HPV and endometriosis: The role of the GP in optimising preconception health for young women

By Dr Celene Hui and Dr Wang Junjie

3/20/2023 2:56:00 PM | Special Delivery

The article is contributed/written by KK Women's and Children's Hospital

Endometriosis and HPV (human papillomavirus) are two key women’s health concerns that can benefit from early identification, lifestyle adjustments and interventions. Primary care visits present key opportunities to engage young women on help-seeking behaviours to optimise their health.

Preventative care and education about women’s health, given as early as the adolescent years, can have far-reaching benefits across a woman’s life course trajectory – such as optimising preconception health, reducing disease likelihood or delaying onset.

Obstetrics and gynaecology experts from KK Women’s and Children’s Hospital (KKH) share recommendations for patient engagement in the primary care setting:

"At KKH, about 90 per cent of women with severe HPV-related diseases, such as cervical cancer, are aged 30 and older.

We encourage HPV vaccination in early adolescence to confer protection against HPV infection in men and women from an earlier age, and reduce the risk of HPV-related diseases."

Dr Wang Junjie, Head and Senior Consultant, Department of Gynaecology Oncology, KKH

HPV : Advice for GPs

What is HPV?

The human papillomavirus (HPV) is a virus that can cause infections in different parts of the body in men and women, such as genital warts. Some HPV strains may also infect the skin of the fingers, hands, mouth, throat and face.
While most infections are transient and resolve on their own within two years, some high-risk HPV strains can lead to severe diseases such as cervical cancer in women, and cancer of the throat, penis and anus in men.
Most people with HPV may never develop symptoms or health problems, and do not know that they are infected.
There is currently no cure or treatment for HPV.

What is the disease burden?

About 85 per cent of sexually-active individuals who do not get the HPV vaccine have HPV infection at some point in their lives.
At the Colposcopy-dysplasia Clinic at KKH:

There are about 2,170 new cases a year, most of which are HPV-related.
About 90 per cent of women with severe HPV-related diseases, such as cervical cancer, are aged 30 and older.

How can it negatively impact preconception health?

HPV is the leading cause of cervical cancer

More than 70 per cent of cervical cancer are caused by HPV types 16 and 18 – the two common high-risk HPV strains.
Cervical cancer is the 10th most common cancer in women in Singapore.

Risk of transmission between partners, mother-to-child

HPV spreads from person to person through anal, vaginal, oral sex or via close skin-to-skin touching during sexual activity.
There is also a low risk of transmission from a pregnant woman to her baby, such as during childbirth.

How can early education help?

Early education and advocacy of HPV awareness can help to:

Encourage HPV vaccination in early adolescence to confer protection against HPV infection from an earlier age
Reduce the risk of HPV-related diseases such as cervical cancer
Reduce overall HPV circulation in the community

What can the GP do?

Encourage HPV vaccination from early adolescence. In Singapore, HPV vaccination is recommended between nine and 26 years of age, and most effective before exposure through sexual activity. Individuals beyond this age range can still benefit from vaccine-generated protection against infections from strains they were not previously exposed to.
Dispel misconceptions that HPV vaccination is harmful or encourages early sexual activity. The safety data for all HPV vaccines indicate no severe adverse effects or reactions linked to vaccination. No research links the taking of HPV vaccine with increase in sexual activities.
Recommend women to continue with regular, age-appropriate cervical screening* as no vaccine prevents all types of HPV that can cause cervical cancer.

*Pap smear once every three years for women aged 25-29 years; HPV DNA test once every five years for 30 years and above.

Resources

For GPs:

HealthHub HPV Vaccine Information Leaflet: Community healthcare professionals can provide patients with this concise guide about HPV vaccination. https://www.healthhub.sg/a-z/medications/491/Human-Papillomavirus-HPV-Vaccine

KK Gynaecological Cancer Centre: Community healthcare professionals can refer a patient for tertiary assessment at the KK Gynaecological Cancer Centre via [email protected] or the Clinic Hotline +65 6394 8803.

For patients:

What is HPV: https://www.healthhub.sg/a-z/diseases-and-conditions/701/faqs-on-hpv-and-hpv-immunisation

HPV vaccination – Benefits, side-effects, precautions and dosage: https://www.kkh.com.sg/patient-care/medicine/human-papillomavirus-vaccine

What is cervical cancer: https://www.healthhub.sg/a-z/diseases-and-conditions/93/topic_cervical_cancer

National Cervical Cancer Screening Programme: https://www.healthhub.sg/programmes/157/cervical-cancer-screening

Cervical cancer – Symptoms, diagnosis, surgical treatment, post-surgery care: https://www.kkh.com.sg/patient-care/conditions-treatments/cervical-cancer-surgery

"Majority of women who present to KKH with endometriosis-related symptoms and problems are aged 20 to 40 years old. Diagnosis from the onset of symptoms can be delayed by up to 10 years.

Proactively engaging women on their menstrual health during primary care visits can bring about early detection and intervention to reduce the burden of endometriosis across their lifespan, control disease progression and protect their fertility."

Dr Celene Hui, Consultant, Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KKH

Endometriosis: Advice for GPs

What is endometriosis?

In women with endometriosis, cells normally found in the inner uterine lining grow in areas such as the ovaries, fallopian tubes, pelvis or lower abdominal cavity.
Severe endometriosis can manifest as adhesions, ovarian cysts and deep infiltrating endometriosis involving areas such as the urinary bladder, ureters and bowel.
General symptoms can include painful periods; heavy or irregular periods; chronic pelvic pain, fatigue; painful sexual intercourse; pelvic mass from large ovarian cysts; enlarged womb from associated adenomyosis; painful bowel- or urinary-related symptoms during periods and difficulty in getting pregnant.

What is the disease burden?

Endometriosis is a progressive disease that affects about one in 10 women in their childbearing years.
Majority of women who present to the KKH Minimally Invasive Surgery Unit with such symptoms and problems are aged 20 to 40 years old. Some women only realise they may have endometriosis whilst undergoing fertility treatment.
KKH treats about 1,200 women with endometriosis-related problems every year.

How can it negatively impact preconception health?

Subfertility and challenges with conceiving

About 30 to 50 per cent of women with endometriosis encounter challenges conceiving.
Endometriosis can negatively impact a woman’s fertility in the following ways:

Localised inflammation
Scarring in the pelvis and adhesions (where pelvic tissues and organs stick to each other)
Ovarian endometriotic cysts
Damaged fallopian tubes
Impaired embryo implantation
Poorer egg quality
Decreased egg supply or ovarian reserve

Delays in diagnosis and increased disease burden

Diagnosis of endometriosis can be delayed by up to seven to 10 years from the onset of symptoms. The non-specific nature of symptoms reduces patients’ awareness of the need for a doctor’s visit, resulting in missed opportunities for diagnosis.
This long interval from onset to diagnosis can lead to disease progression, prolonged pain, loss of fertility, psychological stress, strain on personal relationships, loss of workplace productivity and poor quality of life.

How can early detection help?

Early detection, treatment and prevention of complications can help to:

Provide pain relief
Control and suppress disease progression
Preserve and protect fertility
Optimising the woman’s quality of life across her lifespan

What can the GP do?

Proactively engage female patients on their menstrual health.
Keep a look out for any unusual signs or symptoms that may suggest endometriosis.
Dispel misconceptions and stigma that it is normal to suffer from period pain. Encourage patients to discuss menstrual concerns openly.
Encourage women to seek gynaecological care when menstrual pain affects their day-to-day activities and quality of life.
Refer women to seek urgent medical attention if experiencing acute abdominal pain or rapidly worsening menstrual symptoms.

Resources

For GPs:

The Endometriosis Protocol and Checklist: Developed by KKH, NUH and SGH, this guide contains recommendations for the diagnosis and early treatment of endometriosis, and tips on patient counselling and referrals for tertiary care. Click here for the protocol and checklist.

KK Endometriosis Centre: Community healthcare professionals can refer a patient to the KK Endometriosis Centre for tertiary assessment via the Centre Co-ordinator Hotline +65 9233 1457.

For patients:

Self-assessment quiz: Women can self-identify and assess symptoms suggesting endometriosis with this quiz. https://virtual.miceneurol.com/endoSurvey/KKH
What is endometriosis: https://www.kkh.com.sg/patient-care/areas-of-care/womens-services/Pages/endometriosis.aspx
Managing endometriosis and ovarian cysts: https://www.kkh.com.sg/patient-care/conditions-treatments/endometriosis-ovarian-cysts
Best foods for period/menstrual cramps: https://www.healthxchange.sg/women/urology/period-menstrual-cramps-best-foods

Dr Celene Hui, Consultant, Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital

Dr Celene Hui's clinical interests include intrauterine adhesions and minimally invasive treatment for benign gynaecological conditions. She has been conferred the KKH Service from the Heart award and a gold award at the SingHealth Quality Service Awards for her contribution in clinical service and patient care.

Dr Hui holds the post of clinical assistant professor at the Duke-NUS Medical School. She was inducted into the council of the Obstetrical and Gynaecological Society of Singapore (OGSS) in 2014 and continues to serve on the council today.

Dr Wang Junjie, Head and Senior Consultant, Department of Gynaecology Oncology, KK Women’s and Children’s Hospital

Dr Wang Junjie specialises in managing and treating pre-invasive gynaecological conditions and gynaecological cancers. Dr Wang has a special interest is in minimally invasive management of gynaecological cancers as he feels that patients would greatly benefit from reduced post-surgical pain, quicker recovery and shorter hospitalisation.

Dr Wang holds teaching appointments in all three medical schools in Singapore. He has participated in numerous research trials and released his publications in local and international journals.

Dr Wang graduated from the Yong Loo Lin School of Medicine at National University of Singapore, and completed specialist training in obstetrics and gynaecology, and further subspecialty training in gynaecological oncology. He also undertook an advanced laproscopic oncological surgical fellowship in Switzerland and a surgical fellowship in France.