HPV: Genital Warts and Abnormal Pap tests

The summary answer section is followed by a more in-depth discussion about HPV.

1. What is HPV:
   Human Papilloma Virus is a family of viruses that can cause genital warts and ordinary warts on hands and feet. They can also cause cell damage on the cervix resulting in pap test abnormalities. These cervix cell changes can very, very rarely over time, develop into cancer
2. Why the sudden fuss about HPV?
   There is a new vaccine available which has been heavily marketed directly to the public. This has generated much discussion and reflection about the use and need of a vaccine to prevent genital warts and decrease the risk of cervix cancer. There is also discussion about the use of the vaccine after one has already been sexually active and is likely already exposed to some or all of the 4 viruses in the vaccine, making the vaccine less effective or not effective at all.
3. How common is HPV? 
   Very common. Most of us have been exposed to HPV some time in our lives. There are many members of the HPV family, some more worrisome than others. Many children have warts which disappear, and many adults are exposed to the virus when sexually active.
4. What is the transmission rate?
   How commonly is the virus transmitted between people?
   The transmission of HPV viruses is common from men to women, and women to men. (one recent trial showed that it is more common from women to men during sex) HPV infection is so common, that up to 70% of us have been exposed to the virus.
5. Do I have it? If you are sexually active there is a good chance that you have been exposed and infected. The virus usually disappears without treatment after 18-24 months.
6. How is it transmitted?
   By hand to genitals and from genital/sexual contact
7. Can I get it from public washrooms?
   Unlikely.
8. What is the difference between warts and HPV causing pap test changes?
   Warts areusually caused by benign types of HPV while cervix cell damage can be caused by both benign and more harmful virus types.
9. If I have warts, is the virus there forever or does it go away? It usually disappears after 18 - 24 months, sometimes a little longer. You can easily be re-infected during new sexual contact.
10. Is it the same as Herpes virus?
    "For ever"? This is not like the Herpes Virus. The pathology of the infection is different and the symptoms and treatment are very different from Herpes. Herpes is also a common virus and is often spread during oral sex if one partner has a cold sore.
11. What can I do to help get rid of the virus?
    If you smoke, please stop. Smoking is an aggravating factor by preventing your immune system from adequately fighting off the HPV virus. While we can help get rid of warts using many treatments, your immune system is a major factor in getting rid of the warts and cell changes. The sudden disappearance of multiple warts is usually due to your own immune system kicking in. Smoking can block this action.
12. Can I prevent getting warts?
    Common sense sexual behaviour may decrease the risk of getting warts: Avoid multiple partners, use condoms, and avoid a partner who has other partners currently. Having the vaccine before you are sexually active is probably the best way to prevent warts.
13. What is the difference between High risk (Oncogenic) and Low risk HPV?
    The family of HPV viruses has a group of low risk viruses which are more of a nuisance than a problem. The low risk viruses cause no symptoms or they cause warts and benign changes to the cervix. On the other hand, high risk type HPV viruses can cause more severe cervix cell damage which eventually, although very rarely, can cause cervix cancer. The high risk viruses can also cause anal, mouth and throat cancers.
14. If I have vulva warts will I get Cervix Cancer?
    NO! Cervix cancer is usually caused by a more aggressive virus. It is possible to have warts and then develop cancer but the cancer is not caused by the same virus that caused the warts.
15. What are my chances of getting Cervix Cancer?
    Very, very small, especially if you have regular pap tests. Even if your pap tests are abnormal, the chance of you getting cancer is exceedingly small because of our good health system in Canada which promotes regular pap tests which are free for all women..
16. How does HPV cause pap test changes?
    What does it do? The virus disrupts normalcell development and causes changes or damage called dysplasia. The dysplasia can be picked up on repeated pap tests. Early or low grade changes (LSIL) often disappear without treatment, whereas more severe or high grade changes (HSIL) often require treatment or close observation to avoid the development of pre-cancer or cervix cancer.
17. If I have an abnormal pap test or dysplasia, do I have cancer?
    No. It is very rare to have cervix cancer. (See below about cancers in women. Cervix cancer is way down the list being the 15th most common cancer in women in Ontario) 99% of abnormal pap tests do not indicate cervix cancer! Repeated pap tests are anearly warning system to tell us that you need monitoring or simple treatment to prevent you ever getting Cervix Cancer.
18. Where on my body can I get warts?
    You can get warts anywhere. Children get warts on their hands and feet, whereas sexually active adults usually get warts on the vulva, penis, under the foreskin, anus area(common even without anal sex) the vagina and the cervix.
19. If I have warts, does my partner also have it?
    Your partner usually has warts as well if you are sexually active. If your partner is male, warts are more difficult to find. However, if you wet a paper towel with vinegar solution and wrap it around the penis and scrotum after pulling back the foreskin, smallwhite dots may appear after a few minutes which may be warts. (Not all white dots are warts, so first see a doctor before taking matters into your own hands )
20. How long ago was I infected?
    Difficult to tell. It could have been 2 years ago or longer. It could have been more recent.
21. Can I get warts in the anal area if I have anal sex?
    Absolutely. You can develop warts around the anus if you have anal penetration, including the areas inside your anal sphincter and the rectum.
22. Can I get warts in the anal area during regular sex and touching? 
    Yes. Just by touching the genital area is enough to transmit the virus to many areas, including around the anus and buttocks.
23. Does a condom prevent warts?
    Yes it does, but only by about 60 to 70%. The condom does not cover the scrotum and other exposed skin and some viruses can pass through latex condoms.
24. Can I have sex when I have warts?
    I recommend that you should first have them treated. However, if you are in a monogamous committed relationship, your partner is likely already infected.
25. Can I have sex if I have an abnormal pap test?
    YES. The only time that we wouldrecommend against vaginal penetration is if you have wart lesions in the vagina or on the cervix.
26. Can one get warts in the mouth from oral sex?
    Yes
27. Can warts be treated?
    Yes, we have many ways of getting rid of warts on the vulva, the anus and inside the vagina. Help is available. Don’t be shy or embarrassed to ask. We want you to be free of warts and to feel confident again.
28. Is it common to feel emotional, embarrassed or humiliated by having warts?
    Yes, this is very common. There is a stigma attached to warts which is unfair because warts are so common. Please know that we can help you to get rid of the warts and they will go away forever. Try not to beat yourself up about this (or your partner). Don’t be afraid or embarrassed to go to your doctor and ask for treatment.

 

More information about HPV

What is HPV?
Human papilloma virus, or HPV, is a huge family of viruses, more than 100 different types have been identified. They are very common and have an affinity for the skin and mucous membranes. Many cause warts on different parts of the body, including on the fingers or the genitals (penis, vulva, labia, vagina, anus, buttocks and cervix). They may look different—pale or dark, rough or smooth, raised or flat—depending on where they grow. HPV can also, very rarely, cause certain types of cancer. HPV also commonly cause warts on children especially on the hands and feet (Plantars warts)

How does someone get HPV? 
HPV is a virus spread by close contact, mostly through sexual activity but also by skin-to-skin contact (as in children). HPV can be transmitted by sexual contact with women or men. While there have been rare reports of infection from tanning beds, it is extremely unlikely that this virus would be transmitted through shared clothing, bed sheets, public washrooms, etc.

HPV infection is extremely common - about 3 out of 4 people who have had sex have been exposed to HPV at some time in their lives (up to 26% of sexually active young women test positive at any given time and up 60% will test positive over a three-year time period). The HPV virus is so common that it can almost be considered normal to have it. Usually there are no symptoms, and people do not know they have HPV. People who don't have any signs or symptoms of HPV infection (ie. have no visible warts) can transmit the infection. There is still viral shedding even without lesions present, although the risk of transmission is lower than if there is a lesion.

Genital and anal warts transmitted through sexual contact, are highly contagious (through both anal and vaginal sex). Genital and ordinary warts, however, are caused by different HPV virus strains, which tend to prefer different tissue types. Thus, it’s unlikely to find a wart on the hand containing a genital virus strain, or a wart on the genitals containing an ordinary skin virus strain—and unlikely that you will transfer them between those locations. Rarely, however, genital warts can develop in the mouth or throat of a person who has had oral sex with an infected person.

How can I help reduce my risk of HPV infection? 
If you are sexually active, it is hard to prevent exposure to HPV. Only total absence of skin to skin contact with an infected individual will insure protection. You are atincreased risk for HPV infection if you or your partner has had previous sexual partners, something that you cannot change.

Use of condoms may reduce transmission of the virus to uninfected partners; condoms don’t, however, offer full protection against HPV, since the virus can be transmitted from skin that is not covered. But condoms are the only effective way to protect against other sexually transmitted diseases.

The best way to reduce the risk of genital warts and cervix cancer is to have the vaccine before you have been exposed to the viruses in the vaccine. If you already have had sex and have already been exposed to one or more of the 4 viruses in the vaccine, the vaccine will be less effective or not effective at all. The best time to get the vaccine is before you are sexually active. That is why it is being offered to girls (and hopefully boys soon) from 9 to 13 years old.

Is the virus there forever or does it go away? 
HPV infection usually clears up by itself (usually without one ever knowing that they had been infected). There is nothing you can do to clear the infection; it is cleared by your immune system. The average length of time from infection to cure is about 8 months (most women are able to clear the virus in 6-24 months). Sometimes, however, infection does persist, often without causing cell damage or pap test changes.

If you are in a long-term relationship, and you and your partner are otherwise healthy individuals with normal immune systems, and remain monogamous, you should both eventually become free of HPV disease because of the formation of antibodies against HPV by your own immune system.

How long ago was I infected?
The time from infection until you have any signs (e.g. a wart or abnormal Pap smear), if ever, is both long and variable. It may be anywhere from a few weeks to more than 1 year. In addition, any changes that do occur may not be noticed for additional months or years. Thus, it is often extremely difficult or impossible to figure out who infected whom and when exactly infection occurred.

What is the difference between high risk and low risk HPV? 
Approximately 30 strainsof HPV exist in the genital area and can cause genital warts. These 30 strains can be further broken down to "high" and "low" risk strains: High risk strains may cause cell changes picked up on a Pap smear, which very rarely progress to cancer over a long time. There are approximately 13 high-risk strains of HPV, of which two (16 & 18) are believed to cause about 70% of all cervical cancer and others cause vulva and anal skin damage(dysplasia) and rarely vulva or anal cancer.

Most often, these high risk viruses cause no cell damage and disappear within 2 years, especially in women younger than 30 years old.

Low risk strains sometimes cause changes in a Pap smear, but do not progress to cancer. Of the low-risk strains, two (6 &11) also cause more than 90% of genital warts.

A Cancer-Causing Virus
Out of the whole family of HPV viruses, 13 high-risk strains are known to cause cancer, specifically cancer of the cervix and some other rare cancers (e.g. penis, vulva, vagina, anus or mouth). Almost all cervical cancers occur when certain strains of HPV are present in the cervix. Without the presence of one of these strains, cervical cancer will almost never develop, no matter what other risk factors a woman may have. Thus, HPV is considered a "necessary cause" of cervical cancer. While HPV infection most often goes away by itself, if the infection persists, it cancause changes in the cervix that may slowly lead to cancer if it is not detected and treated early. Most women who have been exposed to HPV, however, do not develop cervical cancer.

HPV infection alone may not cause infected tissue to become cancerous. Cofactors have been associated with an increased risk of cervical cancer, including: smoking and exposure to second-hand smoke, use of birth control pills for more than five years, more than five full-tem pregnancies, other sexually transmitted infections (i.e.Chlamydia or herpes simplex virus 2), folate deficiency, and a weakened immune system.

Cervical cancer incidence and mortality rates have been declining for many decades largely due to widespread regular use of Pap test screening whereby cancerous and precancerous cells can be detected in a slide made from a cervical smear. Thus, the cancer can be found and treatedwhen it is curable, or most commonly before it develops. But even in the Canada, where the Pap test is widely used (although 20-30% of women are seldom or never screened), about 1,300 new cases of cervical cancer were diagnosed in 2007, and 380 women died of the disease. Most of these women did not have regular paptests. The benenfit of regular screening with pap tests prevents the development of cervix cancer by identifying early cell changes before cancer develops. We can then easily treat these early abnormal cells before one develops cervix cancer. To keep perspective, the single most important thing you can do to prevent cervix cancer is to avoid smoking and to have regular pap tests done.

Should I be tested for HPV infection? How do I know if I have an HPV type that is linked to cancer of the cervix?
As mentioned earlier, it is so common to have even the high risk viruses without having any cell changes. Because HPV infection is so common, and usually goes away on its own, it is not routinely tested for. There is nothing for us to treat until the cell changes or damage has occurred and the cell damage is tested by having repeated pap tests.

There is a test to identify the presence of high risk HPV virus’s in the cervix and in and around the genital organs, but we only use that test in certain situations, for example when the pap test is uncertain.

It is also too early to recommend testing specifically for the types associated with cervical cancer as a method for cervical cancer screening, in place of Pap tests because the data and scientific evidence about the benefits of this emerging technology is still uncertain and needs evaluation.

The HPV test is, however, used as a follow-up for women with abnormal Pap tests. If you are over 30 and your Pap test shows mild cell changes, we will suggest an HPV test. If the test is positive for a high-risk (or cancer causing) HPV, you may require an additional procedure (colposcopy). HPV testing is not recommended for moderate or severe cell changes; in such cases a colposcopy is done so that we can look at and remove the abnormal cells. A cervical biopsy may be done at the sametime to confirm the colposcopy findings.

To reiterate, HPV testing is not usually done on women under the age of 30 because it is not uncommon for younger women to have high risk subtypes and the infection usually goes away on its own. HPV testing is not currently covered by OHIP.

Should genital warts be treated?
Though genital warts are caused by HPV strains not typically linked to cancer, you should seek treatment promptly for genital warts if you have them. Having warts is not only a physical and infection concern, but many woman feel emotionally affected and miserable by having being infected. This can affect how you feel about your genital area, your sexual confidence and your relationship. This is an especially difficult time particularly if you are in a new relationship.

At Cosmocare Gynecology, we use many treatment options to remove warts, including applying a clear anti-wart solution (trichlor-acetic acid), special fine tip cautery (hyfrecator), freezing with liquid nitrogen and LASER. The treatment used depends on the size and amount of warts you have. There is also a cream (imiquimod – Aldara) that is effective in some situations (i.e., if you have many small warts over a wide area) that you can apply up to three times a week yourself for about 2-4 months. Many women, however, find this causes severe skin irritation and alternative treatments are often eventually needed. In addition, Aldara takes a long time to be effective and is very expensive.

At Cosmocare, our approach is to clear the warts as quickly as possible so that you can be free of them and move on without worry.

Can I have sex when I have warts? 
This is a difficult question to answer, and depends on whether you are with a long-term partner or a new partner and whether you have wart-like lesions.

If you or your parent has a wart-like lesion, whether you are with a long-term partner, a recent partner, or would like to initiate a new sexual relationship, it is sensible to have the wart treated before further sexual contact.

If you are with a long-term partner, it is even more likely that he has already been exposed to the HPV virus; he may have contracted it from you or you from him.

HPV is more difficult to diagnose in men, and is not possible to do so if there are no visible warts; males with the types of HPV that cause pre-cancerous changes and cancer generally don't have any symptoms at all.

Nevertheless, to reduce the risk of re-infection (as your partner may have already cured their infection)—or to avoid infecting your new partner, you should have the wart treated before having sex.

When I have an abnormal Pap test, can I have sex and do I need to tell my partner?
If you have an abnormal Pap test, but do not have a wart-like lesion on your cervix, then it is probably fine to have intercourse. I do not think that it is particularly necessary to avoid sex or to tell your partner about an abnormal pap test because the risk of transmission to yourpartner is likely the same as women with normal pap tests.

However, if there is a wart-like lesion on the cervix, it is advisable to have that treated first.

The HPV Vaccine

There’s now a vaccine, Gardasil, that can help prevent cervical cancer. The vaccine worksagainst two of the viral strains that promote this cancer (16 & 18), aswell as two strains that can cause genital warts (6 & 11). The HPV vaccine is effective in preventing infection with these four HPV types, which are responsible for 70% of cervical cancer cases and 90% of genital warts.

Thus, the vaccine is not effective against all strains of cancer-promoting HPV, and is most effective in women who have not already been infected with HPV (this is why it is most appropriate for young girls). The vaccine is administered in 3 doses over 6months. It is believed to afford long-term protection; exactly how long protection lasts is not known, but it is for at least 5 years.

The vaccine is most effective before infection occurs, so in order to have a safety margin, children would have to be vaccinated around the age of 9 to 13, before adolescents become sexually active. Females up to age 26 and likely beyond may benefit, even if they are already sexually active, as they may not yet have an HPV infection, and it is unlikely that they would be infected with all four HPV types included in the vaccine. Since September 2007, the HPV vaccine has been offered to grade 8 females as part of the voluntary school-based immunization program. Every else must pay for the vaccine, which is about $400-$500 in Canada, for all three doses.

A pap test is still the best way of preventing cervix cancer and the vaccine is not imperative. Cervix cancer is still an obscurecancer compared to other cancers and has been on the decline in Canada for many years before the HPV vaccine came onto market. This is due to improved screening with pap tests. You do not need to feel that you are harming yourself if you do not have the vaccine. It is important to have regular pap tests. Keeping perspective and not getting caught up in the emotional hype is recommended.

How common is Cervix Cancer in Canada?
Cervix cancer accounted for 1.7% of all new cancers in women in Canada in 2008. Of all the Canadian women who died from their cancer in 2008, cervix cancer accounted for 1.1% of those deaths. The vast majority of women who develop cervix cancer in Canada are those women who have not been screened with regular pap tests, and/or those women who don’t access primary health care.

The vast majority of women who develop cervix cancer in Canada are those women who have not been screened with regular pap tests, and/or those women who don’t access primary health care.

Cancer in Women - Canada 2008
Cancer	Type	New Cases	Deaths
	Total	79400	35000
1	Lung	11300	9200
2	Breast	22400	5300
3	Colorectal	9700	4100
4	Pancreas	1950	1950
5	Ovary	2500	1700
6	NH Lymphoma	3200	1400
7	Leukemia	1850	1000
8	Uterus	4200	790
9	Brain	1100	740
10	Stomach	1000	720
15	Cervix	1300	380
15	Oral	1100	380

http://www.cancer.ca

If there’s a vaccine, can I just forget the Pap test? 
If you have been vaccinated, you will still need a Pap, since the vaccine does not protect against all HPV types, prevents only about 70% of cervical cancers, and may not last a lifetime. This vaccine is not going to make the Pap test obsolete. To guard against cervical cancer, all women should get regular Pap tests. In addition, as already mentioned, if you have been sexually active before getting the vaccine, you may have already been exposed to the one or more of the four viruses in the vaccine, making the vaccine less effective. The vaccine is only fully effective against 4 types of HPV if you have never been exposed to them before.

In addition, as with the flu virus, it is likely that in a few years, other strains of the HPV virus not covered by this particular vaccine will take over as the major causes of cervix cancer making the current vaccine benefit less effective. Thus pap test screening is still currently the best thing you can do to prevent cervix cancer.

Anal sex and warts:
Warts around the anus are common. You can get warts in the anal area during regular sex. Just by touching the genital area is enough to transmit the virus to many areas, including around the anus and buttocks.

You can develop warts around the anus especially if you have anal penetration, including the areas inside your anal sphincter and the rectum which are not easy to see without a special instrument. Sometimes high-risk HPV is spread during anal sex, which over time can cause Anal Cancer. If you are going to receive anal penetration, make sure that your partner always wears a condom, that you use a lot of lubrication, and that you never allow your partner to then have vaginal sexwith you unless the soiled condom is replaced. This applies to anal sex with a male penis or with a dildo/vibrator etc. This step is very important to avoid vaginal contamination and infections. No matter what your partner tells you, you should always insist on protecting yourself. Often a penis may be too large and cause tearing and bleeding which increases your risks of getting an infection (like HIV, Hepatitis C or warts) especially if a condom is not used on a penis, dildo or vibrator. If you experience pain, always STOP to avoidtearing and bleeding!

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