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Changes to the present age policy of cervical screening are currently under consideration. We conducted a retrospective matched case-control study and cost analysis study to identify risk factors for the development of an abnormal smear after age 50 and to determine the impact of age-restricted cervical screening on the annual cost of the screening program. All women (229) from an 11-year birth cohort who developed an abnormal smear at age 50 or over were age-matched for two controls with negative smears. Routine screening smears taken between age 48 and 52 were tested for human papillomavirus (HPV) subtypes 16 and 18. Epidemiologic data were collected by postal questionnaire. Changes in costs under a policy of HPV testing and age-restricted screening were assessed. We found that HPV 16 status was the only independently significant risk factor for abnormal cytology after age 50 with an odds ratio of 10.26 (95% CI 1.25-84.11). A policy of early withdrawal from screening at age 50 on the basis of HPV testing would produce net cost savings. These findings suggest that HPV testing could be a valuable means of identifying the small proportion of women still at risk after 50, and of releasing health care resources.

Respiratory tract papillomas are associated with human papillomavirus (HPV) types 6 and 11; these HPV types are also commonly associated with genital warts (condyloma acuminata). Although most commonly seen in young children, the incidence of respiratory tract papillomas in young adults is increasing. It has been postulated that orogenital contact is the means of transmission in this age group. We performed a survey of adults with genital warts to assess the prevalence of respiratory tract papillomatosis in relation to sexual behaviour and other factors. Fifty-three adult patients (35 male, 18 female) with genital warts attending a genitourinary medicine clinic agreed to examination of the mouth and throat, including indirect laryngoscopy. Seventy per cent of the group had participated in oral sex. Two patients (3.8%) had lesions attributable to HPV infection of the oropharynx and larynx (one with laryngeal keratosis, one with papilloma of the pharynx). There was no specific risk factor identified to predict respiratory tract disease. In view of the high infectivity of genital warts, it is interesting to note the low prevalence of oropharyngeal warts in adults indulging in orogenital contact. Since malignant transformation is known in respiratory tract papillomas, we would recommend that any patient with genital warts who develops unexplained hoarseness has a specialist examination of the upper respiratory tract.