The management of subclinical wart virus infection of the cervix in a genitourinary clinic.

OBJECTIVE--To assess whether cold coagulation to the cervix eliminates subclinical wart virus infection and to determine the effectiveness of treatment for CIN I and II, using cold coagulation, by genitourinary physicians. DESIGN--Prospective study. SETTING--Department of Genitourinary medicine in a large teaching hospital. PARTICIPANTS--All patients who received cold coagulation to the cervix in a 1 year period, who had not had previous treatment. RESULTS--261 patients were enrolled into this study; of these, 138 (53%) patients attended for repeat colposcopy and cytology at one year. Cure rates for lesions were 66% for initial wart virus infection, 80% for CIN I and 94% for CIN II and III. Four (5%) cases in whom repeat cytology was normal had CIN which would have been missed if repeat colposcopy had not been performed at one year. CONCLUSIONS--Cold coagulation is inappropriate treatment for subclinical wart virus infection of the cervix but is useful for the management of patients with CIN. Repeat colposcopy following treatment to the cervix is not necessary if cervical cytology is normal.     

Assessment of psychiatric morbidity in patients attending a colposcopy clinic situated in a genitourinary medicine clinic.

OBJECTIVE--To determine the adverse psychological implications of referral for colposcopic screening within a genitourinary medicine clinic. DESIGN--Cross sectional survey. SETTING--A colposcopy clinic held within a genitourinary medicine clinic. SUBJECTS--160 consecutive women referred to the clinic were assessed for psychiatric morbidity using the General Health Questionnaire (GHQ-28). Women were referred to the colposcopy clinic because of one or more of the following: abnormal cervical cytology, condylomata acuminata, HIV antibody positivity. A history of prior local ablative therapy to the cervix was also included in the analysis. RESULTS--There was no difference in psychiatric morbidity, as detected by the GHQ-28, in women referred to the clinic because of abnormal cervical cytology or condylomata acuminata. The total GHQ-28 scores indicated a significant increase in psychiatric morbidity, with increased sub-scores indicating social dysfunction, anxiety and somatic symptoms, in women who had had prior laser therapy to the cervix. Women with HIV infection attending the clinic were noted to have an increase in GHQ-28 sub-scores indicating social dysfunction and depression. CONCLUSIONS--Women who have undergone laser therapy to the cervix may benefit from psychological evaluation and supportive measures if they develop further genital lesions which require colposcopic evaluation. Women with HIV infection need further psychological evaluation prior to planning intervention and preventative strategies.     

The association between sexually transmitted pathogens and cervical intra-epithelial neoplasia in a developing community.

OBJECTIVE--To determine the association of sexually transmitted pathogens in women with cervical intra-epithelial neoplasia (CIN). SETTING--An urban tertiary referral hospital serving a large indigent developing community. PARTICIPANTS--48 women attending a colposcopy clinic and 49 women attending a family planning clinic. METHODS--Vaginal, endocervical, rectal swab specimens and sera were collected for the detection of sexually transmitted pathogens. Cervical cytology was performed on all patients. Women attending the colposcopy clinic had confirmation of abnormal cervical cytology by colposcopic directed biopsy. RESULTS--The mean age of women with CIN (33 years) was significantly greater than that of the women without CIN (28 years) and that of the family planning group (26 years). There was a high prevalence of sexually transmitted pathogens in all women. A significantly higher prevalence of bacterial vaginosis was found in women with CIN compared to those without (50% vs 20%; p = 0.034). The human papilloma virus (HPV) was detected in 46% of women with CIN and 65% of those without CIN. Chlamydia trachomatis (21%) and Trichomonas vaginalis (39%) were detected frequently in women with CIN. C. trachomatis (14%-21%) was detected more frequently than Neisseria gonorrhoeae (3-5%) in all asymptomatic women studied. CONCLUSION--This study demonstrates a high prevalence of sexually transmitted pathogens in women with and without CIN as well as family planning clinic attenders. Bacterial vaginosis was a significant finding in women with CIN. C. trachomatis was detected in a high proportion of all women studied and found more commonly than N. gonorrhoeae. We therefore recommend that all women attending gynaecological services in a developing community be investigated and treated for sexually transmitted diseases.     

Value of colposcopy in sexually transmitted diseases clinic based on first year''s experience.

Two hundred and thirty two patients underwent cervical colposcopy within the first year of establishing a colposcopy service in the sexually transmitted diseases clinic at St Mary's Hospital, London. Their mean age was 27 years. Cervical intraepithelial neoplasia (CIN) was identified in 68 of 81 (84%) patients whose smears showed dyskaryosis and who underwent biopsy. CIN was also detected in 14 of 41 (34%) patients who underwent biopsy and whose repeat smears were reported as giving normal results. The value of assessing two consecutive smears was evident, however, because none of the 99 patients with CIN had two normal smear results consecutively. Patients requiring treatment underwent laser ablation, which was provided in the department of gynaecology. These results show that colposcopy plays a vital part in managing patients with abnormal smears and indicate that genitourinary physicians need to give priority to developing colposcopy services in their specialty.     

Risk factors in the development of cervical intraepithelial neoplasia in women with vulval warts.

Of 59 women referred with vulval warts whose cervices were assessed colposcopically for the presence of cervical intraepithelial neoplasia (CIN) before local treatment of the wart lesions, 17 had histologically proved CIN, 12 had histologically proved cervical wart virus infection, and 30 had abnormality on colposcopy or cytology. Seven of the 17 with CIN had no abnormality on cervical cytology. No differences in sexual behaviour, smoking habit, or oral contraceptive use were seen between women with CIN and those with no cervical abnormality. Viral DNA typing of the vulval lesions was carried out, but there were no differences in the distribution of viral types between the three different histological groups. Of the 30 women with no abnormality at the initial visit, 23 were followed up colposcopically and cytologically for one to two years. Three of them developed CIN after adequate treatment of the vulval lesions despite the absence of cervical abnormalities on colposcopy at the time of treatment. Studying the known factors linked with CIN failed to show why some women with vulval warts develop CIN, even after treatment of the warts, and others do not. The large number of false negative results on cervical cytology in our patients suggests that women presenting with vulval warts should be screened colposcopically in the first instance. Close follow up of women whose warts are treated and who are thought to have no cervical abnormality at that assessment is essential.     

A colposcopic case-control study of cervical squamous intraepithelial lesions in women with anogenital warts.

OBJECTIVE--To assess whether anogenital warts, present or past, are an indication for women to be referred for colposcopy. DESIGN--A case control study comparing patients with and without a history of anogenital warts. SETTING--A department of genitourinary medicine in West London. PATIENTS--468 patients examined by colposcopy between January 1985 and December 1987 of whom 147 (31%) had abnormal cytology, 163 (35%) had anogenital warts and 158 (34%) had both. MAIN OUTCOME MEASURES--Colposcopic findings and histology of cervical biopsies compared with behavioural and disease variables. RESULTS--Human papillomavirus infection (HPVI) of the cervix showed no relationship with a life time history of vulval warts, or with the presence of anogenital warts on clinical examination, or with any parameter of sexual behaviour included in the study. Cervical intraepithelial neoplasia (CIN) was strongly associated with current IUCD usage (RR = 7.75) and coitarche under 16 years of age (RR = 3.72), but a history of vulval warts yielded a negative association (RR = 0.34), suggesting a protective effect. This relationship held true when cytological dyskaryosis was made the dependent variable (RR = 0.24). CONCLUSIONS--Anogenital warts are not a risk for subclinical cervical HPVI or for CIN and therefore not an indication for colposcopy.     

Screening for cervical intraepithelial neoplasia and cancer in the Sheffield STD clinic.

I undertook a prospective study of the incidence of histologically confirmed cervical intraepithelial neoplasia (CIN) and cancer in women attending a sexually transmitted disease (STD) clinic, and correlated the findings to cervical cytology reports, age, and history of STD of the affected women. Of 2017 women screened, 75 (3.7%) had dyskaryotic cervical smears. Colposcopically directed biopsy tests gave an overall detection rate of 0.55% for CIN3, which was similar to the national average. The false negative rate was 2.9% and cytology tests alone underestimated the degree of pathological change in 12 (30%) of 40 women with mild dyskaryosis. Women under 20 years old made up 43% of those with CIN1 and 38% of those with CIN2. The detection rate of CIN3 was 0.65% for women aged 15-34, which was higher than the national average and suggested earlier onset of CIN3 in our clinic population. There was a high association between genital warts and cervical precancer. This preliminary study confirms the need for routine non-selective screening of women attending STD clinics by cervical cytology tests, colposcopic examination, and biopsy tests where indicated.     

Screening for cervical dysplasia in department of genitourinary medicine.

In 632 patients attending a sexually transmitted disease (STD) clinic who were colposcoped because they were in certain high risk groups for cervical neoplasia, and irrespective of cytological findings, 13 out of 51 biopsied had false negative cytology results. Human papilloma virus (HPV) was the most important sexually transmitted agent associated with cervical intraepithelial neoplasia (CIN), but HPV was also present in most patients with false negative (11/13) and false positive (11/14) cytology results. Screening by colposcopy, as well as cervical cytology, is therefore mandatory and must be available for certain STD clinic patients.     

Clinical significance of human papillomavirus infection of the uterine cervix in the development of cervical intraepithelial neoplasia.

A group of 25 controls and 30 women with lesions of the cervix associated with papillomavirus were studied prospectively by colposcopy and cytology for up to two years to investigate the relation between human papillomavirus (HPV) infection of the cervix and resolution or progression of cervical intraepithelial neoplasia (CIN). We found that the viral changes were transient and that active infection, as judged by repeated colposcopic and cytological examination, resolved in 83% of the patients. Resolution or persistence of the viral infection did not appear to affect the development of the CIN lesion. The proportion of CIN lesions that resolved and persisted were the same for the study group and the controls. Possible reactivation of latent papillomavirus was noted in three control group patients. Our findings indicate that changes in the cervix associated with papillomavirus should not influence the clinical management or follow up of patients with CIN.     

Abnormalities of the uterine cervix in women with vulval warts. A preliminary communication.

Fifty women attending a clinic for sexually transmitted diseases with vulval condylomata acuminata were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 25 (50%) had evidence of cervical infection by HPV and 18 (36%) epithelial abnormalities consistent with CIN 1 or 2.     

Abnormalities of the uterine cervix in women with vulval warts. A preliminary communication

Fifty women attending a clinic for sexually transmitted diseases with vulval condylomata acuminata were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 25 (50%) had evidence of cervical infection by HPV and 18 (36%) epithelial abnormalities consistent with CIN 1 or 2.     

Use of the polymerase chain reaction to detect human papillomavirus type 16 in the cervical scrapes of Irish women with varying grades of cervical intraepithelial neoplasia

Objective To assess the prevalence of HPV type 16 among Irish women with various degrees of CIN.
Subjects One hundred and five women with varying degrees of CIN, detected on prior cytological screening, and thirty-two women with cytologically normal cervical smears.
Methods HPV 16 DNA was detected by the PCR technique, with controls against contamination.
Setting The colposcopy clinic in the Rotunda Maternity Hospital, Dublin, and the Virus Reference Laboratory, U.C.D., from October 1991 to April 1992.
Results HPV 16 DNA was detected in 66% of subjects with abnormal cervical cytology, and in 31% of those with normal cervical smears. A higher HPV 16 prevalence was found among those women with CIN III (74%), than among those with CIN I/CIN II (60%).
Conclusions The prevalence of HPV 16 among Irish women with normal cytology and CIN was similar to previous published studies from other areas, with a higher prevalence in those with abnormal cervical cytology. The usefulness of detection of HPV 16 as an indicator of a higher risk of carcinoma of the cervix is discussed.     

Pilot study of cervical cytology screening in a sexually transmitted diseases clinic.

A pilot study of cervical cytology was carried out on 500 new patients at the women's sexually transmitted disease (STD) clinic at this hospital. The aim was to discover the incidence of abnormal smears in order to gauge the worth of cervical cytology as a routine clinic procedure. Information was also gathered on each patient's age, sexual history, method of contraception used, previous smears, and genital infection. Smears showing carcinoma in situ, dysplasia, or warty atypia were regarded as abnormal, and the relevant patients were referred for colposcopy. Seventy-three (14.6%) had abnormal smears. Eight women (1.6%), average age 29.7 years, had cervical intraepithelial neoplasia grade III (CIN III) confirmed by histology. One third of the patients with abnormal smears had genital warts, and the incidence of abnormal smears was greater in patients with genital warts than in those without warts. We concluded that STD clinics are useful places in which to carry out cervical cytology screening, and we noted a positive association between infection with genital warts and abnormal smears.     

Prognostic factors in cervical human papillomavirus infections.

A prospective follow-up study, without further treatment, of a series of 528 women with cervical human papillomavirus (HPV) infections was conducted from 1981 to the present, with a mean follow-up time of 60.3 months (standard deviation 25.1 months). The women visited the Outpatient Department of Gynecology, Kuopio University Hospital, Kuopio, Finland at six-month intervals. At each visit, a thorough gynecologic examination, PAP-smear, and colposcopy with or without punch biopsy were performed. Epidemiologic data were collected by questionnaire, and complete follow-up data were available for 480 of the 528 women. Of these 480 cases of HPV infection, 58.3% regressed spontaneously, and clinical progression was detected in 14.8%. To establish the prognostic factors associated with the clinical course of cervical HPV infections, the Cox proportional hazards regression model was applied. In the analysis, five variables were included: age, PAP-smear class, grade of cervical intraepithelial neoplasia (CIN), HPV type, and colposcopic appearance at the first visit. In general, patient age at the time of diagnosis was inversely related to the probability of spontaneous regression (P less than 0.01). CIN II, CIN III and HPV type 16 were the most significant independent prognostic factors for progression of cervical HPV infections (P less than 0.001, P less than 0.0001, and P less than 0.001, respectively). We conclude that whenever HPV 16 DNA is found in the cervical biopsy with any grade of CIN, the lesion should be treated. Similarly, the presence of CIN II and CIN III indicates treatment whether HPV DNA are detected or not.(ABSTRACT TRUNCATED AT 250 WORDS)     

A longitudinal study of HPV detection and cervical pathology in HIV infected women

OBJECTIVE: To monitor the presence and persistence of high risk (HR) human papillomavirus (HPV) in cervical brushings from HIV infected women. METHODS: Prospective observational cohort study of HIV infected women. Women were enrolled from the cohort of 164 HIV infected women who attend the colposcopy clinic at the Edinburgh Regional Infectious Diseases Unit. A single cervical brush scrape was obtained from 39 women and two or more samples from 63 women who attended regularly at approximately 6 monthly intervals. HPV typing was carried out using a commercial hybrid capture assay (HCA). Details of antiretroviral therapy, cytological assessment, and histological evaluation were made available and the interrelation with HR-HPV detection analysed. RESULTS: Abnormal cervical cytology, particularly of low grade, was common in these HIV infected women. HR-HPV types were detected in 25% of the women with normal cytology, while over 80% of those with abnormal cytology of any grade were HR-HPV positive. Persistent HR-HPV, as defined by two or more consecutive HPV positive results, was common and found in 27/63 women from whom multiple samples were obtained. HR-HPV was detected at high levels whether or not patients were receiving antiretroviral therapy. Profound immunosuppression was not necessarily associated with progression of cervical disease and no cases of invasive cervical disease were seen. CONCLUSION: While mild dyskaryosis (low grade squamous intraepithelial lesion (LSIL)) and persistence of HR-HPV are common in HIV infected women in Edinburgh, regular cytological and colposcopic evaluation with appropriate intervention and treatment appears to limit the progression of cervical disease.     

Increased incidence of cervical cytological abnormalities in women with genital warts or contact with genital warts: a need for increased vigilance?

OBJECTIVE--To determine whether women who have a history of genital warts or whose sexual partners have such a history were more likely to have borderline or dyskaryotic cervical smears than other women. DESIGN--Prospective study conducted over a five month period. SETTING--A genitourinary medicine clinic in Cambridge, UK. PATIENTS--One hundred and eighty five women who attended the clinic during the study period, on whom cervical cytology was performed. Ninety-seven had a history of genital warts and twenty had partners with genital warts. METHODS--Cervical cytology taken by standard methods. Demographic data and sexual history obtained by questionnaire. Colposcopy was performed on patients with a history of warts or wart contact. OUTCOME MEASURED--Relative incidence of cytological abnormalities in the various groups of patients. RESULTS--"Borderline" nuclear change was the most frequent abnormality reported in the wart contact group (six cases) whereas mild dyskaryosis was the most frequent abnormal finding in those women with a history of warts (21 cases). CONCLUSIONS--Women with warts or contact with genital warts were more likely to have borderline or dyskaryotic cervical smears than women without such a history. Recommendations for follow-up of these patients are made.     

The value of primary colposcopy in genitourinary medicine--a six year review.

OBJECTIVE--To evaluate the effectiveness of primary colposcopy in the genitourinary medicine setting by comparing the cervical cytology and punch biopsy results for women identified as having an abnormal cervical transformation zone. METHOD--A retrospective audit of six years' findings in primary colposcopy was carried out. The punch biopsy findings of 1338 women were compared with their last cervical cytology results. A small sample of biopsies were subjected to in situ hybridisation for human papilloma virus types 6, 11, 16, 18 and cytomegalovirus. RESULTS--The tabulated results demonstrated the variability between histology and cytology. This was explored with reference to other studies. The viral typing showed the dominance of low oncogenic risk human papilloma virus types. CONCLUSION--The findings are discussed against the overall concept of sexual health. Primary colposcopy facilitates empowerment of the patient and her partner through the opportunity for demonstration and explanation of disease processes and options for management. Experience and expertise gathered in six years of primary colposcopy confirm the value of primary colposcopy not only in improved diagnosis and management but also in teaching, audit and research.     

阴道镜直视检查在子宫颈上皮内瘤样病变切除手术中的临床意义

目的:本文研究了在子宫颈上皮内瘤样病变切除手术中应用阴道镜直视检查对患者治疗的临床意义。方法:对我院2009年2月至2010年7月期间进行切除治疗的254例子宫颈上皮内瘤样病变患者的临床资料进行了回顾性分析。结果:在子宫颈上皮内瘤样病变切除手术中应用阴道镜直视能够显著降低切除样本的平均高度和直径。患者平均随访时间为(29.2±3.1)月。39例患者最终确认为治疗无效。采用阴道镜直视切除手术的患者相对于手术中不采用阴道镜的患者,其治疗失败风险并无显著差异(HR:0.49;95%CI 0.21~2.33,P=0.468),而相对于阴道镜检查后立即进行切除手术的患者也无显著差异(HR:0.92;95%CI 0.57~1.68,P=0.846)。对治疗失败风险有显著影响的因素是清晰边界的确定(HR:0.35;95%CI 0.20~0.73,P=0.003)和手术切除直径(HR:2.56;95%CI 0.98~5.89,P=0.068)。结论:应用阴道镜直视于子宫颈上皮内瘤样病变切除手术中能够显著降低切除样本的尺寸,但不会导致治疗失败风险的显著变化。     

Cervical epithelial abnormalities are significantly associated with non-HPV lower genital tract infection in female contacts of warts*

Objectives

• 1 To assess the prevalence of cervical epithelial abnormalities in female sexual partners of men with anogenital warts.
• 2 To examine the possible association between non-HPV lower genital tract infection, and cervical epithelial abnormalities.

Design Retrospective review of the medical records of all female sexual partners of men with anogenital warts attending the GUM clinic in 1990. Setting and patients The department of Genito-Urinary Medicine (GUM), Royal Victoria Hospital, Belfast. Sixty-two female sexual partners of men with anogenital warts. Methods Cervical cytology and colposcopy was performed on all patients. Biopsies were taken of colposcopically identified cervical epithelial abnormalities, Non-HPV lower genital tract infection was detected by routine genito-urinary screening. Demographic data and sexual history were obtained by questionnaire. Outcome measured Overall prevalence of cervical epithelial abnormalities and correlation to the presence of non-HPV lower genital tract infection in the female. Results The overall prevalence of cervical epithelial abnormalities detected with colposcopy and biopsy was 46.8%. The prevalence of koilocytosis and cervical intraepithelial neoplasia (CIN) was 69.6% when non-HPV lower genital tract infection was detected by routine genito-urinary screening. When no infection was detected the prevalence was 33.3% (P < 0.05).     

性交出血与宫颈癌及癌前病变的关联

目的：讨论性交出血与宫颈癌及癌前病变的关系.方法：2011年1月至2012年11月我院妇科门诊在自愿接受宫颈癌筛查的患者中选取有性交出血史的631例患者均进行液基细胞学检查、电子阴道镜下宫颈四象限多点活检＋宫颈管搔刮术（ECC）,然后病理诊断,对临床资料进行回顾性分析.结果：TCT阳性率55.47％,其中LSIL 194例,占30.75％,ASC-US 76例（12.04％）,ASC-H 31例（4.91％）,HSIL 48例（7.61％）,AGC 1例（0.16％）.阴道镜下活检病理结果,宫颈上皮内瘤变（CIN） 176例（27.89％）,其中CINⅡ＋CINⅢ101例（57.39％）;宫颈癌19例（3.01％）.结论：性交出血是宫颈病变的警示,我们要重视有性交出血的患者,重点随访.为了降低其宫颈癌及癌前病变漏诊率及误诊率,要采用积极的检查手段.