This Practice Advisory was developed by the American College of Obstetricians and Gynecologists with the assistance of Lee-may Chen, MD, and Amy J. Park, MD.
The human papillomavirus (HPV)—associated with the development of cervical dysplasia and cancer, in addition to anal, vulvar, and vaginal dysplasias and cancers, genital warts, and oropharyngeal cancer—continues to be a significant cause of preventable morbidity and mortality. Even after surgical treatment, recurrence rates for cervical intraepithelial neoplasia grade 2 or 3 (CIN 2+) range from 10% to 14% 2 . Recent data from meta-analyses and observational studies demonstrate that adjuvant HPV vaccination in the setting of surgically-managed CIN 2+ in previously unvaccinated individuals reduces the recurrence of cervical dysplasia 3 4 5 6 . A meta-analysis of 11 studies (n=21,310) that compared adjuvant HPV vaccination with surgery alone reported a 65% overall risk reduction of new or persistent CIN 2+ with adjuvant HPV vaccination 3 . Another systematic review and meta-analysis of 22 papers also found evidence on the benefit of adjuvant HPV vaccination, especially for CIN 2+ related to HPV genotypes 16 or 18 4 . Additionally, according to a decision analysis published in 2023, adjuvant HPV vaccination for CIN 2+ results in improved quality of life and cost savings due to fewer recurrences of CIN, Pap tests, colposcopies, and repeat excisional procedures 7 . Data from randomized controlled trials are expected to be published in the future.
For individuals who are immunocompromised, the role of “catch-up” vaccination is less clear because of concerns about the effectiveness of HPV vaccination to reduce subsequent CIN 2+ in patients with human immunodeficiency virus, a history of solid organ transplantation, or those taking recently prescribed immunosuppressive medications 8 . More data are needed for these populations.
Updated ACOG Recommendation
Based on data on the benefit of adjunct HPV vaccination, ACOG recommends adherence to the current Centers for Disease Control and Prevention (CDC) recommendations for vaccinations of individuals aged 9–26 years, and to consider adjuvant HPV vaccination for immunocompetent previously unvaccinated people aged 27–45 years who are undergoing treatment for CIN 2+. This recommendation is in alignment with guidance developed by the American Society for Colposcopy and Cervical Pathology 9 . (For details on ACOG’s recommendation on shared clinical decision making for individuals aged 27–45 years who are previously unvaccinated and are not undergoing treatment for CIN 2+, see ACOG Committee Opinion No. 809, Human Papillomavirus Vaccination 1 ).
Clinicians should consider stocking the HPV vaccine in the office in order to increase access to vaccination. If in-office vaccination is not feasible, then a compilation of resources (eg, the local health department) can aid the patient in obtaining the vaccine. Currently, the only HPV vaccine available in the United States is the nine-valent vaccine with the following schedule and dosing 10 :
- For those younger than age 15 years: two doses spaced 6–12 months apart
- For those age 15 years and older: a three-dose schedule with the initial dose followed by the second dose at 1–2 months, and third dose at 6 months after the initial dose
There are some data to suggest that initiating vaccination 0–3 months prior to conization rather than 0–12 months post-conization is more effective in reducing persistent or recurrent high-grade cervical intraepithelial lesions (0.9% vs 6.5%; P=.047) 11 . However, at this time, the optimal timing of adjuvant HPV vaccination remains unknown. Large randomized controlled trials that will inform future practice recommendations are ongoing.
- ACOG Patient Education: Frequently Asked Questions, Human Papillomavirus (HPV) Vaccination
These materials are for information purposes only and are not meant to be comprehensive. Referral to these resources does not imply ACOG’s endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.
- Top 10 Tips for HPV Vaccination Success: Attain and Maintain High HPV Vaccination Rates (Centers for Disease Control and Prevention)
- Steps for Increasing HPV Vaccination in Practice: An Action Guide to Implement Evidence-based Strategies for Clinicians (American Cancer Society)
- HPV Vaccination Best Practices Learning Collaborative: Summary Report and Lessons Learned (American Cancer Society National HPV Vaccination Roundtable)
- Human Papillomavirus (HPV) Vaccines (National Cancer Institute)
Please contact [email protected] with any questions.