Genital Warts

Genital warts are caused by the Human Papillomavirus or HPV. Genital HPV is the most common sexually transmitted infection in the United States. About 24 million people are currently infected with genital HPV. Up to 80% of men and women will become infected at some time in their life.

WHAT IS HPV?
HPV, like all viruses, is a very small organism that needs to infect cells in order to survive. There are more than 120 known types of HPV. Some types cause warts on the hands or feet. Other types cause genital warts or condyloma. There are also types of HPV that infect the cervix (lower part of the uterus) where they can cause either harmless cell changes or potentially precancerous cell changes or dysplasia. (See Human Papillomavirus handout). A person can be infected simultaneously with multiple HPV types. Most people who become infected with genital HPV will not have any symptoms and will not know they have an infection. It has been estimated that fewer than 5% of people with genital HPV will develop warts. The others have subclinical (or invisible) HPV. Whether people with subclinical HPV infection are as contagious as people who have visible warts is not known.

HOW DO YOU GET HPV AND WHEN DO WARTS APPEAR?
HPV infection is usually spread by direct skin-to-skin contact during vaginal, oral, or anal sex with an infected individual. After exposure, warts may take weeks, months or even years to appear; or they may never appear at all. For this reason, it is usually impossible to determine when, or from whom, someone gets the virus. Most men and women are unaware that they have the virus - they spread it unknowingly to their sexual partners. Men and women can develop warts from a partner who does not have any visible signs of the virus. Male or female condoms do not provide complete protection from the virus. The greater number of lifetime partners; the greater the risk of exposure to the virus.

Oral warts do not generally appear after having oral sex with a partner who has genital HPV infection. If you have oral sex, consider dental dams/condoms to decrease transmission of the virus.

HOW WOULD YOU KNOW IF YOU HAD GENITAL WARTS?
Genital warts are skin colored or whitish rough surfaced bumps or growths. Warts appear on the vulva, in or around the vagina or anus, on the cervix, and on the penis, scrotum, groin, or thigh. The warts may be raised or flat, single or multiple, small or large. Some may cluster together to form a cauliflower-like shape. Sometimes it can be hard to tell the difference between warts and normal bumps on the genital areas. Often warts are not noticed because they are small and/or painless. Other warts, depending on the location and size, may itch, feel irritated, or bleed. Sometimes warts will be detected during a physical exam.

CAN GENITAL WARTS AND HPV GO AWAY?
Genital warts can disappear but the virus may remain present for a longer period. Warts may or may not return after the first episode. A person’s immune system fights the virus and eventually, most HPV infections resolve spontaneously in 1-2 years.

IF YOU HAVE GENITAL WARTS AND THEY GO AWAY, CAN YOU GET THEM AGAIN?
Most couples who have sex share HPV types until their bodies’ immune systems get rid of them. Partners who have sex only with each other do not pass the virus back and forth.

After the spontaneous resolution (in 1-2 years), the body’s immune system will remember the virus type and keep you from getting that particular type of HPV again. Because there are many types of HPV, developing immunity to one HPV type does not offer protection from other types. If exposed to another type of HPV, genital warts can reappear.

HOW CAN YOU REDUCE THE RISK OF GETTING GENITAL WARTS?
Any person who is sexually active can be exposed to this common virus. Ways to reduce the risk are:

• Not having sex with anyone.

• Having sex only with one partner who has sex only with you. People who have many sex partners are at higher risk of getting other STIs.

• If someone has visible symptoms of genital warts, he or she should not have direct skin to skin contact until the warts are gone. This may help to lower the risk of giving the virus.

• Condoms (rubbers) used the right way from start to finish each time of having sex helps provide some protection - but only for the skin that is covered by the condom. Condoms do not cover all genital skin, so they don’t give 100% protection.

HOW CAN GENITAL WARTS BE TREATED?
Currently, there is no treatment to cure HPV. However, there are many treatment options for genital warts. The guidelines of the U.S. Centers for Disease Control include the following information:

“The goal of treatment is to remove symptomatic warts. Treatment can induce wart-free periods in most people. No evidence indicates that currently available treatments eradicate or affect the natural history of HPV. Wart removal may or may not decrease infectivity. Untreated warts may resolve on their own, remain unchanged, or increase in size and number. No evidence indicates that the treatment of visible warts affects the development of cervical cancer.”

The treatments for visible warts are either patient applied or provider administered.

Patient applied:

• Podofilox solution (condylox) is a topical liquid that causes wart destruction. It is applied twice a day, three times each week, for up to four weeks.

• Imiquimod cream (Aldara) is a topical immune enhancer. It is different from all other treatments. Other treatments work by destroying the wart tissue whereas Aldara actually boosts the immune system to fight the virus. It is applied three times a week for up to four months

Provider administered:

• Cryotherapy is freezing the wart with liquid nitrogen. This treatment usually requires more than one office visit.

• Trichoroacetic acid (TCA) burns the wart tissue. This usually requires more than one office visit.

• Podophyllin also burns the wart tissue. This usually requires more than one office visit.

• Laser uses intense light to destroy the wart. It is used for larger or more extensive warts, especially those that have not responded well to other treatments.

• Surgical removal of the wart can be by excision or electrosurgery. This has the advantage of removing warts in one office visit.

• Interferon is an antiviral drug that is injected into the wart. It is rarely used any more due to its toxic side effects and high cost.

Points to remember:

• Ask your provider about the recommended treatment, including benefits, side effects, and cost.

• Be sure to understand the follow-up and potential side effects.

• Changing or combining treatment methods may be recommended.

• Inform your provider if you are or may be pregnant. Some treatments should not be used in pregnancy.

• Do not use over-the-counter treatment for warts. They are not intended for use in the genital area.

WHAT SHOULD YOU DO AFTER YOU HAVE BEEN DIAGNOSED AND TREATED FOR GENITAL WARTS?

• Sex partners need an exam only if any unusual bumps in the genital area are present. Also, routine annual exams for women partners are recommended.

• If you have genital contact (vaginal, oral, or anal), consider using condoms or dental dams.

• Women should have regular Pap smears every six months after being diagnosed with genital warts.

• Keep your immune system strong. Maintain a high level of wellness. Eat nutritious food, and get adequate exercise and rest. Do not smoke. Avoid drugs and limit alcohol intake.

WHAT ABOUT PREGNANCY AND GENITAL WARTS?
Genital warts or subclinical HPV do not affect a woman’s ability to get pregnant. Most pregnant women who had genital warts in the past, but not currently, experience no complications or problems during pregnancy or birth. Most children are born healthy to women with a history of genital warts. Because of hormone changes in the body during pregnancy, warts can grow in size and number, bleed, or, in extremely rare cases, make delivery harder. Very rarely, babies exposed to the wart types of HPV during birth develop growths in the throat. Despite this risk, a woman with genital warts does not need to have a cesarean section delivery unless warts are blocking the birth canal. The risk of a cesarean section is greater than the very rare risk to the baby of getting warts. It is important that a pregnant woman notify her doctor or clinic if she or her partner(s) has had genital warts. This way clinicians can determine if they need to treat the warts or not during the pregnancy.

IS IT NORMAL TO FEEL UPSET ABOUT GENITAL WARTS?
Yes, it is normal. You may feel very upset. You may feel ashamed, fearful, confused, less attractive or less interested in sex. You also may feel depressed, have a fear of rejection by your partner or have concern about spreading the infection to others. You may feel angry at your sex partner(s), even though it is usually not possible to know exactly when or from whom the virus was spread. You may be afraid that the genital warts could lead to cancer or that you will never be able to find a sexual partner again. It is normal to have all, some or none of these feelings. It may take some time, but it is important to know that it is still possible to have a normal, healthy life; even with genital warts. A sexuality educator is available at McKinley to counsel students about HPV. To make an appointment call 333-2714.

HOW CAN YOU TALK TO YOUR PARTNER ABOUT GENITAL WARTS?
Before you approach you partner, deal with your own emotions. A positive attitude will help you cope with genital warts. Learn as much as you can about genital HPV so you will be prepared to answer their questions.

Points to remember:

• Try to emphasize the positive fact that you are being honest, even though it is hard. Let your partner know you are telling the truth because you care.

• Be prepared for the possibility of rejection at first.

• Remember that your partner will feel emotional and confused, as you did when you were first diagnosed. Expect a lot of questions.

• Explain that although HPV has no cure, there are many treatments available to get rid of genital warts. Also be sure to explain that the virus goes away completely in most people in 1-2 years. Discuss the fact that safer sex reduces the risk of passing the infection. Also, let your partner know that not everyone who is exposed to genital warts gets infected.

References:
Ho G, Bierman R, Beardsley R, et al: Natural History of Cervicovaginal Papillomavirus Infection in Young Women. New England Journal of Medicine 338(7): 423-428, 1998.
American Society of Reproductive Health Professionals: AARHP Quick Reference Guide to Patient Questions about HPV. Web site at: http://www.arhp.org
American Society of Reproductive Health Professionals: What Women Should Know about HPV and cervical health. Web site at: http://www.arhp.org
American Social Health Association. HPV: Get the Facts. HPV and Abnormal Cell Changes. Web site at: http://www.ashastd.org
American Society for Colposcopy and Cervical Pathology. HPV Testing - Is It for Me? Web site at: http://www.asccp.org/patient_edu.shtml

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