Genital warts

How do you catch them? | How are they diagnosed? | | Can I get rid of them? | Can I do anything? | What about the cervix? | Will I get cancer? | When should I have a Pap smear? | What about condoms? | Help! What should I do?

How do you catch them?

Genital warts (condyloma acuminata) are caused by the human papillomavirus (HPV), more than 100 different types of which are known. Some HPVs cause warts on the fingers and soles of the feet, while about 20 types of the virus thrive in the genital mucosa and are easily transmitted during sexual intercourse, sometimes perhaps also via fingers. Sometimes, though rarely, women may develop warts in their vulva after catching the infection from a sauna bench or similar. In addition to visible wart-like changes, known as genital warts when they present in the genitals, HPV infections can also be silent, in which case it is better to talk about HPV infection or an HPV-related change rather than genital warts.

HPV infections are one of the most common sexually transmitted infection, about 4 to 5 times more common than chlamydia. It is only recently that the very high frequency of HPV infections and their connection to abnormal cells in the cervix have been understood. Wart viruses are not a new phenomenon as such; people have had them for thousands of years.

How are they diagnosed?

According to studies in Finland, eight persons out of ten catch HPV at some point in their lives. The majority just don't know about their infection since it often causes no symptoms and usually disappears spontaneously. Only about 15% of HPV changes are actual genital warts, i.e. easily recognisable, visible, cauliflower-like warts. The majority of HPV infections do not result in visible genital warts. Such cases should not be called warts; it is better to talk about HPV-related changes or use a similar term. In the vagina and uterine cervix in particular, the virus infection often causes no symptoms at all. HPV infections in these areas are therefore often diagnosed on the basis of abnormal cells in a Pap smear (also known as a cervical cytology smear). The majority of abnormal cells in young women are due to an HPV infection.

In women's external genitals, the border between skin and mucosa is thin and fragile. There are often small sores there, which makes it easy for HPV to enter the tissues. An HPV infection increases the burning symptoms related to the sores. Sometimes, the woman has persistent, vague itching and often unsuccessfully takes several courses of anti-fungal medication since most women think the itching is caused by a "chronic" yeast infection.

Can I get rid of them?

The incubation period between infection and visible changes is long, at least several weeks, typically 3 to 4 months and sometimes even several years. Genital warts are a viral condition, and no curative medication is therefore available to date. The infection disappears over time as the body's own immune defence system becomes activated. The recovery rate varies depending on individual differences in immune defence. The infection may persist for 6 to 12 months, sometimes even longer. The person becomes immune to the virus and thus cannot catch the same virus type again, just as you can only have chickenpox once. There are dozens of different HPV types, and having one virus type does not always provide full immunity to the other types. In addition to the visible genital warts that appeared before, the person may also later develop new HPV infections elsewhere on the body.

Vaccines against HPV are being developed to provide artificial immunity against HPV infections.

Even if visible warts disappear, the virus may still be present in the body. According to estimates, less than one person in five or perhaps just one person in ten become virus carriers. In these persons, genital warts or other HPV manifestations may recur even after having been absent for several years or even decades, without the person having caught a new virus infection. This and the long incubation period often make it almost impossible to identify the infection source and time of infection. Stressful situations such as pregnancy often increase the likelihood of a recurrence, but there is great individual variation here as well.

Can I do anything?

Visible warts are psychologically stressful and look unpleasant. It is therefore possible to try and remove them by freezing (cryotherapy), sometimes with laser under local anaesthesia, or independently at home with a prescription medicine available from the pharmacy. However, treatment takes time and determination since the same viral infection may be incubating in other mucosal areas that still look intact. You should also bear in mind that treatment just destroys those warts that are visible to the naked eye but does not eliminate the virus. The disappearance or removal of visible warts thus does not fully eliminate the risk of infection. Repeating the treatments again and again often appears to help. This is because the infection disappears spontaneously, given enough time - not necessarily because of the treatment but despite it!

The newest medicine against genital warts is a prescription cream that is applied locally. It activates the body's immune defence to fight viruses and can thus be used to try and speed up and enhance the healing process that will start naturally in the body if given enough time.

What about the cervix?

Genital warts on women's external genitals and on male genitals are as harmless as warts in any other skin area. Cervical HPV infections are more serious since the virus may cause changes in the cervical mucosa that must be treated. If abnormal cells consistent with HPV are detected in a Pap smear, no immediate measures are usually required. The doctor will monitor the situation and wait and see whether these heal spontaneously. It is essential that a check-up sample is taken within 6 to 12 months. This is to ensure that the abnormal cells are really disappearing spontaneously.

If there is no spontaneous healing or if the Pap smears already suggest a more serious abnormality, further examinations must be performed to find out whether there could be permanent mucosal damage in the cervix. These so-called dysplasias do not necessarily heal spontaneously over time. They must therefore be identified and perhaps removed.

Most types of HPV are benign, and those that cause visible genital warts are often of this kind. These are completely harmless to the cervix. Genital warts should therefore not be mixed up with other HPV-related changes. In cervical HPV infections, some virus types are known to involve a higher risk of abnormal cells that must be treated. If such an abnormality is suspected, a colposcopy (endoscopy to examine the cervix) will be performed. In this exam, the cervix is examined with a microscope. If any areas appear abnormal, small targeted biopsy samples will be taken as necessary. The need for further treatment is determined after the samples have been examined under a microscope. If the biopsy findings show abnormalities requiring treatment, the current practice is to remove the affected area of the cervix under local anaesthesia with an electric loop or with laser. This is done on an outpatient basis.

HPV-related permanent abnormalities in the cervix do not cause any symptoms. Women who wish to take care of their health must therefore remember to have Pap smears every now and then to check that no abnormal cells requiring treatment are silently developing in the cervix.

Will I get cancer?

The risk of a cervical HPV abnormality resulting in cancer is extremely small, so there is no reason to be scared. The virus types causing visible genital warts do not carry any risk of cancer. However, a long-lasting viral infection on the mucosa may result in dysplasia, as mentioned above. If such abnormalities are left untreated for several years, other individual features and factors that further irritate the cervix (such as other infections and particularly smoking) may make the abnormality progress. In extreme cases, the woman may develop cervical cancer, but the process takes several years or even decades. This means you can only develop cancer if you completely forget about having Pap smears taken.

The importance of infections in cervical cancer is also reflected in the empirical observation that nuns practically never have cervical cancer; its prevalence is highest in prostitutes.

Globally, cervical cancer is the second most common cancer among women, since many women, especially in developing countries, cannot have a Pap smear at any point in their lives. The situation is better in Western countries. Finland has been a leader in taking Pap smears, and cervical cancer is actually rare here. Only 150 to 200 cases are diagnosed annually, while the annual rate of breast cancers is more than 3,500 and that of ovarian cancers and endometrial cancers about 600. HPV infections do not always result in cancer. If this was the case, 80 per cent of women would have cancer or a pre-cancer abnormality!

The low rate of cervical cancer in Finland is thanks to Pap smears. Free mass screening for certain age groups are arranged to help identify abnormalities. Several local authorities already invite those aged 25. Local authorities are required by a decree to organise Pap smear screening for those aged 30 to 60 every 5 years. However, there are differences between local authorities in how screening is organised.

When should I have a Pap smear?

Only those women with an HPV infection can develop abnormal cells requiring treatment. Considering how widespread the virus is, this easily happens if she changes partners often enough and forgets to use a condom. The higher the risk of infection, the more frequently Pap smears should be taken. Correspondingly, the interval between Pap smears can be longer if the woman has never been diagnosed with an HPV abnormality and her sexual behaviour does not indicate a high risk of sexually transmitted disease.

  • For most women, having Pap smears every 3 to 4 years is enough 
  • Young sexually active women whose relationships are changing and who perhaps also use oral contraceptives ("the pill") instead of condoms can have a Pap smear as often as every 2 years 
  • If a woman has been diagnosed with HPV, Pap smears could at first be taken as often as once a year to ensure that the abnormalities disappear and do not recur. However, having annual check-ups for the rest of the woman's life and fearing a recurrence is just too much. Over time, tests can be performed less frequently if the abnormalities do not recur 
  • If permanent dysplasia has developed in the cervix and treatment has been necessary, it is best to agree an individual testing interval with a gynaecologist, taking into account the person's entire medical history and the type and grade of abnormality treated 
  • If the couple are not using condoms, it would in principle be a good idea to have a chlamydia test some time after starting a new relationship and a Pap smear after a year or so, because the risk of new infections is highest when starting a new relationship.

On the basis of the above, you can decide for yourself what would be the best Pap smear interval for you.

What about condoms?

If you start a new sexual relationship more often than once a year, it is probably best for your peace of mind to use a condom rather than have frequent Pap smears and STD tests. Condoms are the only way of trying to ensure, at the start of a new relationship, that you do not pass on your own infections to others and do not catch new viruses or bacteria. Unfortunately, condoms do not always provide 100% protection against infection.

If an HPV-related change develops during a longer relationship, you do not need to start using condoms; the infection will have been transmitted already or may do so later when a previous infection activates. Both of you will clear the infection over time. In a long relationship, you will probably have to accept that you may catch your partner's previous infections or pass on yours to your partner at some point, at least when trying for a family.

Genital warts do not cause infertility, although chlamydia does. Genital warts are not a problem during pregnancy and have no impact on childbirth.

Help! What should I do?

If you have caught HPV, don't panic! Look around and think that most people either have the same virus now, have had it before or will have it in the future. The majority of women - and men - you know have probably had the virus for some time without symptoms and then cleared the infection. If no Pap smear was taken over this time, the woman will never know she has had an infection. Neither will she have more frequent Pap smears, unlike her friend who has been diagnosed with the infection and is terrified of developing cancer.

Sometimes, these virus infections only manifest themselves after several decades, when a previous infection reactivates. This often causes unnecessary suspicions of infidelity. Bear in mind that an HPV infection is not necessarily a sign of sexual promiscuity. Even if you've never had casual sex, your partner may be carrying the infection without knowing it. He or she may have had it for a very long time.

If you contract HPV, just remember to check every now and then that the virus has not irritated the cervix. You can also try and control the epidemic by using condoms.

This article was written by
Harri Polvi, Specialist in Gynaecology
This article was reviewed on 26 Nov. 2012 by SI

Key words: Sex, Sexually transmitted diseases, Genital warts