[Question #340] Recent diagnosis of Low Risk HPV - long term marriage

35 months ago
My husband of 21 years was recently diagnosed with genital warts (late October).     When he discovered them he immediately told me and of course was very upset.  I had been in Florida for a week prior to this discovery.   We had intercourse the Saturday before I left for my trip.   I did not notice at the time any visible warts.    When he told me he had what appeared to be GW,  I did a visual inspection and didn't have any indication of genital warts.  He had one of the warts biopsied and it came back positive for HPV.     I did make an appointment with my doctor immediately.  She did a visual inspection and also ran an HPV test along with a Pap and both came back negative.   I do realize the HPV test is only testing for high risk HPVs and generally genital warts are low risk.   When I went to my return visit with her I asked her about receiving the gardasil vaccination and Im 44 and just barely going to make the deadline of approval to receive the vaccinations.  I have already received one dose.   She told me we should absolutely use condoms because every indication shows I am clean of HPV.    We have had inter course  with condoms a few times since I received my first dose of gardasil.   However, the strain on the marriage has been intense.   My husband doubts my fidelity to him.    He has so many doubts that any sexual intercourse using the condoms sets off a range of emotion with him.   I am so shocked by all of this because we have been happily married and faithful for such a long time.   I have read so many conflicting things as he has.   He blames me for his warts and is resentful that I want to use condoms and receive the gardasil shots.   He said he feels very isolated      I guess my questions are, is it possible for genital warts to lay dormant for this long and for only one of us showing symptoms? After receiving the gardasil shots will i be protected in the 90 % chance of it being HPV 6 or 11    He has been hesitant to start treatment.  He just started
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Dear Tina:

Welcome to the forum. I'm happy to answer this. I'm so sorry to hear you and your husband have been so turned into knots over this. It is unnecessary. You, your husband, and your doctor all have some serious misunderstandings about HPV.  My advice to follow assumes what is stated or implied: neither you nor your husband has had other sex partners in recent years. Of course HPV is sexually transmitted, and most genital warts show up within a few months of being infected with HPV. But there are plenty of exceptions, and based on your story, I assume you are among them. (If my assumption is wrong -- and if so, I would suspect your husband of infidelity, not you -- then you both need to be tested for other STDs as well.) So here we go:

First:  HPV infections can reactivate years later, which is the most likely scenario here. Either or both you probably acquired the infection causing his warts years ago, from other partners before you were married.

Second:  You both are infected with the HPV strain causing his warts, or you had it in the past and your immune system cleared it. Either way, you can no longer be infected and cannot reinfect him.

Third:  Warts typically become apparent a few months after catching HPV, so even if you didn't have previously, there is no point in changing your sexual practices at this time. Your doctor is dead wrong on this. Stopping exposure how, or using condoms, is equivalent to closing the barn door not only after the horse has escpeted, but after the horse is galloping over distant hills. It won't protect you at all, or him. I tell my patients in this situation to make no changes at all in their sexual practices.

Fourth:  There is no need and no benefit from the HPV vaccine (Gardasil) in this situation. I don't understand "barely meet the deadline". The standard reccommendation for HPV immunization is that there is no need after age 26. I am unaware of any guideline that would either promote or decline immunization after age 44.

Fifth:  There is no rational reason for your husband to have delayed treatment for his genital warts. I'm glad he has started treatment now.

Those comments address your closing questions, directly or indirectly. But to be sure there is no misunderstanding:

"Is it possible for genital warts to lay dormant for this long and for only one of us showing symptoms?" Yes, indeed. This is not at all rare.

"After receiving the gardasil shots will i be protected in the 90 % chance of it being HPV 6 or 11?" Probably not. As noted above, it's too late:  if you weren't infected previously, you undoubtedly have caught his HPV infection by now. You can assume he had it for at least a few months before the warts showed up.  Second, it is likely you either were infected all along or are already immune due to previous infection. If so, Gardasil won't help.

Where to go from here? First, discuss all this with your husband. Second, consider printing out this discussion as a framework for further discussion with your doctor. (Should she wish professional level clarification, I would be happy to exchange emails with her. It wouldn't be hard to find my email address with a little online searching.) Third, Gardasil is harmless, and now that you have started it, there is no strong reason not to continue, as long as your insurance covers it. But I don't expect it will benefit you. Fourth and most important, discuss all this frankly and sensitively with your husband. It seems he has been taken aback and perhaps frightened by these developments. But truly there is no need. This really shouldn't be the big deal that he has made of it.

I hope these comments have been helpful. Best wishes, good luck, and happy holiday.

HHH, MD
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35 months ago

Thank you so much for your response.  I had a strong feeling to get a second opinion and the internet is so full of conflicting information.  I feel fortunate to have stumbled across this website.  It seems in line with reputable websites such as CDC, etc.   A couple of additional points/questions.   One of the things that I have read numerous times is when there is an active infection (noticeable by GW) the viral load is higher and why condoms were recommended until the GW cleared.  If I'm understanding you correctly, it's irrelevant because I've likely already been exposed, and possibly developed immune response.   Either way, I've already been exposed since we have had a healthy and active sex life in our marriage.     I guess the questions of fidelity came into the "typical" time to develop warts (several months  after exposure) etc and some people carry HPV with no symptoms.  I am guessing my husband assumed I carried the virus to him even though (as far as we can tell) am asymptomatic.   To me that pointed to this isn't a new strain of infection introduced between us  since only one of us is having symptoms.   I doubt we ever gave much thought in our younger days.  I know we each had 4-5 partners before marriage to each other,   In regards to the Gardasil shot, my doctor told me the FDA had just approved the shot for women before age 45 because testing had been done now and although it may not help because of the strong possibility of already being exposed, we thought it was a good course of action.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Thanks for the thanks, and for the follow-up comments. Some responses:

"reputable websites":  Understanding of HPV epidemiology, transmission, recurrence etc is evolving, and advice to patients can differ among equally qualified experts. However, you can minimze the differences by concentrating on professionally run or moderted run websites like this one, CDC, academic institutions, and public health departments.

It may be true that viral load is higher in people with overt HPV lesions like warts and abnormal paps, but not necessarily. This is one of those areas where expert advice is not consistent. My view is that entirely asymptomatic HPV infections seem to very readily transmitted to sex partners, so my guess is that there isn't a large difference between asymptomaic infections and overt, visible ones.

Your description of your husband's reaction does suggest he believes you are the source of his infection. And that may be true. The point is that either of you could have a reactivated, transmissible, asymptomatic infection from long ago. If you develop warts in the next few months, I would guess he was infected chronically with HPV and recently transmitted it to you. (It would be too much of a coincidence for he and you to both develop reactivated warts at the same time.) But if you don't develop warts -- and probably you won't -- there will be no way to know. Either way, it is wrong for him to assume who infected whom.

In my opinion, our collective attitudes toward HPV and genital warts probably were healthier 2-3 decades ago than now. On the one hand, naivete about it (and about the causal role in certain cancers) resulted in many undesirable and even tragic outcomes. OTOH, since the large majority of HPV infections are silent and most never serious, the psychosocial consequences were less than now.

Despite FDA approval through age 45, most clinicians (and I believe most medical insurance) still limits HPV immunization to people below 26. Personally, I would limit it to the occasional patient who, for example, had few lifetime sex partners and is likely to be newly sexually active with new partners, e.g. following divorce, death of a spouse, etc. Even then, the statistical likelihood of new infections is quite low at such "advanced" age!   ;-)  But it's harmless and as already noted, since you've started there is no reason not to complete the vaccine series. But don't be dismayed if warts show up -- as you say, if you were newly exposed over the past few weeks or months, it's probably too late.

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