Genital Warts in Women

Genital warts are benign, soft, skin-coloured or pigmented growths on the vulva, vagina, cervix, perineum and anus caused by human papillomavirus types 6 and 11.

• They are transmitted sexually and often persist or recur.
• HIV infection and pregnancy increase their size and number.
• Treatment removes visible warts; it does not eradicate the virus.

Cauliflower-like, flat or papular growths on the vulva, perineum, vagina, cervix or perianal skin.

• Itching, bleeding on friction, discharge, discomfort and cosmetic distress.
• Differential diagnosis: condylomata lata of secondary syphilis, molluscum contagiosum, skin tags, vulval intraepithelial neoplasia, seborrhoeic keratosis, vulval papillomatosis, squamous carcinoma.
• Complications: secondary infection, bleeding, obstruction of urine flow or labour with large lesions, psychological distress, recurrence, and malignant change in persistent atypical lesions.

Diagnosis is clinical, with biopsy for atypical lesions.

• Clinical diagnosis by examination of the vulva, vagina, cervix and anus.
• Biopsy for atypical, pigmented, fixed, ulcerated or treatment-resistant lesions and in HIV infection.
• Cervical screening (HPV testing or cytology).
• HIV, syphilis, gonorrhoea and chlamydia tests; pregnancy test.

Remove visible warts by patient-applied, clinic-applied or procedural treatment, and counsel on recurrence.

• Supportive: keep the area clean and dry; avoid scratching; condoms; counsel that warts may recur; inform partners; advise against smoking.
• Pharmacological: patient-applied: podophyllotoxin 0.5 percent solution or gel applied to the warts twice daily for 3 days then stopped for 4 days, repeated for up to 4 cycles; imiquimod 5 percent cream applied at night 3 times weekly, washed off after 6 to 10 hours, for up to 16 weeks. Clinic-applied: trichloroacetic acid 80 to 90 percent applied sparingly weekly for up to 6 weeks, with sodium bicarbonate to neutralise excess. Give HPV vaccine to unvaccinated eligible girls and women.
• Procedures: cryotherapy with liquid nitrogen every 1 to 2 weeks, electrocautery, laser or surgical excision under local anaesthesia (1 percent lignocaine, maximum 3 mg/kg, absolute maximum 200 mg plain) for large or resistant warts. Treat vaginal and cervical warts only by clinic-applied methods.
• Special groups: in pregnancy use trichloroacetic acid, cryotherapy or excision; podophyllotoxin and imiquimod are not used. Caesarean delivery is reserved for warts that obstruct the birth canal or risk heavy bleeding. In HIV infection start or optimise antiretroviral treatment because recurrence is higher. In immunosuppression biopsy persistent warts to exclude neoplasia.
• Red flags: pigmented, ulcerated, bleeding or fixed lesions, rapid growth, no response after 3 months, obstruction of urine flow.
• Follow-up: review every 2 to 4 weeks during treatment; recheck at 3 months for recurrence; continue cervical screening.