Human papillomavirus (HPV) is a common sexually transmitted virus that causes abnormal growth of tissue on the feet, hands, vocal cords, mouth, anus and genitals. There are over 70 types (strains) of HPV and it is possible to have more than one strain at one time. In women, HPV can grow on the cervix, vagina, vulva, urethra, and/or anus. Genital and anal HPV can cause two kinds of abnormal tissue growth: genital warts and cervical dysplasia.
Genital Warts (Condyloma Acuminata)
When genital warts first appear, they may be small pink or red bumps on the vulva, cervix, or anus or immediately surrounding skin. They are usually painless, but may cause itching, burning or slight bleeding. Genital warts can be found on the urethra, anus, inside the vagina, or on the cervix.
Genital warts can be frustrating to treat, as some will disappear on their own, while others may not, even with treatment. There is no magic treatment for genital warts, and several methods may be tried depending on where, how large and how many warts have been there. Early detection and treatment is important as it makes it easier to get rid of warts. Over-the-counter gels and creams for treating genital warts are generally not recommended.
Dysplasia or lesions refers to abnormal changes in the size, shape or appearance of cells that line the cervix. Changes to the cells can range from mild to severe. Although dysplasia is not cancer, if left untreated it can turn into cancer. Dysplasia is found mostly on the cervix, but can also be on the vagina or vulva and usually there are no symptoms.
Diagnosis and Screening
Early diagnosis is important in treating HPV-related conditions, especially since they often do not have obvious signs or symptoms. Therefore, routine screening is critical to getting early treatment. There are several types of screening methods, described below.
Pap Smear: This is a test in which a doctor will collect cells from your cervix or anus. A Pap smear can detect any inflammation, and in most cases predict abnormalities in cervical cells. For women living with HIV, if your CD4 cell count is below 300 or has been dropping, it is suggested that you have a Pap smear every six months. If you have an abnormal Pap smear, further evaluation with a colposcopy is suggested.
Anal Pap Smear: An anal Pap smear is like the cervical Pap smear, the cells are collected from the anus. If any abnormal cells are found, an anoscope (similar to a colposcope -- see Colposcopy) is used to look inside the anal canal.
Many providers have limited or no experience with anal Pap smears. In addition, anal Pap smears are not a routine part of the standard gynecological exam. As a result, anal Pap smears are often not done. Talk with your doctor about a specialist who is able to do an anal Pap smear.
We can advocate for doctors to attend trainings on anal screenings. As positive women are living longer with HIV, consistent and quality healthcare is critical. It is important that we advocate for medical procedures such as anal Pap smears to become routinely available components of HIV care.
Colposcopy: A solution of diluted vinegar is applied to the cervix/anus to remove the mucus and highlight the abnormal cells. Using a light and an electric microscope (called a colposcope, or anoscope if they're looking at anal tissue), the doctor can look at the tissue closely. The vinegar makes the abnormal cells white and the normal cells appear pink. Lesions, warts and inflammation are usually visible during the colposcopy, however it is difficult to determine if the changes are mild or severe. If abnormal cells are seen a biopsy is usually done.
Biopsy: A small amount of tissue is taken from the area where abnormal cells are found. A biopsy can tell the difference between a mild lesion and a severe lesion. A biopsy can be uncomfortable and painful. Some women experience mild bleeding after the procedure. There are several types of biopsies, explained below.
Cervical and Anal Biopsy: This is the standard biopsy. A small pair of forceps is used to remove a sample of the abnormal tissue from the cervix or anus. More than one sample may be taken, depending on the amount of tissue detected by the colposcopy/anoscopy.
Endocervical Cutterage: This procedure is done if a doctor is unable to determine if there is abnormal tissue beyond the cervix. A small spoon shaped instrument called a curette is used to remove the cells. The procedure takes 10-15 minutes and may cause cramping.
Dilation and Curettage (D&C): If abnormal cells are found beyond the cervix, a D&C will be conducted. Abnormal cells from the cervical canal and lining of the uterus are removed. A local anesthesia will be administered and the procedure may cause cramping and spotting.
Reading the Pap Smear Results
There are two methods that have been used to read the results from Pap smears. Most labs use the Bethesda System. Results are divided into categories based on the changes in the size and shape of the cells. Some labs may use another system to report the results called the Cervical Intraepithelial Neoplasia (CIN) System. In this system the degree of cell abnormality is assigned a number. Below is a chart explaining what the results for the Bethesda and CIN Systems mean.
|Bethesda System||CIN System||What does this mean?|
|Negative for Squamous Intraepithelial Lesions or Dysplasia||Not Applicable||There are no abnormal cell changes detected.|
Atypical (unusual) Squamous Cells of Undetermined Significance (ASCUS)
ASC-H is a new category added which means atypical squamous cells and high-grade lesions cannot be ruled out.
|Atypia||There may be inflammation in the cervix; however, it cannot be determined if the cells are normal or abnormal. Suggest follow-up with a colposcopy.|
|Low Grade Squamous Intraepithelial Lesions (LGSIL)||CIN I||Mild cell abnormalities (dysplasia) are present on the surface of the cervix. For women living with HIV, treatment is not considered standard; however, careful monitoring is strongly suggested.|
|High Grade Squamous Intraepithelial Lesions (HGSIL)||CIN II/ CIN III||Moderate to severe dysplasia and/or precancerous lesions. Treatment is recommended.|
The success rate of treating HPV in women living with HIV has been inconsistent. For the treatment of genital warts, there is a higher rate of recurrence after therapy. As a result more frequent and costly treatment and follow-up is required and can be a source of frustration. For treating dysplasia, the effectiveness has been shown to be dependent on the level (high or low grade dysplasia). Low grade dysplasia may or may not progress and can be a chronic condition. However, if a woman has a low CD4 count and high HIV viral load, she may be at a higher risk for developing high grade dysplasia. So, in this case, a doctor may recommend treatment for low grade dysplasia. For women with high grade dysplasia, treatment is strongly recommended, however may not always be effective.
Screening, monitoring and managing HPV infections are crucial for women living with HIV. While there is a lack of consensus in the medical community for treatment and management of HPV infection, there is an effort to establish guidelines to better serve women living with HIV. The Centers for Disease Control (CDC) recommends HIV-positive women receive two Pap smears a year within the first month of diagnosis. If the results are abnormal, colposcopy or biopsy is suggested.
Human Papillomavirus Treatment Chart
|What Is It?/How Does It Work?/How to Use It?||Used for ...||Patient Applied/|
|Podofilox||A solution or gel that chemically damages the warts is applied. Using a cotton swab for the gel or your finger for the solution, apply to the visible warts twice a day for 3 days, followed by 4 days of no therapy. Can be repeated for up to 4 cycles.||Genital warts||Patient applied||Not recommended for use during pregnancy|
|Imiquimod||A cream that stimulates immune responses against warts. Apply cream once daily at bedtime, 3 times a week for up to 16 weeks. Wash area with soap and water after 6-10 hours after application.||Genital warts||Patient applied||Not recommended for use during pregnancy|
|Podophyllin resin||A brownish and yellowish chemical that is applied directly to the affected area and allowed to air-dry. This chemical will damage the warts.||Genital warts||Provider administered||May cause a burning sensation as it dries. The solution can be absorbed into the body and can cause side effects. Thus, some providers may thoroughly wash off the solution 1-4 hours after application.|
|Trichloroacetic (TAC) or Bichloracetic acid (BCA)||Chemicals that destroy the warts by burning them. A small amount is applied only to the warts and allowed to dry. The warts will turn a white color, shrink and then disappear. Can be repeated weekly and may require multiple treatments.||Genital or anal warts||Provider administered||May cause a burning sensation|
|Cryotherapy or Cryocauterization||Liquid nitrogen is applied to affected area using an instrument called a cryoprobe. Liquid nitrogen freezes and kills the abnormal cells. Can be repeated every 1-2 weeks. Cryo-cautery uses an electric probe to burn off the abnormal cells.||Genital or anal warts; cervical or anal dysplasia||Provider administered||May require multiple treatments. May experience some pelvic pressure or menstrual like cramps during the procedure. May cause cervical scarring, which may make the cervix difficult to see during exams. Because of the heavy water loss from this procedure, drink lots of fluids.|
|Interlesional interferon||Applied as cream or injection. Interferon triggers your immune system to fight infection. Interferon may be applied directly to genital warts as a cream or injected into the warts and the skin surrounding them. May require multiple treatments.||Genital warts||Provider administered||Usually used if other treatment methods have failed.|
|Laser vaporization or abalation||A high intense light stream is used to kill abnormal cells.||Cervical or anal dysplasia||Provider administered||Laser vaporization can cause some cervical scarring although less than cryosurgery. Procedure is done in the hospital under general or local anesthesia.|
|Electro-cauterization||LOOP Electrosurgical excision procedure (LEEP) uses a small wire, which has an electric current running through it, to burn or destroy the abnormal tissue.||Genital or anal warts; cervical or anal dysplasia||Provider administered||A local anesthetic may be used and you may experience mild cramping for up to 24 hours after the procedure.|
|Cone Biopsy||A cone biopsy is used to both diagnose and remove abnormal tissue. A cone shape tissue sample is removed from the cervix. This is an in-patient procedure; however, a general or spinal anesthesia is usually recommended. The tissue that is removed is sent to the laboratory for examination. If dysplasia is found, no further therapy is needed (assuming that all affected cells have been removed). If cancer is found, additional treatment may be recommended.||Cervical or anal dysplasia||Provider administered||Usually done for high grade dysplasia, recurrent dysplasia, and suspected cancer|
Genital wart removal is recommended during pregnancy. Specific types of HPV (6 and 11) can be transmitted to infants and children causing respiratory problems.
Please note that Podofilox, Imiquimod, and Podophyllin are not recommended for use during pregnancy as they are absorbed by the skin and may cause birth defects in the baby.
Things to keep in mind after surgical procedures:
You may have a slightly odorous watery and/or bloody discharge for several weeks after procedure. You can wash the labia (vaginal lips) with warm water several times throughout the day and use sanitary pads not tampons.
Avoid intercourse or douching for at least 3 weeks following the procedure. (Note: douching is generally not recommended, ever, as it can worsen -- and may cause -- GYN conditions.)
Can use Tylenol or Advil as needed for pain relief.
Contact the provider if any of these occur:
Treatment for Cervical Dysplasia
The treatment for cervical dysplasia depends on several factors including:
The severity (mild, moderate, or severe dysplasia).
Presence of HPV.
Risk factors (including smoking or an untreated sexually transmitted disease).
NOTE: Cervical and anal dysplasia can return after treatment. Recurrence may be more likely if you have higher HIV levels.
Keep in mind that the treatment is to get rid of the abnormal tissue, not the virus. This means that the virus is present in your body and the abnormal cells can come back even after treatment. For women living with HIV, genital warts are more likely to reoccur after treatment.
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