Beyond the Adolescent Window: HPV Vaccination in Adult Women

Human papillomavirus (HPV) vaccination has traditionally targeted girls and adolescents before sexual debut, when its preventive potential is greatest. However, many women reach adulthood unvaccinated or incompletely vaccinated, a gap widened by the COVID-19 pandemic. This narrative review summarizes the current evidence on HPV vaccination in adult women and its implications for gynecological practice. Sexual debut, previous infection, or a positive HPV test does not preclude benefit, because few women have been exposed to all vaccine types; nevertheless, the vaccine is prophylactic and does not treat established infection or lesions. In women aged 27 to 45 years, trials show favorable immunogenicity, efficacy, and safety, and vaccination is recommended through shared clinical decision-making that considers prior exposure and the risk of new exposures. Evidence above 45 years of age remains scarce. After excisional treatment of cervical intraepithelial neoplasia grade 2 or worse, meta-analyses predominantly based on observational studies suggest lower recurrence rates following adjuvant vaccination, although this benefit has not been consistently confirmed by randomized controlled trials. We also discuss additional vaccination with the nonavalent vaccine after bivalent or quadrivalent series, single-dose schedules, people living with HIV, and cervical screening in vaccinated women, in whom HPV-based testing maintains better performance than cytology. Missed opportunities remain common, and the absence of a recommendation from a health care professional is among the main reasons adults remain unvaccinated. Reviewing vaccination history at every gynecological visit, combined with individualized counseling, may help close the gap between vaccinated young cohorts and unvaccinated adult women and support cervical cancer elimination goals.