How common is HPV?
In the United States, HPV is considered to be 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. Because HPV is so common and prevalent, a person does not need have to have a lot of sexual partners to come into contact with this virus.

What about HPV and cervical cancer?

• There are many different types of genital HPV.
• Only certain types of HPV are linked with cervical cancer. These are usually called "high-risk" types.
• The types of HPV that cause raised external genital warts are not linked with cancer. These are called "low-risk" types.
• These wart-types of HPV usually are not usually found on a female's cervix, and therefore, are not going to carry any risk of cancer.
• It is common for a person to be exposed and have more than one type of HPV, including several "high-risk" types. Yet, most women do not develop cervical cancer.
• Cervical cancer usually takes years to develop.
• The majority of cases of cervical cancer are in women who have either never had a Pap smear, or have not had one in five years or more.
• Cervical cancer can be prevented if a female gets a Pap smear at regular intervals. This way, if abnormal cell changes are found, it can be monitored and / or treated before progressing to cervical cancer.
• Most of the time, men will not have any symptoms or health risks such as cancer with the "high-risk" types of HPV. It is the female's cervix that needs to be monitored.

What are the symptoms of genital warts?
Only certain types of HPV cause genital warts. Other types, not related to genital warts, can cause abnormal cell changes on the genital skin, usually on a female's cervix.

What do warts look like?
Genital warts appear as growths or bumps. Warts may be raised or flat, single or multiple, small or large. They tend to be flesh-colored or whitish in appearance. Warts usually do not cause itching or burning.

Sometimes genital warts are so small that they can not be seen with the naked eye. This is sometimes called "subclinical HPV." Therefore, a person may not even know he or she has the type or types of HPV that cause genital warts.

The types of HPV that cause raised external genital warts are not linked with cancer. These types are usually harmless.

Where can genital warts appear?

How often can episodes of genital warts occur?

• Some people only have one episode, while others have recurrences
• When warts are present, the virus is considered active
• When warts are gone, the virus is latent (sleeping) in the skin cells - it may or may not be contagious at this time
• Genital warts may or may not return after the first episode
• A healthy immune system helps fight the virus
• Warts may appear within several weeks after sex with someone who has the wart-types of HPV, or it may take several months or years to appear. Or, warts may never appear. This makes it hard to know exactly when or from whom someone got the virus.

• Any person who is sexually active can get genital warts.
• The types of HPV that cause genital warts are usually spread by direct skin-to-skin contact during vaginal, anal or (rarely) oral sex with someone who has this infection.
• Genital warts are most likely to be transmitted when symptoms (warts) are actually present, but sometimes warts are too small to see with the naked eye (subclinical HPV).
• Very little is known about passing subclinical HPV to sex partners. Some experts think it may be less contagious than genital warts you can see.
• The types of HPV that cause genital warts do not usually seem to cause warts on other body parts such as the hands.
• Warts on other parts of the body, such as the hands, are caused by different types of HPV. People do not get genital warts by touching warts on their hands or feet.
• Warts are not commonly found in the mouth, so some experts believe that transmission through oral sex is not likely.
  

How can a person find out if they have genital warts?
Sometimes, warts can be very hard to see. Also, it can be hard to tell the difference between a wart and normal bumps on the genital area. If someone thinks he or she has warts or have been exposed to HPV, they should go to a doctor or clinic. A doctor or nurse will check more closely and may use a magnifying lens to find smaller warts.

A biopsy is not necessary for diagnosing genital warts. This is only done if the bump is unusual looking or discolored.

To look for warts or other abnormal tissue, doctors or nurses may put acetic acid (vinegar) on the genitals. This causes warts to turn white and makes them easier to see, especially if they are viewed through a magnifying lens such as a colposcope. However, the vinegar can sometimes cause other normal bumps to be highlighted, so this method of diagnosis can be misleading.

There are no blood tests available to diagnose a person for HPV.

How can someone reduce the risk of getting genital warts?
Any person who is sexually active can come across this common virus. Ways to reduce the risk are:

• Not having sex 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.
• If someone has visible symptoms of genital warts, he or she should not have sexual activity until the warts are removed. This may help to lower the risk of giving the virus.
• Condoms (rubbers), used the right way from start to finish each time of having sex may help provide minimal protection - but only for the skin that is covered by the condom. Condoms do not cover all genital skin, so they don't protect 100%.
• Spermicidal foams, creams and jellies are not proven to act against HPV and genital warts, but they work against some other STDs. These are best used along with condoms, not in place of condoms.
• If someone was exposed to a type of HPV that causes genital warts, it would be unlikely that he or she will become re-infected with that same type, since immunity will be set-up at some point.
• It is important for partners to understand the "entire picture" about HPV so that both people can make informed decisions based on facts, not fear or misconceptions.
  

• Currently, there is no treatment to cure HPV; there is no cure for any virus at this point. However, there are several treatment options available for genital warts.
• The goal of any treatment should be to remove visible genital warts to get rid of annoying symptoms. No one treatment is best for all cases.
• Treating the warts may possibly help reduce the risk of transmission to a partner who may have never been exposed to the wart-types of HPV.
• When choosing what treatment to use, the health care provider will consider the size, location and number of warts, changes in the warts, patient preference, cost of treatment, convenience, adverse effects, and their own experience with the treatments.
• Some treatments are done in a clinic or doctor's office; others are prescription creams that can be used at home for many weeks.

Treatments done in the doctor's office include:

• Cryotherapy (freezing off the wart with liquid nitrogen). This can be relatively inexpensive, but must be done by a trained doctor or nurse.
• Podophyllin (a chemical compound that must be applied by a doctor or nurse). This is an older treatment and is not as widely used today.
• TCA (trichloracetic acid) is another chemical applied to the surface of the wart by a doctor or a nurse.
• Cutting off warts. This has the advantage of getting rid of warts in a single office visit
• Electrocautery (burning off warts with an electrical current)
• Laser therapy (using an intense light to destroy warts).This is used for larger or extensive warts, especially those that have not responded well to other treatments. Laser can also cost a lot of money. Most doctors do not have lasers in their office and the doctor must be well-trained with this method.
• Interferon (a substance injected in to the wart). This is rarely used anymore due to extensive side effects and high cost. Less expensive therapies work just as well with fewer side effects.

At-home prescription creams:
These are only available by a prescription from a doctor:

• Podofilox cream or gel (Condylox®). This is a self-applied treatment for external genital warts. It doesn't cost much, is easy to use and is safe, but it must be used for about 4 weeks.
• Imiquimod cream (Aldara®). This is also a self-applied treatment for external genital warts. It is safe, effective and easy to use. This cream is different than any other treatments. Other treatments work by destroying the wart tissue, but Aldara actually boosts the immune system to fight HPV.
  
  

• Most pregnant women who have had genital warts previously but no longer do would be unlikely to have any complications or problems during pregnancy or birth.
• Most children are born healthy to women with a history of genital warts.
• Because of hormone changes in the body during pregnancy, warts can grow in size and number, bleed, or, in extremely rare cases, make delivery harder.
• Very rarely, babies exposed to the wart-types of HPV during birth may develop growths in the throat.
• Despite this risk, a woman with genital warts does not need to have a cesarean-section delivery unless warts are blocking the birth canal. This is because the risk of a cesarean section is greater than the very rare risk to the baby of getting warts.
• It is important that a pregnant woman notify her doctor or clinic if she or her partner(s) has had genital warts. This way they can determine if they need to treat the warts or not during the pregnancy.

HPV: Get the Facts
HPV and Abnormal Cell Changes

What is cervical dysplasia?
When a female goes to a clinic or her health care provider for a Pap smear, they are screening the cells on her cervix to make sure that there are no abnormal or precancerous changes. If the Pap smear results show these cell changes, this is usually called cervical dysplasia. Other common terms the health care provider may use include:

• Abnormal cell changes
• Precancerous cells changes
• CIN (cervical intraepithelial neoplasia)
• SIL (squamous intraepithelial lesions)
• "Warts" on the cervix

All of these terms mean similar things - it simply means that abnormalities were found. Most of the time, these cell changes are due to HPV. There are many types of HPV that can cause cervical dysplasia. Most of these types are considered "high-risk" types, which means that they have been linked with cervical cancer.

• Just because a female has cervical dysplasia, it does not mean she will get cervical cancer. It means that her health care provider will want to monitor her closely every so often - and possibly do treatment - to prevent further cell changes that could become cancerous.
• HPV is a very common virus, and most females with HPV do not develop cervical cancer.

What about abnormal Pap smear results?
The term "abnormal Pap smear" is broad and not very specific. There are many different systems that health care providers use to classify a Pap smear. Within each system, there are different degrees of severity or abnormalities. Different classification systems and degrees of severity include:

• Descriptive System: mild, moderate, or severe dysplasia
• CIN System: CIN (cervical intraepithelial neoplasia) 1, 2 or 3
• Bethesda System: ASC-US (Atypical Squamous Cells of Undetermined Significance - which means the results look borderline between “normal” and “abnormal”); ASC-H (Atypical Squamous Cells - borderline, but may really include High-Grade lesions); Low-Grade or High-Grade SIL (squamous intraepithelial lesion)
  
• Class System: Class 1 though Class 4.

Women with abnormal Pap smears are usually examined further for cervical problems. This may involve coming back for a colposcopy and biopsy, or coming back in a few months for another Pap smear. If the Pap smear result is “ASC-US,” then a test for HPV may be performed to see whether HPV is causing this borderline “normal-abnormal” Pap smear result.

It is important for a female to get a Pap smear at regular intervals by the time she reaches 18 years of age, or by the time she becomes sexually active - which ever comes first.

What's the difference between a Pap smear, a biopsy and an HPV test?

A Pap smear is a screening to find abnormal cell changes on the cervix (cervical dysplasia ) before they ever have a chance to turn into cancer. The majority of precancerous cervical changes are caused by HPV.

A biopsy is similar to a Pap smear, but a larger cluster of cells is removed from the cervix to see if there are abnormal cell changes. It is a good way to confirm the earlier Pap smear result and to rule out cancer. If a biopsy is done, it will be performed at the same time as the colposcopy.

An HPV test is different than a Pap smear or biopsy. This test checks directly for the genetic material (DNA) of HPV within cells. The only commercially available test for HPV is called Hybrid Capture II™), produced by Digene.

It is most convenient if the HPV test is done in the laboratory from a liquid-based Pap test sample. The most common commercially available liquid-based test is called ThinPrep®, manufactured by Cytyc.

When is the HPV test used?
If a Pap smear result is borderline between "normal" and "abnormal." This is usually called "atypical squamous cells" or "ASC-US." The HPV test is most commonly used to determine which women with a borderline result are likely to have precancerous changes on their cervix (HPV positive) and which are most likely to be normal cells (HPV negative). It helps to rule out whether HPV is causing the borderline abnormal cells.


When is the HPV test NOT used?

• If the Pap smear results show dysplasia or precancerous changes. This is because it is automatically assumed that the HPV is the cause.
• The HPV test can not be used on males.
• The HPV test is only FDA approved to be used on the female's cervix.

Can a male find out if he has the cell changing-types of HPV?
Research has shown that the HPV test usually shows false negative results in men. This is because it is difficult to get a good cell sample to test from the thick skin on the penis.

Most people will not have visible symptoms if they are exposed to HPV. Therefore, for most, the virus is subclinical (invisible). This is especially true for males. If a male is exposed to the cell-changing types of HPV, he would be unlikely to have symptoms. If there are no symptoms for males, it is hard to test for it.

Most of the time, men will not have any health risks such as cancer with the "high-risk" types of HPV. It is the female's cervix that needs to be monitored.

How can a person get the types of HPV that cause cell changes?

• Any person who is sexually active can be exposed and get the cell-changing types of HPV.
• Most people are exposed to the cell-changing types of HPV at some point, but not everyone (especially males) will actually have abnormal cell changes (dysplasia).
• The types of HPV that cause abnormal cell changes are usually spread by direct skin-to-skin contact during vaginal, anal, or possibly through oral sex, with someone who has this infection.
• The cell-changing types of HPV are most likely to be given to a partner when dysplasia is actually present.
• Very little is known about passing subclinical (invisible) HPV to sex partners. Some experts think it may be less contagious than when the cell changes are present.
• The types of HPV that cause abnormal cell changes do not typically cause symptoms on other body parts such as the hands.
• Recent research studies have shown a relationship between a cell-changing type of HPV and some rare head and neck cancers, but there is not much evidence that oral sex definitely transmits these types of HPV.

How can someone reduce the risk of getting HPV?
Any one who is sexually active can come across this common virus. Ways to reduce the risk are:

• Not having sex 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.
• If someone currently has abnormal cell changes, he or she should not have sexual activity until after the cells have been treated or have self resolved. This may help to lower the risk of transmission.
• Condoms (rubbers), used the right way from start to finish each time of having sex may help provide minimal protection - but only for the skin that is covered by the condom. Condoms do not cover all genital skin, so they don't give 100% protection.
• Spermicidal foams, creams and jellies are not proven to act against HPV, but they work against some other STDs. These are best used along with condoms, not in place of condoms.
• If someone was exposed to the types of HPV that can cause abnormal cell changes, it would be unlikely that he or she will become re-infected with those same types since immunity will be set-up at some point.
• Realize that most people are exposed to one or more HPV types in their lifetime, and most will never even know it because they will not have visible symptoms.
• It is important for partners to understand the "entire picture" about HPV so that both people can make informed decisions based on facts, not fear or misconceptions.

How are abnormal cells treated?

• Currently, there is no treatment to cure HPV; there is no cure for any virus at this point. However, there are several treatment options available for treating the abnormal cells.
• Sometimes treatment may not even be necessary for mild cervical dysplasia . These cells can heal on their own and the health care provider will just want to monitor the cervix. HPV may then be in a latent (sleeping) state, but it is unknown if it totally gone or just not detectable.
• The goal of any treatment will be to get remove the abnormal cells. This may also end up removing most of the cells with the HPV in them.
• If the abnormal cells are treated, or if they have healed on their own, it may possibly help reduce the risk of transmission to a partner who may have never been exposed to the cell-changing types of HPV.
• When choosing what treatment to use, the health care provider will consider many things:
  · location of the abnormal cells
  · size of the lesions on the cervix
  · degree or severity of the Pap smear results
  · degree or severity of the colposcopy and biopsy results
  · HPV test results (if this test was needed)
  · age and pregnancy status
  · previous treatment history
  · patient and health care provider preferences

There are a variety of treatments for cervical dysplasia:

• Cryotherapy (freezing the cells with liquid nitrogen).
• LEEP (Loop Electrosurgical Exision Procedure)
• Conization (also called cone biopsy)
• Laser (not as widely used today due to high cost, lack of availability, and not all doctors are well-trained with using it. LEEP is more commonly used)
• No treatment at all since even mild abnormal cell changes may resolve without treatment. The health care provider may just monitor the cervix by either doing a colposcopy, repeat Pap testing, or a test for HPV.

What about pregnancy, HPV, and cervical dysplasia?

• For some pregnant women, cervical dysplasia may increase. This may be due to hormone changes during pregnancy, but this is not proven.
• If a woman has an abnormal Pap smear during pregnancy, even if it's severely abnormal, many health care providers will not do treatment. They will just monitor the cervix closely with a colposcope during the pregnancy.
• Sometime (a few weeks) after delivery of the baby, the provider will look at the cervix again and do another Pap smear or another biopsy. Many times after pregnancy, the cell changes will have spontaneously resolved - and no treatment will be necessary.
• The reason that many health care providers do not want to do treatment during pregnancy is because it may accidentally cause early labor.
• The types of HPV that can cause cell changes on the cervix and genital skin have not been found to cause problems for babies.

What about HPV and other cancers?
Anal dysplasia and anal cancer:

• Anal cancer is a rare occurrence that has been strongly linked to "high-risk" types of HPV.
• Abnormal cell changes in the anal area (anal dysplasia or anal neoplasia) are more common among individuals who engage in receiving anal sex.
• However, anal dysplasia has also been reported in some females who have a history of severe cervical dysplasia
• Treatment is available for anal dysplasia and anal cancer

Penile Intraepithelial Neoplasia (PIN) and penile cancer:

• Cancer of the penis is extremely rare in the United States, and HPV is not always the cause
• There are some cases of cell changes (neoplasia) on the penis, which are caused by "high-risk" types of HPV.
• Most males do not ever experience symptoms or health risks if they get one or more "high-risk" types of HPV.
• Penile neoplasia can be treated.
• There is not a cancer screening for the penis because cancer of the penis is extremely rare, and because it is difficult to get a good cell sample from the penis.

Vaginal Intraepithelial Neoplasia (VAIN) and vaginal cancer:

• HPV has been linked with some, but not all, cases of cell changes in the vagina and with vaginal cancers.
• Various treatment options are available for vaginal neoplasia, depending on how mild or severe the cell changes are in this area.

Vulvar Intraepithelial Neoplasia (VIN) and vulvar cancer:

• HPV has been linked with some, but not all, cases of cell changes on the vulva (outside female genital area) and with vulvar cancers.
• Various treatment options are available for vulvar neoplasia, depending on how mild or severe the cell changes are in this area.