Hpv Infection

1 What is HPV Infection?

HPV is a group of viral infections that affects the skin and moist membranes of our body like cervix, anus, mouth and throat.

Of all the infections caused by herpes, genital herpes is the most contagious and spreads through sexual contact and direct contact with genital areas.

2 Symptoms

According to the CDC, most HPV infections go away on their own without any sign or symptom. This means that infected people may have unknowingly passed HPV to sexual partners.

For a minority of cases, the virus doesn’t go away and can cause serious health problems. These include genital warts and warts in the throat (known as recurrent respiratory papillomatosis, or RRP).

HPV can also cause cervical cancer and other cancers of the genitals, head, neck, and throat. The types of HPV that cause warts are different from the types that cause cancer. As such, having genital warts caused by HPV does not mean that you will develop cancer.

Cancers caused by HPV often don’t show symptoms until the cancer is in later stages of growth. Regular screenings can help diagnose HPV-related health problems earlier. This can improve outlook and increase chances of survival.

3 Causes

HPV infections are caused by a group of more than 200 related viruses. More than 40 HPV types can be easily spread through direct sexual contact, from the skin and mucous membranes of infected people to the skin and mucous membranes of their partners.

The various routes of transmission of virus are vaginal, anal and oral. Other HPV types are responsible for non-genital warts, which are not sexually transmitted.

Sexually transmitted HPV can be classified as high risk and low risk:

  • Low-risk HPVs, which do not cause cancer but can, cause skin warts (also known as condylomata acuminata) on or around the genitals, anus, mouth, or throat.

For example, HPV types 6 and 11 cause 90 percent of all genital warts. HPV types 6 and 11 also cause recurrent respiratory papillomatosis, a less common disease in which benign tumors grow in the air passages leading from the nose and mouth into the lungs.

  • • High-risk HPVs, which can cause cancer. About a dozen high-risk HPV types have been identified. Two of these, HPV types 16 and 18, are responsible for most HPV-caused cancers.

HPV infections are the most common sexually transmitted infections in the United States.

In fact, the Centers for Disease Control and Prevention estimates that more than 90 percent and 80 percent, respectively, of sexually active men and women will be infected with at least one type of HPV at some point in their lives. Around one-half of these infections are with a high-risk HPV type.

Most high-risk HPV infections occur without any symptoms, go away within 1 to 2 years, and do not cause cancer. Some HPV infections, however, can persist for many years. Persistent infections with high-risk HPV types can lead to cell changes that, if untreated, may progress to cancer.

Which cancers are caused by HPV?
High-risk HPVs cause several types of cancer.

  • Cervical cancer: Virtually all cases of cervical cancer are caused by HPV, and just two HPV types, 16 and 18, are responsible for about 70 percent of all cases.
  • Anal cancer: About 95 percent of anal cancers are caused by HPV. Most of these are caused by HPV type 16.
  • Oropharyngeal cancers (cancers of the middle part of the throat, including the soft palate, the base of the tongue, and the tonsils): About 70 percent of oropharyngeal cancers are caused by HPV.

In the United States, more than half of cancers diagnosed in the oropharynx are linked to HPV type 16.

  • Rarer cancers: HPV causes about 65 percent of vaginal cancers, 50 percent of vulvar cancers, and 35 percent of penile cancers. Most of these are caused by HPV type 16.

High-risk HPV types cause approximately 5 percent of all cancers worldwide.

In the United States, high-risk HPV types cause approximately 3 percent of all cancer cases among women and 2 percent of all cancer cases among men.

Who gets HPV infections?
All sexually active individuals are at risk of getting HPV, the most commom mode of transmission of virus being sexual.

HPV infections are more likely in those who have multiple sexual partners. Because the infection is so common, most people get HPV infections shortly after becoming sexually active for the first time.

Someone can have an HPV infection even if they have no symptoms and their only sexual contact with an HPV-infected person happened many years ago.

4 Making a Diagnosis

The futility of traditional methods allowed scientists to explore other important methods to diagnose HPV infection which include:

  • Colposcopy and acetic acid test
  • Biopsy
  • DNA test (PCR, Southern Blot Hybridization, In Situ Hybridization)
  • Pap Smear

Colposcopy and acetic acid test
Colposcopy is a procedure performed as an outpatient procedure using a colposcope.

Colposcopy is the examination of the cervix, vagina, and in some instances, the vulva after the application of acetic acid solution; coupled with obtaining colposcopically directed biopsies of all lesions suspected of representing neoplasia.

Colposcopic findings are graded according to degree of acetowhite lesion, surface contour, mosaic pattern, and punctuation. Greater abnormalities of these parameters are related to severity of the lesions.

Acetic acid test

  • Soaking acetic acid into suspicious lesions can enhance the degree of suspicion in lesions without classic features.
  • The method involves applying a 3–5% acetic acid–moistened gauze pad for 5-10 minutes on suspected lesions of the penis, cervix, labia, or perianal area.
  • Inconspicuous, flat, genital lesions that might be difficult to assess become visible. Genital warts, dysplastic, and neoplastic tissues turn white (acetowhite).
  • False-positive results are common and can result from anything that causes parakeratosis (e.g. candidiasis, psoriasis, lichen planus, healing epithelium, sebaceous glands).

The acetic acid test should not be used for routine screening. It can be used for visualizing subclinical genital HPV-associated lesions, identifying lesions for target biopsy, and for demarcating lesions during surgical therapy.

The use of colposcopy screening is only to be recommended for

  • Immunosuppressed transplant recipients.
  • Human immunodeficiency virus (HIV) positive women.
  • Women with three consecutive inadequate samples, after three tests in a series reported as borderline nuclear change in squamous cells, and be referred for colposcopy after one test reported as borderline nuclear change in endocervical cells.
  • Positive cervical cytology for malignant cells or suspicious cells but clinically normal looking cervix.
  • Women must be referred after two tests reported as mild dyskaryosis.
  • Women must be referred for colposcopy after one test reported as moderate dyskaryosis or severe dyskaryosis, at least 90% of women with such test results should be seen in a colposcopy clinic within four weeks of referral.
  • Women must be referred for colposcopy after one test reported as possible invasion or reported as glandular neoplasia, and 90% should be seen urgently within two weeks of referral.

Biopsy
Colposcopy allows tissue sampling (biopsy) that is targeted to the abnormal areas. In fact, the biopsy of abnormal areas is a critical part of colposcopy because treatment will depend on how severe the abnormality is on the biopsy sample.

If the biopsy results show pre-cancer (dysplasia) or cancer, then treatment is recommended. The dysplasia may be mild, moderate, or severe. Excisional biopsy is recommended when colposcopic appearances indicate high grade abnormality, when low grade colposcopic change is associated with severe dyskaryosis or worse, or when a lesion extends into the canal.

In genital warts, the most characteristic feature is the presence of koilocytes, which are mature squamous cells with clear perinuclear zone. The nuclei of koilocytes may be enlarged and hyper chromatic, double nuclei are seen often as well.

DNA techniques
Initial methods of HPV detection used were direct probe hybridization such as dot blot and Southern blot. Besides being labor-intensive and time consuming, they had low sensitivity, required large amounts of DNA in clinical samples, and have largely been superseded by amplification technology, which has allowed detection of low-level virus copy numbers in clinical samples.

The established routine method for viral detection is the hybridization of viral nucleic acids.

The two main techniques are: 

  • Hybrid capture HPV DNA Test 2 (hc2): HC2 in conjunction with the Pap test is now approved by the FDA. Since the FDA-approved Hybrid Capture 2 test can detect as little as 1 pg of HPV DNA/ml; its sensitivity and specificity are almost comparable with PCR-based detection methods.

The advantages of the Hybrid Capture 2 test are the relatively simple handling and good reproducibility of results, which make this test the best standardized HPV detection method. While the exact HPV type cannot be identified, “low-risk” and “high-risk” HPV genotype groups are detected.

  • Polymerase chain reaction: PCR is a selective target amplification assay capable of exponential and reproducible increase in the HPV sequences present in biological specimens.

Indications

  • Primary Screening in conjunction with the Papanicolaou (Pap).
  • Test or as a Stand-Alone Test for women over 30 years of age.
  • PAP smear or Pap test.

Apart from premalignant and malignant changes, viral infections like HPV infection and Herpes can also be detected. Positive test requires further confirmatory tests like coloscopy, cervical biopsy, and DNA tests like PCR.

ACOG revised recommendations for Pap smears are:

  • Women from ages 21 to 30 be screened every two years instead of annually, using either the standard Pap or liquid-based cytology.
  • Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years with either the Pap or liquid-based cytology.
  • Women with certain risk factors may need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.

5 Treatment

There is no cure for the virus itself, but many HPV infections go away on their own without any treatment. In fact, about 70 to 90 percent of cases of HPV infection are cleared from the body by the immune system.

When treatment is needed, the goal is to relieve symptoms by removing any visible warts and abnormal cells in the cervix.

Treatments might include:

  • Cryosurgery — freezing the warts off with liquid nitrogen.
  • Loop electrosurgical excision procedure (LEEP) — using a special wire loop to remove the abnormal cells.
  • Electrocautery — burning the warts off with an electrical current.
  • Laser therapy — using an intense light to destroy the warts and any abnormal cells.
  • Prescription cream — applying medicated cream directly to the warts. (Do not use over-the-counter wart treatments on the genital area)

In some cases, no treatment is needed. However, your doctor will closely watch any cell changes during your regular screening appointments.
Only a small number of women infected with HPV will develop cellular changes that need to be treated.

6 Prevention

The only way to prevent HPV is to practice safe sex with your partner(s).

While condoms do not eliminate the risk of HPV infection, using a condom consistently and properly during vaginal, anal and oral sex decreases the chances of getting HPV or passing it on to your partner. Using a condom will also help to protect you from other sexually transmitted infections and reduce the chances of unintended pregnancies.

Other ways to reduce your risk of infection include delaying sexual activity, limiting your number of sexual partners and considering your partners' sexual history as this can create a risk to yourself.

There are now two HPV vaccines authorized for use: Gardasil® and Cervarix™.

  • Gardasil® provides protection against four HPV types: two that cause approximately 70 per cent of all cervical cancers (HPV-16, HPV-18) and two that cause approximately 90 per cent of all anogenital warts in males and females (HPV-6 and HPV-11).
  • Cervarix™ provides protection against the two HPV types that cause approximately 70 per cent of all cervical cancers (HPV-16 and HPV-18).

Who should get the vaccine?

  • Gardasil® - Gardasil® is approved for use in females and males aged 9-26. (In April 2011, Gardasil® was approved for use in women up to the age of 45 years.) The vaccine requires 3 doses to be given over the course of 6 months (0, 2 and 6 months). 

The primary age group recommended for vaccination is females aged 9 to 13. HPV is a sexually transmitted infection, and ideally, the vaccine should be administered to females before they become sexually active in order to ensure maximum benefit.

They also recommend the vaccine for females 14 to 26 years of age as there still is the potential for benefit regardless of previous history of sexual activity, Pap abnormalities, cervical cancer, anogenital warts or a known HPV infection.

Gardasil® may be administered to females over 26 years of age. 

Gardasil® is also recommended in males between 9 and 26 years of age, and in men ≥ 9 years of age who have sex with men. As with females, receipt of Gardasil® between 9 and 13 years of age prior to onset of sexual activity is recommended in order to ensure maximum benefit.

Males between the ages of 14 and 26 years would also benefit from Gardasil® even if they are already sexually active as they may not yet have HPV infection and are very unlikely to have been infected with all four HPV types in the vaccine.

  • Cervarix™ - Cervarix™ is approved for use in females aged 10 to 25. The vaccine requires 3 doses to be given over the course of 6 months (0, 1 and 6 months).

The primary age group recommended for vaccination is females aged 9 to 13. HPV is a sexually transmitted infection, and ideally, the vaccine should be administered to females before they become sexually active in order to ensure maximum benefit.

There are also recommendations of the vaccine for females 14 to 26 years of age as there still is the potential for benefit regardless of previous history of sexual activity, Pap abnormalities, cervical cancer, anogenital warts or a known HPV infection.

Cervarix™ may be administered to females over 26 years of age.

What do the vaccines protect against?

  • Gardasil® provides protection against four HPV types: two that cause approximately 70 per cent of all cervical cancers (HPV-16, HPV-18) and two that cause approximately 90 per cent of all anogenital warts in males and females (HPV-6, HPV-11).
  • Cervarix™ provides protection against the two HPV types that cause approximately 70 per cent of all cervical cancers (HPV-16, HPV-18).

The HPV vaccines will not have an impact on an existing infection or any of the outcomes of an existing HPV infection, such as anogenital warts. The vaccines are preventative against infection with the virus types for which they are indicated. There is currently no vaccine that will give protection against all HPV types.

How effective are the vaccines?

The HPV vaccines have demonstrated very high efficacy in preventing the types of HPV infection for which they are indicated. If you are infected with one of the HPV types in the vaccine, the vaccine will still protect against the other type(s) in the vaccine.

HPV DNA testing is not recommended prior to vaccination.

Are the vaccines safe?
Yes, the vaccines are safe. For both vaccines, the most common side effect is brief soreness at the site of injection.

Also, you cannot become infected with HPV from the vaccines and the vaccines do not contain any antibiotics or preservatives, including mercury or thiomerosal.

Will girls/women who have been vaccinated still need cervical cancer screening?
The HPV vaccines currently available do not protect against all types of HPV. Even when someone is vaccinated, it is still possible to become infected with one of the types of HPV that the vaccine does not protect against. Therefore, it is important that vaccinated girls/women continue to have regular Pap tests.

The recommendations for Pap screening vary depending on the province or territory you live in. Ask your local health care provider about the recommendations in your region.

How long does vaccine protection last? Will a booster shot be needed?
Studies are ongoing to determine the length of time for which the vaccines will provide protection and if further immunization or a booster dose is necessary for continued protection.

7 Alternative and Homeopathic Remedies

A few alternative and homeopathic remedies exist for HPV infection, which include:

  • Oregano Oil - Oregano oil, a natural cure for HPV virus from the mint family helps in reducing the warts effectively. This cure is cost-effective that has to be applied onto the wart to get relief. Before applying, it is necessary to dilute the oil as it may sting a bit.
  • Echinacea - Echinacea is a natural cure for HPV virus, also called as purple coneflower. This cure is a perennial prairie herb that can be used in the form of tea and tincture that provides outstanding results against warts. It has polysaccharides and phytosterols that improve white blood cells (WBC) to destroy this virus.
  • Calendula - Calendula can be consumed orally or as a suppository that is commonly used in curing warts. Normally called as marigold flower, Calendula oil acts efficiently in removing the warts caused by HPV infection.
  • Goldenseal - Goldenseal is a natural cure for HPV virus that is used along with Echinacea in removing the warts. This cure has the same effect in stimulating the immune system by increasing the white blood cells count. Goldenseal produces twisted stem called as rhizome used as a natural remedy. It has a substance, berberine that has the composition to kill the strains of microorganisms.
  • Mushroom - Mushrooms such as Reishi and Shitake, is the natural cure for HPV virus infection. It has anti-viral activity to kill the effects of this virus that provides relief from genital warts.
  • Pau d’Arco - The liquid extract of Pau d’Arco has the composition to fight against the action of HPV virus. This natural cure for HPV virus in the liquid extract form can be applied on the warts infected region and has the ability to shrink and make them disappear.
  • Thuja - Thuja leaf and its oil, has the anti-viral remedy to treat against genital warts caused by HPV virus infection. It stimulates the cells in the immune systems that are needed to kill and search the virus infected cells.
  • Astragalus - Astragalus acts as an immune stimulator and anti-viral agent to fight against HPV virus. It initiates the p-53 gene that in turn invokes the production of interleukin-2. This substance kills the HPV virus and improves immunity against cancer.
  • Tea Tree Oil - Tea tree oil, a natural cure for HPV virus has the anti-viral and anti-microbial ability to reduce warts enormously. It is an internal and topical disinfectant that increases the immunity level in the body.
  • Garlic - Garlic has a strong anti-microbial tendency and contains a substance called as Allicin. This content has the ability to destroy pathogens, which can be applied directly on to genital warts providing great relief.

8 Lifestyle and Coping

To ensure a healthy lifestyle after HPV diagnosis, it is imperative to receive treatment immediately.

  • Anogenital HPV infection is very common. It usually infects the anogenital area but can infect other areas including the mouth and throat. Most sexually active people get HPV at some time in their lives, although most never know it.
  • Partners who have been together tend to share HPV, and it is not possible to determine which partner transmitted the original infection. Having HPV does not mean that a person or his/her partner is having sex outside the relationship.
  • Most persons who acquire HPV clear the infection spontaneously and have no associated health problems. When the HPV infection does not clear, genital warts, precancers, and cancers of the cervix, anus, penis, vulva, vagina, head, and neck might develop.
  • The types of HPV that cause genital warts are different from the types that can cause cancer.
  • Many types of HPV are sexually transmitted through anogenital contact, mainly during vaginal and anal sex. HPV also might be transmitted during genital-to-genital contact without penetration and oral sex. In rare cases, a pregnant woman can transmit HPV to an infant during delivery.
  • Having HPV does not make it harder for a woman to get pregnant or carry a pregnancy to term. However, some of the precancers or cancers that HPV can cause, and the treatments needed to treat them, might lower a woman’s ability to get pregnant or have an uncomplicated delivery. Treatments are available for the conditions caused by HPV, but not for the virus itself.
  • No HPV test can determine which HPV infection will clear and which will progress. However, in certain circumstances, HPV tests can determine whether a woman is at increased risk for cervical cancer. These tests are not for detecting other HPV-related problems, nor are they useful in women aged<25 years or men of any age.

9 Risks and Complications

There are several risks and complications associated with HPV infection.

  • Warts: HPV can lead to a wide variety of warts. Genital warts are harmless, flat and cauliflower-like in appearance. These warts can appear on the vulva, vagina, cervix or anus in women and on the penis, scrotum or anal region in men. Common warts are benign raised growths on your fingers and hands. Sometimes, these warts are painful and can bleed.

Plantar warts are benign and tough and appear on the heel or balls of your feet. Like common warts, plantar warts can cause pain. Flat warts refer to darker and slightly raised growth that appears on your elbows, face, knees, hands or wrists.

  • Cervical Cancer: HPV infection can cause normal cervical cells to become abnormal. In fact, approximately 12,000 women get cervical cancer each year.

Risk factors for getting cervical cancer include having multiple sexual partners, having sex at a young age, having a weak immune system and not having regular Pap smears.

Typical symptoms of cervical cancer include abnormal vaginal bleeding, constant vaginal discharge, heavy menstrual periods and postmenopausal bleeding. Other symptoms include pelvic pain, unintentional weight loss and loss of appetite.

  • Penile Cancer: HPV infection can cause penile cancer. Penile cancer is rare and affects one out of 100,000 men annually in the United States.

Symptoms of penile cancer include changes in your penis. It may change in color, become thicker or have a buildup of tissue. As the cancer progresses, you may notice a growth or sore on your penis.

Typically, these lesions are painless but painful growths and sores can exist. In some cases, you may have no symptoms at all. When you discover penile cancer, the disease may have already progressed.

  • Anal Cancer: Anal cancer can affect both men and women. The Centers for Disease Control state that 1,700 men and 2,700 women get anal cancer in the United States each year.

Symptoms of anal cancer include anal bleeding, discharge, itching and pain. Sometimes, you may notice swollen lymph nodes in your groin or anal region. When you go to the bathroom, you may have diarrhea, constipation or changes in the shape of your stools.

In some instances, you may be asymptomatic.

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