HPV refers to a group of more than 80 viruses. They are responsible for warts anywhere on the body, but only certain types are sexually transmitted. These are called condylomata acuminatum, better known as genital warts or venereal warts. More than 30 types of HPV can infect the genital tract. Like other warts, they can not be cured but they can be treated.
Warts are the "clinical" version of this infection; that is, they can easily be seen and diagnosed. However, there is a much more common version, referred to as "subclinical," in which the virus resides under the skin and cannot be seen. Some experts believe that HPV causes warts in about 30 percent of infected people and subclinical infections in the other 70 percent. The subclinical varieties have been linked to cancer, so it is important for women to have yearly checkups including Pap smears to detect precancerous cervical changes.
HPV is coming close to being considered an epidemic in the United States. Since it is a nonreportable disease, accurate figures aren't available, but it is believed that 20 million Americans currently live with this virus. An estimated 5.5 million Americans are newly infected with the HPV virus every year.
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Genital Warts: Don't Judge by Appearances
Although these warts signal the presence of the human papillomavirus (HPV), they show up in as few as 30 percent of infections. The cases in which the wart doesn't appear are actually more dangerous, since this type of HPV has been linked to the development of cervical cancer. The danger of cancer resulting from undiscovered infection makes the need for regular checkups all the more urgent. When discovered early enough, cervical cancer can usually be cured. |
Risk factors:You are more likely to get genital warts if you are between the ages of 20 and 24, if you or your partner have multiple or casual sexual partners, and if you have another STD, such as chlamydia or herpes simplex virus (HSV). If you are pregnant, using oral contraceptives, or have a condition that suppresses the immune system such as Hodgkin's disease or leukemia, you are also at higher risk for viruses such as HPV. Researchers have also found that white people have higher rates of HPV than do others. People who smoke put themselves at higher risk as well.
Signs and symptoms:Many people with HPV have no signs or symptoms. If and when warts appear, they can be on the vulva, in or around the vagina or anus, on the cervix, or anywhere on the groin or thighs. They may also be found in the mouth. Warts on men usually show up on the penis or scrotum. The warts can appear as raised or flat, small or large, and single or clumped in a group that sometimes looks like cauliflower. Normally, the warts are flesh-colored and painless. They can also appear as slightly pink or grey. Rarely, they cause itching, pain, or bleeding.
Cause:HPV is spread by skin to skin contact, especially during vaginal, anal, or oral intercourse. It is thought that the virus enters the body through tiny breaks in the skin, which could be caused by the friction of sex or even by using tampons incorrectly. Once it is in the skin, the virus makes its way into the lower layers of skin. It can stay there for months or years, and may never come back up to the surface at all. For this reason, it is important to understand that if you are diagnosed with HPV, you could have gotten it at any time in your past sexual life.
Incubation period: Viral infections are harder to get than bacterial ones. It can take from four to six weeks to infect a partner with HPV. In two-thirds of infected people, it can be up to nine months before any warts appear.
Possible health effects:Although the reason is unclear, women with HPV are at increased risk for cancer of the vulva and cervix. However, only a few strains have been linked to cancer (types 16, 18, 31, 33, 35, 45, 51, 52, and 59), and the potential for malignancy is low. These strains usually cause subclinical infections. The strains that cause visible warts (types 6 and 11) do not lead to cancer. Annual pap smears are particularly important for women with malignant strains, and for women at high risk for exposure to any type of STD. In addition, women with HPV should periodically have an examination of the cervix, vagina, and vulva.
Diagnosis: HPV remains a mystery because it can not be grown in the lab and there is no blood test for it. For the 30 percent of people with the clinical or outward expression of the virusthe wartsdiagnosis is made just by looking at them. Some warts are very hard to see because they are flat and look like normal skin, so your doctor will look at them through a magnifying lens called a colposcope. Also, your doctor or nurse may put a vinegar-like substance called acetic acid on your cervix and on the skin of your vagina. If the area then turns white, it is possible you have HPV. This test is no longer recommended for routine use because it's not very accurate. A Pap smear is now the primary means of diagnosing subclinical HPV, although an abnormal smear doesn't always mean you have HPV.
To confirm the diagnosis, a test is now available that detects HPV DNA in cervical cells. This test is currently approved only as a way of determining the risk of cervical cancer when a Pap smear proves abnormal. However, it appears to be equal or superior to the Pap test in detecting cervical cancer in older women, and some experts predict that it will eventually replace Pap smears for those age 35 and over, especially since patients can collect the necessary cervical samples themselves. Others expect the test to permit a reduction in the frequency of Pap screening. For example, a woman who has both a negative Pap smear and a negative HPV test may be able to safely switch from an annual Pap smear to one taken every three to five years.
Treatments:Treatment of HPV should be considered cosmetic rather than curative. Like other viruses, no therapy has been shown to cure HPV. Many treatment regimens are available and the choice is based on factors, such as the size and number of warts, as well as the expense, convenience, and potential adverse effects of the treatment. Regardless of treatment, one in four HPV-infected people will have a recurrence within three months. Many studies have shown that small warts and warts that have been present for less than one year are the ones most amenable to treatment. In any case, never use an over-the-counter wart remedy for genital warts.
Nothing. Letting the warts go away by themselves is actually a common treatment. Within three months, 20 to 30 percent of patients' noncervical warts will have cleared up on their own. After two years, 90 percent will be gone.
Cryotherapy. The warts are frozen with liquid nitrogen. This relatively inexpensive treatment is best used for small, single warts. There may be pain at the site where the liquid is applied.
Podofilox (Condylox). This prescription drug is applied at home with a cotton swab, twice daily for three days, followed by four days of no treatment. You can repeat this cycle up to four times. This safe and relatively inexpensive drug is for external warts only, not those that might be in the vagina or on the cervix. You will probably feel burning and experience some irritation. Do not use this drug if you are pregnant.
Podophyllin (Pododerm, Podocon-25). Podophyllin is an inexpensive chemical applied by a doctor or nurse. Although its use has been widespread for years, it is no longer recommended in the United States or Europe because it is not very effective and may cause harmful side effects in large doses.
Imiquimod (Aldara). This drug stimulates the immune system to target warts. The cream, which comes in 1 and 5 percent strengths, is applied with a finger at bedtime three times a week for as long as 16 weeks. You should wash the area with mild soap and water 6 to 10 hours after application. Although this relatively new drug has not been tested head-to-head against podofilox, results seem similar, with many, if not most, patients free of warts within 8 to 10 weeks.
Trichloroacetic acid (Tri-Chlor). This medication is absorbed by the wart and causes it to slough off. You will feel some burning at the site of application. Application is repeated weekly for up to six weeks. It is also best used for external warts.
Electrocautery. Warts are destroyed with an electric current. Local anesthesia is required, and discomfort is moderate.
Laser vaporization. Intense light is used to destroy the wart. This procedure is useful for extensive warts on the genitals or vocal cords and should be tried only after other regimens have failed. Local anesthesia is required, scarring and infection are possible, and you will probably need analgesic for the pain for about three weeks. Laser treatment is also expensive.
Interferon therapy. Injected into the wart itself, this antiviral drug is not generally recommended because it is expensive, time-consuming, produces adverse effects in many people, and has not proven to be any more effective than other treatments.
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Don't Jump to Conclusions About HPV
Because the incubation period for HPV varies dramatically and signs of the infection can take months to show up, an attack of genital warts can be very misleading. Experts at the Centers for Disease Control and Prevention (CDC) warn that you often can't be sure of the source of infection. They note that, within ongoing relationships, sexual partners are usually infected by the time of diagnosis. To make matters more confusing, a new outbreak of warts is quite likely several months after treatment. However, this does not necessarily mean that you've been re-infected. In fact, it's usually just a recurrence of the original infection.Doctors at the CDC still don't know how long HPV remains contagious. To be on the safe sideand protect against other STDsthey recommend using condoms with future partners. They also say that, even though you may no longer be contagious, honesty about past STDs is still the wisest course. |
Follow-up:If either you or your partner are being treated with medication, it is advisable to abstain from sex, due to the possibility of reinfection and because the friction caused by sex could impede healing. Once the warts are gone, you do not need to return to your clinic. If your partner does not have obvious warts, there is no need for him to be treated.
Prevention:Most experts believe that recurrences of warts are caused by the virus being reactivated rather than by reinfection. Condoms do offer some protection from reinfection, though. Obviously, areas not covered by the condom, like the vulva and scrotum, are vulnerable to repeat infection. Spermicides have not proven to be effective against HPV. You can help protect yourself from HPV by trying to prevent the tiny skin abrasions through which the virus can enter the body. For example, the tender lining of the vagina can tear easily when it is dry. Since sexual intercourse can cause lacerations of the vagina, use a lubricant if dryness is a problem. Also, don't use tampons at the beginning or end of your period when the vagina is dry; use a sanitary pad instead, until your period is well underway and again towards the end. Several promising vaccines to prevent HPV are currently undergoing clinical trials, but approval is at least five years away.
Pregnancy:Pregnant women should not use podophyllin, podofilox, or imiquimod, as their safety during pregnancy has not been established. Other treatments should be discussed with your doctor. Infants born to HPV-infected mothers can be born with warts in and around their larynx (voice box) although this is very rare. Cesarean deliveries are not necessary unless warts are so extensive that they block the birth canal.
