What is the human papillomavirus?

The human papillomavirus (HPV) is the most common sexually transmitted infection and it affects the skin and mucous membranes in the genital region. This includes the skin on the anus, rectum, penis, vulva, vagina and cervix. Both men and women can carry HPV and can pass it from person to person via contact with an infected person. It is estimated that 75 percent of reproductive age, sexually active adults have been infected with HPV at some point in their lives. This amounts to over 6 million infections each year, with more than half occurring in people between 18 and 25 years old.

There are over 130 types of HPV of which 30-40 can affect the genitalia and anus. HPV may not be symptomatic, it may cause genital warts to develop, or it may cause abrasions that could lead to cancer. There is a difference between the strains of genital HPV that cause genital warts and the strains that cause cancer. Repeated infections with versions of “high-risk” HPV that do not cause warts can lead to cancer. Almost all cases of cervical cancer involve HPV infections prior to the development of the cancer.

What are the symptoms of HPV?

The low-risk version of HPV causes genital warts to develop. These warts appear as a small bump or as a group of bumps on the genital region. They can have a variety of shapes and sizes, and appear on any of the genital surfaces of men or women. The warts may not have any symptoms at all; however, they may cause feelings of itchiness, burning, or soreness. Warts in the vagina may cause bleeding after sex, and warts in the urethral opening may block urination or cause bleeding, but latter are rare. They can show up within a few weeks or even months after having sexual contact with an infected person, or they may not show up at all. The warts may go away on their own; they may never change; or, they may change size and increase in number. The important factor about genital HPV warts is that they will not turn into cancer.

The high-risk version of HPV can cause cancer. Unfortunately, cervical cancer does not show any symptoms until it is in it advanced stages. Other HPV-related cancers in the genital region do not show symptoms until they reach advanced stages as well.

How is HPV diagnosed?

There are three ways that HPV infections can be diagnosed. The first way is visual confirmation of genital warts. These are the most common signs of HPV infection. Other methods of diagnosing HPV infection require one or all three tests: the Pap test, the HPV test, and the colposcopy.

The Pap test, or Pap smear, is part of a routine pelvic exam that tests for changes in the cells of the cervix. A swab of the surface of the cervix is taken and then tested for abnormal cells by looking at the sample under a microscope. Many types of abnormal changes in cervical cells are possible, although only certain abnormal cells may be the cause of cervical cancer. Your doctor should explain to you which type of abnormal cells you have.

The HPV test actually tests for the human papillomavirus. The HPV test can be done at the same time as a Pap test, as it is also just a swab of the surface of the cervix. However, the HPV test looks for DNA from the virus while a Pap test looks for changes in the cells of the cervix. The HPV test is recommended as part of the routine pelvic exam for women ages 30 and older since by age 30, HPV infections occur much less often. Women over 30 are more likely to have persistent HPV infections that can lead to cervical cancer. The HPV test is not recommended for women younger than 30 unless they have had an abnormal Pap test because the infection normally goes away on its own.

Having an abnormal Pap test means that there are changes in the cervical cells and an HPV test is necessary to see if HPV is causing the changes in the cells. Having an abnormal Pap test and a positive HPV test means that more testing is necessary to decide if and how to treat the infection. Testing positive for HPV does not mean that a woman has cervical cancer; rather, a positive HPV test indicates the possibility of an infection with a high-risk strain of HPV that may increase the risk of precancerous changes to the cervical cells. Having a normal Pap test and a positive HPV test means that you just have an HPV infection and you will need to be retested in six months to a year to make sure the infection has gone away. If the HPV is still present, more tests may be necessary. 

There are a variety of things that can affect the HPV test. Women should not use tampons or any vaginal medicines, creams, or douches 48 hours before the test. If the cervical swab does not have enough cells, or if a woman is already infected with high-risk HPV, then the test results may not be useful.

Another method of diagnosis of HPV is the colposcopy. The colposcopy allows the doctor to look more closely at the cervix with a colposcope (large microscope with a bright light at the end to allow the doctor to see into the vagina all the way to the cervix) and examine the abnormal cells that were found in the Pap test. Women remain in the same position for the colposcopy as they do for a Pap test, with their feet in the stirrups, and acetic acid (vinegar) is put on the cervix. This makes the cells fill up with water so that light will not pass through them and then the doctor can see them better. The full cells turn white and the more abnormal the cells are, the whiter they are. If the doctor can see all of the abnormal tissue, then a sample of tissue is taken to the lab for analysis.

How is HPV transmitted?

HPV is passed during physical contact with the infection on another person. It is usually transmitted during sexual intercourse, but because HPV lives on the skin, the virus can be conveyed via any physical contact with the infection as well. However, since most HPV infections do not have any symptoms, HPV can be passed without knowing about it, even if years have passed since a person last had sex. This is probably why so many people have been infected with HPV at some time in their lives, and they do not even know they are infected.

How can HPV transmission be prevented?

The first line of HPV prevention is the HPV vaccine called Gardasil. It is FDA-approved for females aged 9-26 (with health insurance, it’s only covered for women that fall in that age range and men would have to pay full price for the vaccine). It protects against the four most common strains of HPV. However, it does not prevent transmission of all strains of HPV, so women would still need to continue to use other methods of prevention. Condoms do offer some protection from HPV transmission, but they are not completely effective since HPV can exist outside the areas that are protected by condoms. Also, no tests have been developed to detect it in men who are usually the silent carriers of the virus.

How is HPV treated?

Most HPV infections clear up on their own. For those that do not, there is no treatment that completely eliminates an HPV infection. Warts caused by HPV can be removed, although this does not rid the body of the infection and the warts can return. The warts can be treated at home with medications in the solution, gel, or cream form. A doctor can treat the warts with stronger topical medications, injections, or liquid nitrogen (to freeze the warts off). There are also two surgical procedures that doctors may use as well: traditional surgical removal or laser removal of the warts.

HPV infections that cause changes to the cervical cells can be treated by a variety of procedures, even though the virus itself cannot be removed. One of the most common procedures is called the LEEP, or the Loop Electrosurgical Excision Procedure. LEEP is used after an abnormal Pap test to get rid of the abnormal cells—to prevent them from turning cancerous. The LEEP procedure uses electrical current running through a thin wire to painlessly cut away the changed cells in the vicinity of the wire. The procedure occurs in much the same way as a Pap test, with a woman’s legs up in stirrups, as an outpatient procedure.

The cervix is numbed before the abnormal cells are removed, and the removed tissue can be examined afterwards to check for invasive cancer. There are some side effects to the procedure; cramping may occur for a few hours, there may be vaginal bleeding or discharge for up to three weeks, having sex and using tampons should be avoided for three weeks, and no douching should be done. If a woman experiences a fever, heavy bleeding, pelvic pain, or a discharge that smells bad or has a yellowish color, she should call her doctor. Having a LEEP does not affect a woman’s ability to get pregnant, though it may lead to preterm delivery of future pregnancies. After a LEEP, a woman will need to have frequent Pap tests, approximately every 3-6 months for the first year. Some doctors don’t recommend the LEEP procedure as it can leave women prone to other infections.             

Another procedure to remove abnormal cervical cells is cryotherapy. Cryotherapy freezes the part of the cervix with the abnormal cells in order to remove precancerous cells. Cryotherapy is generally done after a colposcopy, when all the abnormal tissue is visible. Cryotherapy is another outpatient procedure that requires the woman to be in the same position as a Pap test, but this time cryo probes are inserted into the vagina. Once the abnormal tissue is covered by the probes, liquid nitrogen flows through them, freezes them and in turn freezes the abnormal cells on the surfaces, killing them. The abnormal cervical cells should be frozen for three minutes, then a break is taken to let the cervix thaw, and then the cell should be frozen again for three minutes. This procedure may cause some cramping, and a woman may feel some cold or heat during the process. After cryotherapy, there may be some discharge for a few weeks, and nothing should be put in the vagina for three weeks. Similar to the LEEP, if a woman experiences a fever, heavy vaginal bleeding, severe pain, or smelly or yellow discharge that can indicate an infection, she should call her doctor as soon as possible. As with the LEEP, frequent Pap tests (every 3-6 months) will be necessary after cryotherapy.

If the abnormal cells are not just on the surface of the cervix another procedure, called a cone biopsy, will be performed to find out the extent of the abnormal tissue. A cone biopsy removes a piece of cervical tissue, in the shape of a cone, from high up in the cervix. When the biopsy is taken, some normal cells are removed as well to ensure that an edge of healthy cells is left in the cervix. The cone biopsy is an outpatient procedure, and is performed with a woman in the same position as for a Pap test. An anesthetic, either general or local, will be used and it may be performed during or after a colposcopy. As with the LEEP and with cryotherapy, there may be slight discharge after the treatment. Again, nothing should be inserted in the vagina for three weeks, and if fever, heavy bleeding, pain, or smelly or yellow discharge occurs, women should call their doctor immediately. After a cone biopsy, women need to have a Pap test every 4-6 months until she has multiple that are normal.

A cone biopsy is a surgical procedure and it does carry more risk than the other treatments mentioned above. Rare changes may occur to the cervix that causes infertility or the inability to carry a pregnancy to term. There is also a less-than 10 percent chance of vaginal bleeding that could lead to the need for a blood transfusion or vaginal packing. A cone biopsy may remove all the abnormal tissue; however, the procedure may need to be repeated, or the biopsy may show that further treatments are needed. If a cone biopsy cannot remove all of the abnormal tissue, or if the cancer has progressed too far, surgery, chemotherapy or radiation may be recommended.
           
HPV Safety

While there is no cure for HPV, most infections clear themselves within a couple years, without causing any adverse effects to the infected woman. However, if HPV infection results in genital warts, or abnormal cervical cells, there are options available to treat the symptoms of the problem. There are various methods of wart removal that can be utilized, although the warts may come back. If abnormal cells are detected, the LEEP, cryotherapy, or cone biopsy can remove the abnormal cells, and possibly the HPV infection, from the cervix before the precancerous cells have spread or detect a deeper spread of the cancer into the cervix. As a safety precaution, women are encouraged to have a Pap test at least once a year and men checked for genital warts by either a dermatologist or urologist. For more information on the HPV vaccine, Gardasil, go here.