Need expert opinion

[345medhelpFAN]

In Jan. 2004 a girl I was dating developed genital warts a few weeks after having sexual contact with me.  I then went for a complete check up with a urologist.  He examined me with vinegar, etc and saw no warts.  I followed up in May and again on Sept 3rd.  Again, he performed a complete overview and found nothing.  I am no longer dating the girl from this past winter, we moved on for different reasons, not warts.  At the end of May I began dating a new girl.  On August 1st she developed a genital wart.  My urologist can't find anything and he is checking with a magnifying glass, etc.  Myself and my girlfriend have had complete physicals, we are both healthy.  My girlfriend is using Condolyx for the warts when they pop up.
We are using condoms and do not have sex while she is using Condolyx.  

Questions:

1.  From reading about warts, it appears at some point, maybe weeks, months, but your body will suppress the warts/HPV virus.  It doesn't leave you, but your immune system eventually suppresses it....in your experience, how long on average have you been seeing healthy young people getting to this point...6 months?  

2.  Warts are very common, and neither girl I was with was a virgin, but do you think I am carrying this in latent form?  Maybe I had a small wart that was missed?


My girlfriend and I are have had trouble getting a doctor to offer an solid opinion on the above questions.


best!

[H. Hunter Handsfield, M.D.]

Genital warts are caused by certain types of human papillomavirus (HPV), but the large majority of HPV infections are asymptomatic--no warts and nothing visible with acetic acid (vinegar) or any other method.  No examination by a doctor can ever prove the absense of HPV.

The answer to your second question is yes, you may have an asymptomatic HPV infection.  But HPV infections are extremely common, and it can take months or longer for warts to show up.  So while it is possible you infected both partners--that seems likely, with warts appearing in both partners "a few weeks" after starting each relationship--there is no way to know for sure.  At this point, you can assume you and your current partner both are infected with HPV; if you didn't give the virus to your partner, by now you have caught it from her.  But there is no way to know for sure who had it first.

The good news is that the answer to your first question is yes.  Eventually--probably several months, i.e. pretty soon now--your immune system will control your infection.  The same will happen with your partner and her warts will stop recurring.

In the meantime, it's a good idea to avoid vaginal intercourse when she is using Condylox--not so much to prevent transmission, but because the treatment can be irritating and sex might be uncomfortable.  The need for condoms is less clear.  You and your partner probably are not going to re-infect each other with HPV; even though your immune system hasn't yet cleared the infection, almost certainly it is preventing reinfection with the same HPV type.  And condoms aren't very good at preventing HPV anyway, because during intercourse there is plenty of skin-to-skin contact beyond the area the condom covers.  So using condoms is optional.

Reading between the lines, it seems you and your partner have a healthy understanding of the implications of HPV in your relationship and aren't letting it dominate your sex life.  Good show!  In the long run, it's not a big deal.

Good luck--    HHH, MD

[345medhelpFAN]

Thank you, that was the most clear answer I have received.  One follow up question.

1.  Should my current relationship fall apart or we part ways.  If my body has suppressed the HPV infection, lets say its a year from now...does a new partner need to be concerned about getting warts?  I have never had any, but I clearly have or had an active HPV infection.  Better yet, if my current girlfriend and I were not together, should a new partner of her be concerened.  My understanding is if u believe u have an active HPV infection, warts or no warts, you should notify your partner and practice safer sex.  If however, you have been wart free for months, a year and you practice safer sex....well, is this a conversation you need to have with a new partner?  How contagious are you if you have a suppressed form of HPV?

[H. Hunter Handsfield, M.D.]

Ah, there's the rub.  For most STDs (herpes, HIV, untreated syphilis or chlamydia, etc) you would have a clear ethical obligation to inform future partners before having sex with them.  But HPV and warts are less clear.  Since almost everybody catches HPV within their first 4-5 lifetime sex partners, many of the partners you might choose are already infected; most HPV infections lead to nothing serious; and if you're going to have sex at all, nothing practical can be done to prevent transmission of the virus (e.g., condoms don't work well).  So CDC and other authorities consider it optional as to whether you need to routinely inform prospective partners, and I agree.  Some say yes, others no; it's up to you and I can't give you strict advice.

That said, consider what it will be like, and what the impact on the relationship might be, if you don't tell her ahead of time and a problem appears.  Being honest up front may be wisest.  But it's a very personal decision.

Good luck--   HHH, MD

[345medhelpFAN]

Here is a science point/question (this will be my last one, you have been great).

I have read that if you come in contact with genital warts you have a high likelihood (up to 70%) chance of getting genital warts.  So if you have warts, you remove them, your body suppresses the virus...a suppressed virus is a lot less contagious than an active infection, right?  I think I got the HPV infection from an older woman I dated at the end of last year, December time frame.  Then the two girls I have been with in the following months, both of which had not been with many parnters...got warts, I have remained asymptomatic.  So at this point I feel I have suppressed the virus or I will shortly.  I should be less contagious in the suppressed form?  Correct?

[H. Hunter Handsfield, M.D.]

To rephrase, I think you are asking two questions.

1) Does infectivity of HPV--the likelihood of transmission to a sex partner--decline as the immune system suppresses the infection?  Yes.  It's hard to prove from a research standpoint, but as the immune system suppresses (and maybe completely cures) the infection, the chance of transmitting to partners almost certainly drops to much lower levels, probably to zero.  However, we don't know very much about how fast this happens; an average of several months to a year is a good guess, but undoubtedly there are exceptions in both directions.

2) Is infectivity greater in the presence of overt warts than it is for asymptomatic HPV infection?  (Corollary:  Does treating warts--i.e., removing visible wart tissue--reduce the chance of transmission to the infected person's partners?)  The answer is much less clear.  Common sense says yes; overt warts might have more virus than asymptomatic infection of the genital skin and mucous membranes, and more virus presumably means greater chance of transmission to a partner.  On the other hand, most persons who get gential warts catch them from someone who does not have warts him/herself (as may have happened from you and your partners)--so infectivity can be plenty high without warts.

Best wishes--   HHH, MD

[345medhelpFAN]

Point of clarification:

When we say warts can take months or years to show up, we are talking about the HPV virus living in an incubation period...that incubation period can be short or long.  Once the virus comes out of the incubation period, the infection becomes "active".  When it becomes active you can have zero symptoms or you can have visible warts, etc.  My infection is active or has recently been suppressed or cured, the entire time asymptomatic.  Assuming I don't come in contact with a new HPV strand (e.g. my girlfriend and I stay together, no one cheats, etc), I should be pretty sure that I will not develop visible genital warts at this point from this strand.

[H. Hunter Handsfield, M.D.]

Probably true, you likely won't get visible warts from this particular HPV infection.  But that's not certain; warts sometimes appear years later, perhaps because of changes in the immune system's control of the infection.

HHH, MD