The challenge with diagnosis, however, is that HPV often doesn’t produce obvious signs of infection, which can prompt people to delay testing. In some cases, individuals may first be diagnosed with HPV when they are diagnosed with a related cancer.
Tests for Women
HPV testing can be done during a pelvic exam—either by itself or at the same time as a Pap smear. This may be done during a routine gynecological exam or specifically because HPV is suspected.
During a Pap smear, cells are gently scraped from the cervix and examined under a microscope to check for signs of dysplasia, which can result from HPV infection. A visual exam will also be performed to identify genital warts (which typically have a cauliflower-like appearance, but can also be flat and flesh-colored). Remember, though, that the absence of warts does not mean you are clear of HPV.
Another test, called the HPV test, checks for the actual virus rather than for changes in cervical cells. It is used in women 30–65 years old, either in response to an abnormal Pap smear or as part of a routine screening. It can be performed at the same time—and even with the same swab—as the Pap smear (a practice known as co-testing).
Recommendations
HPV screening recommendations can vary by a woman’s age and other factors:
For women aged 21 to 29 years, a Pap smear is recommended every three years. However, HPV testing is not done routinely, but can be added automatically if the Pap smear is abnormal (reflex HPV testing), as HPV infections are common in women in their 20s and rarely lead to cancer. During this time, most HPV infections will be short-lasting and resolve on their own with no long-term consequences. For women 30 to 65, either a Pap smear can be performed every three years, HPV testing alone can be done every five years, or co-testing with a Pap smear and HPV test can be performed every five years. HIV-positive women 21 to 29 years should have a Pap smear every 12 months when first diagnosed. After three normal results, the testing can be extended to one Pap test every three years, as long as the results are normal.
The Pap and HPV tests only take a few minutes to perform. The Pap results are usually returned in two weeks; HPV test results may take longer. Both are typically covered by insurance.
Tests for Men
Most HPV infections in men are evidenced by the appearance of one or more warts on the penis, scrotum, thighs, groin, or anus. However, if a wart is internalized, it can often only be identified by examining the anal canal with an anoscope and/or using an anal Pap smear.
The anal Pap smear employs the same technology as a cervical Pap smear and is used to identify dysplasia in cells taken from the anus. The test can be an important tool for men who engage in receptive anal sex, since internalized warts are often not felt.
Recommendations
Despite this, the Centers for Disease Control and Prevention (CDC) currently advises against routine anal Pap screening in men, as there is insufficient data available to recommend this type of anal cancer screening for those at risk. Moreover, unlike HPV tests used in women, there is no such test currently available to confirm either an anal or oral infection.
To this end, the CDC does acknowledge that some healthcare providers perform anal Pap smears in those who may be at increased risk—including men who have sex with men (MSM) who engage in receptive anal sex and men with HIV. MSM who are HIV-positive are especially at risk. This group has a 37-fold greater risk of anal cancer compared to the general population.
In the absence of screening guidelines, you need to be your own advocate and, if needed, seek care from a doctor or clinic specializing in men’s health or MSM-specific care.
Typically, these tests are not covered by insurance.
Biopsy of Genital Warts
If a wart looks suspicious or is hard to identify, the doctor may perform a biopsy to remove a sample of tissue to analyze in the lab. While the anesthetic injection used to numb the skin can be painful, the procedure itself is usually not.
Once removed, the tissue can be examined under the microscope. The lab will then either tell you that there are no abnormal cells (meaning that everything is fine) or that there are abnormal cells called koilocytes. Koilocytes will appear hollow or concave under the microscope and are characteristic of HPV infection.
A genital wart biopsy may be indicated if:
The HPV diagnosis is uncertainA wart is bleeding, inflamed, or has an atypical appearanceThe person has HIV or is immune compromisedThere has been worsening of the condition since the previous exam
If an HPV Test Is Positive
In the same way that the absence of warts does not mean you are clear of HPV, the presence of a genital wart does not mean you will get cancer.
Unless there is evidence of neoplasia (the uncontrolled, abnormal growth of cells), the doctor would consider a positive result of an HPV screen to be a “red flag” and continue to monitor the condition closely.
While dysplasia may progress to cancer over time, the risk is highly variable. Low-grade dysplasia usually goes away on its own without treatment. By contrast, high-grade dysplasia without treatment may develop into an early form of cancer known as carcinoma in situ (CIS).
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In the unlikely event that cancer or precancer is diagnosed, you would be referred to an oncologist to stage the disease and decide upon the appropriate course of treatment. Fortunately, early diagnosis almost always confers to greater treatment success.
