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Am Fam Physician. 2005;72(01):178-181

The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on the clinical management of women with human papillomavirus (HPV) infection. ACOG Practice Bulletin No. 61 was published in the April 2005 issue of Obstetrics and Gynecology.

HPV infection can be diagnosed clinically (genital warts), cytologically (Papanicolaou smear), or virologically (DNA testing). The more severe abnormalities attributed to HPV infection correspond to the traditional classification of precursor lesions of invasive cervical cancer: mild, moderate, or severe cervical intraepithelial neoplasia (CIN, which includes low-grade and high-grade squamous intraepithelial lesions [LSIL and HSIL, respectively]). Each year in the United States, up to 3 million women are diagnosed with atypical squamous cells of undetermined significance (ASCUS) and more than 1 million women are diagnosed with LSIL. Results of a 2001 study by the National Cancer Institute showed that 83 percent of women with LSIL tested positive for high-risk HPV DNA. Most cervical HPV infections diagnosed by polymerase chain reaction and other nucleic acid detection methods seem to be transient. However, older patient age and high-risk HPV types are associated with infections of longer duration.

Treatment for genital warts should be guided by patient preference and physician experience. Because of a similar risk of recurrence, no single treatment for external genital warts can be recommended over other treatments. Visible genital warts often resolve spontaneously. Warts that are small in size and few in number will respond to almost any treatment or to no treatment at all. Warts on moist or mucosal surfaces generally are more responsive to topical treatments compared with warts on dry surfaces. Warts that do not respond to a particular treatment after three physician-administered treatments, and warts that are not cleared completely after six treatments, should be reevaluated. Pregnant women should not use patient-applied topical treatments.

Although evidence that condoms offer complete protection from HPV infection is lacking, condom use may reduce the risk of HPV-related disease such as genital warts and cervical neoplasia. Condom use may be effective in the clearance of HPV and HPV-related lesions.

A combination of cervical cytology and HPV DNA testing is appropriate in women 30 years and older. If this combination is used, women with negative results on both tests should be rescreened no more than every three years. Women older than 30 years with negative cytology who test positive for high-risk HPV DNA should repeat both tests in six to 12 months. Patients with persistent high-risk HPV should undergo colposcopy regardless of the cytology result.

Studies using combined HPV DNA testing and cervical cytology have a 99 to 100 percent negative predictive value for CIN grades 2 and 3; women with negative concurrent test results can be reassured that their risk of unidentified CIN grades 2 and 3, and of cervical cancer, is approximately only one in 1,000. HPV DNA testing is not recommended in women with LSIL, atypical squamous cells that cannot exclude HSIL, or atypical glandular cells. Women with high-risk HPV types who have ASCUS or LSIL, but who are not found to have CIN grade 2 or 3 at their initial colposcopy, have an approximately 10 percent risk of developing CIN grade 2 or 3 within two years.

HPV DNA testing could be used as a test of cure in women with CIN grade 2 or 3 at six to 12 months after excision or ablation of the transformation zone. Women with high-risk HPV should be referred for colposcopy.

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