Women’s Health

The burden of Human Papilloma Virus and cervical cancer in the Arab World


By Dr Sabah Al-Lawati

Human Papillomavirus, more commonly known as HPV, is a DNA virus which spreads through sexual contact. HPV consists of a group of over 100 different viruses, with at least 30 strains known to cause different types of cancer. The HPV group of viruses has a global prevalence of approximately 10-22%.

Over 100 types of HPV exist. Some HPV types are termed “low-risk” since they cause only benign skin warts, whereas high-risk types of HPV can cause anogenital cancers, particularly cervical neoplasia, or cervical cancer. Among highrisk strains, HPV 16 and 18 are most common among cervical cancer patients (associated with 50.5% and 13.1% of cervical cancers, respectively). Most women are probably infected with at least one if not several types of HPV strains during their sexual life.

Most low-grade cervical lesions spontaneously regress, but approximately 10% to 13% will progress to a high-grade lesion, which will eventually put the individual at risk for invasive cervical cancer. Worldwide, every two minutes a woman dies of cervical cancer and each year more than 500,000 women will be newly diagnosed and more than 270,000 women will die.

Though the incidence of cervical cancer is lower in the Middle East compared with the rest of the world, most cases of cervical cancer are detected at a late stage when the disease may have become more advanced. Furthermore, in spite of the well-known benefits of the Pap smear test, a very small number of women in this region are tested annually, largely through opportunistic screening during a regular gynecologic examination. Therefore, it is crucial for physicians to advise their patients on the importance of protection in terms of regular and consistent screening and possible vaccination against HPV.

Cervical cancer’s impact on women’s lives is multifaceted. First, cervical cancer and its treatments often profoundly affect women’s overall mental and physical health via infertility, morbidity, and mortality. In this respect women bear the greatest burden if diagnosed at younger ages and more advanced stage. Additionally, many patients experience negative psychosocial reactions, e.g. fear, shock, denial, anxiety, depression, anger, and shame. Unfortunately, these concerns are rarely voiced and addressed, as patients often feel uncomfortable and embarrassed.

Individuals with active HPV infection that is not clinically apparent can potentially transmit the virus; therefore, elucidating its prevalence together with providing adequate education regarding protection from the virus is important.

HPV prevalence in the Middle East

HPV related infections are less common in the Middle East region compared with the rest of the world, though the exact prevalence of HPV is not as well determined as it is for other countries. In recent years, several studies have attempted to study the prevalence of HPV in the general population in the Middle East region.

The Executive Board of the Health Ministers’ Council for GCC States published a report in 2005 “1998–2005 Cancer Incidence Report of Gulf Corporation Council States”, which states that cervical cancer is the 11th most common cancer in the GCC states. The report further shows that between January 1998 and December 2005, there were 1,314 cervical cancer cases reported from all GCC states, accounting for 1.8% of all cancers and 3.6% of cancers among females. The overall rate for women in all GCC States was 3.0 per 100,000 of the population. Qatar reported the highest incidence of cervical cancer (8.4 per 100,000 women) followed by Oman (7.8), Bahrain (6.5), UAE (5.9), Kuwait (4.5), and KSA (2.2). The UAE’s Cancer Registry Program revealed that the annual average of the reported cervical cancer cases had tripled in 2005 when compared with that from 1998-2004. However, this report only determined prevalence up to 2005 and only in the GCC states.

Globocan 2008 estimated incidence rate of cervical cancer among women in the Middle East, up to 2008, to be ~6.6 per 100,000 (Figure 1). This incident rises in the UAE to 6.7-11.2 per 100,000. The overall incident in the Middle East region had increased from the previous Globocan 2002 figure of 4.3 per 100,000 and had almost doubled from the GCC Report published in 2005.

Another study presented at the American Society of Clinical Oncology (ASCO) 2010 meeting by MA Seoud and colleagues utilised a large literature survey to specifically determine HPV prevalence, rather than just cervical cancer prevalence, in the Middle East & North Africa (MENA) region. The study determined, using data available from literature published up to 2009, that the prevalence of HPV is around 5%-12% in the general population and 60%-90% of cervical cancers in the MENA region are positive for HPV with HPV 16 as the most predominant type.

Further to the literature review carried out by Seoud et al in 2009, recent studies have also been performed to look at the prevalence of HPV in the Middle East. A recent study published by A Al-Thani and colleagues in Qatar examined the prevalence of different HPV types in 95 women living in Qatar. The results showed a prevalence of up to 70% of high-risk HPV types in women with gynecological problems. However, it must be emphasised that this study was carried out in women with pre-existing gynecological problems and the results do not represent the general population of Qatar.

Another recent study presented at The International Human Papillomavirus Conference and Clinical Workshop in July 2010 by S Akhtar of Kuwait University, reported a systematic review carried out to assess the prevalence of genital HPV infection in women of the Middle East. The results of the review suggest that the prevalence of HPV infection ranged from 5% to 31% in the general population, 80% among women with cytological abnormalities and almost 100% among women with cervical carcinoma. Specific prevalence of HPV infection ranged from 4.9% in Lebanon, 13% in Palestine, and 31.6% in Saudi Arabia. Women with cytological abnormalities had much a higher prevalence of about 80% in Turkey and Saudi Arabia, where it was almost 100% among women with cervical carcinoma. The predominant HPV subtypes were HPV-16/18.

More recent studies in specific countries, published between 2010 and 2011, include a study of 3,011 Kuwaiti women, by Al- Awadhi R et al, showing that 40.8% of all HPVs were found in women 30-39 years of age, 29.6% in women 40-49 years of age, 19.7% in women over 50 years and 9.9% in women less than 34 years old. The prevalence of positive HPV findings of 5.5% was also shown in a cohort of 402 females in Iran.

Specific data is not yet available on the HPV burden in the general population of United Arab Emirates. However, a 2010 World Health Organisation (WHO) paper (United Arab Emirates: Human Papillomavirus and Related Cancers, Fact Sheet 2010), reported that every year an estimated 48 women are diagnosed with cervical cancer and 2 die from the disease (an incidence rate of 9.9 per 100,000 women). Cervical cancer ranks as the 4th most frequent cancer among women in United Arab Emirates, and the 3rd most frequent cancer among women between 15 and 44 years of age.

The scarcity of data regarding the burden of HPV infection in the Middle East demonstrates the need for more studies to map out the HPV infection load in the female population of the region.


Most infections with HPV are benign, but persistent infections with HPV types of high malignant potential are associated with the development of cervical cancer. Cervical cancer causes significant morbidity and mortality, interfering with the quality of life of the patients and their families. It also poses a major financial burden on healthcare systems worldwide.

The studies carried out to investigate the prevalence of cervical cancer/HPV in the Middle East from 1998 to 2010 reveal that the annual average of the reported cervical cancer cases and HPV incidence, although low compared with the rest of the world, has increased substantially in recent years. This alarming increase accentuates the need for awareness and preventive screening, with use of conventional Pap smear and HPV DNA testing, and vaccination programmes in the region. Indeed, the variation of the prevalence of HPV in the Middle East compared to the rest of the world may itself be a manifestation of the lack of routine screening programmes in the region as well as a reflection of societal disapproval of extramarital sexual activity.

Many women remain unaware that Stress Urinary Incontinence is treatable

By Maya El Hachem

Stress urinary incontinence can happen to anyone, but it is most prevalent among women between the ages of 30 and 65. Studies have shown that more than 30% of women around the globe have problems with urine control, causing involuntary leaks from the bladder with a cough, laugh or sneeze or even sudden intense urges to go to the bathroom.

Stress urinary incontinence occurs when pelvic muscles supporting the bladder and urethra have been damaged or weakened, so that they may not hold the urethra in its correct position. Sudden movements from the diaphragm put stress on the bladder, causing the urethra to lose its seal and allowing urine to leak out.

Many women assume stress urinary incontinence is just a natural part of aging or an inevitable consequence of having children. They live under continuous fear of embarrassment, especially when it negatively impacts their daily social activities.

Due to these misconceptions, many women remain unaware that stress urinary incontinence is a common and treatable medical condition.

Doctors say that the problem is that “more than 50% of women with stress urinary incontinence have never mentioned it to their doctors, and of those who did, 61% waited for years before finally discussing it. It is important for women to realise that they are not alone. The good news is that stress urinary incontinence is not dangerous and it is treatable with proper intervention.

“Diagnosis depends mainly on the medical history, clinical and ultrasonic examination in addition to cystometric analysis, known as a cystometrogram (CMG). It is important for the patient not to be embarrassed and discuss her case with her doctor in order to get a correct diagnosis.”


There are many factors that can cause or aggravate stress urinary incontinence such as pregnancy and childbirth, frequent heavy lifting, estrogen deficiency, menopause or obesity. A close examination of the patient’s medical history and daily habits can help determine what may be causing the condition.

Transit causes include excessive drinking of liquids specially those containing caffeine which activates bladder action. The use of diuretics also causes bladder disorders. A further possible cause is urinary tract inflammation which has the same symptoms as neurogenic bladder and bladder stones.

Some permanent causes may aggravate the condition such as ageing, weak pelvic muscles, which is the most common and dangerous cause for incontinence in women, due to repeated labours especially if forceps are used during surgery. Also, weak pelvic muscles may occur after the menopause, while recent studies attribute it to genetic factor. Neurological disorder of the urinary bladder due to major operations like vaginal or abdominal hysterectomy is another permanent factor.

There are many things that one can do to improve urinary incontinence. Making small changes to lifestyle can help reduce symptoms, for example. However, most importantly, talking to the doctor about medication is essential to manage the condition.

Several medications and therapies can be used to treat stress urinary incontinence. The condition can be treated by bladder training or using an enlarging substance that is injected around the neck of the urethral sphincter to keep this sphincter closed. In some advanced cases, a bladder lifting surgery or bladder neck lifting surgery is prescribed and usually done with regional anaesthesia. This has been shown to lead to recovery and actual improvement in more than 90% of cases.

 Date of upload: 10th Jul 2011


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