Why I Got the HPV Vaccine at Age 52

Even though the upper limit for the vaccine is 45

The HPV or human papillomavirus vaccine is approved in the United States for ages 9 to 45, but I chose to get vaccinated when I was 52 years old. I get a lot of questions about this whenever I post about it on social media, so I thought I’d run through how I made the decision to get vaccinated. 

The photo above is from when I received my first dose.

Some Background Information

Infection with HPV can cause cervical, anal, and oropharyngeal (mouth and throat) cancers in addition to genital warts (as well as some vaginal, vulvar and penile cancers). The vaccine is Gardasil-9, it protects against nine types of HPV, seven which are cancer causing and two that cause genital warts. From a cancer standpoint, it reduces the rate of cervical and anal cancers, and it is believed that it will also reduce rates of mouth and throat cancer as well as vaginal, vulvar and penile cancers (these studies are still ongoing). Basically, the HPV vaccine is a cancer moonshot. 

HPV vaccination is recommended for everyone between the ages of 9 and 26, although before sexual activity is ideal, because the vaccine is most effective before exposure to HPV has occurred. Another bonus to getting vaccinated earlier is if you start vaccination before age 15 you only need two doses, but if you are 15 or older you need three.

In 2019, the upper age limit for vaccination was extended to 45, although the official recommendation isn’t to vaccinate everyone between the ages of 27 and 45. This is what the CDC has to say:

Vaccination is not recommended for everyone older than age 26 years. Some adults ages 27 through 45 years might decide to get the HPV vaccine based on discussion with their clinician, if they did not get adequately vaccinated when they were younger.

As a doctor, I understand this guideline. Because most people who get cervical cancer acquire their cancer-causing infection earlier in life. So if you want to get the best bang for your public health dollars, you want to vaccinate everyone under the age of 26, because this is the peak time for acquiring HPV. 

While I understand this kind of recommendation, I also hate them because it leaves things a little wishy washy for those between the ages of 27 and 45. The guidance from the CDC basically boils down to, “Are you going to have a new sexual partner?” And while some people might definitely know, not everyone does. And then there are people who are in what they believe to be a monogamous relationship, but then later find out that they are not. I’m sure every OB/GYN has seen someone in their 40s or 50s with a lifetime of normal cervical cancer screening and then all of a sudden they have an abnormal result. And when the truth of it all comes out, they find out they weren’t in a monogamous relationship after all. But perhaps the biggest issue is when a vaccine is’t universally recommended, insurers or governments sometimes won’t pay. Meaning, you could have a discussion with your provider about your risk, decide you are a good candidate for the vaccine, but because you are 38 years old you could be stuck paying out of pocket depending on where you live and/or your insurance. Currently it is $268.02 per dose in the United States and you need three doses.

While giving the vaccine to people over 45 may not be cost effective for the pubic, because the HPV vaccine is incredibly safe, it may be cost effective for you on an individual level. And I’m including peace of mind in cost effectiveness, because not all costs are financial. Also, the vaccine doesn’t just prevent cancer, by reducing HPV infections it reduces abnormal cervical cancer screenings, meaning abnormal tests and biopsies, which are stressful and sometimes painful.

How I Made My Decision

At 52 years of age I was outside of the approved age range of 9-45 years, but I also knew the biggest risk for getting HPV was a new sexual partner and I had just left a long term relationship and was planning on having a new partner or partners. I was also likely to be having sex with someone who, because of his age, would not be vaccinated against HPV. 

While most people catch the HPV that gives them cervical cancer when they are younger, not everyone does. In my career I’d seen a few women with cervical cancer who had almost certainly acquired their HPV in their 40s or 50s and that really weighed on me. 

Statistical modeling tells us there is a 50% chance that a woman with cervical cancer (at any age) acquired her cancer-causing HPV by age 21, a 75% chance she acquired it by age 30, and 90% chance she acquired it by age 40. Meaning, 10% of people (a minority, but definitely not zero!) who eventually get cervical cancer, acquired their HPV when they were age 40 or older. Just like the patients who I had seen. 

While the peak risk of being HPV positive is among women ages 25 and younger, there is a second peak in the menopause transition/early menopause years. Some researchers believe this second peak is due to reactivation of a dormant infection acquired earlier, possibly due to hormonal changes of the menopause transition, and hence an infection that an HPV vaccine wouldn’t likely help. But there is a lot of research that challenges that thinking and some (many?) could be new infections. It’s possible this is the age where women are more likely to have a new partner or the hormonal changes may make it easier to acquire HPV if exposed. Or both.

It’s also important to lay some background here. The idea that women in their 40s, 50s, and gasp 60s could be having new sexual partners seemed to not have figured significantly in a lot of the initial research. Our society has for too long discarded women who are 40 and older as being unfuckable, so I can’t help but think that absurd belief has biased some work in some ways. Meaning, the default would be to think HPV infections in the 40s, 50s, and 60s must be reactivation.

(If you haven’t seen it, do watch the video Last F**kable Day, from Inside Amy Schumer. You can find it here).

But I knew there was data that showed a new sexual partner was absolutely associated with an increased risk of HPV…even for women ages 40-60. One study that had a major impact on my decision followed women in Brazil for 10 years, and during that time they came in regularly and were tested for HPV every 4-6 months and they also provided a lot of details about their lives, including sexual partners. For women over the age of 40, a new sexual partner was a significant risk factor for developing an infection with a cancer causing type of HPV. In addition, people who had previously had a cancer causing infection could clear it and then get infected again years later, meaning natural immunity isn’t necessarily long lasting. In fact, we now know natural immunity after infection with HPV 16 or 18 varies significantly. For example, after an infection with HPV 16 some people are immune for less than a year and others for 30 years. Meaning, there are people who are 45 years and older who are at risk for an HPV infection because they either never had the infection before or because they had the infection, but have over time lost immunity. 

When you are thinking about the HPV vaccine, your primary goal is to prevent new infections. And it is true, the older you are, the more likely you are to have had HPV and hence may have antibodies. However, there are two important caveats. The Gardasil vaccine protects against seven types of cancer-causing HPV and having previously had all of them is unlikely, meaning for me, even if I’d had two or three types of HPV and my immunity to those types did happen to be long lasting, with the vaccine I could still could get protection against several more. And perhaps most importantly, even if I had previously had HPV 16 or 18, the two most cancer causingHPV types, and cleared the infection without health consequences I may have lost my immunity. 

I did wonder what my odds were of not having immunity (protective antibodies) to HPV 16 or 18? I had never had an abnormal cervical cancer screening, so I had not had HPV to my knowledge. However, it may never have been picked up with cervical cancer screening if it was acquired and cleared in the interval between screenings. 

When I was making my decision to be vaccinated, I found a study looking at antibodies in the blood against HPV 16 and 18 for people who previously had normal cervical cancer screening and also for those who had a precancer. For someone who was 50-59 (my age range) who had never had an abnormal cervical cancer screening, there was a 21.8% chance of antibodies to either HPV 16 or 18. Realistically, for me, the chance was probably higher, because the same study also showed the chance of having antibodies increased for someone with three or more lifetime sexual partners. But even accounting for that, there was a decent chance I did not have protective antibodies against both HPV 16 and 18 and that sealed the deal for me.

Side note, the HPV vaccines produce a very robust immune response, better than after infection. So if you get vaccinated at age 11 or 12 there is every reason to believe this produces a very long lasting immune response.

What About People Who Previously Have Had Abnormal Cervical Cancer Screening?

In the same study I quoted about antibodies, for someone who is between 50-59 and previously had a pre-cancer of the cervix there was a 36.3% chance of having antibodies to either HPV 16 or 18 or another way to look at is, a 63.7% chance of not having antibodies. This is likely because antibodies can disappear over time, and importantly, some data suggest there are people who lose their immunity rapidly and they may be more vulnerable to reinfection. And of course some cervical cancers are caused by types other than 16 or 18, so even if you’ve had a precancer, the odds you had an infection with all seven types of cancer causing HPV that the vaccine protects against are extremely low. 

Researchers have studied whether HPV vaccination might reduce the risk of recurrence of precancers of the cervix for those who get vaccinated at the same time as their treatment for the precancer, and there is a suggestion of benefit, but the data isn’t conclusive. As the vaccine is so safe, many people do suggest this approach and in Spain it is the recommendation. 

So I Got the Vaccine Because…

• There was a good chance I did not have immunity to both HPV 16 and 18 and therefore was likely to get protection against one or both of these types of HPV as well as some of the other five cancer causing types. I was unconcerned about protection again warts (I mean, it was an added bonus, but for me this was all about preventing abnormal cervical cancer screening and cancer).

• I was about to do the one thing that increased my risk of getting cancer causing HPV–have a new sex partner.

• If I caught a cancer causing type of HPV at age 52 I was likely to live long enough to suffer the consequences (and that includes the hassle of tests and treatment of precancers). 

• Even though there isn’t data on how well the vaccine works for people over age 45, I was okay with that unknown given there is little to no downside risk and everything we know about the vaccine tells us it produces a very robust immune response. If I did not get vaccinated, started dating, and a few years down the road had an abnormal cervical cancer screen I would be so pissed that I didn’t get vaccinated. Like so pissed. 

Fortunately, my insurance covered the vaccine, which I appreciate means I had a lot of privilege. I would have paid for the vaccine if needed, which I also recognize is a privilege. 

Whether you consider vaccination for HPV over age 45 (or over age 26 for that matter), it really boils down to your individual risk the best you can determine. If you are going to have a new sexual partner, you are at risk for HPV regardless of your age. 

And that is how I decided to get vaccinated for HPV at age 52. 

References

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