Genital Warts on Women

Everything About Genital Warts!

When genital warts is my talking point, frequently someone in the room says; “It’s not common in our country”. We now know thanks to research by Prof. Dr. Nejat Özgül, published in 2011 thanks to data collected from KETEMs around Turkey that; the frequency of genital warts in Turkey is around 97 to 131 in 100.000, which is around the SAME rates as France and Spain. You can find the research on the internet.

Another afflictive part of this issue is; despite the fact that it is an easily curable disease, due to social and psychological problems caused by it, it is regarded as a nightmare by the patients.

This is due to exaggerated presentations and misinformation published on the internet. For this reason, I decided to share information with academic basis, without exaggerations or misinformations on my website.

The information below was prepared in a question-answer format, using the most frequently asked questions by the patients. I hope that this information will be helpful for you.

1.      1. GWhat is Genital Warts (condiloma acuminado or condiloma in short)? Which areas are infected by it and how it is detected? How can I detect condolimas?

Genital warts are seen mostly around vaginal area (large and small vaginal lips), inside the vagina, cervic area and around or inside the anus. These are lesions that differ in size, mostly brown, over the surface and look like the head of a burnt match. They might affect a larger area or might be sparse.

They might be detected as large and protruding dark brown or pink masses when they merge. They will bleed if plucked. It requires attention especially when waxing. Bleeding is not a big problem. But the blood that touches the infected area might get infectious. The lesions you see above and below are genital warts, common after waxing.

If a fresh and large wart is detected on a woman or men, such as the one on the picture above, it has a higher infection rate.

The patient will notice bleeding while waxing frequently but will not take a precaution. Sometimes patients pluck the condilomas. A former patient plucked off her condilomas thanks to advice from her boyfriend by using a razor. The results were a disaster) This causes the lesions to spread a lot faster.

2.      2. Which HPV types cause it?

Condyloma (genital wart) is a sexually transmitted disease, caused by HPV types 6 and 11. Between 90 to 94 percent of all condilomas are caused by Types 11 and 6.

HPV types 6 – 11 – 40 – 42 – 43 – 44 – 54 – 61 – 72 – 81- 89 might cause genital warts (condyloma).

Most importantly, HPV types 6 and 11 might cause mouth and throat warts in addition to genital warts. The important point here; is the fact that the genital area, mouth and throat mucous tissues show great affinity towards types 6 and 11, which means they don’t cause warts in other areas
easily.

Despite this fact, HPV types 2, 7, 6, 11, 16, 18, 32 and 57 might cause papillary lesions, but a very small proportion of these are warts. Lesions are usually small but tall protrusions. The types that cause warts in the mouth are 6 and 11.

3.      3. How it gets transmitted? What happens after the transmission?

Condyloma (genital wart) is a sexually transmitted disease, caused by HPV types 6 and 11. In the USA, 5.6% of all sexually active people between the ages of 18 and 56 have a diagnosed genital wart history.

The prevalence rates in Turkey are 154 in 100.000 and incidence rates are between 97 and 131 in 100.000. The recurrence rates are between 15 and 37 in 100.000. The incidence rates in the USA are between 170 and 205 in 100.000. The rates in Turkey are more similar to the ones seen around Europe.

The genital warts IS ACTUALLY present in Turkey. Don’t believe people who say “We don’t have it, cause polygamy doesn’t exist in Turkey” 😊 The issue is not really related to polygamy as much as it is thought.

Genital warts are most infectious during oral, anal and genital contact.

It might infect patients through mouth mucous during oral sex.

A frequently asked question is; if the disease is infectious in cases other than sexual contact.  

Mothers with condyloma might infect the baby during birth. But this is a very rare occurance. I will answer this question in more detail on another part. But other than these two ways; wearing the same clothes or using the same towel is an anectodal explanation, which I don’t believe the accuracy of.  

 

One of the most frequent questions asked about infection is the time of it. After all the research, we still don’t know the effects of this virus on our immune system clearly. But the observations show that the virus have stayed idle for a long period of time with a group of people, after entering their system through epithel tissues. So they can stay idle in cells without being activated and the disease might occur years after, in a period when the immune system is weak.

If we generalize, the occurance of the disease after the initial infection is within the first 8 weeks. Warts are frequently seen during the first 8 weeks after the infection. But the progression of the disease might differ from patient to patient, according to the situation of their immune systems.

While 40% of women do not have warts despite infection, around 40% have small lesions.If you notice lesions similar to these, do not wax or try to pluck the lesions out with your nails or any other device. These lesions might disappear naturally after 2-3 weeks.

Around 20% of occurances see that these lesions are prevalent and aggressive. The reason for this difference between patients, is due to the relation between the patient, virus and the immune system of the patient. Some women have strong immune systems which eliminate the virus quickly. (These figures were taken from a related article published on North America Obstet and Gynecology Magazine. Figures might differ on various sources. The reason for mentioning this numbers is to give an estimation of the ocurrance and prevalence rates.)

4.      4. How are Genital Warts Diagnosed and Which Methods are Used for This Purpose?

Most warts don’t cause discomfort, but they might cause pain or itchiness according to their location. Genital warts have a flat, popular  and peduncle corpus and are caused by genital mucous.

They are mostly seen on the vaginal entrance region called introitus on women, on the base of the penis and body for circumcised men and on the skin the head of the penis for uncircumcised men. Other than these most frequent regions, genital warts might be seen on; anus and around all genital areas (cervix, interior of the vagina, urinary tract, anus area and testicle skin area etc.).

Genital warts’ diagnosis is done by a clinician. If; there is doubt on the diagnosis, the warts don’t disappear through standard treatment, the situation advances through treatment, the lesion is not typical, the immune system of the patient is suppressed (Leukema, AIDS etc.), the warts are colored, swollen and bleeding, the diagnosis must be confirmed by a biopsy.

Some clinicians diagnose the warts by applying 3-5% acetic acid on the lesion and observing the lesion turning white. This method has its advantadges and disadvantadges. The biggest criticism of this method is due to the fact that acetic acid might turn skin white for a number of other factors. On the other hand, flat warts are seen with ease thanks to the asetic acid application. Especially during a peniscopy, the use of acetic acid is important to detect flat and hard to see warts.

5.      5. Do They Really Cause Cervical Cancer? Or like you asked: “I read it and apparently I have an 80% chance of having cervical cancer. Is this true doctor?”

It is both a YES and a very big NO!

Yes, HPV types 6 and 11 increase your chance of having cervical cancer. But the increased risk is very small and your chances of having it is only minimally larger than someone without the virus. For this reason, these types are evaluated as “Low Risk”.

So no, you have around 80% chance (which is not even applicable to other types) of not having cancer. The important part is, that you continue taking smear regularly and have vaccinations. The natural immune system will not protect you for each infection. This is why it’s important to have vaccinations in order to make sure you are immune.

6.      6. How Can I Protect Myself from Condylomas and Warts?

The ideal method for protection is monogamy, which is having one partner. I don’t believe that this is a very realistic approach though. Although most of us have monogamous relations, there will be naughty ones amongst us. As a Turkish saying goes; “No mortal is flawless.” 😊

According to various sources, condom use helps prevention by between 40 and 80 percent. If by any chance the female has active and observable condyloma, there will be contact with the penis root as this part is exposed.

For this reason, the penis root is where these warts are most frequently seen on males. For men, having circumcision is a big advantage. Although some of the statistics gathered by research among muslim and jewish men contradict this theory, most research show that circumcised men have a lower chance of contacting HPV.

But the primary method of protection is vaccination. Vaccination provides around 95 to 100 permanent percent protection from warts, among teens who are not sexually active yet.

7.      7. What are the Treatment Methods?

The Essence of Genital Warts Treatment

The most common point of all the stories told by my patients is that they have been through medicinal and operationsl treatment numerous times. In fact, it is very important to talk to the patient and discuss this process thoroughly before any procedure. It is actually the ethical thing to do for the doctors, to discuss and reflect the financial burden this probably long process will create.

While planning the treatment process for general warts (condylomas) three basic factors must be considered:

1.      1. The Intent of the Patient and Their Previous Experiences: If the patient has been treated numerous times before, for example if the below medicinal treatments which I will shortly mention were applied but failed, they might choose an operation.

2.      2. Medical Capabilities: The medical centre where the patient went to might not have the destructive devices that are necessary for the operation. Otherwise, the patient might have another systemic disease which prevents them from having the operation.

3.     3.  The Experience of the Clinitian/Doctor: In todays world, it is believed that differents treatment and monitoring routines developed by clinics and doctors are important for achieving best results.

Although research conducted until today show that different wart treatment methods do not have an edge over each other, I personally believe that cauterization is the better one, as it doesn’t make the lives of patients miserable. Cauterization also most likely will cure the problem in the first treatment. On the other hand, some patients prefer medical treatments (creams, pomade).

As I have emphasized earlier, the role of the doctor should be to lay all the cards on the table for the patient with the benefits and disadvantages, while discussing different options and making a mutual choice with the patient.

The method of the treatment is determined by factors such as; the size, quantity, anatomical location and shape of the wart, in addition to the preference of the patient, the cost of treatment, the benefits it will provide, its side effects and the experience of the doctor. The reaction of the patient to the treatment is determined by; the current situation of their immune system and their compatibility with the chosen treatment.   Generally warts are either on moist or folded areas, so they respond well to surface treatment.

The method of treatment should be changed, if no improvement is observed in the end of the treatment and there is no regression or side effects. Most genital warts respond to treatment within the first 3 months of treatment. The effectiveness of the treatment should be monitored during the process.

When the treatmen is done flawlessly, most of the time there won’t be any complications. It is possible for the patients to develop hypo-hyper pigmentation (decolorization or overcolorization of the skin) after ablative treatment. This might also occur on treatment types carried out through the immune system (imiquimod).   Epulosis in the scar area and unlevel skin is rarely seen in cases where the time between the treatments were not enough for the scar to heal.

The treatment might cause chronic pain syndromes on the outer genital area or painful defecation on patients with anal warts. Some systemic side effects were also reported, which are extremely rare and mostly occur after the use of podophyllin.

It is MEANINGLESS to apply general anaesthesia to patients during cauterization of condylomas and genital warts. General anaesthesia might rarely be necessary, on selected cases where the infection is widely spread and covers a large area.

A) Medical Treatments:  

1. Podophyllin:  Podophyllin is an herbal based medicine we use for a long time, that slows the cell cycle. It is prepared by adding to paraphin with a 5 to 25 percent ratio. It should be applied between 1 to 3 months.  It is an antimitotic (one that prevents mitosis) medicine.

It is relatively cheaper, and in most sources, it is said to be an easy-to-use medicine as the patients can apply it themselves. But unfortunately, reality is different. The patients who use the medicine understand this point after a very short period.

Pofophyllin treatment is applied by a cotton stick in the first three days, twice a day. The crucial point is to avoid contact with uninfected tissue. The following four days the treatment is paused.   After which, the treatment is applied again for 3 days. This cycle can be repeated for up to 4 times.

The hardships of this treatment are; avoiding contact with uninfected tissue, keeping the treated warts area under 10cm2 and the amount of podophyllin used under 0.5ml. If possible, the doctor carries out the first treatment, showing the patient how podophyllin is applied and which warts are the priority to start the treatment on.

Soft or mild irritation and pain might occur after treatment. It should NEVER be applied on open wounds.

Due to insufficient information on the use of podophyllin during pregnancy, it is recommended to avoid this type of treatment for pregnant women. IT SHOULD NOT BE USED DURING PREGNANCY.

2. Imiquimod:  It is an immune booster, applied on the surface, that increases the production of interferon and other cytokines (immune intermediaries). Imiquimod cream is applied 3 nights a week and once each application. This treatment might last up to 16 weeks.

6 to 10 hours After the application of the cream, the area should be cleaned with water and soap extensively.   . Imiquimod application might cause rashes, swelling, erosion/ulceration, vesicle, in addition to color loss on skin. Due to its side effects, it’s NEVER recommended to use on penis surface, vagina area and vulva. It is extremely irritant and should NEVER BE APPLIED to normal skin.

Imiquimod use might hinder the effectiveness of condom and vaginal diaphragm. Due to insufficient information on the use of imiquimod during pregnancy, it is recommended to avoid this type of treatment for pregnant women. IT SHOULD NEVER BE USED DURING PREGNANCY.

An important and less known point, is that if aldara is ineffective at first and after 12 weeks of proper use, there is no improvement,  it should not be tried a second time and the patient should try a different method. When it’s applied for a second time, it might worsen the situation.

Bunun sebebi ilacın hpv’nin çekirdeğinde erken protein gen lokuslarından bazılarında yaptığı etkidir. Sonuçta farklı bir yönteme geçmek şarttır.

3.Sinecatechins: This ointment is an active green tea extract called Cathecin. It is applied by finger, 3 times a day, covering all areas of warts. It should not be used for longer than 16 weeks. The applied area should not be washed after use. Sexual contact should be avoided after the application of the ointment.

The most common side effects of sinecatechins are; erythema, itching, burning, pain, ulceration, edema, swelling and vesicles. The use of this medicine might cause ineffectiveness of condoms and vaginal diaphragms.

There is no scientific data to compare the effectiveness and safety between this type of treatment with the others. It should not be applied on people with oppressed sinecathechin immunity, HIV virus and genital herpes, due to lack of data on its safety and effectiveness.

Also due to insufficient information on the use of this medicine during pregnancy, it is recommended to avoid this type of treatment for pregnant women. IT SHOULD NOT BE USED DURING PREGNANCY.

4.(Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA): It is a medicine that is used for years, where we apply between 3 to 5 percent acetic acid. It is used on pregnant women, since it is known not to be harmful for children and has no systemic effects. It should be applied around 1-2 months.

Both these chemicals make a positive impact thanks to their properties that chemically coagulate proteins in warts by corroding/burning. Despite these chemicals widespread use, these medicines have not been researched extensively.

As method of application; the area that TCA is applied to turns white and the patient should avoid sitting or getting up before this area dries up. If necessary, the treatment can be applied once or twice a week. The important thing is to avoid contamination on uninfected areas. If too much TCA is applied, talc, sodium bicarbonate or liquid soap should be applied. It can be used during pregnancy.

B) Operational Treatments: 

1.Electrocauterization: This is by far my favorite treatment. It is usually applied without the need for general anesthesia. It is a treatment where the patient can be treated for good with one step.

The crucial point is that the application should be done by an experienced doctor, cauterizing the lesions in the correct depth. Although medical books state that this treatment might leave marks, it is a very rare occurrence.

The first 10 days, the area might have a bad visual look. After 20 days, the cauterized areas mostly heal without a problem. On the other treatment types, the patient is dependent on the doctor. They might have to visit the doctor frequently. But after cauterization is completed in one step and the patient will only come for a control after 20 days.  

2. Cryocautery: It is destroying by freezing. It aims to destroy the lesions directly. It is a method, most frequently used by dermatologists, which is relatively harder to apply. It requires different cryo tips. It is hard to destroy warts in the correct depth with cryo. The warts may also be frozen by spray.

The reason I do not prefer this method is, because it requires different cryo tips and if spray is used, the results are hard to foresee. During a 2012 research comparing laser with cyrocautery, conducted on 160 cases, the rate of recurrence for patients treated with cryo is twice compared to laser treated patients. (Azizjalali M. ve ark. CO(2) Laser therapy versus cryotherapy in treatment of genital warts; a Randomized Controlled Trial (RCT). Iran J Microbiol. 2012;4:187-90.)

On the other hand, another research comparing imikamol and krikoter, show that krikoter are more effective for treatment compared to imikamol. (Stefanaki C. ve ark. Comparison of cryotherapy to imiquimod 5% in the treatment of anogenital warts. Int J STD AIDS. 2008 Jul;19(7):441-4.)

3. Laser: : It is a very expensive treatment option, that has no advantedge over other options. If aims to destroy lesions. The problem is that it is not used in most medical centers (almost none of them) and it might cause pain in vulva area. (Tschanz C. ve ark. Vulvodynia after CO2 laser treatment of the female genital mucosa. Dermatology. 2001;202(4):371-2.)

C) Alternative Treatments

Alternative treatments are ones that we either don’t have sufficient information on, or the ineffective ones. These are; interpheron inside the lesion, photodynamic treatment and surface cidofovir applications.

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