Never Got the HPV Vaccine? Talk to Your Doctor if You're Under 45

"When the vaccine first rolled out, it was not marketed well," said Tamika Felder, a cervical cancer survivor and founder and chief visionary officer of the nonprofit organization Cervivor.

The FDA's original approval for girls only was part of the problem, Felder said. Additionally, because HPV is a sexually transmitted infection (STI), the vaccine quickly became known as a "sex vaccine," which caused hesitation on the part of some parents.

"I don't want little Johnny and Jill having sex early because they got this vaccine," Felder described as the reaction doctors often encountered from parents early on.

I can attest to that. I remember my mom telling me only people who were having "premarital sex" needed a vaccine like that.

Others had similar experiences.

Lydia, who turned 30 last year, was just the right age to receive the vaccine when it was first released. "My family doctor was excited at the idea that I would be able to get it, and from the little that I knew about it, it seemed like a good idea to me, as well," she recalled. But her grandmother, who was her legal guardian at the time, felt differently.

"My grandma was pretty strictly focused on total premarital abstinence," Lydia said, "So, she didn't see a reason for me to get the HPV vaccine if I wasn't going to be having sex (which, in her mind, I absolutely wasn't). A little ironically, my sister, seven years older than me, had just been diagnosed with HPV."

Her grandmother also worried about the newness of the vaccine and what potential side effects there might be down the road. So, Lydia didn't get the vaccine. As the years progressed, lack of transportation and health insurance prevented her from having regular doctor's visits. "Now that I'm a Real Adult, I have great insurance," Lydia told me, "and my last yearly pap smear showed that I have, in fact, picked up HPV at some point, and one of the dicier versions of it, to boot."

Human papillomavirus is the most common sexually transmitted infection. There are more than 200 strains of HPV, but 14 are considered high-risk because they are known to cause several types of cancer. HPV16 and HPV18 account for more than 70 percent of cervical cancer cases and precancerous cervical lesions, according to the World Health Organization (WHO).

The original HPV vaccine approved in 2006, Gardasil, protected against four types of HPV. The vaccine currently used in the United States, Gardasil 9, prevents the four types in the original vaccine, along with five additional types—and can protect men and women against several cancers, as well as genital warts.

"HPV infections cause more than 35,900 cancers annually in the United States, occurring more often in women than in men—21,100 versus 14,800 cases, respectively," according to a 2021 article in the Journal of Women's Health. "Although cervical cancer is the most prevalent HPV-related malignancy in women, the virus is also responsible for a significant percentage of anal, vaginal, and vulvar cancers."

Unfortunately, misunderstanding and misinformation about the importance of the HPV vaccine was common during those early years, from both parents and practitioners.

A year after the vaccine was rolled out, I was 23 and married, and I asked my doctor about receiving it. "You don't need it," I remember her telling me. "You're married and monogamous, so there's really no need."

Francessca's doctor was of the same opinion. "I remember going to my pediatrician's office for my annual checkup. I was 12 or 13 years old and my doctor asked my mom, who is a nurse, if I would be getting the HPV shot," recalled Francessca, who is 27 now. "She shouted, 'No! What kind of mother do you think I am?' And his response was, 'Good, that's what I thought.'"

When Francessca asked what the big deal was, her mother told her she could only get HPV if she had multiple sex partners. Her doctor then asked, "Do you plan to have multiple partners?" Francessca said no.

"The last time I inquired about the vaccine, I was 19 and my doctor at the time told me I didn't need it since I've only been with one person," Francessca added.

"This is part of the problem, stereotyping like this, and it's a missed opportunity," Felder said. "It doesn't matter if you're in a monogamous, long-term relationship or not, the vaccine is about protecting you—and your partner, as well—but really protecting you."

"I wish more people understood how widespread HPV is and how easy it is to contract," added Sarah Nielsen, Ph.D., a vaginal cancer survivor. "Since you can have HPV without any symptoms, you can easily unknowingly spread it to others."

In a 2014 study published in the Journal of the American Sexually Transmitted Diseases Association, scientists estimated "the average lifetime probability of acquiring HPV was 84.6 percent for women and 91.3 percent for men." This probability ranged from 58.4 percent for those with one opposite-sex partner by age 44 to 100 percent for those with 15 or more opposite-sex partners by age 44.

So, even if you've only had one opposite-sex partner, your likelihood of contracting HPV is still almost 60 percent.

"You can get HPV from any single romantic skin-to-skin contact," Nielsen said. "You need only be intimate once to be potentially exposed."

"Most people have HPV, they just don't realize it," confirmed Irene Aninye, Ph.D., a molecular and integrative physiologist and chief science officer at the Society for Women's Health Research. "You get it and your body's immune system often deals with it without showing any symptoms.

"But if you persistently get these particular high-risk strains," Aninye continued, "that's what can lead to cervical cancer and other cancers."

In 2018, the FDA again amended its HPV vaccination guidelines—this time expanding the age range up to 45 for both men and women.

In its announcement, the FDA cited a study of approximately 3,200 women 27 through 45 years of age, who were followed for an average of 3.5 years. During that time, Gardasil was found to be 88 percent effective in the prevention of "persistent infection, genital warts, vulvar and vaginal precancerous lesions, cervical precancerous lesions, and cervical cancer related to HPV types covered by the vaccine."

The effectiveness of Gardasil 9 for men in the same age group was "inferred from the data" of the women's study, as well as efficacy data from younger men (ages 16 to 26) and a clinical trial of 150 men, ages 27 to 45.

But you should temper your expectations before you race out the door to the nearest clinic.

"The vaccine is a prophylactic vaccine," Aninye explained. "Which means you have to get it before exposure. If you've been exposed, it's no longer as effective at preventing HPV infections."

"Because HPV infection generally occurs soon after first sexual activity, vaccine effectiveness will be lower in older age groups," Markowitz confirmed. "Also, some previously exposed adults will have developed natural immunity already. Evidence suggests that although HPV vaccination is safe for adults ages 27 through 45 years, it wouldn't be expected to have much benefit for most people in this age group.

"Nevertheless," Markowitz continued, "some adults who are not adequately vaccinated and who weren't exposed to HPV in the past might be at risk for new HPV infection and might benefit from vaccination in this age range."

Noel T. Brewer, Ph.D., a professor of Health Behavior at the UNC Gillings School of Global Public Health and vaccination advisor to the WHO and CDC, gave the example of a close friend who "divorced at age 38 after being married to the same man for 19 years. She is an excellent candidate for the vaccine, given her likely low exposure to the virus," he stated.

"You won't be protected from the strains you were previously exposed to," Felder added, "but you're going to protect yourself from whatever ones you haven't been exposed to yet."

In its HPV vaccination guidelines, the CDC states vaccination is not recommended for everyone over age 26. So, how do you know whether you should get it or not?

The CDC recommends "shared clinical decision-making," which, simply put, means talk to your doctor. Because doctors don't routinely ask adults if they received the HPV vaccine as a child, you'll most likely need to initiate the conversation.

"Talking to your doctor so they know this is a priority for you is important," Aninye said. "Depending on your personal risk, your doctor will talk to you about what the particular benefits are for you, if you need additional testing and what your risk factors are for the various cancers."

When I broached the subject to my OB-GYN at my annual appointment, she felt it would still be beneficial for me to receive the vaccine now, based on my medical history and risk factors. For Lydia, who has already been diagnosed with one of the high-risk strains of HPV, her doctor said it would be more useful for her to focus on regular pap smears and other prevention methods. Francessca told me she would like to get the vaccine and plans to talk to her doctor soon.

"I think it's an individual choice to get the vaccine if you are older than 26, but it should be made with a doctor," said Tami Rowen, M.D., M.S., an associate professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at UCSF. "There likely isn't harm, aside from rare vaccine reactions, even if there isn't a benefit."

If, after speaking with your doctor, you decide to get the HPV vaccine, there are a few things to know.

Dosing schedule

Unlike the vaccine for kids, which is given in a two-dose schedule, people ages 15 to 45 need three doses, over the course of six months.

The second dose is given two months after the first, and the third dose is given six months after the first (four months after the second).

Safety and side effects

The HPV vaccine has "been studied globally with millions of people for 10-plus years with absolutely no data suggesting it causes harm," Nielsen said. "Instead, all of the data suggests that it is a really effective way to prevent HPV and any HPV-related precancer and cancer."

Just as with any other vaccine or medication, however, side effects can occur. According to the patient information provided by Gardasil, these include pain, swelling, redness, itching, bruising, bleeding, a lump where you got the shot, headache, fever, nausea, dizziness, tiredness, diarrhea, abdominal pain, sore throat and fainting.

The only side effect I experienced after my first dose was minor pain at the injection site for about 48 hours, though your experience may be different depending on your body's immune response.

Insurance coverage and out-of-pocket costs

The vaccine is considered preventive, so most insurance companies will cover the cost. However, according to my OB-GYN, not all insurance companies have caught up with the FDA's expanded age range, and some still require anyone over the age of 26 to pay out of pocket.

When checking my personal coverage, I found conflicting information on the insurance company's website regarding age range, so I called customer service. Initially, it seemed I stumped them with the question of whether a 37-year-old woman would be covered. But, after over an hour on the phone and being placed on hold several times, I had my answer: Yes, the cost would be covered at 100 percent.

Good thing, too, because Gardasil 9 is not cheap. The first dose of the vaccine was billed at $260 and my provider charged another $44 for a nurse to administer it, for a total of $304. If the other two doses are billed at the same rate, that will be $912 total. So, it's definitely worth checking with your insurance first to see if you're covered.

If you don't have insurance or your insurance won't cover it, you have options. Give your county health department and local clinics a call to see if they stock Gardasil and what payment options they provide. Often, these facilities have access to programs and grants that either provide it for free or at a reduced cost, depending on your income level and insurance status. One woman I spoke with, who is uninsured, told me she went to her local health department and paid about $30 for her doses.

It's worth noting again that the vaccine doesn't protect against all strains of HPV—and it doesn't cure HPV if you already have it. This means using protection while having sex is an important part of prevention, regardless of vaccination status.

Additionally, as the medical professionals I spoke with stressed, whether you have received the vaccine, plan to get it soon, or aren't going to get it at all, the vaccine is just one of three important steps in protecting yourself against cancers caused by HPV.

"Cancer prevention is threefold," Aninye explained, "primary prevention (vaccine), secondary prevention (screening and early diagnosis), and tertiary prevention (treatment of cancer)."

When it comes to cervical cancer and the many other cancers caused by HPV, early diagnosis is key, so make sure you are up-to-date on your screenings, including receiving regular Pap/HPV tests.

"Even if you're vaccinated, you still need screening," Aninye said, "but it becomes that much more important if you're unvaccinated that you stay on top of your screening regimen so your doctor is able to catch any issues as early as possible."

At the end of the day, it's about making an informed decision about what's right for you. "You can google a lot, but Google can't give you a conversation," Aninye said. "So, have that conversation with a trusted source.

"The most important piece," Aninye concluded, "is having the conversation and then being equipped with that information so you feel comfortable with the path forward. You want to know you can trust your body, and that you're armed with how to live better and healthier."