46-Year-Old Woman in Botswana with Postcoital Bleeding

Posted by • May 23rd, 2014

In the latest Case Record of the Massachusetts General Hospital, a 46-year-old woman with HIV and a high-grade squamous intraepithelial lesion was evaluated in Botswana because of postcoital bleeding. During examination of the cervix and vagina, a large fungating lesion was seen. Diagnostic procedures were performed.

Postcoital bleeding is defined as bleeding that occurs during or after sexual intercourse not related to menses, and the differential diagnosis varies with age and menstrual status. Postcoital bleeding typically results from a surface lesion of the lower genital tract, but it may also occur with diseases of the endometrium.

Clinical Pearls

What is the most common cancer in women in sub-Saharan Africa?

Cervical cancer is the most common cancer in women in sub-Saharan Africa, especially in those who have HIV infection. Approximately 11% of patients who have cervical cancer present with postcoital bleeding.

What are the risk factors for genital HPV infection and what serotypes are associated with the development of cancer?

HPV is the cause of the most common sexually transmitted infections worldwide, although only a small fraction of infections lead to clinical disease. Genital HPV infection is associated with multiple risk factors. Risk factors for HPV-related disease and progression to cancer can be infectious (persistent infection with high-risk HPV, such as HPV types 16 and 18), environmental (e.g., smoking), sexual (e.g., young adult at sexual debut, multiple partners, and multiparity), hormonal (e.g., long-term use of combined oral contraceptives), and immunosuppressive (due to HIV or immunosuppressive therapy). There are more than 130 types of HPV, of which 30 to 40 infect the genital mucosa and are categorized as low-risk or high-risk, depending on their likelihood to facilitate progression to cancer. Chronic infection with a high-risk type of HPV is essential for the development of cancer, in conjunction with such cofactors as smoking and immunosuppression. Virtually all cases of cervical cancer and 40% of cases of vaginal cancer are attributed to HPV infection, with HPV types 16 (HPV-16) and 18 (HPV-18) accounting for 60 to 70% of cervical cancers and 75% of vaginal HPV-related cancers.

Table 3. Risk Factors for Genital HPV-Related Disease and Progression to Cancer.

Morning Report Questions

Q: What are important considerations for management of patients with co-infection with HPV with HIV?

A: HIV and HPV are interrelated sexually transmitted diseases that share similar risk factors and probably facilitate each other’s acquisition. HIV-infected women have a higher prevalence of persistent infection with HPV, especially with high-risk types, than do women without HIV infection, and they have rapid progression to clinical disease. There seem to be conflicting data on the effect of ART on HPV-related disease, but most studies have shown that ART is not associated with a reduction in the rates of cervical cancer.

Q: Is vaccination against HPV likely to be efficacious in sub-Saharan Africa?

A: Vaccination against HPV-16 and HPV-18 is efficacious in the prevention of invasive cervical cancer. Vaccination is also thought to be effective in patients with HIV infection. In the absence of robust secondary screening and treatment programs, vaccination against HPV remains the best long-term strategy to reduce the incidence of cervical cancer and other anogenital cancers. The authors expect an even greater reduction in the incidence of these cancers when newer HPV vaccines that include five additional oncogenic types (HPV-31, 33, 45, 52, and 58) become available. Although HPV-16 and HPV-18 account for the majority of cervical cancers in sub-Saharan Africa, the proportion of cancers associated with HPV-31, 33, 45, 52, and 58 in this region is higher than the proportion in other parts of the world, making it likely that these future vaccines will result in a large benefit.

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