Cervical dysplasia in Nigerian women infected with HIV

Objective

To determine the prevalence of and risk factors for cervical dysplasia in HIV-positive women receiving care at the Jos University Teaching Hospital in Nigeria.

Methods

A total of 369 HIV-positive women had cervical cytology performed; HIV-1 RNA viral load and CD4 counts were measured.

Results

Of 369 participants, cervical dysplasia was present in 107 (29.0%) women. However, cervical cytology was abnormal in 252 (68.3%). Among those with abnormal cytology, 145 (57.5%) women had ASCUS, 56 (22.2%) had LSIL, and 51 (20.2%) had HSIL. Median CD4 lymphocyte count was lower in women with dysplasia compared with those without (142 vs 170 cells/mm³; P = 0.04), while median HIV RNA viral load was higher in women with dysplasia (101 781 vs 77 479 copies/mL; P = 0.002). Low CD4 count (< 200 cells/mm³) and evidence of HPV infection were significantly associated with cervical dysplasia.

Conclusion

A high prevalence of cervical dysplasia was found among HIV-positive Nigerian women, which was associated with increased immune suppression.     

Visual inspection with acetic acid and cytology as screening methods for cervical lesions in Cameroon.

OBJECTIVES: To assess the accuracy of visual inspection with acetic acid (VIA) as a screening method for cervical lesions. METHODS: VIA and cytological smears were carried out on the cervices of non-pregnant women aged 30-60 years with no previous history of cervical cancer. Cervices with aceto white lesions or positive Pap smears, and one in ten negative cervices (control), were biopsied. RESULTS: 5010 women were enrolled, 4813 (96.1%) were screened. 4767 (99.%) had adequate cytology smears. 574 (11.9%) had colposcopy. 1743 biopsies were obtained of which 528 were controls. The sensitivity of VIA was 70.4% versus 47.7% for Pap smear. VIA specificity was 77.6% versus 94.2% for Pap smear; PPV for VIA was 44.0% versus 67.2% for Pap smear; and NPV for VIA was 91.3% versus 87.8% for Pap smear. CONCLUSIONS: VIA has acceptable test qualities and may in low resource settings be implemented as a large scale screening method.     

Factors affecting compliance in the first year of postcolposcopy surveillance among women with a high incidence of cervical cancer

Objective

To assess postcolposcopy compliance among women with abnormal cervical screening results and to identify factors associated with noncompliance for postcolposcopy follow-up.

Methods

In a retrospective study, the records of women who underwent colposcopy at Srinagarind Hospital, Thailand, between January and December 2010 were reviewed. Women were considered to be noncompliant if their total follow-up time after colposcopy was less than 12 months. Univariate and multivariate logistic regression methods were used to determine factors significantly predicting noncompliance.

Results

Among 548 women who underwent colposcopy, the percentage of noncompliance was 49.5% (95% confidence interval [CI], 45.1%–53.7%). The risk for noncompliance rose significantly among those without intraepithelial lesions (OR, 2.19; 95% CI, 1.53–3.13), younger age (OR, 1.79; 95% CI, 1.19–2.67), and low education level (OR, 1.58; 95% CI, 1.11–2.24). Risk for noncompliance was significantly lower among those with a previous history of abnormal smear (OR, 0.39; 95% CI, 0.24–0.64).

Conclusion

The percentage of noncompliance with postcolposcopy follow-up was high among the study women. The significant independent factors predicting noncompliance were previous history of abnormal smear, severity of cervical histopathology, age, and education level.     

Factors associated with pathologic colposcopic and cytologic changes in 500 clinically asymptomatic women

Objective

To determine the role of cytologic and colposcopic diagnosis in the early detection of pathologic cervical changes and the effect of the number of births, a history of abortion, the number of sexual partners, and contraceptive use on pathologic colposcopic and cytologic changes.

Method

The 500 study participants were seen at the Obstetric-Gynecologic Clinic of Prishtina, Kosovo, in 2006 and 2007. They were assigned to 5 groups of 100 according to number of births, a history of abortion (whether spontaneous or induced), and total number of sexual partners, but the use of contraceptives was also analyzed. All participants underwent cytologic and colposcopic evaluations.

Results

Colposcopic atypia was observed in 70 participants (14%) and 77 (15.4%) had other findings. The degree of colposcopic atypia increased with the number of sexual partners, as did the frequency of infections. Most (91.2%) of the women with positive cytologic results were from groups 1 and 2, and the remaining 8.8% of these women were from groups 3, 4, and 5. From 44 patients with positive pathology results, 29 (65.9%) had chronic cervicitis, 13 (29. 5%) had hyperplasia, and 2 (4.5%) had carcinoma in situ.

Conclusion

Number of births, a history of abortion, number of sexual partners, and contraceptive use directly affected pathologic colposcopic and cytologic changes.     

Three-step versus “see-and-treat” approach in women with high-grade squamous intraepithelial lesions in a low-resource country

Objective

To investigate the frequency of cervical intraepithelial neoplasia (CIN) 2 or greater in women with high-grade squamous intraepithelial lesion (HSIL), and to evaluate whether colposcopically-directed biopsy is a necessary procedure for managing HSIL in a low-resource country.

Methods

A retrospective review was undertaken of women with HSIL on a Pap smear.

Results

Of 348 women who had undergone colposcopically-directed biopsies and loop electrosurgical excisional procedure (LEEP), 321 (92.2%) had CIN 2 or greater. Of these, 279 were diagnosed with CIN 2 or greater on biopsy as were 264 on LEEP. The lesions in women who had CIN 2, satisfactory colposcopy, and more biopsies were more likely to be completely excised by biopsy. The mean length of time between the initial Pap smear and LEEP was significantly longer than between the initial Pap smear and biopsy.

Conclusion

Women with HSIL can be effectively managed using the see-and-treat approach in a low-resource country owing to the frequency of CIN 2 or greater.     

Analysis of outcome in women with borderline glandular change on cervical cytology

Objective

To review the outcome of women presenting with borderline glandular smear on cervical cytology and to investigate correlation between cytology, colposcopy and histology and subsequent smear history.

Study design

A 5 year retrospective analysis of outcome in all women reported with borderline glandular changes on cytology between 2001 and 2005 at the John Radcliffe Hospital, Oxford, and Cheltenham General Hospital, Gloucestershire, was performed. Cytology, colposcopy, histology and follow-up cytology data at 6, 12 and 24 months after index smear were collated.

Results

Of 92 women with borderline glandular smears, 56 were referred for colposcopy. This accounts for 0.9% of the total referral (6293) to the colposcopy units. A significant rate of abnormal histology was noted, with CIN 1, 2, 3, CGIN or worse in 20 women (36%) and benign pathology in 18 women (32%). Colposcopy had a sensitivity of 82%, specificity of 39%, negative predictive value of 80% and positive predictive value of 49% in predicting abnormal (premalignant/malignant) histology. Only one woman with normal histology at presentation had subsequent abnormal cytology (1/31), whereas abnormal histology at presentation was strongly associated with subsequent abnormality on follow-up cytology over 24 months (8/21) with a p value = 0.0058.

Conclusion

Colposcopic examination and biopsy of colposcopically identified abnormalities is reliable, with negative colposcopy having a high negative predictive value. We also recommend thorough colposcopic examination before any invasive investigation as over treatment may impact on the future reproductive outcome [1].     

Relationship between interpregnancy interval and cervical length in high-risk women

Objective: Our objective was to evaluate the relationship between the interpregnancy interval (IPI) and next-pregnancy mid-trimester cervical length (CL) in women at high risk for recurrent spontaneous preterm birth (SPTB).

Methods: Retrospective review identified high-risk women, defined as a prior SPTB <36 weeks, who began scheduled serial transvaginal sonographic CL screening at 16–18 weeks gestation between December 2008 and November 2010. All CL assessment ended by 22^6/7 weeks, and weekly 17-α hydroxyprogesterone caproate, 250?mg IM, was recommended to all patients. Details of the prior and current pregnancy were collected, and regression models were used to evaluate the relationship between IPI and CL shortening.

Results: One hundred and eight women with singleton gestations and a qualifying SPTB underwent CL screening. The mean (SD) birth gestational age (GA) of the last pregnancy was 25 (10) weeks, the median IPI was 613 (range 49–6038) days, and the mean (SD) delivery GA in the current pregnancy was 36 (5.3) weeks. Linear regression found no significant relationship between the IPI and the GA of the current birth (p?=?0.98). There was a weak significant relationship between IPI and shortest CL (p?=?0.04). However, after controlling for the GA of the prior pregnancy, this relationship was non-significant (p?=?0.13).

Conclusions: IPI does not predict next birth outcome or next-pregnancy mid-trimester CL in high-risk women managed with progesterone and ultrasound-indicated cerclage.     

Comparison of the diagnostic value of the visual inspection with acetic acid (VIA) and Pap smear in cervical cancer screening

ObjectiveThis study aimed to compare the diagnostic value of VIA with Pap smear in screening for cervical cancer.Materials and methodsIn this cross-sectional study, 440 women who had eligibility criteria, in Kashan city were assessed. All women underwent Pap smear test and then a visual inspection with acetic acid and colposcopy-biopsy (Gold Standard). Then, the diagnostic value indices including the specificity, sensitivity, positive and negative predictive values for the results of VIA and Pap smear were analyzed by SPSS V16 software.ResultsFinding showed that 29.9% of women had abnormal Pap smear. The false positive rate of Pap smear was 40.2%, and its false negative rate was 37.4%. For VIA, the false positive and false negative rates were 21.2% and 4.6%. The sensitivity, specificity, NPV and PPV of Pap smear was 29.7%, 85.5%, 59.8%, 62.6%, and these values for VIA was 94.6%, 81.6%, 78.8%, 95.4% respectively. Combination of Pap smear and VIA showed the sensitivity of 97.3% and 100% in low grade and high grade cervical lesions.ConclusionVIA has a higher sensitivity than Pap smear in detection of low and high grade cervical lesions, however, its specificity is less than Pap smears. Therefore it is recommended to use of VIA along with Pap smear to reach a higher sensitivity.     

Prevalence of pathology in women attending colposcopy for postcoital bleeding with negative cytology

Objective To determine the frequency of cervical pathology and the incidence of cervical neoplasia in women presenting with PCB at the colposcopy clinic with negative cytology. Design A retrospective study. Setting A district general hospital. Population Eighty-seven women with postcoital bleeding and negative cytology were seen in the colposcopy unit during 1 January 2003 to 31 December 2005. Methods Women were identified from computer records and details were extracted from the case notes. Main outcome measure Histopathological diagnosis. Results Six women (6.9%) had cervical intraepithelial neoplasia. There were no cases of invasive cancer. Thus in our study 6.9% women with postcoital bleeding had abnormal histology even though they had normal smears. Other identifiable causes were cervical polyp (12.5%), ectopy (33.6%) and Chlamydia (2.3%). No pathology was found in 50% of women. Conclusion Women with postcoital bleeding even with normal smears appear to be at much greater risk of cervical neoplasia than the general population. Unfortunately there is no general consensus for management of these patients. Hence further research is needed to standardise the management of women with PCB. Patients should be reassured that in vast majority of cases no serious pathology is detected.     

Prevalence and genotype distribution of human papillomavirus in women with cervical cancer or high-grade precancerous lesions in Chengdu, western China

Objective

To study the prevalence and genotype distribution of human papillomavirus (HPV) among women with cervical cancer or high-grade squamous intraepithelial lesions (HSIL) in western China.

Methods

Cervical cast-off cells from 144 women with cervical cancer and 63 women with HSIL were tested for HPV genotypes using an oligonucleotide microarray.

Results

The overall HPV prevalence was 80.6% in cases of carcinoma and 61.9% in cases of HSIL. The most common genotypes were HPV-16 (carcinoma, 68.1%; HSIL, 34.9%) and HPV-58 (carcinoma, 8.3%; HSIL, 17.5%). Other high-risk types included HPV-18, -31, -33, -35, -45, and -52, with HPV-18 more common in adenocarcinomas than in squamous cell carcinomas (21.4% vs 3.1%; P < 0.02). The HPV prevalence was lower among patients older than 49 years (P < 0.02).

Conclusion

The prevalence of HPV-16 and HPV-58 was high. This finding may help to improve HPV vaccination and cervical cancer prevention programs in western China.     

Tubal ligation frequency in Oklahoma women with cervical cancer

Objective

Infrequent Pap screening is an important risk factor for cervical cancer. We studied the association between contraceptive methods, screening frequency, and cancer.

Methods

Women (n = 2004) enrolled in the cross-sectional Study to Understand Cervical Cancer Endpoints and Determinants (SUCCEED) underwent colposcopy to evaluate an abnormal Pap test. Questionnaire data were compared between those with cervical intraepithelial neoplasia (CIN) 3/adenocarcinoma in situ (AIS) and those with invasive cancer to identify factors associated with cancer. Logistic regression was used to calculate age-stratified measures of association between contraceptive method and Pap frequency as well as tubal ligation (TL) and cancer risk.

Results

In all age groups, women with TL were more likely to have had no Pap screening in the previous 5 years compared to women using other contraception: 26-35 years (OR 4.6, 95% CI 2.4-8.6; p < 0.001), 36-45 years (OR 3.8, 95% CI 2.1-7.0; p < 0.001), and 46-55 years (OR 2.2, 95% CI 1.0-4.9; p = 0.050). Subjects with cancer (n = 163) were more likely to have had a TL (41% vs. 21%, p < 0.001) than those with CIN 3/AIS (n = 370). Age-stratified analyses showed increased odds of tubal ligation in women with cancer versus those with CIN 3/AIS between 25 and 45 years, with a significant increase in women 26 to 35 years old (OR 3.3, 95% CI 1.4-8.1; p = 0.009). Adjusting for Pap frequency changed the effect only slightly, suggesting that increased risk was not fully mediated by lack of screening.

Conclusion

Contraceptive type is associated with Pap screening. Women with TLs obtain less frequent Pap testing and may be at an increased risk for cervical cancer.     

Impact of alternative management policies on health-related quality of life in women with low-grade abnormal cervical cytology referred for colposcopy

Objective

To assess the health-related quality of life (HRQoL) over 30 months among women who received colposcopy following low-grade abnormal cervical cytology.

Design

751 women with low-grade abnormal cytology were seen for colposcopy. Of these, 350 additionally underwent either immediate treatment by large loop excision of the transformation zone (LLETZ) or investigation by punch biopsy followed by treatment of high-grade cervical intraepithelial neoplasia if present. The HRQoL of the women was assessed on seven separate occasions over 30 months by means of the EQ-5D instrument. Outcomes for women receiving colposcopy only, colposcopy with biopsy and colposcopy with LLETZ were compared.

Results

Women experienced modest short-term increases in HRQoL, statistically significant for the colposcopy only and biopsy groups but not for the LLETZ group. HRQoL in all three groups thereafter fell until 12 months following recruitment, significantly so for the LLETZ group. Changes in EQ-5D index score arose primarily from changes in severities in the “pain and discomfort” and “anxiety and depression” domains. Changes in the visual analogue scale (VAS) representations of quality of life corresponded closely to those of the index scores and most of the VAS scores themselves did not differ from VAS population norms. All inter-assessment changes in index scores were smaller than the minimum important difference for the instrument. Beyond 18 months from recruitment, HRQoL stabilised in all three groups.

Conclusion

Women referred to colposcopy following a low-grade abnormal smear test result experienced a short-term improvement in their health-related quality of life, but the long-term effect was insubstantial. HRQoL over the post-recruitment follow-up period did not vary by intervention.     

Screening history of women with invasive cervical cancer in north-east Italy

Objectives

To describe screening histories of women with invasive cervical cancer (ICC) in Friuli Venezia Giulia, after the introduction of organized screening, in order to identify possible reasons undermining prevention of ICC. To investigate associations between screening histories in relation to women's survival and tumor characteristics, with a focus on organized and opportunistic screenings.

Study design

438 women, diagnosed with ICC between 1999 and 2005, were identified using the regional Cancer Registry. Cytological and histopathological information were obtained through regional health databases. Associations between different screening histories and characteristics of women and their tumors were evaluated by means of odds ratios (OR) and corresponding 95% confidence intervals (CI), through multinomial logistic regression models adjusted for age; death risks were estimated by computing hazard ratios (HR) with 95% CI, using Cox models adjusted for age, tumor stage, and histology.

Results

165 (38%) women with ICC had no Pap smears: 71 (16%) never attended the organized screening despite invitation; 69 (16%) were never invited because they were above 64 years of age; and 25 (6%) were yet to be invited. Conversely, 273 (62%) women underwent screening: 141 women (32%) had opportunistic screening; 132 (30%) women attended the organized program. A total of 193 (44%) women had ICC detected at screening. Compared to women with ICC who had never been screened, those screened within the organized program were more often at stage IA (46%), were seldom at stage II or higher (OR = 0.3, 95% CI: 0.1-0.6, vs. IB), and showed a lower risk of death (HR = 0.6, 95% CI: 0.3-1.0).

Conclusions

In Friuli Venezia Giulia, the lack of screening among older women and of compliance with organized programs among women in the target population are the main limitations in cervical cancer secondary prevention. Our findings indicate that participation in organized screening has a beneficial effect in terms of down-staging and improved survival as compared to both absence of screening and opportunistic screening.     

A Study of Cervical Intraepithelial Neoplasia in Pregnancy

Objective

To find the incidence of human papillomavirus (HPV) infection and cervical intraepithelial neoplasia (CIN) in pregnant women and compare Pap smear with the HPV DNA test in detecting HPV infection.

Materials and Methods

Hundred antenatal women, irrespective of gestational age, were enrolled as subjects in this prospective pilot study for blood investigations, wet mount examination of cervical discharge, Pap smear, and high-risk HPV DNA detection of cervical scrape by PCR. Women showing abnormality in Pap smear and/or those who were high-risk HPV DNA positive were subjected to colposcopy.

Results

The incidence of HPV-positive pregnant women was 18 %. Koilocytosis on Pap smear was observed in six women. Three high-risk HPV DNA-positive women showed changes consistent with CIN 1 on colposcopy.

Conclusions

The HPV DNA test is the most sensitive and reliable in detecting HPV infection as compared to Pap smear, but considering the cost of PCR, Pap smear screening of all antenatal women was recommended.     

Outcome in women with no endocervical component on cervical cytology after treatment for high-grade cervical dysplasia

Background:  Cervical cancer and its precursors still remain an important cause of morbidity and mortality despite adequate screening programs. It is now established practice in Australia that a Pap smear without an endocervical component, which is otherwise negative, does not warrant an earlier repeat smear. This study aims to determine if the lack of an endocervical component in women with previously treated high-grade abnormalities of the cervix increases the risk of subsequent cytological abnormalities.
Method:  Data were retrieved from an electronic database in the Oncology and Dysplasia Unit at The Royal Women's Hospital in Melbourne, Australia. Women who underwent treatment for high-grade cervical abnormalities from 2000–2004 were included in the study. Women with negative cytology immediately after their operations were first identified, and the incidence of subsequent cytological abnormalities was calculated and then separated according to their endocervical status.
Results:  Of the 1260 women in the study population, seven developed high-grade abnormalities (six with an endocervical component and one without) and 107 developed low-grade abnormalities (98 with an endocervical component and nine without).
Conclusion:  The lack of an endocervical component was not statistically significantly associated with a higher incidence of either high-grade or low-grade abnormalities. Therefore, women who have had previous treatments for high-grade abnormalities do not need to have earlier repeat smears or intervention if the cytology lacks an endocervical component.     

High-grade histologic lesions in women with low-grade squamous intraepithelial lesion cytology from a region of Thailand with a high incidence of cervical cancer

Objective

To evaluate the prevalence of and predictors for underlying significant lesions in women with low-grade squamous intraepithelial lesion (LSIL) smears.

Methods

Records were retrospectively reviewed for 208 women with LSIL who underwent colposcopy and histological evaluation from October 2004 through April 2009.

Results

Mean age of the patients was 38.5 years. Forty-four (21.2%) women were nulliparous; 20 (9.6%) women were postmenopausal; 29 (13.9%) women tested positive for HIV. Thirty-three (15.9%) women were current users of combined oral contraceptive pills. The pathological results of initial colposcopic evaluations were: 63 (30.3%) with cervical intraepithelial neoplasia (CIN) 2-3; 62 (29.8%) with CIN 1; 4 (1.9%) with cervical cancer; and 79 (38.0%) with no epithelial lesion. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity were significant independent predictors for high-grade disease.

Conclusion

Approximately one-third of women with LSIL in our population have underlying significant lesions. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity are significant predictors for high-grade lesions.     

Patient distress and satisfaction with optical spectroscopy in cervical dysplasia detection

OBJECTIVE: The aim of this investigation was to evaluate the impact of optical spectroscopy, a new approach for the detection of cervical dysplasia, on patient well-being and satisfaction. STUDY DESIGN: Patient distress and satisfaction with optical spectroscopy compared with the Papanicolaou test and colposcopically directed biopsy were measured in a volunteer sample of 314 women with no history of abnormal Papanicolaou test findings. RESULTS: Participants reported significantly less pain and anxiety (P<.001) during optical spectroscopy than during the Papanicolaou test or colposcopically directed biopsy. Generally, participants found spectroscopy equal to the Papanicolaou test and to biopsy on a variety of questions that measured satisfaction. There were statistically significant differences between spectroscopy and the Papanicolaou test or biopsy on issues such as the discomfort and fear caused by the test, the amount of time taken, the room lighting, and perceptions of accuracy. CONCLUSION: That patients reported less distress during spectroscopy than during a Papanicolaou test, colposcopy, or biopsy suggests the possibility of improved adherence to cervical cancer screening and follow-up in settings in which it is used.     

Effect of delivery route on natural history of cervical dysplasia

OBJECTIVE: This study was undertaken to determine the (1) impact of delivery route on the natural history of cervical dysplasia and (2) overall regression rates of cervical dysplasia in pregnant women. STUDY DESIGN: A retrospective analysis was performed on 705 pregnant women with abnormal Papanicolaou tests who presented for prenatal care at the Kapiolani Medical Center Women's Clinic in Honolulu, Hawaii, between 1991 and 2001. Data collection included demographics, delivery route, and cervical pathology. RESULTS: Two hundred one patients met the inclusion criteria. Regression rates for vaginal and cesarean section groups were as follows: atypical squamous cells (64% vs 70%, P = .32), low-grade squamous intraepithelial lesion (58% vs 42%, P = .073), and high-grade squamous intraepithelial lesion (53% vs 25%, P = .44). Of the total population, 30% of lesions persisted postpartum, 58% regressed, and 12% progressed. CONCLUSION: Mode of delivery does not influence the natural history of dysplastic lesions. Gravid and nongravid women have similar regression rates.