HPV Symptoms, Causes & Management
HPV stands for Human Papilloma Virus. There are over 130 known strains of HPV of which 30 different types affect the ano-genital area and these are further categorised into Low-Risk HPV and High-Risk HPV based on their ability to produce abnormal cells and cancers.
Low-Risk HPV – strains of HPV not associated with cancers
Such strains of HPV are more likely to cause skin warts and genital warts. Genital warts are most commonly associated with HPV types 6 and 11.
High-Risk HPV – strains of HPV associated with cancers
Such strains of HPV which may cause abnormal cell changes (cell dysplasia) associated with the development of certain cancers. This can include cervical, vulval, vaginal, penile and anal cancers, as well as some types of head and neck cancers. Types 16 and 18 cause 70% of cervical cancers and pre-cancerous lesions.
Contrary to popular belief, HPV can affect both men and women and is most commonly sexually transmitted. It can also be transmitted via close genital skin-to-skin touch.
How common is HPV?
Yes. Evidence suggests that approx. 8 out of 10 sexually active men and women will contract a strain of HPV at least once in their life, although most of these will not even know they have had it. The World Health Organisation estimates that over 80% of women will have HPV at least once before the age of 50.
For the detection of changes on the cervix (often invisible) that may develop into cancer.
Symptoms of HPV
The symptoms of HPV depend on the type of HPV you have. However, our understanding of the behaviour of different types of HPV is in its infancy and is being further researched as we write this.
- It is important to know that some patients can have both Low and High Risk HPV types.
- It is not entirely clear why some patients develop symptoms whilst others do not.
- Those with underlying medical conditions with a suppressed immune system are more likely to get the symptoms and the recurrence of symptoms after successful treatment.
Symptoms from Low Risk HPV types
Low Risk HPV presents as warty lesions on the skin or mucosa – the lining of various cavities in the body, for example, your lips.
Certain HPV genotypes produce lesions on hands and feet, whilst other types mainly affect the ano-genital area. There are a few types like 104 (TBC) which is known to produce lesions more widely including on the face, eyebrows, mouth, hands, feet and the genitalia.
HPV types 6 and 11 were known to cause 90% of genital warts before the widespread administration of HPV vaccines in girls and boys in the UK. Click here to see images of genital warts.
Some experts think that protection against HPV types 6 and 11 may leave one more likely to get exposed to other types of HPV. Furthermore, due to advancements in HPV molecular testing it’s possible to pick up other types of HPV which we could not detect with earlier generation tests.
To learn about the complications of warts due to Low Risk HPV, please visit this page.
Symptoms from High Risk HPV types
High Risk HPV does not produce typical genital warts. Many patients may have this without any symptoms. However, some people will present with patches, plaques, ulcers and non-specific lesions on the affected area some of which will progress with the passage of time to become precancerous and eventually cancerous lesions.
Generally, this process is a slow one taking many years to develop from an early lesion to a cancerous one but can have a rapid course in some people especially if they have an immunosuppressive medical condition or are on immunosuppressants.
It’s possible that someone who has got genital warts (presumably due to Low Risk HPV) can also have High Risk HPV at the same time. This is why your clinician may recommend a High Risk HPV test for those presenting with genital warts.
Sometimes, innocuous looking changes in the skin or mucosa on the penis, vulva, around the back passage or in the mouth can be attributed to a non-specific cause whilst in reality it may be due to underlying High Risk HPV infection.
In those who don’t clear the virus naturally, HPV can change the structure of the cells (cell dysplasia) which may lead to further complications.
The main complication of High-Risk HPV infection is the risk of developing cervical, vulval, anal, penile and mouth or throat cancers. Not all high risk HPV infections lead to cancer, but it’s crucial to attend cervical screening and colposcopy appointments as per the medical advice.
Sometimes patients with underlying skin conditions such as Lichens Sclerosis, Eczema, Psoriasis of the ano-genital area can have associated High Risk HPV infection thus substantially increasing the risk of cancer.
Complications of High Risk HPV in women
High risk HPV are most common in women aged 18-30 but can occur at any age in sexually active women. Cervical cancer is more common in women over 35, indicating that many women become infected with HPV at a younger age, and the persistence of a High-Risk infection results in slow progression to cervical cancer.
- Precancerous lesions of vulva (Vulval Intraepithelial Neoplasia – VIN)
- Cancer of vulva
- Precancerous lesions of vagina (Vaginal Intraepithelial Neoplasia – VaIN)
- Cancer of vaginal wall
- Anal Intraepithelial Neoplasia (AIN)
- Cancer of anus
- Precancerous lesions of oral cavity
- Oral cancer
Neoplasia is a technical word to describe both abnormal cell growth and cancers.
Complications of High Risk HPV in men
Penile cancer is 10 times less common than cervical cancer, but is also highly correlated with High-Risk HPV infection and history of external genital warts. It can lead to:
- Precancerous lesions of penis (Penile Intraepithelial Neoplasia, PIN)
- Penile cancer
- Anal Intraepithelial Neoplasi (AIN)
- Cancer of anus
- Precancerous lesions of oral cavity
- Oral cancer
A case control study of more than 100 men with penile cancer reported that the risk of penile cancer in men with a history of external genital warts was 5.9 times the risk compared to men with no such history. The presence of High Risk HPV in these patients contributed to this increased risk of penile cancer.
What increases the risk of cancers from High Risk HPV?
- The presence of more dangerous High Risk HPV types
- The presence of more than one High Risk HPV types
- The persistence of High Risk HPV
- Smoking increases the risk from High Risk HPV
Can I have HPV without having symptoms?
Yes. In fact, most people with HPV have mild, unnoticeable or no symptoms and so they do not even know they have the virus.
A key characteristic of HPV (both Low and High Risk types) is the ability to be in the host body without producing any symptoms (latency).
The virus may take weeks to years to produce symptoms after first acquiring it. But, even if you have no symptoms, the virus can still be shed from the genital area and transmitted to new partners.
Can the symptoms of HPV be that of another infection or condition?
Occasionally, genital warts may be confused with other dermatological conditions such as Molluscum Contagiosum, sebaceous keratosis or skin tags. If you are unsure, it’s best to see a specialist for a confirmed diagnosis.
I think I have HPV. What should I do?
If you think you have Low or High-Risk HPV, we recommend seeking medical advice from a healthcare professional. They will be able to test and diagnose you, and discuss the next steps and management options if necessary.
Causes of HPV
How is HPV transmitted?
High and Low Risk HPV can be transmitted via:
- Vaginal sex
- Anal sex
- Oral sex (this can occasionally cause warts to appear inside the mouth, on the lips or on the face)
- Close genital contact (and this includes hand to genital contact).
- Sharing of sex toys
You do not get HPV from:
- Sharing baths or towels
- Swimming pools
- Toilet seats
- Sharing cups, plates, cutlery
Can condoms protect against HPV transmission?
Condom and femidom use offers only partial protection. This is because HPV is shed from a much wider genital and anal tissue area than the condom can cover (i.e. the labia, scrotum or anus). Furthermore, HPV may be present on absolutely normal looking skin.
What increases the risk of getting HPV?
Being sexually active
Men and women who are sexually active are likely to get at least one strain of HPV over the course of their lives. You can still get HPV even if you have only had sex with one other person, and even if you use a condom. However, those who have unprotected sex, and those who have a higher number of partners are at an increased risk, as are those who became sexually active at an earlier age.
Previous genital conditions
Previous history of other sexually transmitted infections, genital warts, abnormal smear tests, or cervical or penile cancer increases the individual’s risk of contracting HPV.
Poorly controlled diabetes, especially type 1 diabetes mellitus, is associated with more severe cases of genital warts, poor response to treatment and higher chances of recurrence.
If your partner(s) has had a higher number of partners, a history of HPV, genital warts, other sexually transmitted infections, cervical or penile cancer, then your individual risk of getting HPV is increased.
Smokers are more likely to get HPV. It’s thought that tobacco use weakens the immune system, in turn making those more vulnerable to infection. One study reported that HPV DNA was 3.5 times more frequent in normal endometrial samples of smokers compared to non-smokers.
Weaker immune system
Those who have a weakened immune system, such as those with HIV/AIDs, or those who are taking immunosuppressant medication have a higher risk of developing HPV due to increased susceptibility to infection.
How can I prevent HPV?
HPV vaccines can protect against 9 different strains of HPV. However, protection is limited to the type of strains present in the vaccine.
Whilst condoms or femidoms may reduce the risk of transmitting or getting HPV, it does not completely eradicate the risk.
Recommend your partner gets treatment for genital warts. Having an active case of genital warts makes the virus easier to spread. Although treating and removing the warts won’t get rid of the underlying HPV infection, it may have an effect on how much virus is present in the warts and how transmittable it is.
Can I find out who gave me HPV?
It can be difficult to establish how and when you first got HPV, as the virus has a habit of lying dormant for months, or even years before any symptoms become present (if at all).
This means that you or your partner(s) could have had HPV for years without knowing it. As such, if your partner has HPV it does not necessarily mean that they have been unfaithful.
Can I have a vaginal delivery if I have HPV?
Whilst uncommon, HPV can be transmitted to the newborn during vaginal delivery. Women with genital warts are at a higher risk of transmitting HPV to the foetus compared to the mothers who are just HPV carriers without any warts. Potential exposure of the newborn to the virus at the time of vaginal delivery is not considered a risk to the baby, and usually of no clinical significance.
Studies show that babies who contract the infection during delivery are usually able to clear it naturally within 6 months without any serious complications.
Patients can have a natural birth even if genital warts are present, but this is the decision of the consultant or midwife delivering the child. If the mother has large genital warts which are blocking the birth canal, or pose any risk to mother or foetus during delivery, the medical team may recommend a caesarean section instead of a vaginal delivery.
Management of HPV
This information is for general guidance only. Any positive test result will be discussed with you by your clinician with your individual circumstances in mind.
What happens if I have Low Risk HPV?
Whilst this can be disheartening news, you should take comfort in the following:
- Most patients will naturally clear the virus with the passage of time
- Genital warts, should you develop them in future, can easily be treated
- You can discuss with your clinician if HPV vaccines will protect against other types of HPV
- You can always speak to your clinician about any specific concerns that you may have
We may recommend your partner to seek HPV testing & HPV vaccination. Furthermore, they may have already been exposed to the virus so starting to use protection may not be of much value.
When thinking about your future partner(s):
- They may have already been exposed to the virus from a previous partner.
- They may have already had the HPV vaccine.
- The role of condoms in HPV transmission may be partial
- Repeating LR-HPV tests in 6-12 months may be an option
- Stop smoking (where applicable)
If you are concerned about being Low Risk HPV positive and have no symptoms
In addition to the above, you may not have developed genital warts and if you can keep your immune system healthy, you may prevent developing warts in the future
If you have non-specific lesions
The lesion is likely to be a genital wart and should be treated as such.
If you have suspected/confirmed genital warts
The positive result will tell you the type of HPV responsible for your warts. The result may identify cases of HPV vaccine failures where they arise or warts due to non-vaccine preventable HPV types.
Furthermore, Genital warts can easily be treated and we can help you with that.
The only way to conclusively confirm a diagnosis of genital wart is to perform a histopathological examination of a biopsied lesion, in conjunction with the HPV tests to identify the type(s) of HPV causing the lesions in an individual case. Such examinations are not required for routine management of genital warts.
If you have had abnormal smear results
Low risk HPV types can produce low grade abnormalities on cervical smear and simultaneous negative HR HPV tests can be reassuring in such patients.
If your partner is HPV positive
If you both have the same Low Risk HPV genotype, then there is no concern about further HPV transmission.
If you both have the different Low Risk HPV genotypes, then we can discuss ways to refrain from getting other Low Risk HPV genotypes.
If you have a Low Risk HPV genotype but they have a High Risk HPV genotype, then we may recommend more routine HPV screening and a possible course of HPV vaccination.
What happens if I have High Risk HPV?
In the event of a positive result, we will recommend all female patients for a cervical smear +/- colposcopy based on your previous smears/HPV test results. The following table should provide further guidance:
Male patients may require a high resolution anoscopy after a clinical assessment.
This may be followed by a repeat High Risk HPV test in 6-12 months time as per current guidelines.
We would also advise you to tell your partner so that they may get tested and avoid long-term complications to their health. After speaking with them, their clinician may recommend the HPV vaccine as well. They may have already been exposed to the virus so starting to use condoms/femidoms may not be of much value.
Furthermore, it is recommended you stop smoking (where applicable) to reduce the risk of abnormal cell growth and other consequences.
Is there a cure for HPV?
There is currently no treatment for HPV infection. However, many people spontaneously clear the infection due to their immune response. It is believed that 90% of people will clear the infection naturally within 2 years. Many patients have had HPV infection in the past and spontaneously cleared without ever recognising this.
The spontaneous cure rate may be lower in those with:
- History of smoking
- Diabetes mellitus
- Immunosuppressive medical conditions
- Immunosuppressant drugs for various medical conditions
- Use of steroids
Can I get reinfected with HPV?
Yes. You can become reinfected with HPV, both with the same type, or with another type. Reinfection is often associated with sexual activity and new partners. HPV does not have associations with natural immunity.
Page reviewed by Dr. Manoj Malu (Clinical Director)
Last reviewed date: 2 January 2021
Next review due: 2 January 2022
Whilst this content is written and reviewed by sexual health specialists, it is for general guidance only. It is not intended to replace the advice of your clinician.
References & Further Reading
- IARC Monographs on the Evaluation of Carcinogenic Risks to Humans Volume 90: Human Papillomaviruses
- World Health Organisation: Human papillomavirus (HPV) and cervical cancer
- Anal Cancer Foundation: What Is HPV?
- University of Oxford Vaccine Knowledge Project: HPV (Human Papillomavirus)
- American Society for Microbiology: Human Papillomavirus and Cervical Cancer
- The Journal of the American Osteopathic Association: Metastatic Penile Squamous Cell Carcinoma to the Retroperitoneum in a Man With Human Papillomavirus Type 45
- Translational Andrology and Urology: Relationship between human papillomavirus and penile cancer—implications for prevention and treatment
- Jo’s Cervical Cancer Trust: How people get HPV
- The Journal of Obstetrics and Gynaecology Research: Possible non‐sexual modes of transmission of human papilloma virus – Sabeena
- Virology Journal: Rate of vertical transmission of human papillomavirus from mothers to infants: Relationship between infection rate and mode of delivery
- Cancer Epidemiol Biomarkers Prev: Relationship between cigarette smoking and human papillomavirus type 16 and 18 DNA load
- Journal of Virology: How Does Tobacco Smoke Contribute to Cervical Carcinogenesis?
- Clinical Microbiology Review: Human Papillomavirus and Cervical Cancer
- BMJ: Epidemiology of genital warts in the British population: implications for HPV vaccination programmes
- American journal of epidemiology: Risk factors for cervical intraepithelial neoplasia: differences between low- and high-grade lesions
- NHS England: Primary High Risk HPV Testing with Cytology Triage
- Gov UK: Cervical Screening – Helping you decide
- The British Society for Colposcopy and Cervical Pathology: About Cervical Screening.
- NHS: Overview – Colposcopy
- CDC: STD Facts – HPV in Men
- International Journal of Environmental Research and Public Health: Prevalence and Risk Factors of Human Papillomavirus in Male Patients: A Systematic Review and Meta-Analysis.
- Sexually Transmitted Infections – British Medical Journal: Human papillomavirus in men: comparison of different genital sites
- Cancer Epidemiology, Biomarkers and Prevention: The Human Papillomavirus Infection in Men Study: Human Papillomavirus Prevalence and Type Distribution among Men Residing in Brazil, Mexico, and the United States
- HHS Public Access: HPV infection and re-infection in adult women: the role of sexual activity and natural immunity