Impact of an HPV diagnosis on the quality of life in young women
Introduction
The Human Papilloma Virus (HPV) is one of the most common causes of sexually transmitted diseases, some viral subtypes infect the genital mucosa (most frequently the epithelium that covers the cervix), causing cellular abnormalities in Pap Tests and otherwise diagnosed by means of colposcopy and biopsies. Experimental and clinical data, as well as epidemiological evidence, indicate a direct association of some types of HPV with cervical carcinoma.
More than 120 genotypes that infect man have been identified, with specific types of HPV that infect the genital tracts of men and women numbering about 30 [1]. Types of HPV are subdivided into categories of low and high risk for neoplastic transformation. The low risk genotypes are associated with benign lesions, like the anogenital condyloma or genital warts while some types of anogenital HPV (16, 18, 31, 33, 35) are strongly associated with cervical intraepithelial neoplasia (CIN) of the vulva, penis, and scaly carcinoma. The cervical carcinoma was the first cancer to be recognised by the World Health Organisation as being totally ascribable to an infection [2].
HPV infections are very common in the population: it is estimated that more than 75% of sexually active women are infected with an HPV during their lifetime, peaking with women between the ages of 18 and 25 [3]. Of this high number of infections, only 1% of the population will develop condylomatosis florida lesions, while the infection causes subclinical lesions in the majority of cases. The infection is often asymptomatic and in most cases (70–90%) transitory, because the virus is eliminated by the immune system before developing a pathogenic effect [3]. The persistence of the viral infection is a necessary condition for the development of a carcinoma. The acquisition of a high-risk viral genotype increases the probability of persistent infection and, in this case, precancerous lesions may develop that, if not cured, may progress to a carcinoma [3]. Such lesions may also be present 10 years prior to the development of the cancer itself.
Although it is clear that the human papillomavirus plays an important role in tumoral development, it is just as evident that the viral infection alone is not sufficient to cause a cervical tumour. The malign transformation of a normal epithelial cell also depends on other physical and chemical oncogenous factors [4] like cigarette smoke, the long-term use of oral contraceptives, co-infection of other sexually transmitted diseases [3], a high number of sexual partners, a higher age, a high number of births. The risk of developing a tumour also depends on the balance between the immune system and the genetic characteristics of the host.
From a medical point of view, there is a vast amount of literature on this subject. Over recent years, HPV has been much talked about and a vaccine has even been developed (already available in Italy for youths 12 years of age and older). However, there is not much literature on this problem regarding the psycho-social reaction to an HPV diagnosis, especially from a psychological point of view.
Studies on women who have had anomalous Pap Test results have highlighted psychological consequences like anxiety, fear of cancer, sexual problems, changes in body image, difficulty in reproductive functions [5], [6], hypochondria [13], a sense of helplessness, anger, and a fear of being labelled [11]. A study on the social and interpersonal impact of the HPV test identifies anxiety as the most common reaction. The impact varies and is correlated to an affective state and personal history, social and cultural standards, and sexual habits, with cognitive understanding [7]. An American study on 489 HPV-positive men and women found that the initial reaction to the HPV diagnosis included depression, anger, isolation, fear of rejection, shame, and feelings of guilt [9]. In addition to distress caused by these psychological aspects, fear of gynaecological examinations, concern about transmitting HPV, and the fear of being judged negatively by sexual partner are very common; following infection by HPV, some individuals perceive themselves as being less sexually attractive and report a diminished sensation of well-being from sexual contact.
Anxiety and distress have repercussions on thoughts and feelings regarding past, present, and future relationships [8].
In contrast to these data, a study on sexual activity found no particular differences between women diagnosed with HPV and those who had not received the diagnosis as far as physical intimacy in sexual activity, feelings towards sexuality, and feelings towards relations were concerned [10]. In comparing the results of various studies, the fact that the presence of visible genital lesions produces psycho-social consequences different from those identified by people who present an asymptomatic form of the infection must be taken into consideration. The results of studies on patients with visible genital lesions cannot be generalized to include those who do not have visible signs of the infection.
Another study pointed out that women may have a lack of information on HPV. Their lack of adequate knowledge regarding the infection may contribute to intensifying the emotions felt [11]. One study, in fact, found that women with HPV who knew of the sexual transmissibility of the infection but who were not aware of the fact that it is very common and frequent obtained the highest scores regarding feelings of shame and being labelled [14].
Psycho-social and behavioural responses are also influenced by a sense of personal risk (perception of personal risk), by the subjective significance given to HPV and the Pap Test result, by the cognitive understanding of the Pap Test results, by the locus of control, and by the quality of affective relationships [12].
This work evaluated, by means of psychological tests, the impact an HPV diagnosis has on the quality of life in young women, with particular reference to the immediate reaction upon communication of the diagnosis, the psychological experience, the psychophysical well-being, the potential cognitive-behavioural modifications, and the psycho-sexual sphere of patients affected by this disease.
The objective of this study was to investigate whether or not the communication of being affected by the human papilloma virus by a physician influences the quality of life and the psychophysical well-being of women between the ages of 20 and 45.
The initial hypotheses formulated were:
- First Hypothesis:
there is an emotional reaction at the time of diagnosis.
- Second Hypothesis:
the diagnosis and knowledge of being affected by HPV influences the psychological picture and especially levels of anxiety, mood, reactivity, psycho-physiological disturbances, fears, obsessions and compulsions; emotional reactions expressed at the time of diagnosis are correlated with these aspects;
- Third Hypothesis:
the diagnosis influences sexual function.
- Fourth Hypothesis:
the HPV diagnosis influences the subjective overall satisfaction and quality of life.
The experimental group was composed of 36 women who were diagnosed with HPV; the patients were recruited at the U.O. Department of Obstetrics and Gynecology—ASL 13 Mirano (VE); during a periodical check-up, the patients were invited to participate in the study (Fig. 1).
The control group consisted of 36 women; this group had some characteristics in common with the experimental group; geographic origins (Northern Italy).
Three self-evaluation questionnaires were used following a brief, structured interview during which the following questions were asked:
- –
How much time had passed since the diagnosis?
- –
Did the patient have an emotional reaction at the time of diagnosis? If so, the patient was asked to indicate what type of reaction.
The questionnaires used in this study were the following:
CBA 2.0 (Cognitive Behavioural Assessment, by Bertolotti, Michielin, Sanavio, Simonetti, Vidotto, and Zotti, 1986 [19]): battery of 9 cards that measures the cognitive-behavioural aspects. In this study, we considered:
- Card2
(STAI-X1): measures state anxiety and consists of 20 items;
- Card3
(STAI-X2): measures trait anxiety and consists of 20 items;
- Card10
: an abridged version of the STAI-XL. It evaluates trait anxiety manifested by the subject at the conclusion of the battery and offers the possibility of comparison with the level of anxiety manifested at the beginning of the compilation of the questionnaire.
- Card6
(QPF/R): consisting of 30 items, this card investigates psycho-physiological reactions and disturbances of potential clinical significance;
- Card7
(IP/R): allows the compilation of two overall indexes and five subscales that study specific groupings of fears;
- Card8
(QD): consisting of 21 items, this card measures dysphoria and depressive manifestations of subclinical significance.
- Card9
(MOCQ/R): Consisting of 21 items, this card supplies the overall score and three indexes, studies intrusive thoughts and compulsive behaviours.
SAT-P (Satisfaction Profile by Majani and Callegari, 1998 [15]): measures subjective satisfaction and the quality of life, supplies an analytical scoring in 32 items and a more synthetic one subdivided into five areas: psychological functionality, physical functionality, work, sleep/nutrition/free time, social functionality.
BISF-W (Brief Index of Sexual Functioning For Woman by Taylor, Rosen, and Leiblum, 1994 [16]): Italian adaptation (Panzeri, Donà, Optale now being prepared) of a self-evaluation questionnaire that measures female sexual function. It consists of 22 questions for a total of 49 items that evaluate the qualitative and quantitative aspects of sexual behaviour; this instrument stands apart from other tests present on a national level in that it measures normal sexual function and the lack of sexual dysfunction. The questionnaire supplies 7 dimensions (thought/fantasy; excitation; frequency, receptivity/initiative; pleasure/orgasm; satisfaction; problems) and 4 factors (sexuality of the couple; self-erotic sexuality, satisfaction/dissatisfaction, anal sexuality).
The statistical analyses were conducted with the SPSS 14.0 statistical package for Windows.
Section snippets
Results
- First Hypothesis:
It resulted that 62% of the cases had a reaction to the communication of the HPV diagnosis. The most frequent emotional reactions were: fear (25%), anxiety (17%) and fear (17%), while only 3% of the cases reacted with anger. About 38% of the persons affirmed that they felt no reactive emotion regarding the diagnosis. The data in literature that indicate fear and anxiety as the most common emotions at the time of diagnosis have been confirmed (Fig. 2).
- Second Hypothesis:
To evaluate if the diagnosis influences
Conclusions
The HPV diagnosis caused emotional reactions, especially fear and anxiety, in most subjects of our sample. The discovery of an infection leads to consequences on levels of manifested anxiety, on intrusive and pervasive thoughts, on obsessive and compulsive behavioural attitudes, and on concerns regarding hygiene, infection, and contamination. The HPV diagnosis does not significantly influence the quality of the sexual sphere, however it did come to light that most women affected by HPV
Conflict of interest statement
We declare that we have no conflict of interest.
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