Genital Warts/HPV

I have been diagnosed with genital warts. What are genital warts?

What causes genital warts?

How is HPV spread?

How common are genital warts?

What are my risks associated with pregnancy with a history of genital warts?

How long after exposure do symptoms appear and how long will the infection last?

Are genital warts dangerous?

Do I need treatment for genital warts?

What treatment options are available?

The big question – How will this affect my sexual relationship?

How can I reduce the risk of getting HPV?

I have been diagnosed with genital warts. What are genital warts? 
Genital warts are growths or bumps caused by the Human Papillomavirus (HPV) that appear in the genital area. They are usually rough or "cauliflower-like" in texture and may be raised or flat. They may appear as a single bump or in multiple clusters and can be very tiny or occasionally more extensive. Some warts are so small that they cannot be seen with the naked eye. Sometimes a person may not even know he or she has the type of HPV that causes genital warts. This is called “sub-clinical HPV.” The most common size of warts we see at Campus Health is about 3 mm, or a little smaller than the end of a pencil. If left untreated, they may continue to grow over a period of several months, but will eventually heal on their own over a period of months to years.

What causes genital warts? 
Genital warts are caused by an infection with the Human Papillomavirus (HPV). There are over 100 types of HPV. Only a few strains of HPV cause genital warts (usually 6 and 11). In most cases, the virus is harmless. Other types of HPV can cause abnormal changes on the cervix called dysplasia (see the abnormal pap test section). Common skin, hand, and plantar warts on the feet are also caused by strains of HPV. The different strains are “site specific.” Common warts on the hand will not affect the genital area.

How is HPV spread? 
The type of HPV that causes genital warts is most easily spread through direct skin-to-skin contact. This can be through vaginal, anal, oral sex (rare), or external genital skin-to-skin contact with an infected partner. The virus has also been found in semen and vaginal secretions. It is thought that the virus is most contagious when there are warts present on the tissue.

There are several factors that work together to cloud the issues of transmission. First, some of the sites for infection, such as the inside of the vagina or the urethra of the penis, are not easily inspected for the presence of warts. Next, genital skin is covered with its share of bumps making it difficult to differentiate small warts from normal bumps. Finally, even sub-clinical infections, those that can’t be seen with the naked eye, can be contagious. This means someone could, quite unknowingly, pass the virus along.

Most HPV transmission occurs with skin-to-skin contact. Although still a controversial area, some experts believe that HPV may rarely be transmitted by “fomites,” or objects that carry infectious material from one person to another. At this time, science simply doesn’t have the tools to pin down explanations for these rare instances of alleged nonsexual transmission.

How common are genital warts?
In the United States, HPV is considered the most common sexually transmitted disease (STD). Some studies estimate that the majority of the sexually active population is exposed to at least one or more types of HPV, although most do not develop symptoms. In one study, 46% of women visiting a college health clinic were found to have HPV in their genital tracts when tested. Most people who have had multiple sexual partners, or who have a sex partner who has had multiple sexual partners have been exposed to or infected with HPV. Increasing the number of partners greatly increases the risk of infection. Studies have indicated that 85% of people with a history of more than 10 sexual partners have been infected with HPV. Using a condom decreases the chances of transmission; however, even when latex condoms are used all of the time, more than 10% of users will become infected. The condom does not always cover all infection sites. Although the virus is very common, most people will not know they have the virus because their immune systems will keep it "in check" (sub-clinical infection).

Are genital warts dangerous?
In most cases genital warts are harmless. Researchers agree that some types of genital HPV do play a major role in the development of cervical cancer. For more information regarding cervical cancer, please refer to the section on HPV and dysplasia. The HPV types that cause warts are not likely to have any role in genital cancers and are classified as low risk HPV types.

What are my risks associated with pregnancy with a history of genital warts?
The reassuring news is that the virus appears to have no link with miscarriage, premature labor, or other types of pregnancy complications. Fortunately, the risk of transmitting the virus to the baby is extremely low.

If you have active genital warts when you are pregnant, you may find that they grow more rapidly due to the expected decline in normal immunity, as well as increased hormones and blood supply. Several appropriate forms of treatment are available if you have bothersome symptoms associated with the warts. Even if you are not experiencing discomfort, it may be wise to treat visible warts before delivery, because this may reduce the amount of virus present and lower the risk of transmission.

How long after exposure do symptoms appear and how long will the infection last?
We certainly don’t have all the answers to these questions yet. Often, warts will appear three to nine months after exposure, but latency periods of years have been reported before the emergence of symptoms. For example, it has been found that immune-compromised patients who have been sexually inactive for many years may suddenly develop warts or abnormal Pap tests.

When genital warts are treated, the symptoms usually resolve in one to nine months (see treatment options). If left untreated, the warts will eventually heal on their own over a period of months to years. Researchers are unable to reliably detect the virus in its latent stage, making it impossible to know whether in some cases the immune system completely clears the virus from the body, or whether the virus remains at undetectable levels, capable of reemerging if the immune system weakens.

Do I need treatment for genital warts?
This decision often depends on the size and location of the warts, potential discomfort, and other issues – some of them cosmetic. The warts will eventually clear without treatment, but this usually takes a period of months to years.

The goal of treating warts, according to the Centers for Disease Control and Prevention, is to remove visible genital warts and get rid of annoying symptoms. If the warts are eliminated, the patient is considered “cleared.” This will probably reduce, though may not eliminate, the chance of transmission.

What treatment options are available?
The Campus Health Service offers three treatments. The first two, trichloracetic acid and liquid nitrogen, are applied at the Health Service. Imiquimod (Aldara) is a topical cream that may be applied by the patient at home.

TCA: 
The warts can be removed by topical application of trichloracetic acid (TCA). This causes a chemical burning of the skin, which destroys the wart tissue. A topical anesthetic may be applied to decrease the temporary discomfort with treatment. Students may purchase Hurricane Gel Anesthetic (available over-the-counter at our Campus Health Pharmacy) to self-apply 30 minutes before their appointment to decrease the discomfort with treatment. The advantage of this treatment is that it is fairly quick and inexpensive. Besides the fact that the treatment can be uncomfortable, another disadvantage is that it usually requires more than one treatment because new warts can continue to form for a period of weeks or months, until the immune system triggers a response.

Liquid Nitogen:
Warts may also be treated by topical freezing with a liquid nitrogen solution. The advantages and disadvantages are comparable to the TCA treatment.

Imiquimod (Aldara):
Imiquimod, or Aldara, is a topical cream that is applied directly to the affected area by the patient at home. It requires a series of applications. We have had a high success rate with the use of Aldara for women at the Campus Health Service. Most genital warts clear within one to four weeks with this method, as compared to two to sixteen weeks with the other treatment methods. Other advantages include the ability to self-treat at home and less painful treatment.

Patients are advised to apply a very thin layer of cream to the wart area 3 times a week. It should be washed off with mild soap 6 to 10 hours later. Sexual contact should be avoided while the cream is on the skin. If you decide to have sexual relations, apply Aldara cream after—not before—sexual activity. In addition, Aldara cream may weaken condoms and diaphragms: therefore the cream should not be left on during sexual activity. Patients may experience some localized burning after application, but it is usually less severe than with TCA or liquid nitrogen. If burning does occur, we advise the patient to decrease the frequency of application. Some women will be more prone to yeast infections during Aldara treatment and may wish to take some yeast medication preventatively. Aldara is much more effective for women than for men, probably because of differences in genital skin. It is not recommended for use in pregnancy.

The disadvantage of this treatment is that it requires a prescription for the medication and the medication is expensive. A one to three week supply (depending on the extensiveness of the warts) will cost about $30 at the Campus Health Pharmacy. Although the medication is expensive, the patient may save money on the number of office visits required.

The big question – How will this affect my sexual relationship?
There is no easy answer. You and your partner will need to review the information and make decisions based on mutual caring.

If you have been with your current partner for more than a few weeks, then he/she has probably already been exposed to the virus and abstaining at this point in time most likely will not help in preventing an outbreak in your partner. Long-term partners probably share the virus and re-infection should not occur.

If you are considering a new partner, there will be a risk of spreading the virus/warts to the new partner. Approximately two-thirds of people who have sex with a partner with active warts will develop warts themselves. Although using a condom is helpful, it does not provide complete protection because it does not cover the whole genital area. Also, having genital contact without “intercourse” can still put partners at risk, since the virus is spread through skin-to-skin contact. The virus is most easily spread when active warts are present, but the virus may still be spread after the warts have healed, especially during the first 6 months after active warts. Condoms should always be used until couples have been tested for other STD’s and both partners are comfortable with the idea that they may contract an STD from the other partner.

How can I reduce the risk of getting HPV? 

• Not having sex or genital skin-to-skin contact 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 STDs.

• Condoms used the right way from start to finish each time you have sex may help provide protection.

• Don’t smoke. Smoking interferes with your immune system and there is a higher incidence of cervical and genital HPV (and slower healing) associated with smokers.

• Keep your body and immune system as healthy as possible. Get enough sleep, eat healthy foods, and include reasonable amounts of physical activity and laughter in your life.