Human papillomavirus DNA is present in practically every squamous malignancy of the female genital tract. This article reviews the pathophysiology of HPV, clinical findings, diagnostic techniques, treatment options, and management during pregnancy
infectious nature was not described until 1894. A virus was implicated as an etiologic agent in 1907, but the human papillomavirus (HPV) particle was not seen with electron microscopy until 1949. To this day, there has been no convincing demonstration of a method for culturing HPV in tissue.
It has been suggested that microtrauma allows the virus to enter the skin or mucosa of the genital tract. The virus enters the cells at the basal layer and matures as it passes through the parabasal, spinous, and granular layers of the epithelium. At the granular cell level, viral DNA replication, late protein synthesis, and viral particle assembly are carried out. Integration of the viral DNA into the host genome does not occur until the cervical intraepithelial neoplasia III/carcinoma in situ stage of development.
Overt condyloma acuminatum may be seen in the perianal area, perineal body, vulva, vagina, or cervix; subclinical HPV infection may also be seen in each of these areas.
The main techniques for detecting HPV infection are listed below:
HPV must be regarded as having the potential for infecting the entire genital tract, since only very early disease tends to be localized. The object of therapy is to remove all overt and subclinical HPV infections detected during the diagnostic evaluation.
Overt condylomas typically enlarge during pregnancy. This growth is probably the result of high progesterone levels in the mother. The lesions may become large enough to cause hemorrhage. Podophyllin therapy is contraindicated because of its toxicity and risk of teratogenesis. Agents such as bleomycin and 5-FU are also contraindicated because of their antimitotic and cytotoxic actions. TCA solution may be useful, however. Cryotherapy and the CO2 laser have also been helpful in reducing the number and volume of warts. Imiquimod has a category B rating, but no clinical data on its use during pregnancy are available. In almost every case, HPV disease will diminish after delivery.
For localized warts, TCA offers the best combination of effectiveness, low morbidity, and expense. When the labia and vulva are involved, the use of TCA or 5-FU is recommended. For extensive vulvar disease, laser therapy is best used for the labia, perineal body, or perianal areas. Alternatively, intralesional and/or intramuscular interferon, either alone or in combination with laser therapy or 5-FU, may offer the best hope of controlling the virus.
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