M E D iC A L
O U R N A L
Sophie Oerchain, Jesse de Paula Neves-Jorge, Liliana Andrade, Aarao Mendes Pinto-Neto, Joao Pinto e Silva
In fe c tio n b y th e h u m a n p a p illo m a v iru s in te e n a g e rs
se x u a lly a c tiv e : c lin ic a n d su b c lin ic m a n ife sta tio n s
T o c o g in e c o lo g y D e p a rtm e n t a n d P a th o lo g ic A n a to m y D e p a rtm e n t,F a c u ld a d e d e C ie n c ia s M e d ic a s, U n iv e rsid a d e E sta d u a l d e C a m p in a s (U N IC A M P ) - C a m p in a s, B ra zil
This research studies the association- of the cervical condylom a w ith the intraepithelial neoplasia, during sex activity, pregnancy, diagnose m ethods, cytology and colposcopy in teenagers. The objective of this research is to study the propaedeutics for the uterine coli condylom a diagnose in a group of teenagers. For this purpose, w e have studied 131 teenagers sexually active w ith ages betw een
14 and 19 years and presenting histologically confirm ed uterine coli condylom a. A ssociation w ith intraepithelial neoplasia, sexual
ativity duration, m ethod of diagnose, pregnancy analysis, cytology and colposcopy results and association w ith vulva and vagina injuries w ere evaluated. The high association rate w ith condylom a and intraepithelial neoplasia after a short tim e of sexual activity and the none presence of m acroscopic w arts in the genital organs in 80% of cases presenting cervical condylom a, dem onstrate that: a
m ore careful investigation w ith colposcopy.and biopsy of the inferior genitals of the w om en-teenagers sexually active is needed, w hen
presenting m odified cervical cytology.
U N ITE R M S : C ondylom a. Teenager. U terine coli.
IN TR O D U C TIO N
G
e n ita l( H P V ) in f e c tio nis m o r e f r e q u e n tb y th ein te e n a g e r sh u m a n p a p illo m a v ir u sf r o m 1 5 y e a r s o n , w ith a m a x im u m p r e v a le n c e till 2 5 y e a r sa p p r o x im a te ly . V e r y u n u s u a l in c h ild h o o d a n d a f te r 6 0
y e a r s a g e ( 1 ,7 ,1 4 ) . D a ta o b ta in e d b o th in E u r o p e a n d
U n ite d S ta te s o f A m e r ic a s u g g e s t th a t d u r in g th e la s t 2 0
y e a r s th e H P V in f e c tio n s in c r e a s e d c o n s id e r a b ly , a s w e ll
Address for correspondence:
Sophie Derchain
Rua Dr. Antonio Hossri, 6 2 9 -Cidade Universitciria
Campinas/SP - Brasil - CEP 13083-141
a s o th e r s e x u a lly tr a n s m itte d d is e a s e s ( 7 ) . S in c e 1 9 8 2 a
h ig h in c r e a s e in th e in f e c tio n s d ia g n o s e h a s b e e n
e x p e r ie n c e d , b a s e d o n th e g r e a t n u m b e r o f c y to lo g ic ,
c o lp o s c o p e a n d h is to p a th o lo g ic a l e x a m in a tio n s o f th e
u te r in e c o li in ju r ie s ( 1 ,7 ) . A c c o r d in g to B ir o a n d H illa r d
( 1 9 9 0 ) th e in f e c tio n b y H P V , e v e n b e in g f r e q u e n t in
te e n a g e r s , o n ly 1 0 % o f th e c a s e s a r e s y m p to m a tic .
C e r v ic a l c ito lo g ie s in th is g r o u p o f w o m e n , s h o w
in f e c tio n e v id e n c e b y H P V
or
r a te s v a r y in g f r o m 1% to2 8 % , a c c o r d in g to d if f e r e n t s u r v e y s . I n c o lp o s c o p e
a s s e s s m e n t, 5 % to 1 0 % o f th e te e n a g e r s s h o w s o m e
c o n d y lo m a ty p e ( 3 ,7 ,8 ,1 3 ,1 4 ) .
I n f e c tio n b y H P V is v e r y im p o r ta n t to d a y d u e to its
a s s o c ia tio n w ith th e u te r in e c o li c a r c in o m a , s h o w in g a
g r e a t p r e v a le n c e in L a tin A m e r ic a , a p p e a r in g a b o u t 2 0
y e a r s a f te r th e f ir s t in f e c tio n b y H P V ( 4 ) . P r e s e n tly , th e
m o s t o f th e g y n e c o lo g ic a l e x a m in a tio n s a r e c a u s e d b y th e
c e r v ic a l in tr a e p ith e lia l n e o p la s ia ( N I C ) a n d c o n d y lo m a ( 5 ) .
S ao P aulo M edical Journal/R P M 113(4): 948-952,1995 D E R C H A IN , S .F.M .; N E V E S -JO R G E ,J.P .; A N D R A D E , L.A .L.A .; P IN TO -N E TO , A .M . & P IN TO e S ilV A , J.L.C . -Infection by the hum an papillom avirus in teenagers sexually
O n th e o th e r s id e , te e n a g e rs s e x u a lly a c tiv e a re
p a rtic u la rly v u ln e ra b le a n d it is p ro b a b le th a t e p ith e lia l
n e o p la s tic a lte ra tio n s s ta rts ju s t a ro u n d th is a g e . A b e tte r
k n o w le d g e o f th e s u b -c lin ic a l m a n ife s ta tio n s a n d th e H P V
in fe c tiv e b e h a v io r m a y h e lp to e s ta b lis h th e ra p e u tic a n d
c o rre c t fo llo w in g o f y o u n g p a tie n ts p re s e n tin g c o n d y lo m a
(3 ,8 ,9 ,1 0 ,1 2 ).
C A S U IS T IC A N D M E T H O D S
T h is s tu d y w a s p e rfo rm e d w ith 1 3 1 te e n a g e rs
s e x u a lly a c ti v e w ith a g e s v a ry in g b e tw e e n 1 4 a n d 1 9 y e a rs ,
b e in g a tte n d e d a t th e C e n te r o f A tte n tio n to W o m a n 's
H e a lth a t U N IC A M P , fro m S e p te m b e r 1 9 9 0 till M a rc h
1 9 9 2 .
P a tie n ts w e re s e n t to th e a m b u la to ry d u e to c lin ic
g e n ita l c o n d y lo m a o r a b n o rm a l c e rv ic a l c y to lo g ic s m e a r.
T h irty s ix p a tie n ts (2 7 % ) w e re p re g n a n t w h e n e x a m in e d
fo r th e firs t tim e . A ll p a tie n ts a g re e d to p a rtic ip a te o f th e
s tu d y a n d , a fte r a n s w e rin g a q u e s tio n n a ire , w e re s u b m itte d
to a c o m p le te g y n e c o lo g ic a l e x a m in a tio n , in c lu d in g c e rv ic
-v a g in a c y to lo g y , c o lp o s c o p y a n d b io p s y o f th e s u s p ic io u s
c o li v u lv a a n d v a g in a a re a s . A ll la m in a fo r th e h is to lo g ic
s tu d y w e re e v a lu a te d b y th e s a m e p a th o lo g is t.
M o rp h o lo g ic a l c rite ria fo r th e c o n d y lo m a d ia g n o s e w e re
th e fo llo w in g : k o y lo c ita tis , a ty p ia o f th e s u p e rfic ia l la y e rs
o f e p ith e liu m , b in u c le o u s , a c a n th o s is , d y s k e ra to s is ,
p a ra k e ra to s is a n d /o r h y p e rc e ra to s is a n d th e in c re a s e o f
u n u s u a l m ito s is in th e b a s a l la y e rs . In th e c a s e s p re s e n tin g
s tru c tu ra l d is tu rb a n c e o f e p ith e liu m , n u c le u s a ty p ia s a n d
u n u s u a l m ito s is , b e s id e s th e o th e rs m e n tio n e d , d ia g n o s is
o f th e c e rv ic a l in tra e p ith e lia l n e o p la s ia a s s o c ia tio n to
th e c o n d y lo m a w a s d o n e .
T a b le I
D is tr ib u tio n a c c o r d in g a g e
o f
th e te e n a g e r s p r e s e n tin g c o n d y lo m a u te r in e c o liA g e (y e a rs )
NQ
(% )1 4 2 (2 )
1 5 9 (7 )
1 6 2 2 (1 7 )
1 7 3 2 (2 4 )
1 8 3 4 (2 6 )
1 9 3 2 (2 4 )
T O T A L 1 3 1 (1 0 0 )
R E S U L T S
D is trib u tio n o f th e p a tie n ts c o n s id e rin g a g e , s h o w e d
th a t 7 5 % o f te e n a g e rs w e re 1 7 y e a rs -o ld o r m o re (T a b le
I). T w e n ty s ix o fth e p a tie n ts w e n t in d u e to e v id e n t c lin ic a l
c o n d y lo m a in th e e x te rn a l g e n ita ls a n d 1 0 5 w e re
a s y m p to m a tic , p re s e n tin g o n ly o n e a lte ra te d o n c o tic
c y to lo g y . F ifty s ix p a tie n ts (4 0 % ) w e re in fe c te d b y th e
H P V d u rin g th e ir firs t y e a r o f s e x u a l a c tiv ity . F o llo w in g
w e re th e re s u lts o b s e rv e d o f a s s o c ia tio n b e tw e e n N IC a n d
c o n d y lo m a in 4 1 % o f c a s e s : N IC I, 2 4 (1 8 % ); N IC II, 2 3
(1 7 % ) a n d N IC III, 7 (5 % ).
T a b le II s h o w s N IC in c id e n c e a c c o rd in g to th e a g e
o f th e p a tie n ts . It w a s o b s e rv e d th a t N IC a p p e a re d in o n ly
2 7 % o f p a tie n ts b e tw e e n 1 4 a n d 1 5 y e a rs , h o w e v e r, le v e ls
o f 4 0 % w e re re a c h e d b y p a tie n ts 1 6 /1 7 a n d 1 8 /1 9 y e a rs
-o ld .
T a b le III s h o w s re la tio n b e tw e e n N IC a n d th e p e rio d
o f s e x u a lly a c tiv e life . In c id e n c e w a s s im ila r b e tw e e n
g ro u p s , in d e p e n d e n tly fro m th e p e rio d o f s e x u a l a c tiv ity .
C y to lo g ic a l e x a m in a tio n s h o w e d N IC o r k o ilo c ito s is in
8 6 % o f th e c a s e s . O n th e o th e r s id e , h o w e v e r, 1 4 % o f th e
p a tie n ts in c lu d e d in th is s tu d y p re s e n tin g u te rin e c o li
c o n d y lo m a , h is to lo g ic a lly d ia g n o s tic a te d , p re s e n te d n o
c y to lo g ic s m e a r.
In th e c e rv ic a l c o lp o s c o p y , 9 1 % o f th e c a s e s
p re s e n te d w h ite e p ith e liu m p re s e n c e , a s s o c ia te d o r n o t to
le u c o p la s ia , m a s o c h is m o r u n u s u a l v a s e s . C o lp o s c o p y
a s s e s s m e n t o f v a g in a a n d o f v u lv a s h o w e d a b n o rm a lity in
m o re o f th e h a lf o f p a tie n ts : 3 2 v u lv a in ju rie s (2 4 % ): 1 1
v a g in a in ju rie s (8 % ) a n d , in 3 8 , in ju rie s in b o th a re a s . O n ly
2 3 p a tie n ts w ith v u lv a o r v a g in a in ju rie s w e re s u b m itte d
to b io p s y , 2 1 o f th e m p re s e n tin g c o n d y lo m a o n ly a n d 2 o f
th e m a s s o c ia te d to e p ith e lia l n e o p la s ia .
D IS C U S S IO N
N e a rly 4 0 % o f th e p a tie n ts in c lu d e d in th is s tu d y
w e re d ia g n o s e d a s H P V in fe c te d d u rin g th e ir firs t y e a r o f
s e x u a l a c tiv ity . A s a lre a d y k n o w n , in c u b a tio n p e rio d o f
H P V v a rie s fro m 3 w e e k s to 8 m o n th s . T h e re fo re , in fe c tio n
c a n s h o w u p fe w tim e a fte r firs t s e x u a l in te rc o u rs e (7 ,1 4 ).
T h e fa c t o f fo u n d in g a s s o c ia tio n b e tw e e n N IC a n d
c o n d y lo m a in 4 1% o f th e c a s e s s tro n g ly s u g g e s ts th a t th o s e
p a th o lo g ic e n titie s m a y b e c a u s e d b y th e s a m e a g e n t. T h e
re s u lts o fN IC II a n d III in 2 3 % o f th e s e w o m e n , c o n firm s
th e h y p o th e s is th a t H P V in fe c tio n m a y c a u s e n e o p la s ia
D E R C H A IN , S .F .M .; N E V E S -J O R G E ,J .P .; A N D R A D E , L .A L .A ; P IN T O -N E T O , A M . & P IN T O e S IL V A , J .L .C . - In fe c tio n b y th e h u m a n p a p illo m a v iru s in te e n a g e rs s e x u a lly _ _ . L !• • I ~ _ ! . - I_ . _ l - _ I ~ _ ~ ~ . . [_ _ . • ._. • .! _
Table II
Distribution of teenagers with coli condynoma according the association with NIC and age
T o ta l B io p s y 1 4 -1 5 1 6 -1 7 1 8 -1 9 T o ta l
nQ
(%)
nQ
(%)
nQ
(%)
nQ
(%)
O n ly c o n d y lo m a 8 (8 3 ) 3 1 (5 9 ) 3 8 (5 8 ) 7 7 (5 9 )
C o n d y lo m a a n d N IC 3 (2 7 ) 2 3 (4 1 ) 2 8 (4 2 ) 5 4 (4 1 )
T O T A L 1 1 5 4 6 6 1 3 1
transform ations of the epithelial cells in a short tim e period.
T his study also did not show any association betw een the
N IC and the sexual activity period. T his indicates that the
m ost im portant factor for N IC is only the sexual activity
and the H P V infection. N either age of patient nor the
sexual activity duration w ere im portant.
H P V infection diagnose is usually m ade in w om en
through the custom ary cervic-vaginal cythologic sm ear
(2,3,5). In this study, the m ost part of the teenagers w ent
in for exam ination due to m odified oncotic cythology and
only 20% presented m acroscopic condylom atose injuries
in the external genitals. C ythologic exam ination, how ever,
even enabling diagnose in m ost of the cases, the 14% rate
of patients w ith uterine coli condylom a and negative
oncotic cythology is quite high. T his high false-negative
index confirm s that cytology solely is not sufficient to keep
aw ay the H P V infection and that colposcopic evaluation
is essential in teenagers w ith clinical condylom a in external
genitals. O n the other side, colposcopy only is not capable
to determ inate difference betw een absolute condylom a and
injuries associated to N IC . T herefore, colposcopic biopsy
of suspicious injuries m ust be done independently of the
age of the w om an (14).
M ore than half of the patients studied presented
injuries concom itantly in vulva and vagina. A s the vulva
or vagina biopsy is a m ore aggressive procedure, only 23
patients w ere subm itted to it. A ll biopsies w ere com patible
w ith condylom a and tw o cases presented association w ith
N IY .
It is w ell know n, already, that H P V m ay cause
cythologic m odifications in different areas, according to
the several subtypes. H ow ever, treatm ent and prognostic
of intraepithelial neoplasia in teenagers is not w ell defined
(7,14).
O ccurrence of 27% in pregnant w om en of this group
is slightly higher than the expected, consideri ng a
Table III
Distribution of teenagers with uterine coli condyloma
according to association with NIC and time of sexual
activity considering completed year periods
Table IV
Association between macroscopic genital warts and
pregnancy in teenagers with uterine coli condyloma
B io p s y = < 1
n
Q (% )2 -4
nQ (% )
= > 5
nQ
(% )
G e n ita l w a rts
P re g n a n t
nQ
(% )
N o t p re g n a n t
nQ
(% )
O n ly c o n d y lo m a 3 2
C o n d y lo m a a n d N IC 2 1
(6 0 ) 3 9
(4 0 ) 2 6
(6 0 ) 6
(4 0 ) 7
P re s e n t
(4 6 ) A b s e n t
(5 4 )
T O T A L
1 2
2 4
3 6
(3 3 )
(6 7 )
95
1 4
8 1
(1 5 )
(8 5 )
T O T A L 5 3 6 5 1 3
s a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 3 (4 ): 9 4 8 -9 5 2 ,1 9 9 5 D E R C H A IN , S .F .M .; N E V E S -J O R G E ,J .P .; A N D R A D E , L .A .L .A .; P IN T O -N E T O , A .M . & P IN T O e S IL V A , J .L .C . -In fe c tio n b y th e h u m a n p a p illo m a v iru s in te e n a g e rs s e x u a lly
9 5 1
p o p u l a t i o n o f a p p r o x i m a t e l y 2 0 % b r a z i l i a n w o m e n s e x u a l l y a c t i v e b e t w e e n 1 4 a n d 1 9 y e a r s ( 6 ) . T h i s c a n b e e x p l a i n e d b y t h e h i g h e r p r e v a l e n c e o f c o n d y l o m a d u r i n g p r e g n a n c y a n d , a l s o , t h e h i g h e r p e r c e n t a g e o f w o m e n s u b m i t t e d t o c e r v i c - v a g i n a l c y t h o l o g i c e x a m i n a t i o n d u r i n g p r e n a t a l p e r i o d ( 7 , 1 1 , 1 4 ) .
S i n c e c o n d y l o m a a n d
N rc
a r e p r e s e n t l y c o n s i d e r e d a s b e i n g d i s e a s e s a s s o c i a t e d t o c e r v i c a l c a n c e r , t h e e a r l yd i a g n o s e i s a v e r y i m p o r t a n t s u b j e c t , a s t h e r e a r e m a n y d o u b t s r e g a r d i n g t r e a t m e n t a n d f o l l o w i n g d u r i n g a l o n g t i m e p e r i o d . T h e r e f o r e , t h e m a i n p u r p o s e o f t h i s w o r k w a s c a l l t h e a t t e n t i o n f o r t h e n e e d o f a c e r v i c p a t h o l o g i c a l c o n t r o l p r o g r a m i n t e e n a g e r s w i t h l e s s t h a n 2 0 y e a r s , i n s p i t e o f t h i s p r o c e d u r e n o t b e i n g c o m p u l s o r y i n m a n y o f t h e c e r v i c a l c a n c e r c o n t r o l p r o g r a m s .
RESUMO
O b je tiv o : 0 o b je tiv o d e s ta p e s q u is a e e s tu d a r a p ro p e d e u tic a p a ra d ia g n 6 s tic o d o c o n d ilo m a d o c o lo u te rin o e m u m g ru p o d e a d o le s c e n te s . M a te ria l e m e to d o s : p a ra e s te p ro p 6 s ito , 1 3 1 a d o le s c e n te s s e x u a lm e n te a tiv a s c o m id a d e e n tre 1 4 e 1 9 a n o s , c o m c o n d ilo m a h is to lo g ic a m e n te c o n firm a d o d o c o lo u te rin o , fo ra m e s tu d a d a s . A a s s o c ia 9 8 .0 c o m n e o p la s ia in tra -e p it-e lia l, a d u ra 9 8 .0 d a a tiv id a d -e s -e x u a l, 0 m -e to d o d ia g n 6 s tic o , 0 -e s ta d o g -e s ta c io n a l, o s r-e s u lta d o s d a c ito lo g ia -e d a c o lp o s c o p ia e a a S S o c ia 9 8 .0 c o m le s 6 e s v u lv a re s e v a g in a is fo ra m a v a lia d o s . R e s u lta d o e c o n c lu s a o : a a lta a s s o c ia 9 8 .0 e n tre c o n d ilo m a
e n e o p la s ia in tra -e p ite lia l, a p 6 s u m c u rto p e rfo d o d e a tiv id a d e s e x u a l e a a u s e n c ia d e v e rru g a s m a c ro s c 6 p ic a s n o s 6 rg 8 .o s . g e n ita is e m 8 0 % d o s c a s o s c o m c o n d ilo m a c e rv ic a l m o s tra m a n e c e s s id a d e d e u m a in v e s tig a 9 8 .0 c u id a d o s a c o m c o lp o s c o p ia
e b i6 p s ia d o tra to g e n ita l in fe rio r e m m u lh e re s a d o le s c e n te s s e x u a lm e n te a tiv a s , c o m c ito lo g ia c e rv ic a l a lte ra d a .
D E R C H A IN , S .F .M .; N E V E S -J O R G E ,J .P .; A N D R A D E , L .A .L .A .; P IN T O -N E T O , A .M . & P IN T O e S ilV A , J .L .C . -In fe c tio n b y th e h u m a n p a p illo m a v iru s in te e n a g e rs s e x u a lly a c tiv e : c lin ic a n d s u b c lin ic m a n ife s ta tio n s
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Sao Paulo M edical Journal/RPM 113(4): 948-952,1995 DERCHAIN, S.F.M .; NEVES-JORGE,J.P.; ANDRADE, L.A.L.A.; PINTO-NETO, A.M . & PINTO e SILVA, J.L.C. -Infection by the hum an papillom avirus in teenagers sexually
