Human Papilloma Virus

What is Human Papilloma Virus?

Human papilloma virus (HPV) is a virus most commonly known for its association with cervical cancer and genital warts.  This is a sexually transmitted virus that is spread by direct contact with infected individuals.  Patients may carry the virus in the absence of cervical changes or genital warts.  Some individuals develop warts or cervical changes that resolve on their own.  Others go on to develop persistent warts, cervical cancer, penile cancer, or anal malignancy.

There is emerging evidence that human papilloma virus is also responsible for certain head and neck cancers.  The diagnosis of HPV infection can also have negative psychological effects.  Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.

What Causes Human Papilloma Virus?

Human papilloma virus is spread through sexual contact.  Individuals can acquire the virus via direct contact with genital or oral skin lesions.  Patients may also be infected by asymptomatic viral shedding.  Use of barrier devices such as condoms may not protect against viral transmission.

There are multiple types of the HPV virus.  HPV 16 and 18 cause about 70% of cervical and anal cancers.  HPV 6 and 11 are responsible for approximately 90% of genital warts.  These virus causes epithelial cells to undergo precancerous transformations.

In the cervix, this manifests with typical cells, cervical intraepithelial neoplasia, and potentially metastatic cancer.  The virus also promotes uncontrolled cell division leading to the formation of genital warts (condylomata acuminata) and occasionally cancers of the penis, head, or neck.

How Common is Human Papilloma Virus?

Human papilloma virus is exceedingly common in the United States and responsible for frequent primary care visits.  The condition may require referral to a gynecologist, dermatologist, or oncologist.

The prevalence of HPV infection worldwide is about 10 %. Worldwide, the most common types of HPV are 16 and 18.  The prevalence of HPV infection is significantly lower after age 30.

Signs and Symptoms

Anogenital warts are typically found in the anogenital region including the vulva, penis, groin, and perianal skin.  Warts can be solitary or multiple and can have a cauliflower-shaped appearance.  Lesions may be skin-colored, pink/red, brown, or hyperpigmented.  The warts are typically asymptomatic but can be itchy (pruritic) and will occasionally cause pain or bleeding.

Patients with genital warts often have anxiety and depression due to the stigma associated with the condition.

Patients with cervical changes may also be asymptomatic.  Those with cervical cancer can have vaginal bleeding, discharge, and pelvic pain.

Diagnosis

Starting at age 21, most women undergo routine cervical cancer screening with papanicolaou (PAP) smear.  During this test, your doctor will take a sample of endocervical tissue and send it to the laboratory for evaluation of atypical cells and HPV virus.

If you test positive for HPV or atypical cells, your doctor may then refer you to a gynecology specialist to perform a more specific evaluation with colposcopy.  Colposcopy allows a more detailed visualization of the cervix and is often accompanied by cervical biopsy.

Patients with external genital lesions that appear to be cancerous should also have a biopsy taken.  Biopsies are sent to the laboratory so a pathologist can analyze the specimen and determine whether or not there is evidence of malignancy.

Human Papilloma Virus Prevention

HPV vaccination can prevent the acquisition of cervical cancer and genital warts.  There are 3 available HPV vaccinations: Gardasil, Gardasil 9, and Cervarix.  Gardisil immunizes against HPV types 6, 11, 16, and 18.  Gardasil 9 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.  Cervarix only immunizes against HPV 16 and 18.

HPV vaccination is the most effective in individuals that have not yet been infected with HPV – it is not effective in removing pre-existing HPV infection, genital warts, or cervical lesions.  Immunization is typically offered to girls age 11-26 years who have not been previously vaccinated.  It is not recommended in pregnant women.  Immunization can also be offered to boys age 11-21 who have not been previously vaccinated.

Patients with genital warts are typically treated with one of the following topical agents:

• Aldara (imiquimod)
• Condylox (podophyllotoxin)

Your doctor may alternatively recommend cryotherapy, surgical excision, or electrosurgery.