Women's Health Articles - Vulvar Problems
By Date of Release Topic June 11, 2000 Chronic Recurrent Yeast Vaginitis - What Can Be Done? April 16, 2000 Oral Treatment of Bacterial and/or Yeast Vaginal Infections February 20, 2000 Perineal Body Odor February 13, 2000 Restoration of Vaginal Opening Looseness January 23, 2000 Perineal Powder and Pads May Cause Problems December 18, 1999 Recurrence of Warts with Different Treatments November 14, 1999 HPV Type Associated with Cancer November 7, 1999 Vulvar Sweat Gland Cysts July 18, 1999 Genital Warts - Selection of a Treatment Strategy January 31, 1999 Vulvar Intraepithelial Neoplasia (VIN) and Cancer January 9, 1999 Vaginal Conditions After Delivery December 20, 1998 Painful Sex and Vulvar Skin Disease November 1, 1998 Signs and Symptoms of Vulvovaginal Candidiasis August 23, 1998 Irritant Vulvitis Often Misdiagnosed as Yeast April 5, 1998 Painful Intercourse Due to Vulvar Vestibulitis November 9, 1997 Vulvar Cancer and Human Papilloma Virus (HPV)
"I've been diagnosed with having HPV (genital warts). I've had them for over 2 years and since I've known I had them, I haven't had one day without them. No treatment seems to work. The cryosurgery works but as soon as they kill 5, 10 more pop up. What can I do? Is there any way to stop this? Is there something I can do to help?
Genital warts are caused usually by HPV virus subtypes 6 and 11. We do not know entirely the life cycle of the virus but we know it can sometimes cause a warty growth on the skin while at other times it can lie dormant and inactive in skin cells for many years at a time. We do not know why the virus can be reactivated sometimes after many years either. The immune system of the body plays a major role in suppressing the virus from causing warts to grow or even ridding the body of warts if it is strong; if the immune system is weak, it seems to allow more warts and faster growth, and more recurrence of new warts after treatment.
With HPV genital lesions, it is very difficult to tell whether a new wart growth is a recurrence or whether it is due to new exposure and infection by a different subtype of HPV. Although subtypes 6 and 11 are the most common associated with genital warts, there are over 80 subtypes described and others can cause the same appearing lesion (1). HPV is predominantly transmitted by physical contact with the virus. It can be by touching with hands that have come in contact with the virus or sexual contact of genital or perianal skin or even pubic hair (2) that has the virus. In either case, growth or first appearance of the lesions may not be very proximate to the physical skin contact.
What is the natural history of condyloma accuminata (genital warts) untreated?
In order to know how effective a treatment is at getting rid of the warts, we need to know how often the warts go away on their own without any treatment. We can learn that from the few studies that have be done in which patients did not receive any treatment for years and years. Also the studies which have been performed using a placebo control can indicate how often the lesions go away over the short term.
- In children followed for a long time with condyloma accuminata, over 50% regress by 5 years (3).
- In men who did not have treatment for genital warts, it took an average of about 15 months for 50% of them to have spontaneous regression of their lesions (4).
- In a placebo controlled trial of 16 weeks of condyloma treatment in women, only 11% of lesions cleared spontaneously (5).
How often do the warts recur after treatment?
Depending upon the treatment used, different recurrence rates have been noted. The most common treatment currently used is a self-applied, 5% imiquimod cream (Aldara®) that stimulates the immune system to fight off the virus and lesions. It seems to have a genital wart recurrence rate of about 13-19% (5, 6, 7).
Sometimes large condyloma are just cut off under local anesthesia with a knife or scissors. This seems to have a recurrence rate of about 21% (8). In a study using self-applied podofilox gel, the cure rate was low at only 51% but the recurrence rate was only about 10% (9). With respect to the cryotherapy you describe, the recurrence rate is quite high at the level of 73% without any supplemental treatment being given to the cryotherapy (10). Thus while you may have failed other treatments, the current cryotherapy treatment you are receiving seems to be the least efficacious.
What are the risk factors associated with recurrence?
Any disease or medication that suppresses the immune system will increase the risk of genital warts in someone who was previously exposed to the virus. Human immunodeficiency virus (HIV) a major immune suppressing disease but hepatitis, drug use and chemotherapy for other medical conditions can also suppress it.
One study looking at risk of recurrence found that having 5 or more sexual partners within the past 5 years not only was associated with an initial episode of genital warts, but also with recurrences after clearing (11). That same study also found that a history of previous sexually transmitted diseases, a history of oral herpes and a history of allergies were also associated with recurrences. Interestingly, in that study, smoking and oral contraceptive use were not associated with recurrences. Other studies, however, do find that smoking is a risk factor at least for the first occurrence and for progression of the size of the condyloma accuminata 12, 13).
What is the best way to minimize recurrence of warts?
The best treatment results and lowest recurrence rates are associated with use of the imiquimod cream (5%) which stimulates your own immune system to suppress the HPV virus. Whether you have the warts frozen off (cryotherapy), or cut off with a laser, cautery or knife, I think that use of the self-applied imiquimod cream for 4 months in addition or by itself will be the best way to minimize the chance of the warts returning. Also, you should stick with one or no sexual partners and use condoms (14) and avoid orogenital sex(15). This can decrease the viral load to the perineal area. Your partner should also be treated with Aldara® cream since there is a fairly high chance (67%) that he also has lesions(16).
If you are a smoker, this would be a good reason to stop. I would also say that any vulvar procedures such as piercing the labia should be avoided so that the virus is not introduced to the tract of the piercing. Use of a generalized immune system stimulant such as the herbal preparation of echinacea should not hurt this infection and possibly may help against the virus (17). Finally, be sure to have blood tests for HIV and hepatitis B and C if you are having constant recurrences of these genital warts in spite of treatment for over two years.
"I would like to know how accurate the tests are that are out right now for the different strains of HPV. I would like to have the test done if I thought it was reliable in diagnosing if I have the type(s) that is thought to lead to cervical cancer. I am very concerned about HPV and treatments and how from what I have heard that the treatments are not very successful. Do you know?
Exposure to human papilloma virus (HPV) can be measured by testing the blood (serum) for antibodies to the viral capsule or by testing actual tissue such as cells from a Pap smear or tissue from a biopsy for viral DNA fragments. This latter test is known as Viratype. It is more commercially available than the blood antibody testing, but this is a rapidly changing field so you must check as to which tests are locally available.
There have been many different HPV types described. Some are more often associated with cervical cancer or vulvar cancer while other types are more common with benign epithelial lesions such as condyloma accuminata or venereal warts. Having been exposed to one virus type does not prevent getting infection from another virus type. In fact one study looking at seropositivity to HPV type 16 found a 30% incidence of multiple HPV type positivity (1). Patients and doctors alike have difficulty keeping up with this field so let's look at some of the different aspects of HPV.
Which types of HPV are most associated with cancer?
Certain viral subtypes of HPV are much more commonly associated with cancer than other subtypes. The best known of these HPV types are 16, 18, 31, 33, 39, 45, 52, and 58 (2). Type 16 is the most common but it still is not the most frequent type. Types 16 and 18 are the major risk factors for cervical carcinoma, whereas HPV types 6 and 11 cause benign genital lesions.
Over 90 different subtypes of HPV have been described. As you can see it is difficult to test for all of those different subtypes. Sometimes a test is made to screen for 4 or 5 of the most common types but by definition it will not be accurate to pick up all possible HPV infections. This is true for both for tissue DNA typing and blood antibodies.
How accurate is the test on tissue cells to identify HPV infection and type?
Since any test for HPV subtype is limited to only that subtype or group of subtypes, it will miss a certain number of HPV infections. The combinations that have been screened for often include the most common types associated with malignancy. No one knows what other types will be missed so it is only a guess as to how accurate a test is. In general, positives are positive, i.e., there are very few false positive tests. If you are tested positive for say type 16, 18 HPV, then that result is probably 95% certain. The opposite is not true, however. If the test is negative, you could have been exposed to some other type.
The main use of HPV tissue DNA fragment testing has been in uncertain PAp smear results such as the atypical squamous cells of uncertain significance (ASCUS). In this strategy, women with ASCUS Paps which are just usually repeated at 3-4 months, could be tested and if positive for HPV 16, 18 etc., then they could be referred to colposcopy and would have a higher chance of having cervical precancerous changes called dysplasia. Thus if tissue HPV typing is unavailable from your doctor or in your area, having a colposcopy and biopsy would reassure whether or not you have dysplasia which the Pap missed. If the colposcopy is negative, then there would be no treatment even if the HPV test were positive. If the colposcopy and biopsy are positive for dysplasia, then whether the HPV test showed a type associated with cancer would not make a difference in the treatment.
What do the blood tests for antibodies to HPV mean?
Antibodies, especially those called IgG antibodies, are manufactured by the body for a very long time after exposure to HPV. Gradually, over decades they may lessen in amount to undetectable levels, but they may also increase with each repeat exposure. The antibodies indicate exposure in the past to HPV and since the virus particles can stay forever in tissue, it very likely means there are some virus cells of that type still present in the body somewhere.
A positive blood titer for an HPV type only means exposure at sometime in the past. It does not necessarily mean that a current abnormal Pap is due to the type although it may be. Also, if 60-70% of adult females have positive titers to the high risk HPV types, it is almost impossible to know what action to take if your titer is positive except that you need to have regular, periodic Paps and check-ups.
Is HPV always a sexually transmitted disease?
HPV is very frequently transmitted sexually and often explains why dysplasia of the cervix is considered a sexually transmitted disease (3). It is important to understand that is is not always sexually transmitted. In fact children can be positive for HPV antibodies with a background incidence of 3% (4) while 60-70% of adults will show antibodies to HPV types 16, 18 and 33. Since only a few percent of the population ever develops cervical cancer, HPV is not a direct cause and effect.
While not necessarily conclusive that HPV can be transmitted non sexually except during the birth process, women who have never had sex with men, but only with other women can also be positive for HPV (5).
What should I do if I have a biopsy or Pap smear suggestive of HPV?
Options for this situation include:
- No further studies except follow-up Paps according to standard follow-up
- Have the biopsy tissue or Pap cells tested for virus subtype and if positive for a high risk type, treat mild dysplasia more aggressively with excision or destruction rather than just following to see if it resolves on its own.
- have your antibody titers checked and if negative for a high risk HPV type, just continue with annual Paps and check-ups and not a lot of extra visits for repeat Paps
There is no medical treatment for HPV. The only treatment is to remove cells in which the virus has caused some visible changes. The virus lies dormant in many cells, however, so there no way to totally rid the body of the virus or at least to be sure that you have excised all affected cells.
The important concept with HPV is not to become overly concerned about having manifestations of the virus. There is no way that a reasonable person in this day and age should have a cervical cancer develop. they just need to have periodic Pap smears and pelvic exams. Because you have just found out you have HPV cervical changes does not mean your partner has been unfaithful. You could have contracted the virus at any time you ever had sexual relations or so could your partner before meeting you. You or your partner may even have been part of the 3% of people who were positive for HPV from childhood. Try not to despair and panic about this. There are hundreds, if not more, of "incurable" viruses you have been exposed to during your life up to this point and more yet to come. So just be careful and vigilant.
"For the last 6 months I have been having problems with sweat gland cysts on my vaginal area. I have had 2 removed and now have a third on that needs removing, what caused these and is there anything that can be done to prevent them? My doctor says no! Thank you ". anonymous
There are several skin structures on the vulva that can become infected or grow into nodules and bumps that can be quite irritating. As with any skin, there are hair follicles, sweat glands and other skin glands such as Bartholin glands, and vestibule glands. Infectious agents such as viruses and bacteria can cause skin lumps as well.
When a doctor examines the vulvar area, some of the lesions may have characteristic appearances such as HPV virus causing condyloma accuminata, a pox virus causing Molluscum contagiosum, or Herpes Simplex virus causing genital herpes. These can be diagnosed just by looking at the lesions. Other lesions however are not so obvious to diagnose and they may need to have biopsies or special tests performed in order to confirm what is causing the lump or lesion. Since biopsies are painful and some of the tests are expensive, doctor may choose to avoid a biopsy if the lesion in unlikely to be malignant and it appears to be a one or two time problem - not a chronic recurrence. When this happens, the doctor just gives you "a best guess". It is not uncommon to label a vulvar lump or pustule as a hair follicle inflammation or a sweat gland cyst when in fact the degree of certainty is not very high. If the lesion goes away on its own or with simple treatment of sitz bath cleansing or antibiotics, then preciseness of diagnosis is less crucial. The truth is, however, that these lesions need to be biopsied to be sure of what they are. There are many different entities or conditions that can present this way on the vulva and if the problem is recurrent, biopsies are necessary.
- Non pus draining lesions
- Infected, pus draining lesions
- Folliculitis (bacterial inflammation) of a hair follicle - self limited
- Fox-Fordyce disease - inflammatory (non STD) condition of skin sweat glands - requires biopsy
- Hidradenitis suppurativa - inflammatory (non STD) disorder of skin sweat glands - requires biopsy
- Granuloma inguinale - bacterial STD requiring biopsy
- Lymphogranuloma venereum - bacterial STD requiring immunological blood test of culture
- Chancroid - bacterial STD requiring culture
The above is only a limited selection of possibilities. As you can see, biopsies or tests are needed to be sure. If your doctor has not done a biopsy, perhaps you should ask if one would be helpful. Epithelial inclusion cysts, probably the most common of these problems, has a different treatment than hidradenitis suppurativa or Fox-Fordyce disease and a different clinical course.
Epithelial inclusion cysts result when a duct is plugged up and the skin cells, squamous cells, that are usually sloughed as they naturally die off, cannot get out of the duct. New cells keep forming, however and a cyst filled with cells forms under the skin. If those cysts are opened surgically, a cheesy -like contents are extruded.
Some women may form these as a result of surgery or an episiotomy during delivery. Others just seem to have a tendency for the vulvar skin ducts to get plugged up. The only treatment for these is to surgically open the cysts with a needle or scalpel wide enough not to get replugged up, or to actually surgically excise the cyst and close the skin with a stitch.
The first step is to be absolutely sure of the diagnosis. If there are draining, reddened cysts like a pustular acne, a biopsy usually has to be performed in order to confirm what type of lesion in present. Fox-Fordyce disease and hidradenitis suppurativa are very similar. They can both affect the arm pits (axilla) as well as the vulva. Fox-Fordyce disease is a chronic blockage of the sweat gland ducts with a secondary, non bacterial inflammatory response to the secretions and cellular debris in the cysts. Hidradenitis is very similar but tends to have a secondary bacterial infection so that pus draining sinuses are formed. It is a very devastating skin disease that does not have universally curative treatments. Often surgery with complete excision of the gland bearing skin under the arms or across the entire vulva may need to be performed. Irradiation therapy may also be used and antibiotics are used to reduce the inflammatory response.
Since hidradenitis suppurativa is such a chronic devastating disease, large support groups have been formed and help disseminate the latest information about the disease. Some women respond with treatment to antibiotics, Accutane®, or hormonal treatment (e.g., Lupron®) but the mainstay treatment is surgical removal of the skin tissue containing affected sweat glands.
It has been estimated that over 70% of sexually active women have evidence by DNA testing of having been exposed to the human papilloma virus, HPV, which is the cause of genital warts. The virus that causes these fleshy skin growths can lie dormant for many years and just cause vulvar, vaginal or cervical lesions when a women's immune system is suppressed. When lesions start forming, they can spread and recur quite quickly. The lesions are not harmful and they are primarily treated for cosmetic reasons. Since they can be so difficult to treat because of persistent and recurrent growth, the treatment strategy can be quite varied depending upon circumstances.
At the time of a first episode of genital warts, lesions can form very quickly and there is a high viral replication rate. Treatment is often unsuccessful during this phase so many doctors recommend waiting until the rate of growth and new occurrence slows down. This may take 2-6 weeks. Many women do not want to wait this long to begin treatment but there is good reason to wait because the treatment may be less effective for lasting relief. If the lesions are growing rapidly or spreading widely, treatment may need to be started immediately just because an extensive area of lesions may be too difficult to treat later if its area is not arrested at an early stage. Thus treating early is not really an advantage unless it is just to prevent an extensive area of lesions.
Most of the time genital warts, condyloma accuminata, have a characteristic appearance and do not need to be biopsied to distinguish them from precancerous or cancerous lesions. However sometimes they are not so characteristic and biopsy is the only way to make sure the lesions are benign warts. When a woman is closer to menopause, say over 40 and certainly over age 50, doctors have heightened concerns about precancerous lesions such as vulvar dysplasia, so biopsy is recommended. Also, lesions that fail to respond to treatment after several courses of therapy should also be biopsied even in younger women.
Treatments for genital warts are usually based either on the principle of destroying the lesions or the principle of stimulating a woman's own immune system to keep lesions from forming and to breakdown lesions already present. Destructive forms of therapy include topical applications of trichloroacetic acid (TCA) or a podofilox gel. Lesions can also be frozen with cryotherapy or removed with a surgical or laser excision. Larger lesions (over 1 cm/0.5 inches) are best removed by excision. The immune stimulation, a 5% imiquimod cream (Aldara®), takes up to 4 months to clear lesions but is especially suited for a large area of lesions or ones that are difficult to identify.
Treatments of either injecting the lesions with 5-flurouracil (5-FU) or topical applications (Effudex®) cream are not used very much any more because the local side effects are much more common and annoying than other equally sucessful treatments.
What if the treatments do not get rid of the warts?
Agents that suppress the immune system should be evaluated to see if they can be altered. Smoking, alcohol abuse, HIV positivity, as well as steroid use and chronic antibiotics can be a factor. Any chronic illness or immunological illness may also delay clearing.
If topical treatments do not cure or significantly reduce the lesions in 3 or 4 applications or self-applied imiquimod cream used over 4 months, then surgical or laser therapy needs to be considered. Because a woman can have residual pain and scarring from damage of the subdermis from laser, cautery or surgery, these treatments should not be used unless there is first a failure to topical medical therapy.
Once the warty lesions start breaking out, both partners who have been having sexual relations have already been extensively exposed to the virus. Thus it is of no benefit to use condoms with your current sexual partner. Condoms should be used however with any future different sexual partner.
When a breakout of genital warts occurs, a woman cannot always assume that she contracted the virus from her current partner although that is the most likely event. The virus can have been dormant for many years. We occasionally see elderly widows who have not had sexual intercourse for many years have a breakout of genital warts on the vulva or even showing up on Pap smears. Once you have been exposed to the virus, it is harbored in your body forever. This is true of almost all viruses such as herpes (HSV), chickenpox (herpes zoster) and many others.