HPV Warts: The Misunderstood STD An Expert Weighs In on HPV Infection

HPV warts are a common sexually transmitted disease (STD), and yet many women are confused about them. What kind of HPV infection causes warts, how are they treated and how dangerous are they? We turn to a top women’s health expert for answers... Many sexually active women worry about STDs, such as chlamydia or herpes. But there’s another extremely common one you need to watch for. If you’re sexually active, you may have been exposed to external genital warts (EGW), an embarrassing and sometimes painful condition caused by infection from some types of human papillomavirus (HPV). About 20 million Americans are infected with HPV, according to the Centers for Disease Control and Prevention (CDC). An additional 6 million people become newly infected each year. Though HPV warts cause painful skin bumps, they aren’t the same as genital herpes, which is an unrelated virus. But as with herpes, once you’re infected, they stick around for life. “I’ve had older women show up with the warts for the first time in their lives, and they’re widows [who] haven’t had sex for 20 years,” says Anita L. Nelson, M.D., a professor of obstetrics and gynecology at UCLA’s medical school and staff physician at Harbor-UCLA Medical Center in Torrance, Calif. “Suddenly their bodies can’t cope with a virus that they’ve been walking around with for decades, and it shows itself,” Nelson says. To learn more about this common STD, read on as Nelson explains the risks and treatments for HPV warts. What causes external genital warts? They’re caused by certain kinds of sexually transmitted HPV. There are more than 40 HPV types that can affect the genital area of women and men. But more than 90% of genital wart cases are due to HPV types 6 and 11. HPVs are almost always a marker [of sexual activity]. If you look at folks in their 80s or 90s, and their lifetime exposure, about 85% of people will get at least one HPV infection. Genital warts are one of the earliest manifestations of an HPV infection. How common are HPV 6 and 11? Are you ready for this number? One percent of all sexually active women and men get genital warts every year. We see them in everyone – women in pregnancy, young women exploring their sexuality, older women. How soon after contact do the warts typically occur? That’s one of the most frequently asked questions, because [a woman’s] really asking, “Who gave it to me?” Typically, you get warts within 1-4 months [after HPV infection]. But the virus can be kept in check by the immune system until the guard goes down. Does everyone exposed to HPV 6 and 11 get warts? After a woman gets the infection, warts can blossom – or you can have none at all, as the body’s immune system fights [the virus]. It’s the presence of the wart and the [strength of] the immune system that tell us whether she’ll get visible HPV warts. Can HPV warts surface at any time in your life – even years after exposure? Yes, it puts you on a lifetime of surveillance. Sometimes, we’ll see [them] later in life, when people get sick or their immune system gets compromised either by chemotherapy or other drugs. So it’s not just when you get a new sex partner. It’s possible to have to fight [an HPV] infection your whole life. How can a sexually active woman avoid getting HPV warts? Using condoms consistently reduces the risk of acquiring or transmitting the virus and would help decrease the risk of getting the warts in general. Also, interestingly, this virus infects rapidly dividing cells. So anywhere there’s a little trauma, tear or abrasion, the body can pick up the HPV infection and bring it inside the cells. Sometimes we’ll see the warts with younger women, because it’s the first time they’ve had sex and the vaginal tissue isn’t quite elastic. It’s the same with some older women [who have] dryness. Does the number of sex partners a woman has in her lifetime increase the risk of HPV warts? Yes, people who have had more than 10 sexual partners over their lifetime are more likely to report a diagnosis of genital warts than those who’ve had one or two. The more sex partners you have, the more likely you are to have the different types of HPV infection. And there’s no limit to how many [different] HPVs you can have. Limiting the number of partners and using condoms are very important. Are HPV warts spread only through genital contact? No, the virus also [creates] warts in the mouth, throat – even the inside of the eyelids. You can spread the virus from [any] moist source to another. But there has to be a source, and generally you’re going to be carrying [the virus] in the genitals. We have to be quite frank about sexual practices today. There’s a lot of oral-genital contact. If he has a little wart in his mouth, it can wind up on her genitalia – or the other way around. Can HPV warts lead to cervical cancer? There are so many different types of HPV. The ones we usually see with the warts are 6 and 11, and they make up about 90% of the warts. These do not cause cancer. But the other 10% of warts can have viruses mixed in, including those that can cause cancers in the genital area, such as cervical or vulva cancers or even anal cancer. You can’t tell by looking at the wart. But a wart isn’t a death sentence. Are external genital warts more a scary psychological issue than a fatal health danger? It may cause some physical discomfort, such as burning and itching, or even bleeding in an intimate situation. But there’s also psychological discomfort to realize you’ve been exposed to a virus that you’re going to live with for the rest of your life. And somebody’s probably [saying] that some of the viruses cause cancer. So when you find out you have EGW, you have a lot of issues to deal with, not just that little bump. Are women more likely than men to get the warts? No, but we have more statistics on women because doctors tend to [see] women much more routinely. [Gynecologists] do a Pap smear, looking inside and all over. Guys tend to just look at themselves [and] don’t come in for routine exams. A fact I find sad: In most of the clinical trials, the guys have had their warts a lot longer than the women have. When a woman sees one of those things, she rushes [to her doctor] and says, “Get it off of me!” Can Pap tests detect HPV warts? Not the warts, but [they can detect the HPV] virus. How are they diagnosed? You want to have them professionally diagnosed. Usually [physicians] just eyeball them and don’t have to do a biopsy. A doctor can tell right away it’s a wart [because] they have a little attachment to the skin and multiple protuberances from the single stalk. What do the warts look like? They’re chameleons. They can look soft and fleshy, almost like a skin tag, or rock-hard and large with branches like a cauliflower. They can be a small little dot or bigger than your fist. Are they easier to treat if discovered early? Yes, don’t wait. When you feel a bump, especially around the opening of the vagina, or behind the vagina where there has been contact, see your doctor. Also, it’s important to know that once you get infected, it’s a regional infection. For example, you can get a wart inside your anus even if you haven’t had anal sex. How soon should a wart be treated? It’s not a medical emergency. But the HPV warts that are really hard to treat have been there for months and have hardened. If you can’t get an appointment for 2-3 weeks after feeling the bump, don’t freak out. But don’t wait months. Most women will get the HPV virus and their body can handle it. But women with a persistent HPV infection are the ones we want to [identify]. I want to see a young woman three or four years after she has had sex to see if she can handle the virus or not. Is she having persistent infections, which could be a predictor of cervical cancer? Those are the women we want to find, so we can treat any pre-cancers. For women over 30 who got the virus earlier in life, we’re testing to see if they show cells that go awry and also [to determine] if they’re still shedding the virus. When a woman has visible HPV warts, should she stop having sex? When we’re treating women for warts, we ask them to be particularly careful and maybe even abstain from sex. [That’s because] as we’re treating it, [there are] inflammatory changes and maybe even a little ulcer, and those tissues are more vulnerable to acquiring another infection. So take it easy for a while or use condoms. [Abstain from] oral sex too. Once you have HPV warts, are you always contagious? You spread more viral particles when you have a concentration of [warts]. But [with] a treatment, you rev up the body’s immune system, and it will help reduce the amount of viruses you have and spread. You [also] can avoid spreading through safe sex practices. What’s the recommended treatment for HPV warts? Get rid of the warts. We can treat fresh warts with easy topical therapies. There are three [at-home] creams your doctor can prescribe that can be applied in different ways. Imiquimod 5% (sold as Aldara), [is] a cream that’s applied 3 times a week, until the wart melts away, for up to 16 weeks. Imiquimod 3.75% (Zyclara) [is] a cream you use daily for up to 8 weeks. Then there’s podofilox (Condylox), a prescription gel or liquid you use for 3 days and then you take off 4 days, for up to 4 cycles. How do these work? Podofilox works by destroying the skin of the wart. The two imiquimods are really groundbreaking because they don’t play with the wart at all, but instead turn on the body’s immune system, [which] attacks the virus in the wart so it melts away. These therapies have really simplified things. When a new wart comes, just put cream on it. Are there natural remedies? [One treatment is] green tea extract, which is applied 3 times a day for up to 16 weeks. We’re not quite sure how it works, but some people really like the idea [because] it’s natural. Green tea is an antioxidant. You use it in ointment form (Veregen). How are hardened warts treated? If you’ve had them for a while and they’ve hardened, then you’re talking doctor-administered destructive therapies. We can snip them off if they have a tiny base. Or we can freeze them with acids to dehydrate them and kill the cells. For the ones that are really hard to deal with, we’ll [surgically] excise them or do laser treatments. Are women more likely to get HPV warts if they’re on oral contraceptives? It isn’t that the pill causes more problems, but that condoms protect [against HPV infection]. That said, if someone can’t knock down her warts after you’ve treated it, it may be that her immune system is teetering on the edge and the pill pushed it over. But I would never stop [prescribing] a woman’s pill just because she had a wart. Are HPV warts a danger during pregnancy? The virus can be passed on before or during birth, but the warts don’t pose a major risk to the baby’s health. Symptoms of genital warts can get worse during pregnancy, however, because [a woman’s] immune system gets suppressed, [making her more susceptible to viruses and infections]. Warts can blossom so much that they’ll obstruct delivery of the baby. And you have to treat the warts in a way that’s not harmful to the baby. Do the HPV vaccines (recommended for girls ages 9 to 26) protect against the warts? Gardasil protects against the two HPVs that cause 90% of genital warts. Cervarix doesn’t. Both protect against the HPVs that cause 70% of cervical cancers. Warts are tangible, so you can say to your kids, “See that? You don’t want to get one of those.” So it may be part of the discussion about the vaccines. What are the top things a woman should keep in mind about HPV warts? Use condoms and be choosy in your partners. People ought to take a good look at what they’re being exposed to when they’re getting into a relationship where there’s going to be sex. Also, make sure you’re paying as much attention to health in your genital area as you are to other parts of your body. Some women are more in tune with the bottoms of their feet than they are with the beauty of their genitalia. Self-examine, and at least feel if there are any bumps or areas of soreness where there shouldn’t be. And don’t hesitate to see your doctor if you do find anything. For more information, visit our Women's Health Center.