Epidemiological, clinical, and virological characteristics of women with genital warts in Greece

Abstract

This is a prospective study of the epidemiological, clinical, and virological characteristics of cases of genital warts in a Greek University Hospital. The women completed a questionnaire regarding their medical and sexual history and underwent cervical cytology, HPV DNA typing, mRNA testing, colposcopy, Chlamydia testing, and proctoscopy. Univariate and multivariate analyses were performed. The most commonly detected types were type 6 (36.1%) and 16 (24.3%). E6/E7 mRNA testing was positive in 21.5%. Concurrent cervical intraepithelial neoplasia grade 2 or worse was found in 11.1% and intra-anal warts in 10.4%. For chlamydial infection the number of sexual partners was a significant predictor. Women with warts infected with types 6 and 11 constituted only 37.5% of the total. This could have a negative effect on the efficacy of vaccination in reducing the incidence of the disease. Based on the present findings the authors recommend cytology and colposcopy for all women with genital warts.

Full text

Introduction
Genital warts is caused by infection by human papillo-
mavirus (HPV) mostly of low-risk types (6 and 11) and
is a common disease, with 4% of the female population
having been diagnosed with the disease in the UK [1]. In
the UK 80,000 and in the USA over 300,000 diagnoses
are made annually. The condition does not usually cause
major morbidity or mortality, but has serious aesthetic
and psychosexual sequelae. Studies have shown that
women with genital warts have worse body image than
women without or have high anxiety levels and more
commonly have conflicts with their partners [2]. Also
genital warts in pregnancy have been associated with ju-
venile respiratory papillomatosis through vertical viral
transmission to the newborn [3] and obstruction of res-
piratory tract. All these issues make women seek treat-
ment. Given that genital warts is a common disease and
that recurrence following treatment is frequent, the fi-
nancial burden for the healthcare system increases con-
siderably. A single successful episode of treatment of
genital warts has been estimated to cost approximately
400 USD. The high healthcare costs have created an ar-
gument for the use of the quadrivalent HPV vaccine
which aims to prevent not only cervical cancer but also
the acquisition of genital warts.
Given the importance of this condition and because the
lack of detailed data in Greece, the authors undertook this
study in order to address the local epidemiological and mo-
lecular issues of this disease.
Materials and Methods
All women that presented to the colposcopy department of the
University Hospital of Ioannina with genital warts from February
2010 until May 2011 were asked to participate in this study which
had ethical approval from the University of Ioannina. In their ini-
tial visit, each woman had a cervical smear taken which was placed
in ThinPrep medium. This sample was used for the following tests:
a. Liquid based cytology (LBC) which was reported according
to the Bethesda system;
b. HPV DNA testing with a genotyping test for detection of 35
HPV genotypes; the test was considered positive for high-
risk types when at least one of the following types was de-
tected: 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59,
66, 68, 73, 82, and 85.
c. Flow cytometric evaluation of E6/E7 mRNA of high-risk
HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68,
73, and 82) with an HPV detection kit. The test was consid-
ered positive if the result was >1.5%.
In women with symptoms suggestive of possible chlamydial in-
fection such as vaginal discharge, postcoital bleeding or pelvic pain,
an endocervical swab was taken for Chlamydia testing by PCR.
Once the samples were taken, a detailed colposcopic examina-
tion of the whole lower genital tract was performed and any le-
sions were recorded with biopsy if necessary. Colposcopically
directed biopsy was done in patients, who aside from the genital
warts, colposcopy raised the suspicion of a high-grade cervical le-
sion. If perianal warts were evident, or if the patient requested,
Revised manuscript accepted for publication December 2, 2013
Epidemiological, clinical, and virological characteristics
of women with genital warts in Greece
P. Loumpardia1, K. Bourmpos1, G.A. Loumpardias1, V. Kalampoki1, G. Valasoulis1, O. Valari1,
D. Vythoulkas1, E. Deligeoroglou2, G. Koliopoulos1
1Department of Obstetrics and Gynaecology, Ioannina University Hospital, Ioannina
2Department of Obstetrics and Gynaecology, Areteion University Hospital, Athens (Greece)
Summary
This is a prospective study of the epidemiological, clinical, and virological characteristics of cases of genital warts in a Greek Uni-
versity Hospital. The women completed a questionnaire regarding their medical and sexual history and underwent cervical cytology,
HPV DNA typing, mRNA testing, colposcopy, Chlamydia testing, and proctoscopy. Univariate and multivariate analyses were per-
formed. The most commonly detected types were type 6 (36.1%) and 16 (24.3%). E6/E7 mRNA testing was positive in 21.5%. Con-
current cervical intraepithelial neoplasia grade 2 or worse was found in 11.1% and intra-anal warts in 10.4%. For chlamydial infection
the number of sexual partners was a significant predictor. Women with warts infected with types 6 and 11 constituted only 37.5% of the
total. This could have a negative effect on the efficacy of vaccination in reducing the incidence of the disease. Based on the present find-
ings the authors recommend cytology and colposcopy for all women with genital warts.
Key words: Genital warts; Condylomata acuminata; Human papillomavirus; DNA; Fingerprinting; Chlamydia.
CEOG Clinical and Experimental
Obstetrics & Gynecology
7847050 Canada Inc.
www.irog.net
Clin. Exp. Obstet. Gynecol. - ISSN: 0390-6663
XLII, n. 2, 2015
doi: 10.12891/ceog1766.2015

P. Loumpardia, K. Bourmpos, G.A. Loumpardias, V. Kalampoki, G. Valasoulis, O. Valari, D. Vythoulkas, E. Deligeoroglou, G. Koliopoulos 189
proctoscopy was also performed. The treatment choice for the
warts was individualized with usual treatment options including
prescription of podophyllotoxin or imiquimod or laser ablation at
the same or a subsequent visit. At the end of the visit, the women
were asked to complete a questionnaire regarding their medical
and sexual history. The univariate statistical analysis was done with
the Fisher’s exact test and the multivariate by logistic regression.
Results
A total of 144 women with genital warts were included in
this study. The mean age was 25.7 years. The demographic
characteristics are given in Table 1.
HPV DNA genotyping of the cervical smear revealed the
following: Single type HPV infection in 43/144 (29.86%),
multiple type infection in 66/144 (45.83%), negative test
in 15/144 (10.41%), and in 20/144 (13.88%) women geno-
typing was not performed either due to lost sample or lack
of reagents or because a sample was not taken. The most
common detected HPV types were type 6 (36.1%) and 16
(24.3%). The distribution of the various HPV types is
shown in Table 2.
HPV mRNA testing with flow cytometry results were the
following: positive result in 31/144 (21.52%), negative in
80/144 (55.55%), no result due to lost sample or lack of
reagents or because of failure to take a sample in 32/144
(22.22%), and invalid result in 1/144 (0.69%).
The results of the LBC Papanicolaou test were: within
normal limits (WNL) in 22/144 (15.27%), atypical cells of
undetermined significance (ASCUS) in 15/144 (10.41%),
low-grade squamous intraepithelial lesion (LSIL) in 77/144
(53.47%), high-grade squamous intraepithelial lesion
(HSIL) in 8/144 (5.55%), and no data in 22/144 (15.27%).
The histology results showed that 16/144(11.11%) had
cervical intraepithelial neoplasia grade 2 or worse (CIN2+).
Intra-anal warts were detected in 15/144 (10.41%).
PCR for Chlamydia was positive in 8/144 (5.55%), neg-
ative in 42/144 (29.16%), and 94/144 (65.27%) were not
tested. Test results are summarized in Table 3.
Univariate analysis
A positive flow result was significantly associated with
high-risk type HPV DNA presence (p = 0.008) but not with
age or parity. Multiple type HPV infection was significantly
associated with nulliparity (p = 0.033) but not with smoking
or age at first sexual intercourse, however the association with
over five sexual partners marginally failed to reach signifi-
cance (p = 0.059). Chlamydial infection was not associated
with smoking, number of partners, age or parity. Presence of
CIN2+ was only associated with HSIL cytology (p < 0.001).
Multivariate analysis
Chlamydial infection and high-grade histology were
studied dependent variables. Age, smoking, parity, age at
first intercourse, and number of sexual partners were the
independent variables. For chlamydial infection, the num-
ber of sexual partners was a significant predictor with odds
Table 3. — Test results.
TEST Outcome Result (%)
HPV DNA typing Single infection 29.86
Multiple infection 45.83
No type 10.42
Invalid result or no test 13.89
HPV mRNA testing Positive 21.53
Negative 55.55
Invalid result or no test 22.92
Pap test WNL 15.28
ASCUS 10.42
LSIL 53.47
HSIL 5.55
Invalid result or no test 15.28
Chlamydia PCR Positive 5.55
Negative 29.17
No test 65.28
Colposcopy + biopsy CIN2+ 11.11
Intra-anal warts 10.42
Table 1. — Demographic characteristics.
Mean age 25.7 (median 24)
Mean age at first intercourse 17.8 (median 18)
Mean number of sexual partners 6.9 (median 5)
Smokers 65/144 (45.1%)
Nulliparous 130/144 (90.3%)
Vaccinated against HPV 13/144 (9%)
Table 2. — Distribution of HPV types.
HPV type No %
6 52 36.11
11 2 1.38
16 35 24.31
18 2 1.39
31 12 8.33
33 5 3.47
35 2 1.39
42 14 9.72
45 0 0
51 21 14.58
52 4 2.78
53 14 9.72
54 4 2.72
56 5 3.47
58 6 4.17
59 5 3.47
61 6 4.17
62 2 1.39
66 3 2.08
70 4 2.78
73 1 0.69
84 2 1.39
Any 106 73.61

Epidemiological, clinical, and virological characteristics of women with genital warts in Greece
190
ratio 1.25 (95% CI 1.05-1.48) for every additional partner.
For CIN2+ histology, no predictor was found.
Discussion
Genital warts are not only caused by low-risk types. A
proportion will have high-risk type leading to E6 and E7
expression (21%) and CIN2+ (11%). This should not be
overlooked. Therefore, all women should have cervical cy-
tology and colposcopy. If a possible high-grade lesion is
seen on the cervix at colposcopy, it is recommended to not
to use laser vaporization of cervical condylomas, before the
biopsy of the suspicious region. As 10% of women have
intra-anal warts, proctoscopy should be discussed in the
women with relevant sexual history [4].
Even though positive flow cytometry result was not as-
sociated with the finding of CIN2+ in this study, it is known
that E6 and E7 mRNA expression is a key step to cervical
carcinogenesis [5]. It may be that these women in this study
with a positive flow result but no CIN2+ on histology are
at risk of high-grade lesions in the future.
Studies have shown that 90% of genital warts are cause
by types 6 and 11 with up to 50% of lesions containing co-
infections with other types [6-8]. In this study the frequency
of women with genital warts who were infected with types
6 and 11 was 37.5%. The percentage of HPV 11 was only
1.388%. There is a recent male study in which the geno-
types most commonly detected in genital warts were HPV 6
(43.8%), HPV 11 (10.7%), and HPV 16 (9.8%) [9]. The
cost of care of genital warts in England exerts a consider-
able impact on health services which clearly demonstrates
the importance of immunization using the HPV vaccine
[10]. Not taking into consideration the issue of crossreac-
tivity with types not included in the vaccine, immunization
by the quadrivalent vaccine would have prevented at most
60.5% of the cases and by the bivalent 30.5% of the cases
even though the bivalent vaccine is not aimed at preven-
tion of genital warts. The present data suggest that the vac-
cine may not be as effective in preventing genital warts in
particular population.
Simultaneous Chlamydial infection was found in 5.6%
of women with genital warts. The percentage is not high
enough to warrant testing for all women with warts. As no
reliable predictors were found for positive Chlamydia re-
sult, the authors cannot recommend Chlamydia testing in
only a small subgroup of patients with specific epidemio-
logical characteristics. Given the serious effects of
Chlamydia infection on fertility, the authors would en-
courage clinicians to have a high degree of suspicion in
nulliparous women especially when they report multiple
sexual partners.
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Address reprint requests to:
P. LOUMPARDIA, M.D.
Department of Obstetrics and Gynaecology,
Ioannina University Hospital
St. Niarxou Avenue
Ioannina (Greece)
e-mail: bettyloumpardia@hotmail.com