In April 2011 a 16-year-old girl came to Dr Deirdre Little's surgery in rural New South Wales asking why her periods had stopped. When Dr Little investigated she found that the girl was in menopause. No cause for this could be found, and usually isn’t in 90 percent of cases of ovarian failure. But this was not just another case; the incidence of menopause developing without cause in a young teenage girl is so rare that there are no figures for it.
"Susan" asked if her condition could be due to the human papillomavirus vaccine (HPV) Gardasil, because it was after receiving this vaccine that her periods deteriorated. “Probably not,” said Dr Little, but she would look into it for her. What she found from her investigation suggested that Gardasil was at least a possible suspect. Her detailed analysis of the safety studies done on the vaccine revealed serious inadequacies in the testing of this vaccine -- in particular its effect on young adolescent ovaries.
In emailed comments to MercatorNet Dr Little stressed that she is very pro-vaccine, employing a nurse to vaccinate children and adults. She was not looking for problems with Gardasil – the problems arrived in her surgery unbidden.
Three menopausal teenagers
The main purpose of Gardasil is to protect women (and men) against the two most common forms of HPV infection which, if they persist, can cause cancer in the cervix and elsewhere. The vaccine was developed by an Australian immunologist, Ian Frazer, and approved by the US Food and Drug Administration in 2006. In 2007 the Australian government introduced its own national HPV vaccination programme for girls and women aged 12 to 26 years.
“Susan” received her three shots in February, May and August of 2008, the year after her periods began. Within six months they had become irregular and two years later stopped altogether. Initially, a GP offered the oral contraceptive pill to bring back her periods, but without any investigation of her symptoms. Susan was not sexually active. She declined the Pill and sought another opinion instead.
Investigations revealed that her ovaries were in a state comparable to those of a post-menopausal woman: the anti-Mullerian hormone, which indicates ovarian health, was at un-recordably low levels. This is known as premature ovarian failure (POF),
This news was devastating for a 16-year-old girl, but all Dr Little could do was to counsel her about the advisability of hormone replacement therapy and help for other problems. There was no family history to help explain what had happened, and no data available on the incidence of “idiopathic” or “cause-unknown” ovarian failure in young adolescents in the population against which to assess her case.
More worryingly, Dr Little found there was no detailed cellular report (histology report) of the vaccinated rat ovary from safety studies. Only a histology report of the testis was available.
The next girl who came to her about absent periods, aged 18, was diagnosed with the same condition. A third girl had been diagnosed at 17 years of age with ovary failure and also came to discuss her condition. Both had received the HPV vaccinations following the onset of their periods. All three had been given the Pill, which had the effect of delaying diagnosis.
Ovarian tissue freezing options were considered by these girls, and one went ahead with this option through IVF cryopreservation, with a view to possible ovarian re-implantation at a later date closer to her chosen time for motherhood in the hope of ovarian stem cell stimulation developments.
The three cases have been thoroughly documented, described and published in peer reviewed journals over the past three years, and have also been notified to the Therapeutic Goods Administration (TGA), Australia’s drug licensing body.
The safety studies: main concerns
No-one can say at this point that Gardasil has or has not caused POF in these young women, says Dr Little. There is simply not enough information available. But it cannot be ruled out, since her research shows there are serious shortcomings in the testing and approval phases of the drug.
From studying laboratory information and clinical trials in adolescent subjects, these are her main findings and concerns:
* No “normal saline placebo” was ever used -- although reports stated otherwise -- for the young girls’ safety studies. The vaccine was only ever compared with parts of itself in safety studies. This contravenes placebo definitions and requirements. More importantly, it means the prescribing information is incorrect. “Product Information” wrongly states that saline was used as a safety study placebo. The US FDA also misrepresents the younger girl placebo as “saline”. Neither inform the recipient or the prescriber of the correct placebo, which was made up of multiple HPV vaccine components. When prescribers are misinformed, patients cannot give informed consent.
Both the multi-chemical placebo and the HPV vaccine contained a substance whose toxicity to rat ovaries is established at all doses tested, over a tenfold range. There is no dose-response curve to tell us when the injected “polysorbate 80” dosage level begins to have an effect on the mammalian ovary. (It does not begin to have these effects after oral ingestion until it comprises a whole fifth of the rats' total intake, possibly due to its breakdown by gastric juices).
The TGA tells doctors like Dr Little that, since this substance is present in some foods, it cannot possibly be ovary-toxic when serially injected into young girls. “This is alarmingly unscientific,” she told MercatorNet. “Unfortunately, however, it does represent the level of evidence available to reassure us about its safety for our daughters’ ovaries. Informed consent requires more than un-evidenced reassurances.”
* Masking effects of the Pill. The majority of young women in the safety studies were using hormonal contraception at the time, which masks period changes. They were required by the study to use contraception until seven months after their first vaccination.
* Limited definition of “adverse events”. In safety studies, new medical conditions which arose in girls after seven months from their first vaccination were not recorded as vaccine adverse events.
Only reactions defined as “Serious Adverse Events” were recorded for longer time periods in safety studies. These do not, by definition, include menstrual problems because they are not life threatening and will not land you in hospital.
* Safety studies focus on hospital cases. The principal safety studies done since marketing began in 2007-2008 have focussed on hospital presentations and hospital admissions. These studies have no capacity to detect ovarian failure, says Dr Little, noting that she has never yet hospitalized a girl for missed periods. Another post-marketing safety study has looked for pre-specified diagnoses in records of vaccinated girls, but ovarian damage was not included in the specifications of diagnoses to look for.
* Too few girls in the target age group were studied. There were only ever a few hundred young girls in each of the two safety studies which looked at the vaccine target age group. In one of these two studies more than half of the girls had been lost to follow-up 12 months later, leaving only 240 girls; and in the other, it is not recorded how many had begun to menstruate when they were studied, since the mean age was 11.9 years.
* Boys are under-studied. Although boys get HPV too, and pass it on, only a couple of hundred boys were studied, and most of them were also lost to follow-up at 12 months, leaving only 205 in total. One died suddenly of no apparent cause. With nothing found on post-mortem, the investigators were sure it wasn’t the human papillomavirus vaccine.
* Virgins are more vulnerable but under-studied. Reported “systemic” (unwell) adverse events experienced after Gardasil vaccination are more common and more severe in those not previously exposed to the virus strains -- namely, virgins. This is the state of the target group, which is under-represented in safety studies. (This disparity was less marked in the placebo group.)
These are just the most obvious concerns in the evolving story of inadequate research on Gardasil. Japan has withdrawn the vaccine from routine school administration. Dr Little’s research raises questions about the probity of industry-sponsored safety research. It also puts a question mark over prescribing the Pill in the absence of a diagnosis. As she points out, premature menopause in adolescence is easier to diagnose without the presence of hormonal contraception.
Is vaccination of girls worth the risk when screening gives good results?
Vaccination always involves a calculation of risks and benefits. In this case the risks of mass vaccination of pubescent and pre-pubescent girls should be weighed against the incidence of and deaths from cervical cancer in Australia before the HPV vaccine was introduced.
Following the introduction of a national cervical screening programme, these rates more than halved in the decade prior to 2000 in the 20- to 69-year age group in Australia, and 578 new cases were diagnosed in 2000. The incidence was highest in remote areas, with the risk of death from cervical cancer for an Indigenous woman in Australia six times that of a non-Indigenous woman.
In 1989 it was estimated that screening could prevent 90 percent of malignancies. By 2002, the Australian incidence of cervical cancer was 6.2 per 100 000 women and the mortality rate 1.7 per 100 000 women. In 2011 in Australia, there were 229 deaths from cancer of the cervix. Some 72 percent of women diagnosed with cervical cancer survive for at least five years.
In any case, vaccination is not a free pass: up to 30 percent of cervical cancer may still occur in vaccinated individuals so pap smears are still necessary for sexually active women until they reach 70 years of age.
In the light of these facts it is up to the drug companies producing the HPV vaccine and the authorities that approve it to ensure that, in the effort to lower cervical cancer rates more rapidly, they are not putting healthy girls at risk of ovarian damage. Women, if not the licensing authorities, should be demanding comprehensive ovarian research on a drug that could render some of them infertile.
Carolyn Moynihan is deputy editor of MercatorNet, from where this article is adapted with permission. This article is based on information in the following article by Dr Deirdre Little, MBBS DRANZCOG FACRRM:
* Deirdre Therese Little and Harvey Rodrick Grenville Ward. “Adolescent Premature Ovarian Insufficiency Following Human Papillomavirus Vaccination: A Case Series Seen in General Practice,” in the Journal of Investigative Medicine High Impact Case Reports, October to December 2014 1-12
*Deirdre Therese Little and Harvey Rodrick Grenville Ward. “Premature ovarian failure 3 years after menarche in a 16-year-old girl following human papillomavirus vaccination,” in BMJ Case Reports 2012
*D. Little, “Human Papillomavirus Vaccine and the Ovary: the Need for Research,” A paper delivered at the COGI World Congress in Vienna, October 2013
* The Brighton Collaboration in VSQ—VACCINE SAFETY QUARTERLY 2/2014