HPV (Human Papillomavirus)
A common sexually transmitted infection that can be prevented through vaccination and managed with appropriate medical care
Quick Facts
- Type: Viral STI
- ICD-10: B97.7
- Prevalence: ~80% lifetime risk
- Prevention: Vaccination available
Overview
Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. HPV is a group of more than 200 related viruses, with about 40 types that can infect the genital areas, mouth, and throat through sexual contact. While most HPV infections are harmless and clear up on their own, some types can cause genital warts, and certain high-risk types can lead to cancers of the cervix, vulva, vagina, penis, anus, and throat.
Most sexually active people will get HPV at some point in their lives. In fact, HPV is so common that nearly all sexually active men and women will be infected with at least one type during their lifetime. The good news is that for most people, the immune system clears HPV infections naturally within two years without causing any health problems. However, when infections persist, they can cause serious health complications.
HPV vaccines are highly effective at preventing infection with the most dangerous types of HPV. These vaccines work best when given before a person becomes sexually active, which is why they're routinely recommended for preteens and teens. Regular screening, particularly cervical cancer screening for women, can detect precancerous changes caused by HPV before they develop into cancer, making prevention and early treatment possible.
Symptoms
Most HPV infections cause no symptoms and go away on their own. When symptoms do occur, they depend on the type of HPV involved. Low-risk HPV types typically cause genital warts, while high-risk types may cause cellular changes that can lead to cancer over time.
Primary Symptoms
Genital Warts (Low-Risk HPV Types 6 and 11)
Appearance and Location
- Small, flesh-colored, gray, or brown growths
- Cauliflower-like appearance when clustered
- Can appear on vulva, vagina, cervix, penis, scrotum, or anus
- May be raised or flat
- Usually painless but may cause itching
Associated Symptoms
- Mild itching or discomfort
- Bleeding during intercourse (if on cervix)
- Irritation or burning sensation
- Unusual vaginal discharge (rare)
High-Risk HPV (Types 16, 18, and Others)
High-risk HPV types usually cause no symptoms initially but can lead to cellular changes that may eventually develop into cancer if left untreated. These changes are typically detected through screening tests rather than symptoms.
Cervical Changes
- Usually asymptomatic in early stages
- Abnormal Pap test results
- Detected through routine cervical screening
- May progress to cervical cancer if untreated
Oral HPV Symptoms
- Mouth or throat warts (rare)
- Persistent sore throat
- Difficulty swallowing
- Voice changes
- Ear pain
- Swollen lymph nodes
When HPV Progresses to Cancer
Cervical Cancer Symptoms
- Abnormal vaginal bleeding
- Bleeding between periods
- Bleeding after menopause
- Heavier or longer periods
- Bleeding after intercourse
- Unusual vaginal discharge
- Pelvic pain
- Pain during intercourse
Other HPV-Related Cancers
- Vulvar cancer: Persistent itching, burning, or bleeding
- Vaginal cancer: Abnormal bleeding or discharge
- Anal cancer: Bleeding, pain, or itching
- Penile cancer: Changes in skin color or thickness
- Throat cancer: Persistent sore throat, difficulty swallowing
Recurrent Respiratory Papillomatosis (RRP)
- Rare condition caused by HPV types 6 and 11
- Warts grow in the throat or breathing passages
- Hoarseness or voice changes
- Difficulty breathing
- Chronic cough
- More common in children born to mothers with genital warts
Important Notes About HPV Symptoms
- Most HPV infections are asymptomatic
- Symptoms may appear weeks to years after exposure
- Absence of symptoms doesn't mean absence of infection
- Regular screening is essential for early detection
- Many symptoms are also caused by other conditions
- Partner notification may be challenging due to long latency
Causes
HPV is caused by infection with human papillomavirus, a DNA virus that infects epithelial cells of the skin and mucous membranes. Understanding how HPV spreads and establishes infection is crucial for prevention and management.
HPV Virus Characteristics
Virus Classification
- Family: Papillomaviridae
- Genome: Double-stranded DNA virus
- Size: Small, non-enveloped virus
- Types: Over 200 identified types
- Tropism: Epithelial cells of skin and mucosa
HPV Type Classification
- Low-risk types: 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81
- High-risk types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
- Probable high-risk: 26, 53, 66, 67, 73, 82
- Cutaneous types: Cause common skin warts
Transmission Mechanisms
Sexual Transmission
- Vaginal, anal, and oral sex
- Skin-to-skin contact in genital areas
- Does not require penetration or ejaculation
- Can occur even with condom use (uncovered areas)
- Most common mode of transmission
Non-Sexual Transmission
- Vertical transmission: Mother to infant during delivery
- Rarely: Through fomites (contaminated objects)
- Autoinoculation: Spread from one body part to another
- Hand-to-genital contact: Possible but uncommon
Infection Process
Viral Entry
- Virus enters through micro-abrasions in epithelium
- Targets basal epithelial cells
- Establishes infection in dividing cells
- Integrates into host cell DNA
Viral Replication
- Replicates along with host cell division
- Produces viral proteins that disrupt cell cycle
- Causes cellular proliferation
- May remain dormant for years
Oncogenic Mechanisms (High-Risk Types)
Viral Oncoproteins
- E6 protein: Inactivates p53 tumor suppressor
- E7 protein: Inactivates Rb tumor suppressor
- Prevents normal cell death (apoptosis)
- Promotes uncontrolled cell growth
- Accumulation of genetic mutations
Progression to Cancer
- Persistent infection required
- Additional genetic changes needed
- Process takes 10-20 years typically
- Only a small percentage progress to cancer
- Host immune factors play a role
Environmental and Host Factors
Factors Promoting Infection
- Microscopic trauma during sexual activity
- Immunosuppression
- Multiple sexual partners
- Early age at first sexual activity
- Smoking
Immune Response
- Cell-mediated immunity most important
- Most infections cleared by immune system
- Memory immune response variable
- Reinfection possible
- Immunocompromised individuals at higher risk
Latency and Reactivation
- Virus may remain dormant for years
- Can reactivate during immunosuppression
- Difficult to determine timing of initial infection
- May be undetectable between active phases
- Implications for contact tracing
Co-factors for Disease Progression
- Smoking: Doubles risk of cervical cancer
- HIV infection: Increases persistence and progression
- Other STIs: May facilitate HPV transmission
- Hormonal factors: Oral contraceptives, pregnancy
- Nutritional factors: Folate deficiency
Risk Factors
HPV infection risk is primarily related to sexual behavior and immune status. Understanding these risk factors helps guide prevention strategies and screening recommendations.
Sexual Behavior Risk Factors
Number of Sexual Partners
- Increased risk with multiple partners
- Risk increases with partner's number of partners
- Lifetime number more important than recent partners
- Risk present even with single partner
Age at Sexual Debut
- Earlier sexual debut increases risk
- Adolescent cervix more susceptible
- Immature immune system
- Higher likelihood of multiple partners over time
Sexual Practices
- All forms of sexual contact carry risk
- Oral sex can transmit oral HPV
- Anal sex increases anal HPV risk
- Condoms reduce but don't eliminate risk
Demographic Risk Factors
Age
- Teens and young adults: Highest infection rates
- Peak age: 15-25 years
- Adults: Lower infection rates but higher cancer risk
- Elderly: May have persistent infections
Gender Differences
- Similar infection rates in men and women
- Women: Higher risk of cervical cancer
- Men: Higher risk of anal and oral cancers
- Different screening recommendations by gender
Immune System Factors
Immunocompromising Conditions
- HIV/AIDS: Highest risk group
- Organ transplant recipients: Immunosuppressive medications
- Cancer patients: Chemotherapy effects
- Autoimmune diseases: Disease and treatment effects
Genetic Factors
- Certain HLA types associated with persistence
- Family history of cervical cancer
- Genetic variations in immune response
- Rare immunodeficiency syndromes
Lifestyle Risk Factors
Smoking
- Doubles risk of cervical cancer
- Reduces immune function
- Promotes viral persistence
- Affects all HPV-related cancers
Contraceptive Use
- Oral contraceptives: Slight increase in cervical cancer risk
- Long-term use: Higher risk (>5 years)
- Hormonal effects: May promote progression
- Benefits vs. risks: Must be considered
Reproductive and Gynecologic Factors
- Multiple pregnancies: Increased cervical cancer risk
- Young age at first birth: Higher risk
- DES exposure: In utero exposure increases risk
- Previous cervical lesions: Increased recurrence risk
Socioeconomic Factors
- Limited access to healthcare
- Delayed or inadequate screening
- Lower vaccination rates
- Higher rates of smoking
- Nutritional deficiencies
Geographic and Cultural Factors
- Higher prevalence in developing countries
- Limited screening programs
- Cultural barriers to healthcare
- Different HPV type distributions
Co-infections
- HIV: Dramatically increases risk
- HSV-2: May facilitate HPV transmission
- Chlamydia: Associated with cervical cancer
- Other STIs: General increased susceptibility
Nutritional Factors
- Folate deficiency
- Low vitamin C intake
- Low vitamin A intake
- Overall poor nutrition
- Obesity (some HPV-related cancers)
Occupational Factors
- Healthcare workers (rare, hand warts)
- Workers handling meat products
- Generally not a significant factor for genital HPV
Protective Factors
- HPV vaccination
- Consistent condom use
- Monogamous relationships
- Delayed sexual debut
- Not smoking
- Good nutrition
- Regular screening
Diagnosis
HPV diagnosis involves multiple approaches depending on the clinical presentation and screening context. Most HPV infections are diagnosed through screening tests rather than symptoms, as many infections are asymptomatic.
Clinical Evaluation
Medical History
- Sexual history and practices
- Previous abnormal Pap tests
- HPV vaccination status
- Immunosuppression history
- Smoking history
- Family history of cervical cancer
- Contraceptive use
Physical Examination
- Visual inspection of genital areas
- Pelvic examination for women
- Inspection of mouth and throat
- Lymph node examination
- Digital rectal examination if indicated
Screening Tests for Women
Pap Test (Cytology)
- Detects abnormal cervical cells
- Does not directly test for HPV
- Recommended starting at age 21
- Every 3 years for ages 21-29
- Can be combined with HPV testing
HPV DNA Testing
- Detects high-risk HPV types
- More sensitive than Pap test
- Used alone or with Pap test (co-testing)
- Recommended for women 30 and older
- Can identify specific HPV types
HPV/Pap Co-testing
- Combines Pap and HPV tests
- Most sensitive screening approach
- Allows for extended screening intervals
- Recommended every 5 years (ages 30-65)
Diagnostic Tests for Abnormal Results
Colposcopy
- Magnified examination of cervix
- Performed after abnormal screening
- Allows targeted biopsy
- Uses acetic acid to highlight abnormal areas
- Can examine vagina and vulva
Cervical Biopsy
- Tissue sample for histological examination
- Punch biopsy during colposcopy
- LEEP (Loop Electrosurgical Excision Procedure)
- Cold knife cone biopsy
- Determines severity of dysplasia
HPV Testing Methods
HPV DNA Tests
- Hybrid Capture 2: Signal amplification
- PCR-based tests: Target amplification
- Real-time PCR: Quantitative results
- Multiplex PCR: Multiple targets
HPV RNA Tests
- Detect viral mRNA expression
- May indicate active infection
- Higher specificity than DNA tests
- Newer technology
HPV Genotyping
- Identifies specific HPV types
- Important for types 16 and 18
- Guides management decisions
- Research and epidemiological uses
Screening Guidelines
Cervical Cancer Screening
- Ages 21-29: Pap test every 3 years
- Ages 30-65: Pap + HPV every 5 years OR Pap every 3 years
- Over 65: May stop if adequate screening
- Post-hysterectomy: Usually not needed
Special Populations
- HIV-positive women: More frequent screening
- Immunocompromised: Annual screening
- DES exposure: Annual screening
- Previous CIN 2/3: Extended follow-up
Diagnosis of Genital Warts
Clinical Diagnosis
- Visual inspection usually sufficient
- Characteristic appearance
- Acetic acid test (turns white)
- Biopsy if diagnosis uncertain
Differential Diagnosis
- Condyloma lata (syphilis)
- Molluscum contagiosum
- Seborrheic keratoses
- Skin tags
- Pearly penile papules
Testing in Men
- No routine screening recommended
- Visual inspection for warts
- Anal cytology for high-risk men
- Research settings for penile/anal HPV
- Partner notification considerations
Oral HPV Testing
- Not routinely recommended
- Research and high-risk populations
- Oral rinse samples
- Limited clinical utility currently
Test Interpretation
HPV Test Results
- Positive: High-risk HPV detected
- Negative: No high-risk HPV detected
- Type-specific: Identifies HPV 16/18
- Other high-risk: HPV detected but not 16/18
Management Based on Results
- Normal Pap, negative HPV: Routine screening
- Normal Pap, positive HPV: Repeat in 1 year
- Abnormal Pap: Colposcopy usually recommended
- HPV 16/18 positive: Often immediate colposcopy
Treatment Options
HPV treatment focuses on managing visible lesions and precancerous changes, as there is no cure for the virus itself. Most HPV infections clear naturally through immune response, but persistent infections may require intervention.
Treatment of Genital Warts
Patient-Applied Therapies
- Imiquimod 5% cream: Immune response modifier
- Podofilox 0.5% solution/gel: Antimitotic agent
- Sinecatechins 15% ointment: Green tea extract
- Apply as directed by physician
- Monitor for local irritation
Provider-Administered Therapies
- Cryotherapy: Liquid nitrogen freezing
- Trichloroacetic acid (TCA): 80-90% solution
- Bichloroacetic acid (BCA): Alternative to TCA
- Surgical removal: Excision, shave removal
- Laser therapy: For extensive or recurrent warts
Treatment Considerations for Warts
- Many warts resolve spontaneously
- Treatment is primarily for symptom relief
- No treatment prevents transmission
- Recurrence rates are 10-20%
- Multiple treatment sessions may be needed
Treatment of Cervical Dysplasia
Low-Grade Squamous Intraepithelial Lesions (LSIL)
- Observation: Follow-up in 12 months
- Colposcopy: If preferred by provider/patient
- Repeat cytology: Monitor for progression
- Many LSIL lesions regress spontaneously
High-Grade Squamous Intraepithelial Lesions (HSIL)
- LEEP: Loop Electrosurgical Excision Procedure
- Cold knife conization: Surgical cone biopsy
- Cryotherapy: For selected cases
- Laser ablation: Alternative treatment
- Treatment required due to cancer risk
Excisional Procedures
LEEP (Loop Electrosurgical Excision Procedure)
- Most common treatment for HSIL
- Uses heated wire loop
- Outpatient procedure with local anesthesia
- Provides tissue for histological examination
- Minimal impact on future pregnancies
Cold Knife Conization
- Surgical removal with scalpel
- Requires general anesthesia
- Better specimen for pathological examination
- Reserved for specific indications
- Higher risk of complications
Ablative Procedures
Cryotherapy
- Freezing abnormal tissue
- Outpatient procedure
- No tissue specimen obtained
- Limited use in developed countries
- Still used in resource-limited settings
Laser Ablation
- Destroys abnormal tissue with laser
- Requires specialized equipment
- Higher cost than other methods
- No tissue for examination
Follow-up After Treatment
Post-Treatment Surveillance
- HPV testing preferred method
- Cytology acceptable alternative
- First test 12-24 months after treatment
- Annual follow-up for 20 years
- Colposcopy if abnormal results
Treatment Complications
- Bleeding (immediate or delayed)
- Infection
- Cervical stenosis
- Preterm delivery risk (small increase)
- Recurrence of dysplasia
Treatment During Pregnancy
Genital Warts in Pregnancy
- May increase in size and number
- Often regress after delivery
- Treatment usually delayed unless symptomatic
- Avoid podophyllin and 5-fluorouracil
- Cesarean section rarely needed
Cervical Dysplasia in Pregnancy
- Colposcopy safe during pregnancy
- Biopsy only if invasion suspected
- Treatment usually deferred until postpartum
- Close surveillance during pregnancy
Experimental and Emerging Therapies
- Therapeutic vaccines
- Immunomodulatory agents
- Antiviral medications
- Photodynamic therapy
- Currently investigational
Treatment of HPV-Related Cancers
- Standard cancer treatment protocols
- Surgery, radiation, chemotherapy
- Multidisciplinary approach
- HPV status may affect prognosis
- Specialized oncological care required
Partner Management
- Examination of partners usually not beneficial
- Most partners already exposed
- Counseling about HPV transmission
- Vaccination if age-appropriate
- Barrier contraception discussion
Prevention
HPV prevention strategies include vaccination, safer sexual practices, and regular screening. Vaccination is the most effective primary prevention method, while screening enables early detection and treatment of precancerous changes.
HPV Vaccination
Available Vaccines
- Gardasil 9: Protects against 9 HPV types (6, 11, 16, 18, 31, 33, 45, 52, 58)
- Cervarix: Protects against HPV 16 and 18 (limited availability)
- Original Gardasil: No longer available (types 6, 11, 16, 18)
- Highly effective when given before exposure
Vaccination Schedule
- Ages 9-14: 2-dose series (0, 6-12 months)
- Ages 15+: 3-dose series (0, 1-2, 6 months)
- Immunocompromised: 3-dose series regardless of age
- Can be given with other vaccines
Vaccination Recommendations
- Routine: Ages 11-12 years
- Catch-up: Through age 26
- Ages 27-45: Shared clinical decision-making
- Special populations: Immunocompromised, MSM
- Benefits greatest when given before sexual activity
Safer Sexual Practices
Barrier Protection
- Consistent condom use reduces risk by 60-70%
- Does not provide complete protection
- Dental dams for oral contact
- Female condoms may offer more coverage
Partner Considerations
- Limiting number of sexual partners
- Monogamous relationships with uninfected partners
- Partner HPV vaccination
- Delaying sexual debut
- Communication about sexual history
Screening for Early Detection
Cervical Cancer Screening
- Regular Pap tests and HPV testing
- Detects precancerous changes
- Enables early intervention
- Prevents progression to cancer
- Follow established guidelines
High-Risk Population Screening
- More frequent screening for HIV-positive women
- Anal cancer screening for high-risk men
- Oral cancer screening considerations
- Immunocompromised individuals
Lifestyle Modifications
Smoking Cessation
- Smoking doubles cervical cancer risk
- Impairs immune function
- Promotes viral persistence
- Cessation benefits at any age
Immune System Support
- Adequate nutrition
- Regular exercise
- Stress management
- Adequate sleep
- Limit alcohol consumption
Public Health Strategies
Vaccination Programs
- School-based vaccination programs
- Healthcare provider recommendations
- Public education campaigns
- Addressing vaccine hesitancy
- Coverage for underserved populations
Screening Programs
- Population-based screening
- Organized screening programs
- Quality assurance measures
- Reaching underscreened populations
- Self-sampling initiatives
Prevention in Special Populations
Immunocompromised Individuals
- Higher vaccination priority
- Enhanced screening protocols
- Closer medical follow-up
- Partner vaccination important
Men Who Have Sex with Men (MSM)
- Routine HPV vaccination through age 26
- Anal cancer screening considerations
- HIV testing and prevention
- Comprehensive sexual health care
Education and Counseling
- HPV transmission education
- Importance of vaccination
- Screening recommendations
- Safer sex practices
- Addressing myths and misconceptions
- Healthcare provider training
Global Prevention Efforts
- WHO elimination initiative
- Expanding vaccination coverage
- Screening program development
- Training healthcare providers
- Addressing health inequities
Cost-Effectiveness
- Vaccination highly cost-effective
- Screening programs cost-effective
- Prevention vs. treatment costs
- Health economic benefits
- Quality of life improvements
When to See a Doctor
Regular healthcare visits are important for HPV prevention, screening, and management. Many HPV-related conditions are best detected through routine screening rather than symptoms, making regular medical care essential.
Routine Screening and Prevention
HPV Vaccination
- Preteens (ages 11-12) for routine vaccination
- Catch-up vaccination through age 26
- Adults 27-45 for shared decision-making
- Special populations needing priority vaccination
- Questions about vaccination eligibility
Cervical Cancer Screening
- Women starting at age 21
- Follow recommended screening intervals
- More frequent screening if high-risk
- Never had screening before
- Missed recent screening appointments
Seek Medical Attention for Symptoms
Genital or Anal Symptoms
- New growths, bumps, or warts in genital area
- Persistent itching or irritation
- Unusual discharge
- Bleeding between periods
- Bleeding after intercourse
- Pain during intercourse
- Anal bleeding, pain, or itching
Oral and Throat Symptoms
- Persistent sore throat
- Difficulty swallowing
- Voice changes lasting more than 2 weeks
- Ear pain without ear infection
- Swollen lymph nodes in neck
- Mouth or throat lesions
Abnormal Screening Results
- Abnormal Pap test results
- Positive HPV test results
- Need for colposcopy follow-up
- Post-treatment surveillance
- Questions about screening results
Sexual Health Concerns
New Sexual Relationships
- STI testing and counseling
- Contraception counseling
- Vaccination status review
- Risk assessment and prevention
Multiple Partners or High-Risk Behaviors
- Regular STI screening
- Enhanced prevention counseling
- PrEP counseling if appropriate
- Hepatitis B vaccination
Special Circumstances
Pregnancy
- Routine prenatal care
- Cervical cancer screening if due
- Genital wart evaluation
- Delivery planning if extensive warts
- Postpartum follow-up
Immunocompromised Status
- HIV diagnosis or immunosuppressive therapy
- Enhanced screening protocols
- Vaccination status review
- More frequent monitoring
- Symptom evaluation
Family History Concerns
- Family history of cervical cancer
- Genetic counseling if indicated
- Enhanced screening recommendations
- Risk assessment
Questions and Counseling
HPV Information
- Understanding HPV diagnosis
- Partner notification questions
- Transmission prevention
- Long-term health implications
- Fertility and pregnancy planning
Vaccination Questions
- Vaccine safety and effectiveness
- Age-appropriate vaccination
- Previous vaccination history
- Cost and insurance coverage
Emergency Situations
- Heavy vaginal bleeding
- Severe abdominal or pelvic pain
- Signs of severe infection
- Difficulty breathing or swallowing
- Severe allergic reaction to treatment
Choosing the Right Healthcare Provider
Primary Care
- Routine screening and vaccination
- General health maintenance
- Initial evaluation of symptoms
- Counseling and education
Gynecology
- Abnormal screening results
- Colposcopy and procedures
- Complex gynecologic issues
- Specialized women's health care
Other Specialists
- Oncology: Cancer diagnosis or treatment
- Infectious disease: Complex immunocompromised cases
- Dermatology: Extensive cutaneous warts
- ENT: Oral or throat lesions
Preparing for Your Appointment
- List current symptoms and duration
- Document menstrual and sexual history
- Bring previous test results
- List medications and allergies
- Prepare questions about HPV
- Consider bringing a support person
Frequently Asked Questions
How common is HPV?
HPV is extremely common. Nearly all sexually active people will get HPV at some point in their lives. It's estimated that about 80% of sexually active people will be infected with at least one type of HPV during their lifetime. Most infections occur in young people shortly after they become sexually active.
Can HPV be cured?
There is no cure for HPV, but most infections clear up on their own within 2 years due to the body's immune response. Treatment is available for health problems caused by HPV, such as genital warts and precancerous changes. The HPV vaccine can prevent new infections but cannot treat existing ones.
Should I tell my partner I have HPV?
It's generally recommended to discuss HPV with current and future sexual partners. However, this can be challenging because HPV is so common and there's no way to know when or from whom you got it. Your healthcare provider can help you decide how to approach these conversations and provide information for your partner.
Can I get the HPV vaccine if I already have HPV?
Yes, you can still benefit from the HPV vaccine even if you already have HPV. The vaccine protects against 9 types of HPV, so even if you have one type, you can still be protected from the others. Discuss with your healthcare provider whether vaccination is right for you.
Will HPV affect my ability to get pregnant?
HPV infection itself does not affect fertility or your ability to get pregnant. However, treatments for severe precancerous changes (like LEEP procedures) may slightly increase the risk of preterm birth. Most women with HPV have normal pregnancies and healthy babies.
How effective is the HPV vaccine?
The HPV vaccine is highly effective, preventing about 90% of cancers caused by HPV when given at the recommended age. It's most effective when given before exposure to HPV, ideally before becoming sexually active. Even if given after sexual activity begins, it can still provide protection against HPV types not yet encountered.
Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. HPV requires proper medical evaluation and management. Consult your healthcare provider about HPV vaccination, screening, and any concerning symptoms.
References
- Centers for Disease Control and Prevention. Human Papillomavirus (HPV). CDC. 2024.
- Meites E, et al. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR. 2019.
- Fontham ETH, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020.
- Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020.
- Workowski KA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021.
- World Health Organization. Human papillomavirus vaccines: WHO position paper. Wkly Epidemiol Rec. 2022.