[Question #6630] Genital Warts

14 months ago
Hello.  I recently inquired about whether I had contracted genital warts.  It turned out to be folliculitis and dermatitis, thus (not surprisingly) confirming your assessment.  The experience, however, triggered my doing some research on genital warts.  What I have read is that they are widespread in the population and easily transmitted even when wearing a condom.   Is this consistent with your understanding?  Is there any way of minimizing the risk short of abstinence or having only one sexual partner? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
14 months ago
Welcome back. I'm happy to answer these additional questions. (I was logged in when your question popped up. Most users shouldn't expect nearly real time replies!)

Indeed genital warts are "widespread". The Scandinavian countries have health care data systems that allow access to information about every doctor visit, lab diagnosis, etc. Analysis of these data indicate that 20-30% of all people are diagnosed with genital warts at one time or another. In the US, roughly 15% of all persons say they've had genital warts, but the real frequency probably is similar to that in Sweden, Norway, etc. And by the way, GWs are not strongly associated with increased numbers of sex partners -- i.e. only slightly more common in people with 10+ versus 1-3 lifetime partners.

Condoms allow substantial skin-to-skin contact above the condom and therefore they are less effective in preventing HPV than other STDs, especially those transmitted primarily through genital fluids (chlamydia, gonorrhea, HIV, etc). A properly used condom that doesn't fail probably reduces the HPV transmission risk quite a bit, maybe by 80-90%. So not bad for any single exposure. But with a 10-20% failure rate, over time condoms allow a lot of HPV transmission. People who say they use condoms consistently have pretty much the same risk of HPV as those who don't use condoms. Of course part of this reflects the fact that claims of 100% condom use often are inaccurate. Whatever the reasons, condoms aren't very protective against HPV in the long run.

How to minimize the risk? I would still recommend condoms for one-off sexual exposures with new partners; the 80-90% protection is significant. But I do not recommend condoms in monogamous couples in which one person is known to have HPV, such as an abnormal pap smear or current or past warts. Most important, this is among the reasons for HPV immunization. All people should be vaccinated, preferably in their pre-teen or teen years, but anyone up to age 26 should consider it -- and depending on sexual lifesyle, sometimes up to age 40. The vaccine gives 100% protection against the 9 HPV types that cause 90% of human disease related to HPV, including the two types that cause about 90% of genital and anal warts. And against the 7 types responsible for 90% of cancers caused by HPV. (But not effective -- or only slightly effective -- against types that previously infected that person). In areas where HPV immunization has become routine and widely accepted -- e.g. Australia, where almost everyone has been vaccinated -- the frequencies of GWs and HPV related cancers (and pre-cancerous conditions like abnormal pap smears) have declined precipitously.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

PS:  It appears you may be using two different accounts with different usernames. Please combine accounts. or at least stick with one or the other in the future. Thanks.
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14 months ago
Thanks for the insight.  I note that HPV vaccinations appear to have an upper age limit.  Is there a reason that persons such as me (65 years old) are precluded?  Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
14 months ago
New HPV infections are uncommon after age 26 and quite rare after 40-45. In general, such persons tend to have sex with age-similar partners, among whom there are few active/transmissible HPV infections. Equally important, the older one is and the greater his or her sexual experiences, the more likely they are to have already been infected with the HPV types covered by the vaccine. There's little point, for example, in immunizing someone who likely has had several of the 9 types covered by the vaccine. There also are ptactical issues, like the fact that the vaccine costs around $600 and most health insurance follows the recommended age guidelines. Pretty expensive for marginal benefit.---
14 months ago
Wow.  Risk benefit ratio is pretty striking.   I guess that is why I am clean despite dating younger women.  Since I have one question left, please let me ask you an unrelated one.  I understand condom use does not provide adequate protection against herpes, and I always am upfront in communicating to a prospective partner that I contracted herpes years ago and still have occasional outbreaks when highly stressed.  How effective is valacyclovir in reducing risk, and how soon before having sex should it be taken?  Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
14 months ago
Well, you don't know you're "clean" in regard to HPV, only for visible genital warts. Absence of symptoms means nothing in judging whether or not you've had HPV or might still have an active infection. 90% of all people acquire genital HPV, probably a few times for most of us.  

Follow-ups are intended for clarifications of the initial question, not entirely new topics. Briefly, in persons with genital HSV2, ongoing (daily) suppressive treatment with valayclocivr reduces transmisison risk by about 50%. There are reasons to believe that the research underestimated the benefit, and the actual reduction may be somewhat higher, e.g. 60-70% reduced risk. There are no data on taking the drug before sex, only for ongoing daily treatment. It takes 5 days for valacyclovir to reach full effectiveness to prevent transmission, probably with decreasing protection thereafter and probably not effective at all under 24 hours. (Congratulations, by the way, in informing partners about your infection.) If you would like more detail or discussion about this, feel free to post a new question in the herpes category, which would be answered by the forum's herpes expert, Terri Warren.

That completes the two follow-up exchanges included with each question and so concludes this thread. I hope the discussion has been helpful.
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CORRECTED ENTRY: Previously I guessed 3-4 days for valacyclovir to become maximally effective to prevent transmission. In fact, there are published data on this, and I have changed 3-4 days to 5 days.---