Left Out: Why Is It So Hard for Older Women to Get the HPV Vaccine?

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Doctors stop recommending the HPV vaccine to women once they've reached their mid-20s. But is it a good idea for older individuals who still want it?

hpv-vaccine-615.jpgJessica Rinaldi/Reuters

Late last summer, presidential hopefuls Rick Perry and Michele Bachmann propelled the HPV vaccine into the headlines as they sparred over requiring the shot for adolescent girls. Their tussle revived battles between public health advocates and abstinence-until-marriage evangelists over whether it was a potentially life-saving medical precaution or an invitation to promiscuity.

Meanwhile, I had a completely different thought: Hey, what about me?

The human papillomavirus vaccine is FDA-approved only through age 26, with the thinking that by that time women (and men) have had enough sex that they're probably already exposed to the virus and won't benefit. I was 32 then. But I wondered: what if, by luck of the draw, I happen to be an exception? And even if it's a long shot, wouldn't it be worth it for the chance to prevent cervical cancer, just in case?

The HPV vaccine territory for "older" women is uncharted and clouded by a lack of information. Women older than 26 are legally allowed to get the shot, but it's at their doctor's discretion. Since it's an "off-label" use, health insurance generally won't cover it, and it's costly. Some doctors will agree to provide it, some won't. I spoke to a mid-20s woman, an administrative assistant in Sacramento, who asked her gynecologist if she should consider the vaccine.

The doctor told her: "No, you're too old. It's too late for you. I'm sorry you didn't get it before."

Actually, I've learned, it's not quite that simple.

The issue comes down to a conflict between minding the health of populations vs. individuals. Federal regulators naturally care about setting policies that represent the most cost-effective way of protecting the overall population. And to be fair, the research has failed to provide evidence that recommending all older women get vaccinated against HPV fits that bill. Drug maker Merck's study of women 24-45 did show that the vaccine protects those with no prior exposure to the nastiest HPV strains, but taking the study participants as a whole -- an analogy for the overall population of women 24-45 -- not so much. So, the CDC recommends the vaccine just for females ages 11 to 26 and males ages 11 to 21.

That calculation is fine for the feds. But me -- I care about me.

HPV is a fantastically common sexually-transmitted disease, the most common one in the U.S. There are more than 40 strains that can infect the genitals, male and female. The CDC estimates that one in two people in this country will contract the virus at some point in their lives, while other estimates put it closer to four in five. The vast majority of infections cause no symptoms and go away on their own. But when they don't, a handful of strains can cause genital warts and cervical cancer, and less commonly, cancers of the vagina, vulva, penis and anus. HPV causes almost all of the 12,000 cases of cervical cancer diagnosed in the U.S. each year. The virus, also transmittable via oral sex, is driving rising rates of throat cancer, particularly among men. (That's right: oral sex can give you cancer. Yikes.)

Merck's Gardasil, the more widely used of two available HPV vaccines, protects against four of the most pernicious strains. On the market since 2006, the inoculation dramatically reduces teen girls' and young women's chances of getting the abnormal growths that lead to cancer. The vaccine prevents boys and men from passing on the virus to their sexual partners, and scientists expect it's also likely to protect them from throat cancer.

However, if you've already been exposed to the vaccine's four strains, it won't help you. It would seem logical to ask: "How do I know if I'm already exposed?" But the available blood test is pricey, unreliable and used only in research settings.

Among the 3,800 participants in Merck's study of older women, 67 percent showed no sign of prior exposure to the vaccine's HPV strains, and the others had mostly been exposed to only one. That sounds encouraging - except that as many as half of all HPV exposures won't show up on the blood test, so these rates are probably gross overestimates.

So, what's a health-conscious, not-so-young woman to do?

William Tew, an assistant attending medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, who focuses on gynecologic cancers, says of older women getting the vaccine: "I don't personally recommend it. With that said, we don't know. The studies looking at this have been exceptionally limited."

At the very least, he pointed out, research has shown the vaccine to be safe. The most common side effects include headache, fever, dizziness and irritation around the injection site. "So I counsel my patients that if you are going to go for the HPV vaccine, realize that it may not offer any benefit, but it is likely safe," Tew said.

Many doctors say older women get a better bang for their prevention buck just by getting regular Pap smears -- which they should continue to do even if they get vaccinated.

What about the newly single 28-year-old who has had only two, long-term relationships? Or the 50-year-old divorcee who starts dating again after 20 years of marriage?

Dorothy Furgerson, chief medical officer for California's Planned Parenthood Mar Monte chain, said she would recommend the vaccine only to an older woman who has had no more than four sexual partners.

The lack of clarity applies to guys, too. Timm Michaud, a 31-year-old web developer in San Francisco, told me he inquired about the HPV vaccine at two clinics while getting routine STD tests in his late 20s.

"Both of them kind of gave me the brushoff, like, 'Oh, it's only something that girls have to worry about,' or, 'Oh, it's only approved for people up to 26,'" Michaud recalled. Then workers at a travel immunization clinic offered it to him as part of a battery of shots before a trip to South Africa, and he jumped on it.

"As a guy, I want to do something to protect my partners," he said. "I think it's a copout to say you don't really need it because you probably already have it, when you don't really know."

Otis Brawley, chief medical officer of the American Cancer Society and no great fan of overmedication, doesn't buy that thinking.

"The likelihood that you have a 30-year-old, who is not a Catholic nun, who has not been exposed to HPV is really incredibly small," he said. As for vaccinating that woman, "If you're an individual who's very, very worried about this, my first thought is there are a lot of other things in health that I would be much more concerned about."

While cervical cancer causes about 4,000 deaths a year in the U.S., for instance, lung cancer causes 160,000.

My conclusion? By the time the vaccine was getting lots of press, I'd had a number of relationships that didn't last, so I may not have been the best candidate to benefit. Still, population-wide statistics reveal little about the actual health of one individual. I might not have been exposed to all four strains in the vaccine.

I went to Planned Parenthood and shelled out the money: $525 for the three shots over six months (my particular clinic was agreeable to this; Planned Parenthood will not do it in all cases).

Will the immunization ultimately protect me or my partner from cancer? Who knows. For me, it was worth a shot.

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Grace Rubenstein is a reporter and multimedia producer based in the San Francisco Bay Area. Her work has appeared in The New York Times, The Boston Globe, and Parenting and Edutopia magazines.

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