Genital Warts in Pregnancy: Treatment & Prevention

Genital Warts in Pregnancy: Get Lost, HPV!

HPV Infection

Many questions surround the topic of HPV infection. Some are more important to the infected patient; others have a more global significance. For example, how can a woman prevent transmission of HPV to others if she doesn't know she is infected? If new subtypes of HPV are still being discovered, how do we know that a negative test for HPV really means the infection isn't present? Can we find a way to predict which women with HPV will have progressive disease and, therefore, need treatment? How can we decrease the need for painful and expensive testing when HPV infection is suspected?

Research is currently underway to create inexpensive tests to detect HPV DNA (the genetic material of the wart virus) during routine Pap smears. Such detections may also lead to more cost-effective evaluation and follow-up of HPV-positive women. Research is also being conducted to determine whether the presence of the virus subtype can predict the likelihood of progression and need for treatment. Finally, a vaccine has now been developed for HPV infection and has been tested in clinical trials, showing impressive efficacy for prevention of this chronic, potentially dangerous infection. The vaccine is currently in clinical development.

How Is HPV Infection Diagnosed?

Diagnosis of genital warts caused by the human papillomavirus (HPV) is usually straightforward. External warts (those on the skin around the opening of the vagina) usually have a characteristic appearance, which your doctor can easily identify. Further testing is not necessary. Rarely, a biopsy (sampling of the skin for evaluation under a microscope) may be needed to rule out pre-cancer of the external or vaginal skin.

A cervical HPV infection is usually detected during a routine Pap smear. Occasionally, a white, raised wart can be seen on the cervix, but more commonly, the cervix appears normal to the naked eye. When a Pap smear shows abnormalities, colposcopy is the next step in evaluation. In this procedure, your doctor examines your cervix using magnification. Acetic acid (vinegar) is applied to the cervix to make any abnormal areas stand out. Your doctor also biopsies a tissue sample in order to determine whether HPV infection, a pre-cancer, or cancer is present.

How Should External Warts Be Treated?

Numerous treatment options exist for women with external genital warts. The effectiveness of any particular treatment depends on the size and location of the warts, your overall health and immune status, the subtype of virus involved, and whether or not you are pregnant. In general:

  • smaller warts and those located on the thinner skin near the vaginal opening are more likely to respond to treatment;
  • smokers and women whose immune systems are compromised are less likely to achieve lasting success; and
  • smokers and women whose immune systems are compromised are less likely to achieve lasting success; and
  • treatment during pregnancy is usually postponed because spontaneous improvement often occurs after delivery. However, treatment may be indicated for extremely large or rapidly progressing lesions, which may hamper delivery or make cesarean delivery necessary.

Topical Medication

Use of topical medication for small, isolated warts can be applied at your doctor's office or at home. An uncomfortable, burning sensation is a common side effect of this treatment.

  • At the doctor's office-Choices for office treatment in non-pregnant women include trichloroacetic acid (TCA) or podophyllin resin (not to be used in pregnancy, see below), applied weekly until the warts disappear.
  • At home-Two preparations are available for home use: imiquimod (Aldara) and podofilox (Condylox). Imiquimod should be applied at bedtime, three times per week for up to four months. It often causes irritation of the surrounding skin. Podofilox is to be applied twice daily for three days, followed by four days of no treatment. Several weeks are usually required to achieve success.

Cryotherapy and Laser Therapy

Cryotherapy (freezing) using nitrous oxide or carbon dioxide is effective for treatment of small, isolated warts and can be performed in the doctor's office. Warts that do not respond to topical treatment may respond to cryotherapy (see below for more information). For larger or more numerous warts, removal with a carbon dioxide laser is the treatment of choice. This procedure is usually performed under anesthesia in an operating room. Hospital admission following the procedure may be necessary.

During Pregnancy

For women with external warts during pregnancy, cryotherapy and laser removal are the preferred treatment methods. The only topical therapy acceptable for use in the vagina during pregnancy is TCA. Podophyllin resin should not be used during pregnancy women because it may be toxic to the baby.

How Should Cervical Warts Be Treated?

For women with cervical HPV infection during pregnancy, treatment is usually unnecessary. Moreover, because untreated cervical HPV infections rarely progress to severe pre-cancer or cancer, therapy is seldom required, even in non-pregnant women. Only when a biopsy shows moderate or severe dysplasia, is treatment recommended. Patients with long-standing HPV changes on the cervix may be candidates for treatment as well.

Depending on the size and location of the abnormality and the shape of your cervix, the best options for treatment are cryotherapy or loop electrosurgical excision procedure (LEEP). Either therapy can be performed in the doctor's office. Cryotherapy destroys the abnormal area of the cervix by freezing it. As the ice ball melts, a heavy vaginal discharge is expected for three to four weeks. Cryotherapy is relatively inexpensive, quick to perform, and causes little discomfort. However, the long-term success of treating severe pre-cancer is slightly less than with LEEP. LEEP uses a wire loop with an electric current to remove the abnormal area of the cervix. The removed tissue is examined under a microscope. The disadvantages of LEEP include discomfort, need for a local anesthetic, and expense (two to three times that of cryotherapy).

These procedures carry a small risk of causing cervical stenosis (scarring of the cervix) or cervical insufficiency (inability of the cervix to stay closed during pregnancy). Both of these problems are rare and occur less often with cryotherapy.

Another possible outcome is that the pre-cancer recurs after treatment. Even when all of the pre-cancer is removed or destroyed, the virus remains in the lining of the cervix and can resurface in the future. All women with HPV infection should be re-examined regularly.

How Should My Sexual Practices Change Because of HPV Infection?

Although condoms protect against most STDs, they may not be as effective at preventing HPV infection since the virus can be transmitted through adjacent skin contact.

In women, infection of the external skin is common; in men, the skin of the scrotum is often involved. A condom, then, may not cover the affected skin. Still, unless you have a single sex partner who is also monogamous, use of a condom during intercourse is recommended-mainly for the prevention for other STDs.

Little information exists regarding oral sex and the risk of transmission of HPV to a partner's mouth or vocal cords; however, some people have developed warts on the tongue and larynx. You should avoid oral contact with a partner who has overt warts, but otherwise you do not need to change your sexual practices.

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