How HPV Is Diagnosed

Testing Can Vary by Gender, Age, and Even Sexual Orientation

Diagnosis of HPV involves not only detecting the virus, but determining which of the more than 150 related viruses that make up HPV is present. Though most are relatively harmless, it's especially important to find out if the infection involves one of the more than 30 high risk-strains that are strongly linked to cancer. Doctors will use a Pap smear, HPV test, or biopsy—along with their clinical judgment—to form a diagnosis and hopefully catch any high-risk cases before they become a problem. How someone is screened and tested varies based on their gender, age, and even sexual orientation.

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.

HPV diagnosis
Illustration by Verywell

Tests for Women

One of the best ways to detect HPV infection in women is with 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. 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 and over, 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 under 30, a Pap smear is recommended every three years. However, HPV testing is not advised, 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 or co-testing with a Pap smear and HPV test can be performed every five years.
  • HIV-positive women under 30 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.

One of the greatest risk factors for cervical cancer is the absence of regular screening. To avoid complications of HPV, women should follow the above screening schedule and advise their doctors of any warts, lesions, or other abnormalities that have developed in the genitals or anus.

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 Center for Disease Control and Prevention (CDC) currently advises against routine anal Pap screening in men as it is not known whether treating a high-grade dysplasia prevents anal cancer. 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 has issued an advisement that the anal Pap smear may be performed in men who have sex with men (MSM) who engage in receptive anal sex, though no specific screening guidelines have been set. This group has a 40-fold greater risk of anal cancer compared to the general population. MSM who are HIV-positive are especially at risk. 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 uncertain
  • A wart is bleeding, inflamed, or has an atypical appearance
  • The person has HIV or is immune compromised
  • There 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 may develop into an early form of cancer known as carcinoma in situ (CIS).

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.

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