Disease: Genital Warts (HPV) in Women

    Genital warts (HPV) facts*

    • Genital warts are caused by infection with a subgroup of the human papillomaviruses (HPVs).
    • Another subgroup of the HPVs that infect the anogenital tract can lead to precancerous changes in the uterine cervix and cause cervical cancer.
    • HPV infection is now considered to be the most common sexually-transmitted infection (sexually transmitted disease, STD) in the U.S., and it is believed that at least 75% of the reproductive-age population has been infected with sexually-transmitted HPV at some point in life.
    • HPV infection is common and does not usually lead to the development of warts, cancers, or even symptoms.
    • HPV infection of the genital tract is transmitted through sexual contact, although non-sexual transmission is also possible.
    • In many cases genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness.
    • Condom use seems to decrease the risk of transmission of HPV during sexual activity but does not completely prevent HPV infection.

    What are human papillomaviruses (HPVs)?

    There are over 100 types of human papillomaviruses (HPVs) that infect humans. Of these, more than 40 types can infect the genital tract and anus (anogenital tract) of men and women and cause genital warts known as condylomata acuminata or venereal warts. A subgroup of the HPVs that infect the anogenital tract can lead to precancerous changes in the uterine cervix and cause uterine, cervical cancer. HPV infection also is associated with the development of other anogenital cancers. The HPV types that cause cervical cancer also have been linked with both anal and penile cancer in men as well as a subgroup of head and neck cancers in both women and men. Genital warts and HPV infection are transmitted primarily by sexual intimacy, and the risk of infection increases as the number of sexual partners increase.

    The most common HPV types that infect the anogenital tract are HPV types 6, 11, 16, and 18 (HPV-6, HPV-11, HPV-16, and HPV-18), although other HPV types can also infect the anogenital tract. Among these, HPV-6 and HPV-11 are most commonly associated with benign lesions such as genital warts and mild dysplasia of the cervix (potentially precancerous changes in the appearance of cervical cells under a microscope) and are termed "low-risk" HPV types. In contrast, HPV-16 and HPV-18 are the types found in the majority of cervical and anogenital cancers as well as severe dysplasia of the cervix. These belong to the so-called "high-risk" group of HPVs.

    Other, different HPV types infect the skin and cause common warts elsewhere on the body. Some types of HPVs (for example, HPV 5 and 8) frequently cause skin cancers in people who have a condition known as epidermodysplasia verruciformis.

    How common is HPV infection?

    HPV infection is now considered to be the most common sexually-transmitted infection (sexually transmitted disease, STD) in the U.S., and it is believed that at least 75% of the reproductive-age population has been infected with sexually-transmitted HPV at some point in life. It is believed that over 6 million people become infected with HPV every year in the US, and approximately 50% of those infected are between the ages of 15 and 25.

    HPV infection is common and does not usually lead to the development of warts, cancers, or even symptoms. In fact, the majority of people infected with HPV have no symptoms or lesions at all. Determination of whether or not a person is infected with HPV involves tests that identify the genetic material (DNA) of the virus. Furthermore, it has not been definitely established whether the immune system is able to permanently clear the body of an HPV infection. In many cases, a person will test positive for HPV infection and then have negative HPV tests for months to years, only to have a positive test result at a later time. It is presently unclear if this is due to a latent (continuing but hidden) viral infection or if the person has become re-infected with the virus.

    Asymptomatic people infected with HPVs (those without HPV-induced warts or lesions) are still able to spread the infections to others through sexual contact.

    It is important to note that in the U.S. and other developed countries, screening and early treatment of precancerous changes of the cervix have dramatically reduced the incidence of cervical cancer. In developing countries lacking the medical infrastructure or financial means to implement a screening system, the incidence of cervical cancer resulting from HPV infection is much higher. In fact, cervical cancer develops in around 500,000 women each year worldwide, and, in many countries, it is the most common cancer to kill women.

    What are the symptoms of genital warts?

    In many cases genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness. They may result in localized irritation, depending upon their anatomic location. Women who have genital warts inside the vagina may experience bleeding following sexual intercourse or an abnormal vaginal discharge. Rarely, bleeding or urinary obstruction may occur if the wart involves the urethral opening.

    How is HPV infection diagnosed?

    HPV sometimes can be suspected by changes that appear on a Pap smear, since pap smears identify infected abnormal cells that may be precursors to cancer. While HPV infection can lead to precancerous changes in the cervix that are recognized on the Pap smear, the Pap smear itself cannot definitely establish the diagnosis of HPV infection, unless special testing is carried out on the material obtained from the Pap smear. When there is an abnormal Pap smear, the doctor often will do advanced testing on the material to determine if, and which kind, of HPV may be present. HPV also can be detected if a biopsy (for example, from a genital wart or from the uterine cervix) is sent to the laboratory for analysis.

    Is there a DNA test for types of HPV infection?

    In 2009, the U.S. FDA approved the first DNA tests for diagnosis of the common cancer-causing HPV types in cervical samples. Two tests known as Cervista HPV 16/18 and Cervista HPV HR, are used to diagnose the presence of DNA from the two most common HPV types associated with cancer, HPV 16 and 18, and all "high risk" or cancer-associated HPV types, respectively. These tests do not replace standard Pap testing or clinical examination and are used in combination with traditional screening methods to help estimate a woman's risk and aid in management decisions.

    How are genital warts diagnosed?

    Genital warts are fairly common; approximately 500,000 new cases of genital warts are diagnosed each year in the U.S. A typical appearance of a genital wart may prompt the physician to treat without further testing, especially in someone who has had prior outbreaks of genital warts. Genital warts usually appear as small, fleshy, raised bumps, but they sometimes can be extensive and have a cauliflower-like appearance. They may occur on any sexually-exposed area. Most genital warts are caused by HPV-6 and HPV-11, the so-called "low risk" HPV types.

    Is there a cure or treatment for external genital warts?

    There is no cure or treatment that can eradicate HPV infection, so the only currently possible treatment is to remove the lesions caused by the virus. Unfortunately, even removal of the warts does not necessarily prevent the spread of the virus, and genital warts frequently recur. None of the available treatment options is ideal or clearly superior to others.

    • A treatment that can be administered by the patient is a 0.5% solution or gel of podofilox (Condylox). The medication is applied to the warts twice per day for 3 days followed by 4 days without treatment. Treatment should be continued up to 3-4 weeks or until the lesions are gone. Podofilox may also be applied every other day for a total of three weeks.
    • Alternatively, a 5% cream of imiquimod (Aldara, a substance that stimulates the body's production of cytokines, chemicals that direct and strengthen the immune response) is likewise applied by the patient three times a week at bedtime, and then washed off with mild soap and water 6-10 hours later. The applications are repeated for up to 16 weeks or until the lesions are gone.
    • Only an experienced physician can perform some of the treatments for genital warts. These include, for example, placing a small amount of a 10%-25% solution of podophyllin resin on the lesions, and then, after a period of hours, washing off the podophyllin. The treatments are repeated weekly until the genital warts are gone.
    • An 80%-90% solution of trichloroacetic acid (TCA) or bichloracetic acid (BCA) can also be applied weekly by a physician to the lesions. Injection of 5-flurouracil epinephrine gel into the lesions has also been shown to be effective in treating genital warts.
    • Interferon alpha, a substance that stimulates the body's immune response, has also been used in the treatment of genital warts. Treatment regimens involve injections of interferon into the lesion every other day over a period of 8 to 12 weeks.
    • Alternative methods include cryotherapy (freezing the genital warts with liquid nitrogen) every 1 to 2 weeks, surgical removal of the lesions, or laser surgery. Laser surgery and surgical excision both require a local or general anesthetic, depending upon the extent of the lesions.

    Learn more about: Condylox | Aldara

    Precancerous changes (dysplasia) of the cervix

    Women who have evidence of moderate or severe precancerous changes in the uterine cervix require treatment to ensure that these cells do not progress to cancer. In this case, treatment usually involves surgical removal or destruction of the involved tissue. Conization is a procedure that removes the precancerous area of the cervix using a knife, a laser, or by a procedure known as LEEP (loop electrosurgical excision procedure, which uses an electric current passing through a thin wire that acts as a knife). LEEP is also referred to as LLETZ (large loop excision of the transformation zone). Cryotherapy (freezing) or laser therapy may also be used to destroy tissue areas that contain potentially precancerous changes.

    Can HPV infection be prevented?

    A vaccine is available against four common HPV types associated with the development of genital warts and cervical and anogenital carcinomas. This vaccine (Gardasil) has received FDA approval for use in males and females between 9 and 26 years of age and confers immunity against HPV types 6, 11, 16 and 18. Another vaccine directed at HPV types 16 and 18, known as Cervarix, has been approved for use in females aged 10-15.

    Learn more about: Gardasil | Cervarix

    Abstinence from sexual activity can prevent the spread of HPVs that are transmitted via sexual contact, but a person who abstains from sex may still become infected with other HPV types, such as those that cause common skin warts. Some researchers have postulated that HPV infection might be transmitted from the mother to her infant in the birth canal, since some studies have identified genital HPV infection in populations of young children and cloistered nuns. Hand-genital and oral-genital transmission of HPV has also been documented and is another means of transmission.

    HPV is transmitted by direct genital contact during sexual activity. The virus is not found in or spread by bodily fluids, and HPV is not found in blood or organs harvested for transplantation. Condom use seems to decrease the risk of transmission of HPV during sexual activity but does not completely prevent HPV infection. Spermicides andhormonal birth control methods cannot prevent the spread of HPV infection.

    How common is HPV infection?

    HPV infection is now considered to be the most common sexually-transmitted infection (sexually transmitted disease, STD) in the U.S., and it is believed that at least 75% of the reproductive-age population has been infected with sexually-transmitted HPV at some point in life. It is believed that over 6 million people become infected with HPV every year in the US, and approximately 50% of those infected are between the ages of 15 and 25.

    HPV infection is common and does not usually lead to the development of warts, cancers, or even symptoms. In fact, the majority of people infected with HPV have no symptoms or lesions at all. Determination of whether or not a person is infected with HPV involves tests that identify the genetic material (DNA) of the virus. Furthermore, it has not been definitely established whether the immune system is able to permanently clear the body of an HPV infection. In many cases, a person will test positive for HPV infection and then have negative HPV tests for months to years, only to have a positive test result at a later time. It is presently unclear if this is due to a latent (continuing but hidden) viral infection or if the person has become re-infected with the virus.

    Asymptomatic people infected with HPVs (those without HPV-induced warts or lesions) are still able to spread the infections to others through sexual contact.

    It is important to note that in the U.S. and other developed countries, screening and early treatment of precancerous changes of the cervix have dramatically reduced the incidence of cervical cancer. In developing countries lacking the medical infrastructure or financial means to implement a screening system, the incidence of cervical cancer resulting from HPV infection is much higher. In fact, cervical cancer develops in around 500,000 women each year worldwide, and, in many countries, it is the most common cancer to kill women.

    What are the symptoms of genital warts?

    In many cases genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness. They may result in localized irritation, depending upon their anatomic location. Women who have genital warts inside the vagina may experience bleeding following sexual intercourse or an abnormal vaginal discharge. Rarely, bleeding or urinary obstruction may occur if the wart involves the urethral opening.

    How is HPV infection diagnosed?

    HPV sometimes can be suspected by changes that appear on a Pap smear, since pap smears identify infected abnormal cells that may be precursors to cancer. While HPV infection can lead to precancerous changes in the cervix that are recognized on the Pap smear, the Pap smear itself cannot definitely establish the diagnosis of HPV infection, unless special testing is carried out on the material obtained from the Pap smear. When there is an abnormal Pap smear, the doctor often will do advanced testing on the material to determine if, and which kind, of HPV may be present. HPV also can be detected if a biopsy (for example, from a genital wart or from the uterine cervix) is sent to the laboratory for analysis.

    Is there a DNA test for types of HPV infection?

    In 2009, the U.S. FDA approved the first DNA tests for diagnosis of the common cancer-causing HPV types in cervical samples. Two tests known as Cervista HPV 16/18 and Cervista HPV HR, are used to diagnose the presence of DNA from the two most common HPV types associated with cancer, HPV 16 and 18, and all "high risk" or cancer-associated HPV types, respectively. These tests do not replace standard Pap testing or clinical examination and are used in combination with traditional screening methods to help estimate a woman's risk and aid in management decisions.

    How are genital warts diagnosed?

    Genital warts are fairly common; approximately 500,000 new cases of genital warts are diagnosed each year in the U.S. A typical appearance of a genital wart may prompt the physician to treat without further testing, especially in someone who has had prior outbreaks of genital warts. Genital warts usually appear as small, fleshy, raised bumps, but they sometimes can be extensive and have a cauliflower-like appearance. They may occur on any sexually-exposed area. Most genital warts are caused by HPV-6 and HPV-11, the so-called "low risk" HPV types.

    Is there a cure or treatment for external genital warts?

    There is no cure or treatment that can eradicate HPV infection, so the only currently possible treatment is to remove the lesions caused by the virus. Unfortunately, even removal of the warts does not necessarily prevent the spread of the virus, and genital warts frequently recur. None of the available treatment options is ideal or clearly superior to others.

    • A treatment that can be administered by the patient is a 0.5% solution or gel of podofilox (Condylox). The medication is applied to the warts twice per day for 3 days followed by 4 days without treatment. Treatment should be continued up to 3-4 weeks or until the lesions are gone. Podofilox may also be applied every other day for a total of three weeks.
    • Alternatively, a 5% cream of imiquimod (Aldara, a substance that stimulates the body's production of cytokines, chemicals that direct and strengthen the immune response) is likewise applied by the patient three times a week at bedtime, and then washed off with mild soap and water 6-10 hours later. The applications are repeated for up to 16 weeks or until the lesions are gone.
    • Only an experienced physician can perform some of the treatments for genital warts. These include, for example, placing a small amount of a 10%-25% solution of podophyllin resin on the lesions, and then, after a period of hours, washing off the podophyllin. The treatments are repeated weekly until the genital warts are gone.
    • An 80%-90% solution of trichloroacetic acid (TCA) or bichloracetic acid (BCA) can also be applied weekly by a physician to the lesions. Injection of 5-flurouracil epinephrine gel into the lesions has also been shown to be effective in treating genital warts.
    • Interferon alpha, a substance that stimulates the body's immune response, has also been used in the treatment of genital warts. Treatment regimens involve injections of interferon into the lesion every other day over a period of 8 to 12 weeks.
    • Alternative methods include cryotherapy (freezing the genital warts with liquid nitrogen) every 1 to 2 weeks, surgical removal of the lesions, or laser surgery. Laser surgery and surgical excision both require a local or general anesthetic, depending upon the extent of the lesions.

    Learn more about: Condylox | Aldara

    Precancerous changes (dysplasia) of the cervix

    Women who have evidence of moderate or severe precancerous changes in the uterine cervix require treatment to ensure that these cells do not progress to cancer. In this case, treatment usually involves surgical removal or destruction of the involved tissue. Conization is a procedure that removes the precancerous area of the cervix using a knife, a laser, or by a procedure known as LEEP (loop electrosurgical excision procedure, which uses an electric current passing through a thin wire that acts as a knife). LEEP is also referred to as LLETZ (large loop excision of the transformation zone). Cryotherapy (freezing) or laser therapy may also be used to destroy tissue areas that contain potentially precancerous changes.

    Can HPV infection be prevented?

    A vaccine is available against four common HPV types associated with the development of genital warts and cervical and anogenital carcinomas. This vaccine (Gardasil) has received FDA approval for use in males and females between 9 and 26 years of age and confers immunity against HPV types 6, 11, 16 and 18. Another vaccine directed at HPV types 16 and 18, known as Cervarix, has been approved for use in females aged 10-15.

    Learn more about: Gardasil | Cervarix

    Abstinence from sexual activity can prevent the spread of HPVs that are transmitted via sexual contact, but a person who abstains from sex may still become infected with other HPV types, such as those that cause common skin warts. Some researchers have postulated that HPV infection might be transmitted from the mother to her infant in the birth canal, since some studies have identified genital HPV infection in populations of young children and cloistered nuns. Hand-genital and oral-genital transmission of HPV has also been documented and is another means of transmission.

    HPV is transmitted by direct genital contact during sexual activity. The virus is not found in or spread by bodily fluids, and HPV is not found in blood or organs harvested for transplantation. Condom use seems to decrease the risk of transmission of HPV during sexual activity but does not completely prevent HPV infection. Spermicides andhormonal birth control methods cannot prevent the spread of HPV infection.

    Source: http://www.rxlist.com

    In many cases genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness. They may result in localized irritation, depending upon their anatomic location. Women who have genital warts inside the vagina may experience bleeding following sexual intercourse or an abnormal vaginal discharge. Rarely, bleeding or urinary obstruction may occur if the wart involves the urethral opening.

    Source: http://www.rxlist.com

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