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THE QUALITY OF LIFE OF WOMEN WITH GENITAL WARTS/KVALITET ZIVOTA ZENA SA GENITALNIM BRADAVICAMA.

Introduction

Human papillomavirus (HPV) infection is the most common viral sexually transmitted infection [1]. It is estimated that about 80% of sexually active women get a HPV infection by the age of 50 [2]. HPV infection is usually asymptomatic and in about 70 - 90% of cases is transient; it spontaneously resolves within two years, due to good immune response of the body [3, 4]. The HPV infection is most commonly associated with sexually active people under the age of 25 [4]. Genital warts represent a clinical manifestation of a persistent HPV infection caused by low-risk HPV types (most commonly HPV types 6 and 11), characterized by the appearance of single or multiple papules on the skin and mucous membranes in the anogenital region [1, 3, 5]. The prevalence of genital warts, according to several epidemiological studies, is becoming more frequent [6].
Abbreviations

EQ-5D    - European quality of life index version 5D
CECA-10  - Specific Questionnaire for Condylomata Acuminata
DLQI     - Dermatology life quality index
HRQoL    - health related quality of life
VAS      - visual analogue scale
HPV      - human papillomavirus


Although the symptoms are usually less pronounced (itching, burning, increased vaginal discharge and bleeding), the genital warts affect the patients' quality of life [2, 7].

Studies have shown that genital warts have negative psychological effects. Women with genital warts suffer from stress and anxiety, as well as fear related to their social and sexual life being affected by the disease [7-10]. Patients with genital warts are overwhelmed with feelings of shame, embarrassment and guilt and feel less attractive, which adversely affects their sexual activity and enjoyment and may lead to issues with their partner [1, 7, 10]. Besides, there is a feeling of anger, guilt and concern for the future, as well as fear of getting cervical cancer [11].

The aim of this study was to examine the influence of genital warts on the quality of life of infected women and their psychological state by using standardized instruments for measuring the quality of life.

Material and Methods

This prospective study was conducted at the Clinic of Gynecology and Obstetrics of the Clinical Center of Vojvodina and it was approved by the Ethics Committee. Patients with genital warts were invited to participate in the study and after signing the Informed Consent, the following data were studied: age, education, marital status/current relationship, past sexual behavior, condom use, smoking, as well as the location of genital warts. Patients' knowledge about HPV infection was checked through non-standardized questionnaires designed for research purposes.

Three questionnaires were used to measure the patients' quality of life:
Graph 1. Location of genital warts
Grafikon 1. Lokalizacija genitalnih bradavica

vulva                       34%
vagina                       8%
cervix                       1%
perianal                     3%
vilva + vagina              23%
vulva + perianal            14%
vagina + perianal            1%
vulva + vagina + perianal   16%

Note: Table made from pie chart.


1) The generic questionnaire European quality of life index version 5D (EQ-5D) measured the impact of the disease on the general health of patients. It consists of two parts. The first is the descriptive part in which patients describe their problems (three levels: I have no problem, I have a problem, I have a pronounced problem) in relation to five dimensions of health: mobility, self-care, performing usual activities, pain/discomfort and anxiety/depression. The second part of this questionnaire contains a visual-analogue scale (EQ-VAS) where the patients numerically assess their current health status (0 - the worst imaginable health state and 100 - the best imaginable health state) [9].

2) The disease-specific Specific questionnaire for Condylomata Acuminata-10 (CECA is a Spanish acronym for Specific Questionnaire for Condylomata Acuminata) was used to evaluate health related quality of life (HRQoL) in people with genital warts. The impact on the emotional dimension (the first 6 items (CECA-6)) and the sexual dimension (the last 4 items (CECA-4)) was evaluated using these 10 items. On a five-step scale, the respondents chose one answer (never = 5, rarely = 4, sometimes = 3, almost always = 2 and always = 1). The higher the score, the higher the quality of life. The total score of the questionnaire was 10 - 50, the total CECA-6 score ranged from 6 - 30 and CECA-4 from 4 - 20 [9, 10].

3) The general questionnaire for measuring the quality of life in dermatology - Dermatology life quality index (DLQI) consists of 10 multiple choice questions concerning to what extent the skin changes affect the quality of life (very much = 3, a lot = 2, a little = 1, not at all/not relevant = 0) in 10 areas. The total DLQI score ranged from 0 to 30. The higher the score, the greater the negative impact of skin changes on the quality of life: (0 - 1) - no effect, (2 - 5) - small effect, (6 - 10) - moderate effect, (11 - 20) - very large effect, (21 - 30) - extremely large effect [10, 12].

In the statistical data processing, the statistical package for social sciences (SPSS) version 20 was used. The numerical variables were calculated by the arithmetic mean and standard deviation, and categorical variables through percentages. To determine the existence of a difference and correlation between the parameters Student's t-test and F-test were used. The value p < 0.05 was considered statistically significant. The results are shown in tables and graphs.

Results

The general characteristics of the study group are presented in Table 1. On average, the patients were 29 years old (range 17 - 63 years), while 60.6% of them were aged 21 - 30 years. Of all the examinees, 64.8% were high school graduates and 53.5% of them were employed.

About 69% had a sexual partner, while only 19.7% of patients were married. The patients had their first sexual intercourse at the age of 18 years. On average, they had 4 sexual partners. About 79% of patients were nulliparous. Only 33.33% of patients used condoms, and 25.4% has already had a sexually transmitted infection. About 49.3% of patients were smokers. They smoked since the age of 17 years, on average 13 cigarettes per day.

Graph 1 shows the location of genital warts. The genital warts most commonly showed up on the vulva (33.8%), vulva and vagina (22.54%), vul-Z va, vagina and perianal region (15.49%), as well as the vulva and perianal region (14.08%). Knowledge about HPV infection is shown in the Graph 2.

About 94 % of patients knew that HPV infection was a sexually transmitted disease, 79.4% knew that HPV infection could cause genital warts, and 86.6% of patients knew that HPV infection was associated with cervical cancer, but only 54.4% knew that HPV was the cause of cervical cancer. Fifty point eight percent of patients heard about HPV vaccine, while 42.9% of them knew that it was a vaccine for the prevention of HPV infection; 68.2% of patients would get vaccinated with this vaccine.

EQ-5D score

All patients completed the EQ-5D questionnaire. A very high percentage of them (81.4%) felt anxious and worried, 54.3% felt pain and discomfort, while significantly fewer patients had problems with mobility (10%), performing usual activities (8.6%) and self-care (7.1%) (Graph 3).

The mean value of the Q-VAS visual scale was 70.37 +/- 20.8. Patients who had no difficulties with mobility (F = 5.33; p < 0.05), those without problems performing usual activities (F = 9.46; p < 0.05), as well as those who were not anxious/depressed (F = 3.62; p < 0.05) assessed their quality of life as higher.

CECA-10 questionnaire

Seventy respondents completed the CECA-6 questionnaire - emotional dimension, while 69 respondents completed the CECA-4 questionnaire (sexual dimension). The mean scoring for CECA-6 questionnaire was 15.63 +/- 5.99 while the mean scoring for CECA-4 questionnaire was 10.81 +/- 5.55. The mean scoring for CECA-10 questionnaire was 26.61 +/- 10.09. The patients with higher scores in CECA-6 and CECA-10 questionnaires had better quality of life (CECA-10: r = 0.251; p < 0.05) (CECA-6: r = 0.263; p < 0.05).

There was a statistically significant difference in CECA-6 and CECA-10 scores between housewives and students (CECA-6: F = 5.11; p < 0.05; CECA-10: F = 3.56; p < 0.05) as well as between patients without and with sexually transmitted infections, respectively (CECA-6: F = 0.757; p < 0.05; CECA-10: F = 0.150; p < 0.05) (Graph 4).

Dermatology Life Qualit y Index

The dermatological questionnaire was completed by all patients. The average score of the questionnaire was 6.42 +/- 5.82. The patients who previously had sexually transmitted infections had more skin problems than those who had no sexually transmitted infections (F = 0.856, p = 0.005). The patients who had more skin problems estimated that they had a lower quality of life (r = -0.274, p < 0.05). The patients with higher DLQI scores also had lower scores for CECA-6 (r = -0.554; p < 0.01), CECA-4 (r = -0.468; p <0.01), and CECA-10 questionnaires (r = -0.598; p < 0.01) (Graph 5).

Discussion

The genital warts primarily cause stress among the infected women and may have a negative impact on their psychological state and social life. These women have expressed negative emotions such as shame, fear and anxiety, worry about reproductive health, the possibility of having children, as well as about the possibility of further spreading the infection. For that reason, they suffer from an elevated level of anxiety and distress [1-3]. They often blame their partners for getting the infection, which negatively affects their sexual life and the relationship. Similarly, the fear of disease progression negatively affects both their sexual life and health [1-3, 13].

In his study, Waller has proved that the level of knowledge about HPV infection is associated with an emotional reaction and feelings of stigma, shame and anxiety. The knowledge about HPV infection being sexually transmitted, and ignorance about the fact that it is highly prevalent in the population of sexually active women is associated with the highest level of feeling shame and stigma [13]. In our study, although a high percentage of patients heard about HPV infection and answered the questions correctly, generally speaking, the knowledge about HPV virus and the possible consequences of HPV infection is insufficient [6, 14]. We believe that the limitation of the questionnaire on the knowledge about HPV infection is that the questions are direct and suggestive. The real level of the respondents' knowledge on HPV infection would have been checked more successfully if they had to fill in the answers themselves [14].

In our study, a large number of patients (81.4%) were concerned, anxious or depressed due to having genital warts and they estimated that it negatively affected their quality of life. Ninety four point four percent of patients were worried that the warts would not disappear and that they would not completely recover from the infection. About 95.8% of patients worried that the warts would spread causing complications. Additionally, more than half of the patients (54.3%) felt pain and discomfort in the genital region which represented a relevant dimension that genital warts negatively affected their quality of life. Furthermore, 57.7% of women found itching and burning to be significant symptoms, while 64.8% of them felt shame and insecurity [3, 15-18].

The presence of genital warts has more negatively influenced the emotional dimension of the quality of life among housewives compared to students, as well as among women who have not previously had sexually transmitted infections compared to those who had. This may be the consequence of the fact that housewives and women who have not had any sexually transmitted infections have less knowledge about HPV infection, and hence the appearance of genital warts had a significantly higher impact on their quality of life and emotional health.

According to previous studies, HPV infection also has a significant negative impact on the sexuality of women because: a) the infection is associated with changes that occur on the genital organs which play a key role in the female eroticism; b) it may cause vulvodynia and dyspareunia [1]. Pain and discomfort in the genital region, feeling shame and embarrassment, knowledge that they have a viral sexually transmitted infection that can potentially lead to serious health issues affects the sexual life of women in a considerably negative manner [2, 3, 19].

In our study, genital warts showed to have a great impact on the sexual life of women. In about 74.3% of the patients, sexual drive decreased as well as the quality and frequency of sexual intercourse. About 62% of the patients had problems during sexual intercourse, while almost 40% avoided sexual intercourse. One patient (1.4%) even ceased having sexual intercourse after getting genital warts.

Conclusion

Our examination showed that genital warts adversely affected the emotional and sexual dimension of women's quality of life. Although it is a benign disease, the patients suffer from anxiety and depression. They are afraid that they will not recover from the infection and that warts will spread and cause complications. Better education of the population on human papillomavirus infection and its prevention is necessary.

References

[1.] Campaner AB, Vespa Junior N, Giraldo PC, Leal Passos MR. Adverse psychosexual impact related to the treatment of genital warts and cervical intraepithelial neoplasia. J Sex Transm Dis. 2013;2013:264093.

[2.] Graziottin A, Serafini A. HPV infection in women: psycho-sexual impact of genital warts and intraepithelial lesions. J Sex Med. 2009;6(3):633-45.

[3.] Maggino T, Casadei D, Panontin E, Fadda E, Zampieri MC, Dona MA, et al. Impact of an HPV diagnosis on quality of life in young women. Gynecol Oncol. 2007;107(1 Suppl 1):s175-9.

[4.] Steben M, Duarte-Franco E. Human papillomavirus infection: epidemiology and pathophysiology. Gynecol Oncol. 2007;107(2 Suppl 1):S2-5.

[5.] Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis. 2013;13:39.

[6.] Pineros M, Hernandez-Suarez G, Orjuela L, Vargas JC, Perez G. HPV knowledge and impact of genital warts on self esteem and sexual life in Colombian patients. BMC Public Health. 2013;13:272.

[7.] Nahidi M, Nahidi Y, Saghebi A, Kardan G, Jarahi L, Aminzadeh B, et al. Evaluation of psychopathology and quality of life in patients with anogenital wart compared to control group. Iran J Med Sci. 2018;43(1):65-9.

[8.] De Almeida MG, Thome AMT, Filho JBL. The psychosocial and economic burden of genital warts among women assisted in six sexual and reproductive health clinics in Brazil. DST Jornal Brasileiro de Doencas Sexualmente Transmissiveis. 2013;25(4):196-201.

[9.] Vriend HJ, Nieuwkerk PT, van der Sande MA. Impact of genital warts on emotional and sexual well-being differs by gender. Int J STD AIDS. 2014;25(13):949-55.

[10.] Vilata JJ, Varela JA, Olmos L, Colombo JA, Llorens MA, de los Terreros MS, et al. Validation and clinical use of the CECA, a disease-specific quality of life questionnaire for patients with anogenital condylomata acuminata. Acta Derm Venereol. 2008;88(3):257-62.

[11.] Mortensen GL, Larsen HK. The quality of life of patients with genital warts: a qualitative study. BMC Public Health. 2010;10:113.

[12.] Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. Br J Dermatol. 2008;159(9):997-1035.

[13.] Waller J, Marlow LA, Wardle J. The association between knowledge of HPV and feelings of stigma, shame and anxiety. Sex Transm Infect. 2007;83(2):155-9.

[14.] Klug SJ, Hukelmann M, Blettner M. Knowledge about infection with human papillomavirus: a systematic review. Prev Med. 2008;46(2):87-98.

[15.] Woodhall SC, Jit M, Soldan K, Kinghorn G, Gilson R, Nathan M, et al. The impact of genital warts: loss of quality of life and cost of treatment in eight sexual health clinics in the UK. Sex Transm Infect. 2011;87(6):458-63.

[16.] Dominiak-Felden G, Cohet C, Atrux-Tallau S, Gilet H, Tristram A, Fiander A. Impact of human papillomavirus-related genital disease on quality of life and psychosocial well-being: results of an observational, health-related quality of life study in the UK. BMC Public Health. 2013;13:1065.

[17.] Ireland JA, Reid M, Powell R, Petrie KJ. The role of illness perceptions: psychological distress and treatment-seeking delay in patients with genital warts. Int J STD AIDS. 2005;16(10):667-70.

[18.] Woodhall S, Ramsey T, Cai C, Crouch S, Jit M, Birks Y, et al. Estimation of the impact of genital warts on health-related quality of life. Sex Transm Infect. 2008;84(3):161-6.

[19.] Escalas J, Rodriguez-Cerdeira C, Guerra-Tapia A. Impact of HPV infection on the quality of life in young women. Open Dermatol J. 2009;3:137-9.

Ljiljana MLADENOVIC SEGEDI and Artur BJELICA

University of Novi Sad, Faculty of Medicine Novi Sad Clinical Center of Vojvodina, Novi Sad Clinic of Gynecology and Obstetrics

Corresponding Author: Prof. dr Ljiljana Mladenovic Segedi, Klinika za ginekologiju i akuserstvo, 21000 Novi Sad, Branimira Cosica 37, E-mail: ljiljana.mladenovic.segedi@mf.uns.ac.rs

Rad je primljen 13. III 2019.

Recenziran 3. IV 2019.

Prihvacen za stampu 11. IV 2019.

BIBLID.0025-8105:(2019):LXXII:3-4:61-65.

https://doi.org/10.2298/MPNS1904061M
Table 1. Socio-demographic characteristics of patients with genital
warts
Tabela 1. Socio-demografske karakteristike pacijentkinja sa genitalnim
bradavicama

Age (mean +/- SD)/Godine (srednja vrednost +/- SD)   29.72 +/- 8.54
Level of education (%)/Stepen obrazovanja (%)
 Primary school/Osnovna skola                         7.1
 Secondary school/Srednja skola                      64.8
 College/Visa skola                                   5.6
 Faculty/Fakultet                                    22.5
Marital status (%)/Bracno stanje (%)
Single/Nije udata                                    71.8
 Divorced/Razvedena                                   8.5
 Married/Udata                                       19.7
Currently has a partner (yes, %)/Ima seksualnog
partnera (da, %)                                     69.01
Employment (%)/Zaposlenost (%)
 Student/Student                                     25.4
 Employed/Zaposlena                                  53.5
 Housewife/Domacica                                  21.1
Smoking (yes, %)/Pusac (da, %)                       49.3
 Number of cigarettes per day (mean +/- SD)/Broj     13.46 +/- 7.97
 cigareta dnevno (srednja vrednost +/- SD)
 Since what age (age; mean +/-SD)/Pocetak
 pusenja (godine; srednja vrednost +/- SD)           17.62 +/- 2.55
The first sexual intercourse (age +/- SD)
/Prvi polni odnos (godine +/- SD)                    18.33 +/- 2.33
Number of sexual partners (mean +/-SD)
/Broj seksualnih partnera (srednja
vrednost +/- SD)     4.32 +/- 2.49
Previous sexually transmitted infection
(yes, %)/Imala seksualno prenosivu
infekciju (da, %)                                    25.4
Delivery (yes, %)/Porodaj (da, %)                    21.1
Abortion (yes, %)/Prekid trudnoce (da, %)            23.9

SD - standard deviation/SD - standardna devijacija
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Title Annotation:ORIGINAL STUDIES/ORIGINALNI NAUCNI RADOVI
Author:Segedi, Ljiljana Mladenovic; Bjelica, Artur
Publication:Medicinski Pregled
Date:Mar 1, 2019
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