Gynecologic Oncology 107 (2007) S175 – S179

www.elsevier.com/locate/ygyno

Impact of an HPV diagnosis on the quality of life in young women

T. Maggino a,⁎, D. Casadei b , E. Panontin b , E. Fadda b , M.C. Zampieri b ,
M.A. Donà b , M. Soldà a , G. Altoè c
a
Department of Obstetrics and Gynaecology, Mirano General Hospital, ASL 13 Veneto Region, Italy
b
Department of Obstetrics and Gynaecology, Psychological Care Unit, Mirano General Hospital, ASL 13 Veneto Region, Italy
c
Department of Developmental and Social Psychology, University of Padova, Padova, Italy
Received 6 July 2007
Available online 6 September 2007

Abstract

Objective. To evaluate the impact of the communication of an HPV diagnosis on the cognitive-behavioural aspect, emotional experiences,
psychic-physical well-being, and psychosexual sphere in young women between the ages of 20 and 45.
Method. During the period between February 2006 and March 2007, at the U.O. Department of Obstetrics and Gynecology of the ULSS 13 of
Mirano (VE), we distributed three self-evaluating questionnaires (the CBA-20, the SAT-P, and the BISF-W) to 36 women who had been diagnosed
with an HPV infection and 36 women who had never been diagnosed with HPV.
Results. 36% of the experimental group reacted to the diagnosis with fear and 29% reacted with anxiety, while in only 3% of the cases did the
women react with anger. Significant differences emerged in two samples regarding state anxiety and obsessive and compulsive aspects, while there
were no significant differences between the two groups regarding the subjective satisfaction with life quality and sexual function. A significant
positive correlation was found between the sum of anxiety and fear expressed at the time of the diagnosis and the trait anxiety reported in the
Cognitive Behavioural Assessment 2.0.
Conclusions. The results indicate that the prevalent emotions felt at the time of the diagnosis are fear and anxiety. The persons who were
diagnosed with an HPV infection resulted as having higher levels of trait anxiety, obsessions, compulsions, and above all, behaviours and worries
related to hygiene and improbable infections.
© 2007 Elsevier Inc. All rights reserved.

Keywords: Human papillomavirus; Cervical carcinoma; Life quality; Psychophysical well-being; Psychosexual function

Introduction
The Human Papilloma Virus (HPV) is one of the most com-
mon causes of sexually transmitted diseases, some viral subtypes
infect the genital mucosa (most frequently the epithelium that
covers the cervix), causing cellular abnormalities in Pap Tests
and otherwise diagnosed by means of colposcopy and biopsies.
Experimental and clinical data, as well as epidemiological evi-
dence, indicate a direct association of some types of HPV with
cervical carcinoma.
More than 120 genotypes that infect man have been identi-
fied, with specific types of HPV that infect the genital tracts of
men and women numbering about 30 [1]. Types of HPV are
⁎ Corresponding author.
E-mail address: tiziano.maggino@ulss13mirano.ven.it (T. Maggino).
0090-8258/$ - see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ygyno.2007.07.013
subdivided into categories of low and high risk for neoplastic
transformation. The low risk genotypes are associated with
benign lesions, like the anogenital condyloma or genital warts
while some types of anogenital HPV (16, 18, 31, 33, 35) are
strongly associated with cervical intraepithelial neoplasia (CIN)
of the vulva, penis, and scaly carcinoma. The cervical carci-
noma was the first cancer to be recognised by the World Health
Organisation as being totally ascribable to an infection [2].
HPV infections are very common in the population: it is
estimated that more than 75% of sexually active women are
infected with an HPV during their lifetime, peaking with
women between the ages of 18 and 25 [3]. Of this high number
of infections, only 1% of the population will develop condy-
lomatosis florida lesions, while the infection causes subclinical
lesions in the majority of cases. The infection is often asymp-
tomatic and in most cases (70–90%) transitory, because the
S176 T. Maggino et al. / Gynecologic Oncology 107 (2007) S175–S179
virus is eliminated by the immune system before developing a
pathogenic effect [3]. The persistence of the viral infection is a
necessary condition for the development of a carcinoma. The
acquisition of a high-risk viral genotype increases the pro-
bability of persistent infection and, in this case, precancerous
lesions may develop that, if not cured, may progress to a
carcinoma [3]. Such lesions may also be present 10 years prior
to the development of the cancer itself.
Although it is clear that the human papillomavirus plays an
important role in tumoral development, it is just as evident that
the viral infection alone is not sufficient to cause a cervical
tumour. The malign transformation of a normal epithelial cell
also depends on other physical and chemical oncogenous fac-
tors [4] like cigarette smoke, the long-term use of oral contra-
ceptives, co-infection of other sexually transmitted diseases [3],
a high number of sexual partners, a higher age, a high number of
births. The risk of developing a tumour also depends on the
balance between the immune system and the genetic character-
istics of the host.
From a medical point of view, there is a vast amount of
literature on this subject. Over recent years, HPV has been much
talked about and a vaccine has even been developed (already
available in Italy for youths 12 years of age and older). How-
ever, there is not much literature on this problem regarding the
psycho-social reaction to an HPV diagnosis, especially from a
psychological point of view.
Studies on women who have had anomalous Pap Test results
have highlighted psychological consequences like anxiety, fear
of cancer, sexual problems, changes in body image, difficulty in
reproductive functions [5,6], hypochondria [13], a sense of
helplessness, anger, and a fear of being labelled [11]. A study on
the social and interpersonal impact of the HPV test identifies
anxiety as the most common reaction. The impact varies and is
correlated to an affective state and personal history, social and
cultural standards, and sexual habits, with cognitive understand-
ing [7]. An American study on 489 HPV-positive men and
women found that the initial reaction to the HPV diagnosis
included depression, anger, isolation, fear of rejection, shame,
and feelings of guilt [9]. In addition to distress caused by these
psychological aspects, fear of gynaecological examinations,
concern about transmitting HPV, and the fear of being judged
negatively by sexual partner are very common; following in-
fection by HPV, some individuals perceive themselves as being
less sexually attractive and report a diminished sensation of
well-being from sexual contact.
Anxiety and distress have repercussions on thoughts and
feelings regarding past, present, and future relationships [8].
In contrast to these data, a study on sexual activity found no
particular differences between women diagnosed with HPV and
those who had not received the diagnosis as far as physical
intimacy in sexual activity, feelings towards sexuality, and
feelings towards relations were concerned [10]. In comparing
the results of various studies, the fact that the presence of visible
genital lesions produces psycho-social consequences different
from those identified by people who present an asymptomatic
form of the infection must be taken into consideration. The
results of studies on patients with visible genital lesions cannot
be generalized to include those who do not have visible signs of
the infection.
Another study pointed out that women may have a lack of
information on HPV. Their lack of adequate knowledge regarding
the infection may contribute to intensifying the emotions felt
[11]. One study, in fact, found that women with HPV who
knew of the sexual transmissibility of the infection but who
were not aware of the fact that it is very common and frequent
obtained the highest scores regarding feelings of shame and
being labelled [14].
Psycho-social and behavioural responses are also influenced
by a sense of personal risk (perception of personal risk), by the
subjective significance given to HPV and the Pap Test result, by
the cognitive understanding of the Pap Test results, by the locus
of control, and by the quality of affective relationships [12].
This work evaluated, by means of psychological tests, the
impact an HPV diagnosis has on the quality of life in young
women, with particular reference to the immediate reaction
upon communication of the diagnosis, the psychological expe-
rience, the psychophysical well-being, the potential cognitive-
behavioural modifications, and the psycho-sexual sphere of
patients affected by this disease.
Objective and study questions
The objective of this study was to investigate whether or not
the communication of being affected by the human papilloma
virus by a physician influences the quality of life and the
psychophysical well-being of women between the ages of 20
and 45.
The initial hypotheses formulated were:
First Hypothesis: there is an emotional reaction at the time
of diagnosis.
Second Hypothesis: the diagnosis and knowledge of being
affected by HPV influences the psycho-
logical picture and especially levels of
anxiety, mood, reactivity, psycho-physio-
logical disturbances, fears, obsessions and
compulsions; emotional reactions ex-
pressed at the time of diagnosis are cor-
related with these aspects;
Third Hypothesis: the diagnosis influences sexual function.
Fourth Hypothesis: the HPV diagnosis influences the sub-
jective overall satisfaction and quality of
life.
Participants
The experimental group was composed of 36 women who
were diagnosed with HPV; the patients were recruited at the U.O.
Department of Obstetrics and Gynecology—ASL 13 Mirano
(VE); during a periodical check-up, the patients were invited to
participate in the study (Fig. 1).
The control group consisted of 36 women; this group had
some characteristics in common with the experimental group;
geographic origins (Northern Italy).
 T. Maggino et al. / Gynecologic Oncology 107 (2007) S175–S179
Fig. 1. The time interval between the HPV diagnosis and the distribution of the
questionnaire.
Instruments and methodology
Three self-evaluation questionnaires were used following a
brief, structured interview during which the following questions
were asked:
– How much time had passed since the diagnosis?
– Did the patient have an emotional reaction at the time of
diagnosis? If so, the patient was asked to indicate what type
of reaction.
The questionnaires used in this study were the following:
CBA 2.0 (Cognitive Behavioural Assessment, by Bertolotti,
Michielin, Sanavio, Simonetti, Vidotto, and Zotti, 1986 [19]):
battery of 9 cards that measures the cognitive-behavioural
aspects. In this study, we considered:
Card2 (STAI-X1): measures state anxiety and consists of 20
items;
Card3 (STAI-X2): measures trait anxiety and consists of 20
items;
Card10 : an abridged version of the STAI-XL. It evaluates trait
anxiety manifested by the subject at the conclusion of
the battery and offers the possibility of comparison with
the level of anxiety manifested at the beginning of the
compilation of the questionnaire.
Card6 (QPF/R): consisting of 30 items, this card investigates
psycho-physiological reactions and disturbances of po-
tential clinical significance;
Card7 (IP/R): allows the compilation of two overall indexes
and five subscales that study specific groupings of fears;
Card8 (QD): consisting of 21 items, this card measures dys-
phoria and depressive manifestations of subclinical
significance.
Card9 (MOCQ/R): Consisting of 21 items, this card supplies
the overall score and three indexes, studies intrusive
thoughts and compulsive behaviours.
SAT-P (Satisfaction Profile by Majani and Callegari, 1998
[15]): measures subjective satisfaction and the quality of life,
supplies an analytical scoring in 32 items and a more synthetic
one subdivided into five areas: psychological functionality,
physical functionality, work, sleep/nutrition/free time, social
functionality.
BISF-W (Brief Index of Sexual Functioning For Woman by
Taylor, Rosen, and Leiblum, 1994 [16]): Italian adaptation
(Panzeri, Donà, Optale now being prepared) of a self-evaluation
questionnaire that measures female sexual function. It consists
S177
of 22 questions for a total of 49 items that evaluate the qualitative
and quantitative aspects of sexual behaviour; this instrument
stands apart from other tests present on a national level in that it
measures normal sexual function and the lack of sexual
dysfunction. The questionnaire supplies 7 dimensions (thought/
fantasy; excitation; frequency, receptivity/initiative; pleasure/
orgasm; satisfaction; problems) and 4 factors (sexuality of the
couple; self-erotic sexuality, satisfaction/dissatisfaction, anal
sexuality).
The statistical analyses were conducted with the SPSS 14.0
statistical package for Windows.
Results
First Hypothesis: It resulted that 62% of the cases had a
reaction to the communication of the HPV diagnosis.
The most frequent emotional reactions were: fear
(25%), anxiety (17%) and fear (17%), while only 3%
of the cases reacted with anger. About 38% of the
persons affirmed that they felt no reactive emotion
regarding the diagnosis. The data in literature that
indicate fear and anxiety as the most common
emotions at the time of diagnosis have been
confirmed (Fig. 2).
Second Hypothesis: To evaluate if the diagnosis influences cog-
nitive-behavioural aspects, anxious and depressive
experiences, psycho-physiological reactivity, and ob-
sessive and compulsive aspects, the CBA 2.0 (Cogni-
tive Behavioural Assessment: cards 2,3,6,7,8,9,10 [19]
and [20]). Comparisons carried out with Student's t-
distribution on independent samples resulted in signif-
icant statistical differences between the experimental
group and the control group regarding state anxiety
(STAI-X1) with p= 0.014 and obsessive and compul-
sive aspects (MOCQR) with Sign. (2-code) =0.020,
especially in the MOCQR2 Sign (2-code) =0.010
subscale (“Cleaning”, regarding behaviour and concern
related to hygiene and an improbable infection and
contamination). This study found a statistically signif-
icant linear correlation between the sum of anxiety and
fear expressed at the time of the diagnosis, with levels of
state anxiety that emerged in the STAI-X1, with the
sp= 0.335, n =36, pb 0.05 and sign. (2-code) =0.046.
Third Hypothesis: In order to evaluate if the diagnosis influ-
ences sexual function, a t-test was carried out on
independent samples to study the significant differ-
Fig. 2. Reaction expressed at the time of communication of the HPV diagnosis.
S178 T. Maggino et al. / Gynecologic Oncology 107 (2007) S175–S179
ences in both groups in relation to the 7 dimensions
(Mazer, Leiblum, and Rosen, 2000 [17]) and 4
factors (Panzeri, Daniele, Donà, Ronconi, Optale;
2004 [18]) of the BISF-W. No statistically significant
differences emerged from the analyses of both
groups. A Pearson correlation was carried out in
order to evaluate if belonging to a group influences
questionnaire items in a statistically significant
manner. The analysis resulted in a significant
correlation between belonging to the experimental
group and item Q14_8 (ρ=−.302; pb .05) and item
Q15_1 (ρ=−.423;pb .01). In item Q14_8, women were
asked how often they had experienced vaginal infections
over the past month. In item Q15_1, they were asked to
indicate how often health problems had influenced their
level of sexual activity over the past month.
Fourth Hypothesis: In order to evaluate if the diagnosis in-
fluences subjective satisfaction and the quality of
life, the SAT-P was given. The comparison among
the averages with the Student's t-distribution by
independent samples between the control group and
experimental group gave no significant results in the
following five areas: psychological functionality,
physical functionality, work, sleep/nutrition/free
time, social functionality.
Limits of the study
One limit found regards age: initially, the 20–35 age range was
considered, but after having seen the turnout of HPV-infected
women above the age of 35, the age range of the sample was
extended to 45 years of age. This change made a difference
regarding the age between the experimental group and the control
group. In the experimental sample, there are more persons between
the ages of 25 and 45, while in the control group there are more
between the ages of 25 and 35. Therefore, the two samples are not
homogeneous for age.
Another limit regards the size of the sample; seeking to increase
the sample in order to confirm or deny the results obtained up until
now will be an objective of future studies.
Conclusions
The HPV diagnosis caused emotional reactions, especially
fear and anxiety, in most subjects of our sample. The discovery
of an infection leads to consequences on levels of manifested
anxiety, on intrusive and pervasive thoughts, on obsessive and
compulsive behavioural attitudes, and on concerns regarding
hygiene, infection, and contamination. The HPV diagnosis does
not significantly influence the quality of the sexual sphere,
however it did come to light that most women affected by HPV
indicated health problems when asked which factor most in-
fluenced their sexual activity. The knowledge of having an
infection with potential physical disturbances connected to the
pathology is perceived as the factors that influence the quality of
sexual activity and can be conditions that facilitate the onset of
problems in the sexual sphere.
The scope of this study is not to attempt an interpretation of
the results obtained, however, some hypotheses may be formu-
lated. The communication of the HPV diagnosis implies an
awareness of having been infected by HPV. The emotional
reactivity at the time of the diagnosis depends on various
factors: on the contents to the style in which the information is
transmitted by the physician, on cognitive comprehension, on
pertinent knowledge, on the specific reactive style of the in-
dividual, on personal psychological characteristics (like trait
anxiety), on the personal history, on beliefs, and on the social
norms of the individual's cultural group. Initial fear and anxiety
followed by the perception of personal risk can lead a person to
seek information and be more receptive towards news that deals
in HPV detection. Information on its sexual transmissability
and association of the infection with the possibility of devel-
oping cervical cancer and the problems related to the pathology
(like condylomas, therapeutic treatments) can increase the
perception of personal vulnerability or of loss of control of
one's own health, which may in turn increase the manifested
anxiety and fuel worries and obsessions. The mental represen-
tation of the infection and the potential implications, together
with the emotions involved like anxiety and fear of cancer to the
obsession towards hygiene and infection, may converge in
attitudes that are expressed in obsessively and compulsively
protective behaviours towards personal health care.
The style of communications at the time of diagnosing the
infection, the supplying of adequate and understandable infor-
mation on the illness, on it sexual transmissability, on treatments,
and on the importance of screening, may help the person affected
by HPV in acquiring knowledge that is not subject to distortion
and thereby lower the level of reactive anxiety and fear. The
mastery of an adequate and manageable representation of the
infection thanks to education at the time of diagnosis contrasts
the frantic search for information from external sources,
allowing the patient to attain a sensation of control, to diminish
a sensation of vulnerability and obsessive and compulsive
behaviours with a consequential normalization of the anxious
activation. A correct and easily understandable education also
favours adherence to medical advice, thereby improving the
physical conditions of the patients and diminishing the risk of
developing cervical cancer.
Conflict of interest statement
We declare that we have no conflict of interest.
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