Human papillomavirus, genital warts and anogenital cancer

Human papillomavirus (HPV) is a double stranded DNA virus. It is associated with both genital warts and anogenital cancers, and some cancers of the head and neck. 

Genital Warts 

HPV 6 and HPV 11 caused >90% of genital warts.  Warts appear between 3 weeks to 8 months from infection. 

Treatment: 

Soft, non-keratinised warts: podophyllin 

Keratinised warts: cryotherapy 

Either: imiquimod 

Patients with a small number of either type of warts are best treated with cryotherapy from the outset. 

Anogenital cancer 

The 2 main types of HPV associated with cervical cancer are HPV 16 (50% of cases) and HPV 18 (15% of cases). 

HPV 16 and 18 are also associated with up to 90% of all anal squamous cell carcinomas and around 40% of penile cancers. 

Vaccination

Girls aged 12/13 are given 3 doses of either 

• cervarix – active against HPV 16 and 18 or
• gardasil – active against HPV 6,11, 16 and 18 

References:

British Association for Sexual Health and HIV. Guidelines on management of genital warts. 2007. Available at http://www.bashh.org/guidelines 

 Department of Health. Human papillomavirus. The Green Book. 2007. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917

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Cervical cancer

Around 900 women/year die in the UK of cervical cancer.

Presentation includes:

• post-coital bleeding
• intermenstrual bleeding
• post menopausal bleeding
• finding on routine screening

In the UK all females aged 25 to 49 are invited for cervical smear tests to screen for cervical cancer every 3 years, then every 5 years from 50 to 65 years of age.

Around 5% of smears need to be repeated due to inadequate sample.

Risk of cervical cancer is increased in:

• smokers
• those with multiple sexual partners
• younger age of first intercourse
• women on immunosuppressant drugs

It is strongly associated with human papillomavirus, with HPV 16  implicated in 50% of cases and HPV 18 in 15% of cases. 

Management:

• CIN (cervical intraepithelial neoplasia) 1 - can be managed by increased surveillance
• CIN 2 or 3 - ablation or excision
• invasive cancer - surgery, radiotherapy

Prevention:

Vaccination - girls aged 12/13 are given 3 doses of either 

• cervarix – active against HPV 16 and 18 or
• gardasil – active against HPV 6,11, 16 and 18

References:

Green Book. 2007. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917

James, R. et al. Management of cervical cancer: summary of SIGN guidelines. BMJ. 2008; 336(7634): 41-43. 

NHS Cervical screening programme. Cervical Screening: the facts. Available at http://www.cancerscreening.nhs.uk/cervical/publications/in-04.html
 The British Society for Colposcopy and Cervical Pathology.  European guidelines for the management of abnormal cytology.  Available at http://bsccp.org.uk/index.asp?PageID=20

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