have a regular gynecologic exam and all the recommended screening tests including testing for other STDs including chlamydia, gonorrhea and HIV, if necessary. Talk with your health care professional about how often you should be tested.

6. How does HPV affect my fertility?

   HPV is not like other sexually transmitted diseases (such as chlamydia) that can affect your fertility. Of greater concern is that a high-risk HPV strain can lead to cervical cancer. In addition, certain HPV treatments may cause scarring or damage the cervix (such as LEEP or cone biopsy), which may impair fertility or impact a pregnancy (such as increased risk of premature delivery), so it is important to discuss the options with your health care professional.

7. What is the best treatment for HPV?

   This will depend on whether you have strains that cause genital warts or dysplasia. There is no one treatment that all HPV patients should receive. Each case is different, and you should work with your health care professional to choose the one that best fits your needs. A wide variety of treatments have been developed for treating genital warts. In most cases, treatment will require repeat applications.

8. If my partner is diagnosed with HPV, does that mean he or she has cheated on me?

   HPV is a group of more than 150 viruses, 40 of which can infect the genital area. HPV can take weeks, months or years to produce symptoms (if they appear at all). If your partner is diagnosed with HPV, it does not automatically mean there has been recent infidelity. The most important thing you and your partner can do is to learn as much as possible about this disease. It is estimated that as many as 75 percent of reproductive-age men and women have been infected with one or more types of HPV at some point, and most don't know it because not all viruses produce warts. Furthermore, the immune system naturally fights off the virus and evidence of the virus goes away in one to two years.

Lifestyle Tips

Lifestyle Tips

1. Understand testing for human papillomavirus (HPV) infection

   HPV infections are very common and your immune system spontaneously clears most infections. Therefore, even if you have HPV, your risk of developing cervical cancer is extremely low. It's important, however, to have regular Pap test screenings according to guidelines established by the American Cancer Society. It recommends all women begin getting Pap tests at age 21 and be screened every three years. Starting at age 30, women may opt to stretch out screenings to every five years if they get both a Pap test and an HPV test. Women may stop screenings at age 65 if they've had regular screenings and are not at high risk for cervical cancer.
   
   Think of screening for HPV in much the same way you'd screen for cholesterol or other health risk factors: you want to determine what your risks are for having or developing the disease. For women with minor abnormalities on their Pap test, doctors use the HPV test to determine if they have a high-risk HPV infection and need further workup such as a colposcopy. Those who are not infected with high-risk strains of HPV need only regular Pap tests.
   
   For women 30 and older, the advantage of being screened with the HPV test in conjunction with their Pap test is that those women who are negative on both tests have a very low risk for persistent HPV infection or cervical cancer and probably don't need to be screened again for five years. In addition, four high-risk HPV tests have been approved by the FDA to screen for the HPV types most strongly associated with cervical cancer—HPV 16 and HPV 18. Ask your doctor about using one of these tests along with the Pap test.

2. Take precautions for oral sex

   Most sexually transmitted infections, including HPV, can be spread via oral sex. To protect yourself, make sure your partner uses a condom if you're performing oral sex; if he's performing oral sex on you, or if you're having oral sex with a woman, use a dental dam, a flat piece of latex used during dental procedures, available in some medical supply stores. They provide a barrier between the mouth and the vagina or anus during oral sex. Household plastic wrap or a split and flattened, unlubricated condom can also be used. Also, don't brush or floss your teeth right before having oral sex. Either may tear the lining of your mouth, increasing your exposure to viruses.

3. Practice the best protection

   The best protection against any type of sexually transmitted infection besides abstinence is a latex condom. However, it doesn't provide 100 percent protection against sexually transmitted diseases.
   
   If you use a condom, make sure you use it properly. Human error causes more condom failures than manufacturing errors. Use a new condom with each sexual act (including oral sex). Carefully handle it so you don't damage it with your fingernails, teeth or other sharp objects. Put the condom on after the penis is erect and before any genital contact. Use only water-based lubricants with latex condoms. Ensure adequate lubrication during intercourse. Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage.

4. Get tested for STDs

   No one test screens for all sexually transmitted diseases. Some require a vaginal exam and Pap test; others a blood or urine test. And just because you have a negative test doesn't mean you don't have the disease. Chlamydia, for instance, may travel far up into your reproductive tract, so your doctor is unable to obtain an accurate culture. Or your body may not yet have developed enough antibodies to a virus like HIV to turn up in a blood test.
   
   Still, it's important to ask your health care provider to regularly test you for sexually transmitted diseases if you're sexually active in a relationship in which you or your partner is also sexually active with others.
   
   You can also get tested at your health department, community clinic or Planned Parenthood. Or call the CDC at 1-800-CDC-INFO (800-232-4636) for information on free or low-cost clinics in your area.

5. Know whether you have an STD

   While some sexually transmitted diseases may have symptoms such as sores, ulcers or discharge, most have no symptoms. You can't always tell if you or a partner has an infection just by looking. So don't rely on a partner's self-reporting and assume that will prevent you from acquiring a sexually transmitted disease; many infected persons do not know they have a problem.
   
   Even if you have symptoms, they may be caused by something else, such as yeast infections, friction from sexual relations or allergies. Educate yourself about your own body and, in turn, learn about your own individual risk for contracting an STD. One way to do this is to schedule an examination with a nurse practitioner or other health care professional who can sit down with you and help you learn the principles for staying safe and sexually healthy. Don't allow fear, embarrassment or ignorance to jeopardize your future.

Organizations and Support

Organizations and Support

For information and support on coping with HPV, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: http://www.ashastd.org
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

ASHA's STI Resource Center Hotline
Website: http://www.ashastd.org/herpes/herpes_hotline.cfm
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

AWARE Foundation
Website: http://www.awarefoundation.org
Address: 834 Chestnut Street, Suite 400
Philadelphia, PA 19107
Phone: 215-955-9847

CDC National Prevention Information Network
Website: http://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: http://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: http://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Cervical Cancer Coalition (NCCC)
Website: http://www.nccc-online.org
Address: 6520 Platt Ave., #693
West Hills, CA 91307
Hotline: 1-800-685-5531
Phone: 818-909-3849
Email: info@nccc-online.org

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Planned Parenthood Federation of America
Website: http://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Sexual Health: Questions You Have...Answers You Need
by Michael V. Reitano, Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney, Marion McIlhaney

CDC - Human Papillomavirus
Website: http://www.cdc.gov/std/Spanish/STDFact-HPV-s.htm
Address: 1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-888-246-2857
Phone: 404-639-3311

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/common/sexinfections/sti/389.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html