Certain words just don't really pop up in conversation. Gynaecology is one of them. Usually muttered hurriedly and certainly not in polite chitchat, gynaecology is an out-of-bounds topic that even women get a bit squeamish about.

So, prepare yourself for a moment of discomfort. You ready? Good.

Take your prepubescent daughter to the gynaecologist. No, don't wait until she is older. Don't wait until you've finally come round to the fact that she probably isn't just kissing those boys anymore. The fact that she isn't having sex yet is entirely the point. When it comes to vaccinating your daughter against human papillomavirus (HPV), the primary cause of cervical cancer, you need to get in there before the virus has a chance to.

Cervical cancer vies with breast cancer to kill off more South African women than any other cancer. Unlike breast cancer, however, which receives considerable attention, cervical cancer sneaks in insidiously and, because of a poor screening system in this country, results in the deaths of approximately 3700 South African women every year. According to GlaxoSmithKline, your chances of developing cervical cancer as a South African woman are one in 26.

With odds like that, a gamble could very well cost you your daughter's life. We chatted to specialist gynaecologist Dr Carol Thomas about the importance of the HPV vaccine and how you can go about getting it in SA.

What is HPV?

HPV is a highly contagious viral infection that spreads through skin-to-skin contact. Certain strains of the virus infect the male and female genital areas (including the lining of the vagina and cervix) and are sexually transmitted. It is one of the most common sexually transmitted infections in the world and it is estimated that between half and three-quarters of sexually active adults will have HPV at some stage in their lives.

However, only certain strains of the virus are potentially dangerous. In the overwhelming majority of cases, the infection causes no symptoms, is transient and clears due to the body's immune response.

Certain high-risk oncogenic (tumour causing) types of the virus (but most notably types 16 and 18) are responsible for the majority of cervical cancer cases. If you become infected with an oncogenic type of HPV and it persists, it can become integrated in the cervix cells, eventually leading to malignant growth that can spread to nearby organs. Because cervical cancer initially presents with very few symptoms, it is difficult to spot without regular screening (Pap smears).

Although condoms will play a part in the prevention of HPV transmission, they do not provide complete protection because transmission is not limited to penetrative sex. Close contact of areas that are not covered by the condom can also lead to infection.

According to Dr Thomas, the likelihood of becoming infected with dangerous strains of HPV increases with age. This is the result of a number of factors:

• Continued sexual activity with the same partner who may be infected with the high-risk strains.


• Increased likelihood of having new sexual partners.


• Increased likelihood of older partners having had more sexual partners in the past (therefore increasing the likelihood of them being infected).


• Increased likelihood of being infected with HIV which makes the progression of infection to premalignant and malignant cervical change more likely.


• Increased likelihood of being a smoker — smoking is one of the most important co-factors for the persistence of HPV infections.


• The lack of oestrogen in the urogenital tract during menopause and progressive thinning of the vagina and cervical skin favours HPV infection.

What are your choices?

There are two HPV vaccines currently on the market in South Africa — Gardasil (Merck, Sharpe & Dohme) and Cevarix (GlaxoSmithKline). Both protect against the HPV types 16 and 18 and Gardasil also protects against types which result in genital warts. While these warts don't cause cancer, they can cause considerable physical and psychological discomfort.

Although it is better for women to get the vaccine when they are still girls (age 11 to 12), it can be administered with varying degrees of success in older women. The vaccine will work if you haven't already been exposed to HPV types 16 and 18. Even if you have been sexually active (and exposed to some strains of HPV), you may not have been exposed to these particular strains of the virus and the vaccine may, therefore, still be effective.

Gardasil is registered for use in women up to the age of 26 (and in males up to the age of 17) and Cevarix is registered for the use in females of all ages. Dr Thomas suggests that a woman's profile needs to be taken into account, but technically the vaccine could be used in women up until the age of 55.

"For example, a virgin who becomes sexually active at the age of 45, should be vaccinated, especially as she is unlikely to be having intercourse with a 14-year-old boy!"

Although the vaccine has not yet been around long enough to guarantee lifelong immunisation, studies at five years showed that antibody levels were still adequate in preventing infection. According to Dr Thomas, a positive comparison can be drawn between the HPV vaccine and similar vaccines which have been used against Hepatitis and have shown positive results for more than two decades.

There are no negative side effects to the vaccine beyond a bit of redness, pain and swelling at the site of the injection.

Because the vaccine doesn't provide immunisation against all oncogenic types of HPV, it is still necessary to go for regular screening to ensure that you have not developed any cell irregularities.

Getting the vaccine

In an attempt to make the vaccine more accessible, it has been rescheduled (to Schedule 2) so that both brands are available over the counter without a prescription. However, Dr Thomas warns that the injection should only be given by an experienced and competent person. Furthermore, she warns that the vaccine is susceptible to temperature change and needs to be kept cold.

"A practical consequence in my practice has been that many 'self-vaccinators' do not realise that they have to have a series of three (injections) and thought that it was a once-off vaccination. In addition, if they did not know, they often get the timing of the second injection wrong (Cevarix is one month later and Gardasil two months later)."

It is also important to note that the vaccines are not interchangeable — you cannot start with one and switch to the other for the second or third injection.

The biggest barrier for most in getting immunised is the cost. You can expect to pay between R2500 and R3500 for the series of injections (Gardasil is 10 percent more expensive than Cevarix because it protects against two additional types of HPV). However, when weighed up against the cost of cancer, or more importantly life, it is negligible.

Dr Carol Thomas is a specialist gynaecologist with a special interest in adolescent gynaecology. She runs a weekly service dedicated to cervical screening and a vaccination service for both adolescents and adults.