Treatment for Genital Warts

New human papilloma virus serotype are being discovered almost monthly and some of the old types are turning out to have more malignant potential than once thought.

But because physicians lack an inexpensive, widely available test to separate relatively harmless HPVs from dangerous ones, they are left to figure out whether good management means seeking out esoteric tests or treating all HPV patients the same, speakers said here at an American College of Obstetrics and Gynecology meeting.

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Of the 56 recognized HPVs, types 16 and 18 probably pose the greatest risk for genital cancers, said Dr. Ralph M. Richart, a professor of pathology at Columbia University in New York. When cytologic or histologic exams of a cervical biopsy show that a patient has little or no dysplasia, it may be tempting to conclude that her risk for future neoplasia is low. But such a lab report doesn’t rule out infection with a high-risk HPV type, and the patient’s prognosis remains “indeterminate” unless the viral type is identified, said Dr. Richart.

Until recently, HPV types 6 and 11 were thought to confer no risk of malignancy. But a trickle of reports that these viruses have been found in cancers of the cervix, vulva, and penis have moved them to the “low risk” category, he said. Clinically, that means doctors “cannot ignore an HPV 6 or 11 lesion and say it will never, ever be associated with cancer.”

In many instances, knowing the viral type means “we can predict the course of disease,” says Dr. Richard. The rationale for viral typing is growing, and in the future he expects that patients infected with virulent strains such as HPV 18 will be treated and followed more closely than other patients.

The problem is that identifying strains of HPV generally require DNA hybridization techniques, which are time-consuming and available only in research settings. Though these tests may be practical for rare genetic disorders, the cost is probably prohibitive for an infection as common as HPV.

When inexpensive, rapid diagnostic tests for HPV serotypes come on line, “I will employ them routinely,” Dr. Sebastian Faro told MWN. For the moment, “we’re in a holding pattern, trying to decide what’s best for the patient,” says the Baylor professor of obstetrics and gynecology.

Finding out whether a patient has one of the HPV serotypes that research labs can identify now runs between $300 and $400, and “I think we need to consider the cost factors,” Dr. Faro said.

Much of the HPV infection he sees is in patients who are “young and mobile.” Because these 16- to 25-year-olds are likely to “go off to college or be transferred,” Dr. Faro has elected to treat their lesions without knowing the exact HPV type involved. He advocates “limited treatment for limited involvement,” starting with trichloroacetic acid. For more severe lesions, he favors laser therapy followed by 5-fluorouracil.

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All patients with cervical dysplasia and HPV infection must be treated promptly, insisted Dr. Faro. In the absence of atypia, he believes doctors can elect close observation if–and only if -they can rely on the patient to return for frequent examinations.

On the other hand, overtreatment may be taking place in another situation. “Physicians have told me that 30% to 40% of their patients have condyloma of the introitus and vagina,” Dr. Richart said. But when he retests biopsy samples from the introitus and hymenal ring with DNA probes, he has found them “almost uniformly negative” for HPV. “Just because the pathologist says its condyloma doesn’t mean it is.”

Small bumps around the introitus are often entirely normal, noted Dr. Richart, and the HPV types present in most acuminate warts are benign. Condyloma still merits treatment, however, because the infection is sexually transmitted.

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Link Between Impotence and Disease

Erectile dysfunction, long considered a natural consequence of aging, may be more closely associated with disease and lifestyle, according to the largest study on the topic since the Kinsey report in 1946.

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What’s more, a bout or two of erectile dysfunction may be an early warning signal of cardiac or vascular disease.

The study of 1,300 men between the ages of 40 and 70 randomly selected from 10 Boston area communities showed that erectile dysfunction is undoubtedly linked with the aging process. While 52% of the men reported some trouble getting or keeping an erection in the six months prior to an in-home interview and blood test, the problem was more pronounced in older men: 15% of the 70-year-olds in the study acknowledged complete impotence, versus only 5% of the 40-year-olds.

The incidence of lesser degrees of erectile dysfunction also showed an age-dependent trend. According to the investigators, the rate of minimal and moderate impotence in the 40-year-old men was 16% and 17%, respectively. Those percentages increased to 18% and 34% in the 70-year-old subjects, they reported in the January issue of the Journal of Urology.

Applied to the general population, this means an estimated 18 million American men suffer from sporadic or complete impotence.

“The good news is that aging isn’t the whole story, and that in many cases impotence can be prevented or countered,” said John McKinlay, Ph.D., the study’s lead author and director of the New England Research Institute (NERI) in Watertown, Mass. Heart disease, diabetes, hypertension, arthritis and depression all strongly influence the ability to achieve an erection. Add in cigarette smoking and impotence becomes an even more probable–but preventable–problem: smokers with heart disease reported almost three times the amount of complete impotence than non-smokers with heart disease, 56% vs. 21%.

Marcia G. Ory, chief of social science research at the National Institute on Aging, called the NERI study “remarkable” because it was the first to really look at a random sample of American men. But she echoed Dr. McKinlay’s point that aging and impotence don’t necessarily go together. Rather, “The older you get the more likely you are to have other direct risk factors for impotence,” Ory said.

She noted, for example, that at least half of all men with diabetes become impotent, since the disease damages both blood vessels and nerves. “If you could control for these other factors, like diabetes and hypertension, you probably wouldn’t see much association with age,” Ory said.

The study has profound implications for primary-care physicians, according to Dr. John Morley, a professor of geriatrics at St. Louis University School of Medicine. “It shows what we’ve suspected for years, that aging doesn’t necessarily mean impotence,” Dr. Morley said, adding that by demonstrating that impotence isn’t mostly “in men’s heads,” they will be more likely to talk with their physicians about it and perhaps find its physical root.

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Physicians need to ask their male patients about their sex lives, Dr. Morley said. A mention of impotence should be followed by a quick check for thyroid function, an assessment for depression, emerging diabetes or cardiovascular problems.

And based on the NERI results, physicians can urge their patients to quit smoking, exercise to lower blood pressure or help them find a blood pressure or heart disease medication that won’t interfere with sexual function.

Surprisingly, the NERI researchers observed no association between serum testosterone and erectile dysfunction. They did, however, find that the higher the levels of dehydroepiandrosterone sulfate (DHEAS), a metabolite of adrenal androgens, the lower the incidence of impotence.

The association is an exciting one, according to Dr. McKinlay, who added that several published reports link low DHEAS–and thus a higher likelihood of impotence–with cardiovascular disease.

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Experts Hedge on Condom Value

Though condoms and spermicides are widely recommended for “safer sex” practices, the products’ efficacy is more supposed than proven.

Investigators are less than certain that these agents can protect against the human immunodeficiency virus. They hedged in their responses to clinicians’ questions here at the Fourth International Conference on Aids.

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“Are they any good or not? Are we making a mistake recommending them?” asked Dr. Donald Francis, a CDC AIDS advisor to the California state department of health, seeking a bottom-line assessment of condoms.

“I hate to be cagey, but we don’t really know,” replied Dr. Robert Nakamura, a professor of obstetrics and gynecology at Women’s Hospital, Los Angeles County-University of Southern California Medical Center, who’d reported results from in vitro testing of about 30 types of commercially available latex condoms.

All types of condoms are flawed. Smooth or textured, round-tipped or reservoir, straight-sided or tapered, with or without lubrication, with or without spermicide–none of the condoms tested were without flaws.

Products were rated on a scale based on the results of a variety of tests, including water leakage, tensile strength, air burst strength, and pinhole electrical conductivity. Though water leakage seemed most reflective of overall integrity, no single test was conclusive, and the relationship of any defect to a condom’s in vivo ability to block HIV transmission hasn’t been established, Dr. Nakamura noted. He declined to rate the various products. Researchers found no correlation between condom breakage and penis size or ability to maintain an erection.

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Dr. Nakamura said petroleum-based lubricants tend to weaken a condom, but water-soluble lubricants do not.

Dr. Cohn said his team encourages the use of nonoxynol-9 either inside or outside the condom as backup protection in case of breakage. The virucidal agent is the active ingredient in most commercially available spermicides. Findings that confirm the ability of nonoxynol-9 to inactivate HIV in vitro were reported by Dr. Lionel Resnick, chief of the retrovirology labs at Mount Sinai Medical Center in Miami Beach. He noted that the spermicide melts away the fragile viral envelope and that the concentration needed to inactivate cell-associated virus is higher than that for cell-free virus.

But when asked how the in vitro spermicide concentration compares with that “in common use,” Dr. Resnick said they hadn’t the “slightest idea.” Scientists “don’t know how much nonoxynol-9 gets absorbed, how quickly, [or] how pH variations or any number of other factors may alter in vivo effects.”

Another investigator who conducted similar nonoxynol-9 studies, however, was more sanguine about the possibility of extrapolating in vitro findings to clinical reality. Dr. Miroslav Malkovsky, senior scientist at the Medical Research Council clinical research center in Middlesex, England, reported on the ability of four spermicidal preparations–one condom lubricant and three vaginal jellies–to obliterate all evidence of HIV RNA activity on the Southern blot test. Viral concentrations were high, and the various preparations all worked in less than 30 seconds, he said.

But a team whose scheduled poster presentation on the effect of nonoxynol-9 use on HIV transmission in Nairobi prostitutes was withdrawn found no spermicide-related change in HIV serostatus, regardless of condom use.

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A Question of Censorship

1970. The St. Ives Festival in Cornwall Paintings by the woman artist, Monica Sjoo were removed from an exhibition at the Guildhall. They were removed by the police and banned from being exhibited anywhere on city property. The result was the formation of a strong womens group and the open support of many local artists, who all protested at the removal of her works. One of the banned paintings was called “God Giving Birth”.

1971. Margaret Harrisons exhibition at the Motif Editions Gallery in London was closed by the police one day after the show had opened. The work attempted to make ironic comments concerning the advertising of the time which equated women with juicy, consumerable food. Even in the short life of this exhibition a drawing of Hugh Hefner as a Bunny girl complete with Bunny penis went missing.

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1973. In March, five women artists exhibited at the Swiss Cottage Library in London. The exhibition was supported by two manifestos produced by the artists, Liz Moore, Monica Sjoo, Rosalyn Smyth, Beverly Skinner and Anne Berg. The artists were threatened with court action and accused of ‘obscenity and blasphemy’. The ensuing public meeting was emotional and chaotic.

1976. Suzanne Santoro’s book “Towards a New Expression” was removed from the Arts Council exhibition called “Artists Books” shown at the ICA in London.

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1979. Sue Browns work was exhibited at the Centre 181 in Hammersmith. The Sun newspaper reported that the “whole thing is in bad taste” and the deputy Mayor wanted the exhibition closed down. There was a council meeting which then discussed the “pornographic” content of the work. Sue Brown had been cautioned not to speak to the press. Eventually the decision was taken to allow the exhibition to continue.

1984. The Feren Gallery (which is the city gallery in Hull) holds an exhibition of the work of three women artists, Marisa Rueda, Sue Coe, and Jacqueline Morreau. After A successful opening the chairwoman of the council’s cultural services insisted on the removal of one of Sue Coe’s drawings, “The Rape of Rosa Velez” from the show. After the public meeting between the artists, the city council, and a concerned and supportive general public, the picture was restored to its rightful place in the exhibition.

There are many forms of censorship and this minimal listing of events are mainly connected with the closure, or threatened closure of exhibitions. All of these exhibitions were showing art works produced by women. Perhaps the reasons lie within the notion of what is acceptable and what isn’t. Maybe the content of the works produce this outrage, as it is often expressing “female” or “feminist” experience. Ultimately, a brief look at the last ten years reveals only cosmetic changes to so many of the issues and attitudes which have revolved around women artists and their work.

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How to Increase Sperm Count and Overcome Infertility

Joshua Sipek is far too young to know that his entry into the world last month marked a milestone in Australian medical science. His birth, in Adelaide on 12 February, means almost any man may be able to father a child, even if he can produce only one healthy sperm.

Normally a man produces between 50 million and 60 million sperm for every milliliter of semen. But if the sperm count falls to about five million per milliliter, infertility can be a problem. IVF techniques have had limited success helping couples in this situation to conceive a child, even when using a modified process in which sperm is injected into the outer membrane of the egg. But Joshua is proof of the success of a new technique at Adelaide’s Queen Elizabeth Hospital in which sperm is injected directly into the center of the egg, improving the chances of conception.

The process, called Cytoplasmic Sperm Injection, or ICSI, has only been achieved at two other hospitals, in Belgium and Sweden. So far 166 people have undergone treatment at the Adelaide unit; 10 babies have been born since Joshua’s triumphant delivery, with another 50 women expecting. Professor Colin Matthews, the Professor of Reproductive Medicine at Adelaide University and one of the scientists involved in the project, said one of the fathers-to-be had a sperm count of just eight, and that in theory the technology could allow a man to become a father if he was able to produce just one healthy sperm.

Semenax

For Sue-Ellen and Michael Sipek, the technology has delivered them a miracle. The couple were first told in June 1991 that Michael had a low sperm count, and their first attempt to have a baby using a conventional in vitro fertilization technique failed. Two later attempts using the modified IVF technique in which sperm are collected and injected into the outer membrane of the egg, also failed. The couple had also tried natural products that promised to increase the amount of ejaculate such as Semenax and Volume Pills.

The couple then turned to the Adelaide team for help. Mrs. Sipek said yesterday that after three failures using the older IVF techniques, she had not been counting on success. “You get used to disappointment and become a real pessimist,” she said, adding it took her a while to appreciate the historic significance of her pregnancy. “We desperately wanted a child. To be honest, I was just so excited to have a baby,” she explained. “We would have had to look at donor sperm, which we really didn’t want to do. Obviously most people want to have their own child.”

Volume Pills

Professor Matthews said injecting a sperm into the outer wall of the egg was less than satisfactory. “To do that we have to inject multiple sperm, maybe five or 10. Some eggs get fertilized, some don’t and some get over fertilized with more than one sperm.” Until the new process was developed recently by Belgian scientists, it had been virtually impossible to inject sperm directly into the center of the egg without causing damage. The ICSI team uses a tiny pipette, about three-thousandths of a millimeter wide, to suck up an individual sperm located with a powerful microscope. The pipette is pushed into the center of the egg and released. Two or three days after fertilization, when the embryo has divided into six or eight cells, it is implanted in the mother. Professor Matthews said two embryos were normally implanted, giving the woman about a 35 percent chance of pregnancy.

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