Pregnant, with HPV warts

Dear Dr Mitchell,

I have been suffering with HPV warts for almost seven years. I am 25 years old and five months pregnant. Since I have had to stop my treatment, the warts keep growing and growing. I would really like to treat these warts during my pregnancy and need to know about a safe treatment to use.

Human Papilloma Virus (HPV) is a sexually transmitted virus that causes genital warts and also cancer of the genital tract. There are over 100 subtypes of HPV but only a few subtypes cause cancer of the genital tract.

The four main subtypes that cause cervical cancer are types 16, 18, 31 and 45. Sub-type 6 and 11 account for over 90 per cent of genital warts and are considered low-risk types since these do not usually go on to form cervical cancer. Anal, vulval, vaginal and pharyngeal cancers are also caused by the high-risk HPV subtypes. Sub-type 16 is the major type involved in anal and oropharyngeal cancer.

Pregnancy is a relatively immune compromised state and so women can present for the first time with obvious genital warts in pregnancy even though the HPV may have been in the genital area for many years before. The genital warts tend to grow rapidly in pregnancy and in severe cases can extensively cover the vulva and vagina. The safest option for treatment in this case is to burn or cauterise the warts. This can be done safely by injecting the vulva and vagina with some lidocaine to make this a relatively painless procedure. In some cases repeated cauterisation has to be done since the warts can regrow after treatment. The cervix should also be examined at the time of cauterisation of the vulval warts by doing a colposcopy. This shows a detailed visualisation of the cervix to determine if there is involvement by the human papilloma virus and to rule out early abnormal changes that can lead to cervical cancer.

A biopsy of the cervix can also be safely taken if deemed necessary at the time of colposcopy and if there is no suspicion of cancer, definite treatment can be delayed until after delivery when precancerous changes can be successfully treated.

Options for treatment of genital warts such as Podophyllin and Aldara cream (Imiquimod) are not used in pregnancy because of potential risk to the foetus. Once you have genital warts you should do a screening test for syphilis and HIV and the tests should be repeated at 28 weeks gestation to ensure that they are truly normal. Your spouse will need to be examined and if genital warts are detected he should also have them treated to reduce your risk of re-exposure during sexual activity.

Condom usage reduces the risk of recurrence of genital warts from re-exposure by about 75 per cent. This is because condoms do not cover the scrotum, inner thigh and vulval areas where HPV might be present. Non-penetrative sexual activity can cause the spread to the oral cavity and pharynx and subsequent oropharyngeal cancer.

Regular screening by doing Pap smears is extremely important and primary prevention of cervical cancer can be achieved by being vaccinated with the HPV vaccine. This should be given after delivery and completion of breastfeeding. It is given in three doses. The first dose is followed by the second dose one month later and the last dose is given five months from the second dose. It is effective in preventing cervical cancer caused by the four main subtypes of HPV in over 92 per cent of cases.

It is important to cauterise the warts before delivery since the newborn baby can contract the HPV virus while being delivered vaginally if extensive warts are present. This can cause oropharyngeal cancer in adult life, so prevention is important.

Consult your obstetrician and have arrangements made to cauterise the genital warts.

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions via e-mail to allwoman@jamaicaobserver. com; write to All Woman, 40-42 1/2 Beechwood Ave, Kingston 5; or fax 968-2025. Dr Mitchell cannot provide personal responses.

DISCLAIMER: The contents of this article are for informational purposes only and must not be relied upon as an alternative to medical advice or treatment from your own doctor.