Human Papillomavirus (HPV)

HPV

Human papillomavirus (HPV) is one of the most common sexually transmitted infections in the world. Experts estimate that as many as 24 million Americans are infected with HPV, and appears to be on the rise. More than 100 types of HPV have been identified. Some types of the virus cause common skin warts. About one-third of the HPV types are known to spread through sexual contact and live only in genital tissue. Low-risk types of HPV cause genital warts, the most recognizable sign of genital HPV infection. Other high-risk types of HPV cause cervical cancer and other genital cancers.

Like several other sexually transmitted infections, HPV usually causes an infection that does not have visible symptoms. One study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) reported that almost half of the women infected with HPV had no obvious symptoms. Because of the persistent nature of this viral infection, individuals may not be aware of their infection or the potential risk of transmission to others and of developing complications.

As far back as 1991, the Journal of the American Medical Association revealed that almost 50% of sexually active females seeking evaluation for unrelated conditions at a gynecological evaluation at a University Health Center environment demonstrated positive testing for HPV DNA in the vagina. Thus, a decade ago almost half of sexually active females revealed through testing that they had HPV DNA in their vaginas. This data is an astounding revelation regarding the prevalence of this infection that had never before been noticed.

Interestingly, in this study fewer than 10% of patients had actual visible, external signs of skin changes consistent with "genital warts", the most common skin manifestation of HPV. The conclusion, therefore, was that about half of sexually active females ranging in age from 20-40 were infected with HPV, and fewer than one in ten patients were aware of it.

Genital Warts

Genital warts (condylomata acuminata or venereal warts) are caused by few of the many types of HPV. Other common types of HPV infections, such as those that cause warts on the hands, do not cause genital warts. Genital warts are spread by sexual contact with an infected partner and are highly contagious. Approximately two-thirds of people who have sexual contact with a partner with genital warts will develop warts, usually within three months of contact. It is estimated that as many as 1 million new cases of genital warts are diagnosed in the United States each year.

In women, the warts can occur on both the outside and inside of the vagina, on the cervix (the opening to the uterus), or around the anus. In men, they are likely to be found on the tip or shaft of the penis, on the scrotum, or around the anus. Genital warts often occur in clusters and can be very tiny or can spread into large masses on genital tissues. Left untreated, genital warts often disappear. In other cases, they eventually may develop a fleshy, small raised growth with a cauliflower-like appearance. Because there is no way to predict whether the warts will grow or disappear, people who suspect that they have genital warts should be examined and treated, if necessary.

Diagnosis

A medical care provider can often diagnose genital warts by visual examination. Women with genital warts should also be examined for possible HPV infection of the cervix. The doctor may be able to identify some otherwise invisible changes in the tissue by applying vinegar (acetic acid) to areas of suspected infection. This solution causes infected areas to whiten, which makes them more visible, particularly if a procedure called colposcopy is performed. During colposcopy, a magnifying instrument is used to view the vagina and cervix. In some cases, it may be necessary to biopsy cervical tissue. This involves taking a small sample of tissue from the cervix and examining it microscopically.

A Pap smear test may indicate the possible presence of cervical HPV infection. A Pap smear is a microscopic examination of cells scraped from the uterine cervix in order to detect cervical cancer. Abnormal Pap test results are often associated with HPV infection. Women with abnormal Pap smears should be examined further to detect and treat cervical problems. Prevention The only way to prevent HPV infection is to avoid direct contact with the virus, which is transmitted by skin-to-skin contact. If warts are visible in the genital area, sexual contact should be avoided until the warts are treated. Using latex condoms during sexual intercourse may provide some protection but not always. Researchers are working to develop two types of HPV vaccines. One type would be used to prevent infection or disease (warts or pre-cancerous tissue changes); another type would be used to treat cervical cancers. Clinical trials are in progress for both types of vaccines.

Complications

Low-risk papilloma viruses cause warts but not cervical cancer. High-risk viruses are known to cause cervical cancer and have been associated with vulvar cancer, anal cancer, and cancer of the penis (a rare cancer). Although most HPV infections do not progress to cancer, it is particularly important for women who have cervical dysplasia to have regular Pap smears. Pre-cancerous cervical disease is readily treatable.

Genital warts may cause a number of problems during pregnancy. Sometimes they enlarge during pregnancy, making urination difficult. If the warts are on the vaginal wall, they can make the vagina less elastic and cause obstruction during delivery.

Rarely, infants born to women with genital warts develop laryngeal papillomatosis (warts in the throat). Although uncommon, it is a potentially life-threatening condition for the child, requiring frequent laser surgery to prevent obstruction of the airways. Research on the use of interferon therapy in combination with laser surgery indicates that this drug may show promise in slowing the course of the disease.

Oral HPV

In a statement from ASHA (The American Social Health Association), HPV is transmitted through direct skin to skin contact when an infected area comes into direct contact with mucous membranes or the delicate skin of the genital area. This can occur through genital to genital contact, vaginal and anal sex.

It is theoretically possible to transmit HPV through oral sex, though the mouth appears to be a less hospitable environment for HPV than the genital area. Each type of HPV tends to infect a specific skin area, making it unlikely for the types of HPV typically found with genital warts to establish themselves on other skin areas. Research shows that it is uncommon for HPV to be found in the mouth in the form of warts (or lesions). Likewise, transmitting HPV through hand to genital contact is largely referred to as theoretical (especially after genital warts have been successfully removed) and would be rare, at best.

What are they?

Genital warts that are visible are growths or bumps in the genital area. They may be:

• Flat (smooth on the skin)
• Raised (like a bump or skin growth)
• Single (only one wart)
• Multiple (more than one in the same area or many areas)
• Small or large

Genital warts and other abnormal tissue are diagnosed by:

• A doctor or nurse may use a vinegar solution on the genitals (this may sting a little). The vinegar solution makes the warts or abnormal tissue turn white and be easier to see.
• The doctor or nurse may use a special magnifying lens to look closely at the warts or cervical infection-this is NOT a test for HPV, but helps check for it.

Are warts dangerous?

No. The types of HPV that cause raised or "cauliflower"-shaped warts are not the same types that cause cervical, penile or anal cancer, although flat warts are often of the same type. But, if you have genital warts, you may have also come into contact with the types of HPV that are linked to cervical cancer. Like any other sexually active woman, a woman with genital warts should get yearly Pap smears.

How are warts treated?

Some people are never bothered by genital warts and are never treated for them. Sometimes the immune system will manage the HPV infection and the genital warts may go away by themselves.

When choosing what treatment to use your doctor or nurse will consider the size, location and number of warts, changes in the warts, patient preference, cost of treatment, convenience, adverse effects and their own experience with the treatments.

If genital warts are itching, burning or bleeding, or you just want to do whatever you can to get rid of them, there are several ways to treat them.

• Podofilox liquid or gel is a self-applied treatment that can be put on by the patient at home for external genital warts. It doesn't cost much and is safe and easy to use. It's available by prescription only.

• Imiquimod cream is a self-applied treatment that can be put on by the patient at home for external genital warts and warts near the anus. It is safe, effective and easy to use. The cream is not harsh on the skin and does not cause scarring like some other treatments. It's available by prescription only.

• Cryotherapy (freezing off the wart with liquid nitrogen) is relatively inexpensive, but it must be done by a trained doctor or nurse.

• Trichloracetic acid (TCA) is another chemical applied to the surface of the wart by a doctor or a nurse.

• Laser therapy (using an intense light to destroy warts) or surgery (cutting off warts) has the advantage of getting rid of warts in a single office visit. However, treatment can cost a lot and the doctor must be well trained in these methods.

• The drug interferon is sometimes used, but less expensive treatments work just as well with fewer side effects.

**CAUTION: NEVER TREAT GENITAL WARTS WITH TREATMENTS DESIGNED FOR WARTS ON THE HANDS OR FEET**

Some things to think about before any treatment for genital warts:

• Ask your doctor or nurse to tell you about the treatment, including how much it costs and the likely benefits of the treatment.

• Avoid treatments that cause bad side effects or scarring.

• Be sure you know what to do after you have the treatment done, like what to do about any itching, burning or pain, and when to come back to the office or clinic.

• Be patient-most people have to be treated more than once or your doctor or nurse may have to try more than one treatment.

• If you are pregnant or think you might be, tell your doctor or nurse so a treatment can be chosen that won't be harmful to you or your baby.

• Some doctors or nurses may tell you not to have sex while having treatment. This is to protect the treated areas of skin and help it heal.

• It's OK to ask the doctor or nurse questions. They are there to help you and explain what is happening if you have any questions.

None of the treatments listed above is a cure for HPV (although the treatment of warts may help stimulate your immune system to fight warts), and warts can return even months later after treatment. In some cases, warts may come back years later, but that doesn't happen very often. It's hard to tell if the warts that appear much later are a return of the old warts or a new case. In most cases, warts never come back.

Abnormal Cell Changes

If a woman is sexually active, having a Pap smear every year is the best way to keep from getting cervical cancer. Cancer almost always can be prevented before it occurs when abnormal cells are found and treated early.

What is a cervix?

A cervix is the neck of the uterus (womb) that forms the passageway between the uterus and the vagina inside a female's body. The cervix in teen women is often not fully mature. This can make it easier for a teen woman to develop cell changes from HPV and to become infected with other STDs.

How are abnormal cells changes found?

Doctors and nurses test for abnormal cell changes through a simple procedure called a Pap smear. A Pap smear is usually part of an annual pelvic examination. A pelvic exam includes the doctor or nurse checking the external genital area. They also use their hands to feel the shape of the internal reproductive organs to make sure they feel normal.

What is a Pap smear?

A Pap smear is a test made to find abnormal cells on the cervix before they turn into cancer (precancerous changes). Precancerous changes are caused by HPV.

The Pap smear is simple and quick, and most women have little discomfort. A small wooden spatula and a small brush are used to collect cells from the cervix. The cells are fixed onto a slide and the slide is examined by a pathology lab to make sure the cells look normal.

If the cells don't look normal your doctor or nurse may repeat the Pap smear in a few months.

Often, the repeated Pap smear will be normal. Or, they may ask you to come in to look at your cervix with a specially lighted magnifying lens called a colposcope (this looks like a pair of binoculars with a bright light).

If you are asked to repeat your Pap smear in a few months and it is again abnormal, you will also have a colposcopy. As an alternative, some doctors will do a test for HPV and if it is positive for the virus (HPV is found to be present on the cervix) you will have a colposcopy.

When should I get a Pap Smear?

Women should begin having yearly Pap smears when they become sexually active, that is, begin to have sexual intercourse. A yearly Pap smear helps check for any sign of abnormal cell growth on the cervix.

Should I worry about getting cervical cancer?

Cervical cancer, in most cases, is preventable through annual Pap smears. In the United States, approximately 5,000 women die annually from cervical cancer, and in most cases, these would have been preventable deaths if Pap smears had been done regularly.

The main purpose of Pap smears is NOT to screen for cancer. It screens for abnormal cell changes that happen long before any cancer develops. That's why this simple procedure is so important for taking care of your sexual health.

HPV and Penile and Anal Cancer

The same types of HPV that are linked to cervical cancer can also cause abnormal cell changes in the anus and the penis. Not much is written about this, but more and more information is showing that anal cancer and penile cancer are also linked to HPV infection.
 

Information obtained from STD Resource Network should not be used as a substitute for professional medical care or attention by a qualified practitioner, nor should it be inferred as such. Always check with your doctor if you have any questions or concerns about a specific condition or symptoms.

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