Sexually Transmitted Diseases (STDs In Women) (cont.)
Human Papillomaviruses (HPVs) and Genital Warts
What are HPVs?
More than 40 types of HPV, which are the cause of
genital warts (also known as condylomata acuminata or venereal warts), can infect the genital tract of men and women. These warts
are primarily transmitted during sexual contact. Other, different HPV types
generally cause common warts elsewhere on the body. HPV infection has long been
known to be a cause of cervical
cancer and other anogenital cancers in women, and it has also been linked
with both anal and penile cancer in men.
HPV infection is now considered to be the most common sexually transmitted
infection in the US, 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 specific symptoms. In fact, the majority of people infected
with HPV have no symptoms or lesions at all. The ultimate test to detect HPV
involves identification of the genetic material (DNA) of the virus.
Of note, it has not been definitively established whether the immune system
is able to permanently clear the body of an HPV infection. For this reason, it
is impossible to predict exactly how common HPV infection is in the general
population.
Asymptomatic (those
without HPV-induced warts or lesions) people who have HPV infections are still
able to spread the infections to others through sexual contact.
Diagnosis of HPV and genital warts
A typical appearance of a genital lesion 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 can sometimes be extensive and have a cauliflower-like appearance. They may
occur on any sexually-exposed area. In many cases genital warts do not cause any
symptoms, but they are sometimes associated with itching, burning, or
tenderness.
HPV can sometimes be suspected by changes that appear on a
Pap smear, although Pap smears were not really designed to detect HPV. In
the case of an abnormal Pap smear, the clinician will often do advanced testing
on the material to determine if, and which kind, of HPV may be present. HPV can
also be detected if a biopsy (for example,
from a genital wart
or from the uterine cervix) is sent to the laboratory for analysis.
How is HPV treated?
Treatment of external genital warts
There is no cure or treatment that can eradicate HPV infection, so the only
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 treatments are ideal or
clearly superior to others.
A treatment that can be administered by the patient is a 0.5% solution or gel
of podofilox (podophyllotoxin). The medication is applied to the warts twice per
day for three days followed by 4 days without treatment. Treatment should be
continued up to three to four 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 (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-fluorouracil 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 require 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 one to
two 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.
Treatment of precancerous changes (dysplasia) of the cervix related to HPV
infection
Women who have evidence of moderate to severe precancerous changes in the
uterine cervix require treatment to ensure that these cells do not become
invasive 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 a procedure known as LEEP (loop
electrosurgical excision procedure, which uses an electric current passing
through a thin wire that acts as a knife). Cryotherapy (freezing) or laser
therapy may be used to destroy tissue areas that contain potentially
precancerous changes.
What should a person do if sexually exposed to someone with genital warts?
Both people with HPV infection and their partners need to be counseled about
the risk of spreading HPV and the appearance of the lesions. They should
understand that the absence of lesions does not exclude the possibility of
transmission and that condoms are not completely effective in preventing the
spread of the infection. It is important to note that it is not known whether
treatment decreases infectivity.
Finally, female partners of men with genital warts should be reminded of the
importance of regular Pap smears to screen for cervical cancer and precancerous
changes in the cervix, since precancerous changes can be treated and reduce a
woman's risk of developing cervical cancer. Similarly, men should be informed of
the potential risk of anal cancers, although it is not yet been determined how
to best screen for or manage early anal cancer.
The HPV vaccine
Recent research studies have led to the development of a
vaccine 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 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 is currently being tested, and initial trials with the vaccine have shown
that the HPV-16/18 vaccine is safe and induces a high degree of protection
against HPV-16/18 infection. These encouraging results suggest that widespread
vaccination for
HPV types could begin in the near future.
Next: Chancroid »
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