MEDICAL CONDITIONS
Genital Warts In Women
(Human Papilloma Virus)
What are the human papilloma viruses?
The human papilloma viruses (HPVs) are a family of over 60 different viruses responsible for causing warts. The majority of the viruses produce warts in areas other than the genitals. They are responsible for the common warts seen on the hands, fingers, and even the face. Most of these viruses are innocuous, causing nothing more than cosmetic concerns. Several virus "types" are confined primarily to the moist skin of the genitals, producing lesions in this area. The lesions produced by these genital viruses are called genital warts. The virus that causes genital warts is not the same as the virus that causes common warts. You cannot develop genital warts from the virus that causes common warts.
Certain types of genital viruses can cause abnormal PAP smears and even cervical cancer. Once contracted, the virus can stay with the infected individual for life. It is estimated that over 50% of sexually active adults are carriers of one of these viruses. Men and women are equally affected. The chance of being a carrier increases with the number of sexual partners. Infection with HPV is now considered to be the most common sexually transmitted disease in the United States. It is also the leading cause of abnormal PAP smears and pre- cancerous changes of the cervix in women. Even though there are reports of pre-cancerous changes occurring on the skin of the male penis, the incidence is insignificant compared to the large number of women who experience pre-cancerous changes of the cervix.
How are genital warts transmitted?
Genital wart viruses are primarily transmitted through sexual contact. Transmission of the virus through soiled clothing or shared sex objects is unusual, but can occur. These viruses require moisture and cannot survive outside the body for any length of time. Therefore, dry objects do not transmit the virus very well. With sexual intercourse, the virus can enter the body through microscopic tears in the superficial layers of the skin, vagina, or cervix. Once the protective outer layer of cells has been penetrated, the virus begins to invade the underlying cells where it multiplies.
After the virus becomes established in the genital skin, the vagina, or the cervix, it can either remain dormant or multiply to cause a genital wart. The wart is the most contagious stage, but a dormant virus can also be infectious. Therefore, preventing the spread of genital warts is extremely difficult. Condoms do not necessarily protect either party against infection. The infection can be located on the testicles of the male partner or the vulva (skin outside the vagina) of the female partner. From these locations, the virus can spread to the partner during sex. Since there are over 12 genital viral types, a woman can become infected by more than one type. Some "types" are more likely than others to cause pre-cancerous changes on the cervix.
What symptoms and problems can genital wart viruses cause?
Most people infected with the HPV viruses have no symptoms and may not know they are infected. Others may develop genital warts of varying sizes. HPV viruses are believed to be responsible for chronic pain and itching around genital openings, even in the absence of warts. For those women infected with certain virus types, pre-cancerous changes or even cancer of the cervix can develop.
The cervix is the end of the uterus that protrudes into the vagina. Cells on the cervix are vulnerable to infection by HPV viruses. If infected by certain types of HPV virus, the cells of the cervix can be transformed by the virus into pre-cancerous cells over time. A PAP smear is an office procedure where tissue scrapings from the cervix are collected to be examined under a microscope for these pre- cancerous changes. Even among women known to be infected, the chance of developing pre-cancerous changes is small. Furthermore, the transformation from pre-cancerous cells to cancer can take several years. In some women, however, this cancerous transformation can occur in less than one year. The HPV virus can also cause pre-cancerous changes in the vaginal and the skin of the vulva (external genital).
The HPV viruses can cause unsightly genital warts that are frequently difficult to eradicate. In a woman under stress or who has a poor immune system, the warts can be very tenacious. Most warts appear on the genitals as fleshy, firm elevations of the skin, similar to warts found on other parts of the body. The warts are usually not accompanied by other symptoms, however, sometimes, they can cause mild itching. Some warts can be so small as to be detectable only with magnification. Others can become so large as to prevent intercourse or childbirth. However, the incidence of large warts obstructing the birth canal, necessitating cesarean sections for the delivery of babies, is rare.
Even in the absence of warts, the HPV viruses can cause chronic itching or pain around the genital openings. The pain around the genitals can be aggravated by intercourse or touching. Topical treatments with creams and ointments are usually ineffective. Current treatments for this chronic condition include laser surgery, injections of certain medications, or non-intervention in an attempt to allow the problem to resolve on its own over time. Even with treatment, the problem can persist for years and affect the patient both physically and emotionally.
Can the wart viruses be transmitted to the patient's baby?
Many women with HPV infection are concerned about transmitting the viruses to their babies while giving birth vaginally. Although HPV viruses can be transmitted from mother to infant through the vaginal canal, the rate of transmission is very low. Each year, approximately 300 infants (fewer than 0.05% of the babies born to women with HPV infection) are born with the virus on their vocal cords because of birth transmission. An unknown number of babies will also become carriers of the virus on their genital skin. These babies can develop genital warts later in life, even before they are sexually active. Since over one million women infected with HPV give births yearly, it would be impractical to perform cesarean sections on all of them. The American College of Obstetrics and Gynecology (ACOG) currently recommends that women known to harbor the virus give birth vaginally. The ACOG discourages cesarean delivery as a way to avoid possible infection of the newborn.
How is genital wart virus infection diagnosed?
Infection with HPV viruses may not cause symptoms. Therefore, many men and women do not know they are infected. The most obvious sign of infection is the development of a wart. The majority of women with warts may not know they have the condition until they visit their doctor. The doctor may detect the warts during a routine examination of the vagina and vulva. At other times, an abnormal pap smear may be the first sign of infection. Biopsies obtained from the cervix can show evidence of viral infection in the cervix tissue.
The most accurate method of detecting an HPV virus infection is DNA testing. DNA is the genetic material present in all living cells. Each HPV viral type has its own unique DNA sequence. Samples of genital skin cells can be collected and tested for the viral DNA. However, not all infections can be detected even with these sophisticated techniques. Furthermore, DNA testing may not detect all the viral types infecting a given patient. Thus, it is impossible to accurately determine the status of viral infection in all patients.
What is the treatment for genital wart virus infection?
There is currently no cure for these virus infections. There are several ways to treat the warts with varying degrees of success. Since the viruses can live in normal-appearing skin, eradicating the warts does not completely destroy the virus. In the past, laser treatment and caustic chemicals applied to the surface cells of the vagina, vulva and cervix were aggressively used, in hopes of eliminating the virus. However, 90% of the women so treated had evidence of viral recurrence within one year. Many developed chronic problems relating to the treatment that were worse than the infection. Therefore, these treatment methods, aimed at eradicating the virus, have largely been abandoned. Current treatments are targeted at removing visible warts and treating the pre-cancerous changes. These treatments include freezing, laser removal (ablation), burning with acid, excision, and drugs aimed at stimulating the immune system.
In some cases genital warts eventually may develop a fleshy, small raised growth that looks like cauliflower. There is no way to predict whether the warts will grow or disappear. Depending on factors such as the size and location of the genital warts, a doctor may offer you one of several ways to treat them if they are visible. - Imiquimod, an immune response cream which you can apply to the affected area
- A 20 percent podophyllin anti-mitotic solution, which you can apply to the affected area and later wash off
- A 0.5 percent podofilox solution, applied to the affected area but shouldn't be washed off
- A 5 percent 5-fluorouracil cream
- Trichloroacetic acid (TCA)
If you are pregnant, you should not use podophyllin or podofilox because they are absorbed by the skin and may cause birth defects in your baby. In addition, you should not use 5-fluorouracil cream if you are expecting.
Interferon is an immune stimulating medication that strengthens the body's immune system against the virus. The body's immune system consists of cells and proteins that attack and destroy infections and foreign cells. A healthy immune system can keep the wart viruses from spreading and growing. When the immune system becomes weakened, virus growth can become unchecked. Interferon cannot eradicate the viruses, although it may help some manifestations of the infection. Some doctors believe that wart recurrences can be reduced by improving the immune system through good nutrition, adequate vitamin intake, proper sleep and stress reduction.
How can genital warts be prevented?
Except for the few patients exposed to the virus during birth, all HPV infections are acquired through sexual contact. Therefore, the only way to prevent HPV infection is by avoiding sexual contact with an infected person. Unfortunately, there is no reliable way to assure that your sexual partner is not infected with the virus. The vast majority of individuals infected with genital wart viruses do not know that they are infected. Furthermore, the viruses can exist in a "silent" mode and later become infectious. Even expensive DNA testing may not be of any value. DNA tests may not detect all the viruses, and may lead to a false sense of security.
The risk for acquiring genital warts increases in proportion to the number of sexual partners one has. It also increases in proportion to the number of sexual contacts with each partner. Therefore, one reasonable way to decrease the risk is by limiting the number of sexual contacts.
Women can acquire multiple strains of the virus. Subsequent viral strains may be even more cancer-provoking than previous strains. Therefore, frequent PAP smears and gynecological examinations are important to detect any pre-cancerous stages of viral infection. - Genital warts are caused by viruses that are transmitted through sexual contact.
- Most people infected with the viruses have no related symptoms.
- The viruses that cause genital warts increase a woman's risk for cancer of the cervix.
- The genital wart virus can be transmitted from mother to infant during childbirth.
- There is no cure for genital warts virus infection.
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