Sociodemographic factors associated with high-risk human papillomavirus infection

OBJECTIVE: To determine the prevalence of high-risk (cancer-associated) human papillomavirus (HPV) infection in U.S. women, identify sociodemographic factors associated with infection, and explore the implications for prevention of HPV-related disease in the vaccination era. METHODS: Women aged 14-59 years (n=1,921) participating in the 2003-2004 National Health and Nutrition Examination Survey provided a vaginal swab which was evaluated for 37 HPV types. We determined which sociodemographic characteristics were associated with high-risk HPV, using logistic regression models. RESULTS: High-risk HPV infection was present in 15.6% (95% confidence interval [CI] 12.6-18.6%) of participants, corresponding to a population prevalence of 12,028,293 U.S. women. Women living below the poverty line, compared with those living three or more times above it, were more likely to be positive for high-risk HPV (23% versus 12%, P = .03). Among participants living below the poverty line, only Mexican-American ethnicity (odds ratio [OR] 0.4, 95% CI 0.2-0.9) and unmarried status (OR 3.3, 95% CI 1.2-8.9) were associated with HPV prevalence. In contrast, several factors were associated with HPV among participants living above the poverty line, including black race (OR 1.4, 95% CI 1.0-2.0), income (OR 0.92, 95% CI 0.84-0.99), unmarried status (OR 2.0, 95% CI 1.3-3.0), and age (OR for 22-25 year olds 2.4, 95% CI 1.4-4.0). CONCLUSION: High-risk HPV infection is common in U.S. women, particularly in poor women. Cervical cancer prevention efforts in the vaccination era must ensure that all low-income women have access to preventive services including education, Pap test screening, and HPV vaccines. Otherwise, existing disparities in cervical cancer could worsen.     

Risk factors for human papillomavirus and cervical precancerous lesions, and the role of concurrent HIV-1 infection.

OBJECTIVES: To identify risk factors for human papillomavirus (HPV) infection and squamous intraepithelial lesions (SIL) of the cervix, and to measure the impact of concurrent HIV-1 infection. METHODS: Women were studied at a family planning clinic in Nairobi, Kenya. Demographic and historical information was obtained using a semi-structured questionnaire and specimens were collected for sexually transmitted diseases (STDs), HPV, cervical cytology, and HIV-1 testing. RESULTS: HPV was detected in 87 of 513 women (17%), including 81 (93%) oncogenic types (16, 18, 31, 33 and others) and six (7%) non-oncogenic types (6 and 11). HIV-1 prevalence was 10%. HPV detection was associated with HIV-1 infection [adjusted odds ratio (aOR) 3.9, 95% confidence interval (CI), 2.0-7.7], sexual behavior indicators including the number of sex partners and inflammatory STDs, as well as the number of pregnancies (0 or 1 vs. > or = 3, aOR 0.4; 95% CI, 0.2-0.9). SIL was detected in 61 women (11.9%), including 28 (46%) with low-grade lesions (LSIL) and 33 (54%) with high-grade lesions (HSIL). HPV infection was strongly associated with HSIL (OR 14.9; 95% CI, 6.8-32.8). In a multivariate model predictors of HSIL included HIV-1 serpositivity (aOR 4.8; 95% CI, 1.8-12.4), the number of lifetime sex partners (0-1 vs. > or = 4; aOR 3.8; 95% CI, 1.1-13.5), and older age (< 26 vs. > 30; OR 3.9; 95% CI, 1.1-13.6). An analysis stratified by HIV-1 showed a stronger association between HPV and HSIL in HIV-1 negative women (OR 17.0; 95% CI, 6.4-46.3) then in HIV-1 positive women (OR 4.5; 95% CI, 0.8-27.4). CONCLUSION: Our results indicate that HSIL and even invasive cancer are highly prevalent in this setting of women on reproductive age considered to be at low risk for STDs, suggesting that routine Pap smear screening may save lives.     

Malignancies following in situ cervical cancer in Hispanic Americans and non-Hispanic Whites

OBJECTIVES: Some risk factors for cervical cancer in situ convey risk for malignancies of the cervix and other sites. We estimate risk of several malignancies following in situ cancer of the cervix for Hispanic Americans and non-Hispanic Whites. METHODS: Using California Cancer Registry data (1988-1999) we identify 56,020 women with cervical cancer in situ and observe subsequent malignancies in that cohort, with over three million woman-months of follow-up. We focus on cancers of the reproductive system and cancers related to smoking. Risk estimates are standardized incidence ratios, accounting for age, time at risk, cancer type, and race/ethnicity. RESULTS: There is elevated risk for invasive cervical cancer (SIR=4.1, 95% CI: 3.5-4.7), which is significantly higher for Hispanics than for non-Hispanic Whites (SIRs=5.2 and 3.2, respectively, chi2(1)=7.66, P=0.006). Excluding cervix, non-Hispanic Whites show elevated risk for a pool of reproductive cancers (SIR=1.8, 95% CI: 1.4-2.4). While both groups show elevated risk for a pool of smoking-related cancers, only non-Hispanic Whites show significant risk specifically for lung cancer (SIR=1.7, 95% CI: 1.4-2.1). Non-Hispanic Whites show elevated risk for ovarian cancer (SIR=1.8, 95% CI: 1.3-2.4). Ovarian cancer following in situ cervical cancer is disproportionately of borderline histology (G2(1)=7.43, P=0.006). CONCLUSIONS: These results have implications for public health planning for women, as well as better understanding of disparities in care or biologic paths to malignancies in women with in situ cancer of the cervix.     

Prevalence and risk factors of HPV infection among high-risk rural and urban Lithuanian women

AIMS: To investigate the prevalence, persistence and risk factors of high oncogenic risk human papillomavirus (HPV) among urban and rural women of reproductive age coming to consult a gynaecologist. METHODS: A prospective cohort study in urban (Kaunas) and rural (Marijampole) regions of Lithuania. The data were collected in 8 healthcare institutions from women seeking consultation of gynaecologists using a questionnaire for finding out demographic, social, behavioural and biomedical factors. HPV DNA was determined by molecular hybridization method (hybrid capture version II) determining HPV of high oncogenic risk. RESULT: 1,120 women participated in the study. The prevalence of high-risk HPV among the studied women was 25.1%. It was higher among the urban women than among the rural women. The prevalence of high-risk HPV was increased if the subjects had 2 or more sexual partners during the last 12 months (OR 2.81; 95% CI 1.83-4.32), were 19 years of age or younger (OR 2.68; 95% CI 1.47-4.91), were smoking (OR 1.81; 95% CI 1.16-2.81), and had secondary or lower education level (OR 1.43; 95% CI 1.01-2.04). This infection was obviously associated with high- and low-grade squamous intraepithelial changes of the cervix (OR 1.66, 95% CI = 1.08-2.53). CONCLUSION: The incidence rate for cervical cancer in Lithuania is one of the highest in comparison with other European countries. HPV infection was also particularly common in the studied population. About one-fourth of the women were infected with high-risk HPV infection. Young and less educated women were found to be the group that was most exposed to HPV, and therefore public health interventions and education seem to be essential in programs aimed at reducing the incidence of cervical cancer.     

A population-based study of cervical carcinoma and HPV infection in Latvia

OBJECTIVES: We wished to quantify the population-based importance of cervical carcinoma risk factors in Latvia. METHODS: Totally, 223 of 224 eligible cases of incident invasive cervical carcinoma were enrolled during July 1998-February 2001 in Latvia. An age-matched sample of 300 healthy control women was selected from the Latvian population registry and 239 of these women (79%) were enrolled. A demographic and life-style questionnaire was completed, cervical brush samples were analyzed for human papillomavirus (HPV) DNA by PCR and serum samples for HPV antibodies. RESULTS: Risk factors for cervical cancer in multivariate analysis were HPV type 16 or 18 DNA positivity (OR = 32.4; CI 95% 16.5-63.6) and living in the capital (OR = 2.4; CI 95% 1.2-4.7). Oral contraceptive use was not a risk factor (OR = 0.4; CI 95% 0.2-1.1). A strong protective effect was found for having had more than three Pap smears in the last 5 years (OR = 0.07 CI 95% 0.03-0.19). CONCLUSIONS: Inadequate population coverage of Pap smears, in spite of excessive smear usage, caused 28.4% of cervical cancers in age groups eligible for screening. HPV type 16 infection was the most important risk factor for cervical cancer in Latvia, with a population-attributable risk percent for all ages of 58.5%.     

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE: To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer. METHODS: Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, chi(2) tests, and binary logistic regression. RESULTS: The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4-6.7), recent immigrants (OR 5.7, 95% CI 2.0-16), less educated (OR 3.6, 95% CI 1.6-8.0), and uninsured (OR 3.9, 95% CI 1.6-9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1-11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1-6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0-6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0-9.4).. CONCLUSION: We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance.     

Human papillomavirus and cervical cancer from a prospective study in Khon Kaen, Northeast Thailand

The risk of developing carcinoma of the cervix in women infected with human papillomavirus (HPV) was estimated in a nested case-control analysis of 33 cancers (invasive and in situ) and 113 controls, matched by age and sex, from an ongoing cohort study of lifestyle and cancer in a rural population of Northeast Thailand. Oncogenic HPV types were present in 10.8% of control women and in 31/33 of the carcinoma cases, corresponding to an odds ratio of 130.6 (95% CI 11.7-1457.0). There was no significant difference in risk between prevalent cancer cases (diagnosed less than 3 months after HPV testing) and incident cases (diagnosed an average of 2.1 years later). HPV 16 and 18 were the most prevalent oncogenic HPV types present. The results confirm that some two of three of cervical cancer cases in this population of Northeast Thailand are caused by HPV 16 and 18.     

Emergency cesarean delivery in induction of labor: an evaluation of risk factors

BACKGROUND: Induction of labor has been associated with an increased risk of emergency cesarean delivery. Knowledge of factors that influence the risk of cesarean delivery in women with induced labor is limited. METHODS: We performed a case-control study, nested within a population-based cohort of women with induced labor at term during 1991-1996 in Uppsala County, Sweden. Cases were women delivered with emergency cesarean delivery, and controls were women vaginally delivered (n = 193, respectively). Using logistic regression, analyses were performed. Odds ratio (OR) with 95% confidence intervals (CI) was used as a measure of relative risk. RESULTS: Women with a previous cesarean delivery had high risks of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30-30.92). The risk of cesarean delivery was also increased among nulliparous (adjusted OR = 4.92, 95% CI = 2.81-8.61), short (adjusted OR = 2.20, 95% CI = 1.06-4.59), and obese women (adjusted OR = 2.03, 95% CI = 1.07-3.84). A cervix dilatation less than 1.5 cm doubled the risk of cesarean delivery (adjusted OR = 2.26, 95% CI = 1.09-4.66). Mother's age, epidural analgesia, oxytocin augmentation, gestational age, and birthweight were not significantly associated with risks of cesarean delivery. CONCLUSIONS: Women with a previous cesarean delivery, nulliparous, short, and obese women with induced labor are at high risk of a cesarean delivery. When there is a need to deliver a woman with a previous cesarean section or a nulliparous woman with other risk factors for cesarean delivery, it may be prudent to consider an elective cesarean section.     

Lack of evidence that proline homozygosity at codon 72 of p53 and rare arginine allele at codon 31 of p21, jointly mediate cervical cancer susceptibility among Indian women

OBJECTIVES: The objective of this study was to identify whether variants of p53Arg72Pro and p21Ser31Arg were associated with increased risk for cervical cancer (CaCx), either independently or jointly, among Indian women. METHODS: Genotyping was done by PCR-RFLP using DNA from (i) 120 cervical biopsy tissues of squamous cell carcinoma of the cervix (of which 82 were HPV16/18 positive), and (ii) a total of 205 cytologically normal cervical scrapes (121 HPV-negative and 84 HPV16/18-positive samples, considered as discreet groups). Multiple logistic regression analyses were performed to examine additive or interactive effects of the two factors and for determining age-adjusted OR (95% CI) and P values. RESULTS: The observed association of proline homozygosity at codon 72 of p53 with CaCx infection (Bhattacharya, P., Duttagupta, C., Sengupta, S. 2002.Proline homozygosity in codon 72 of p53: A risk genotype for Human Papillomavirus related cervical cancer in Indian women. Cancer Lett 188: 207-211) was retained among Indian women harboring HPV16/18 (OR(age-adjusted) = 3.76; 95% CI = 1.03-13.80; P = 0.04). Significant independent association was evident between the p21 arginine allele (rare allele with frequency of 0.1) at codon 31 and CaCx, compared to HPV-negative cytologically normal controls (OR(age-adjusted) = 2.01; 95% CI = 1.00-4.06; P = 0.05). The two risk factors jointly failed to show statistical interaction towards susceptibility to CaCx. The p21 arginine allele was significantly associated with CaCx in the p53 proline non-homozygous group of subjects (OR(age-adjusted) = 2.68; 95% CI: 1.21-5.91; P = 0.01), and specifically in the p53 heterozygous group (OR(age-adjusted) = 2.91; 95% CI = 1.12-7.56; P = 0.03). CONCLUSIONS: p53 and p21 act in series in mediating cell cycle arrest. However, the two risk factors, p53 proline homozygosity and p21 arginine allele, although part of a common causal pathway, appear to act in a mutually exclusive manner.     

Human papillomavirus testing as an optional screening tool in low-resource settings of Latin America: experience from the Latin American Screening study

Hybrid capture II (HC II) test for oncogenic human papillomaviruses (HPV) was carried out in a cohort of 4284 women at their first clinical visit. Overall prevalence of HPV was 17.1%, decreasing with age from 33.9% among women below 20 years to only 11.0% among those older than 41 years. HPV prevalence was significantly higher among current smokers (odds ratio [OR] = 1.31; 95% CI 1.1-1.6), in women with two or more lifetime sexual partners (OR = 1.9; 95% CI 1.6-2.4), and those women with two or more sexual partners during the past 12 months prior to examination (OR = 1.6; 95% CI 1.2-2.2). HPV detection increased in parallel with increasing cytologic abnormality, being highest in women with high-grade squamous intraepithelial lesion (P= 0.001). Specificity of the HPV test in detecting histologically confirmed cervical disease was 85% (95% CI 83.9-86.1). Sensitivity of the HPV test in detecting histologic abnormalities increased in parallel with disease severity, ranging from 51.5% for cervical intraepithelial neoplasia (CIN) 1 to 96.5% for CIN 3 and 100.0% for cancer, with respective decline of positive predictive value. These data suggest that HPV testing with HC II assay might be a viable screening tool among this population with relatively high prevalence of cervical disease.     

Factors predicting intermediate endpoints of cervical cancer and exposure to human papillomavirus (HPV) infections in young women screened as potential targets for prophylactic HPV vaccination in south of Brazil

OBJECTIVE: To explore the predictors of intermediate endpoints of cervical cancer in 500 women living in Porto Alegre. STUDY DESIGN: Five hundred randomly selected women (mean age 20.3 years, range 15-25) were screened using PCR detecting 25 HPV types (HPV6, 11, 16, 18, 31, 33, 34, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 66, 68, 70, and 74). Women were interviewed and serum samples were analysed for antibodies to HPV16 and HPV18 VLPs. Regression models were constructed to analyse predictive factors for (a) HPV PCR status, (b) HPV16-seropositivity, (c) HPV18-seropositivity, and (d) SIL in the PAP smear, used as intermediate endpoints of cervical cancer. RESULTS: Specific HPV types were identified in 137 (27.4%) of the 157 (31.4%) PCR-positive women. PAP test result was the most powerful independent predictor of HPV status in PCR (p = 0.0001), followed by the sexual activity started (p = 0.001) (adjusted OR 34.075, 95% CI: 4.650-249.715). PAP test SIL was independently predicted only by the HPV PCR status (p = 0.0001) (OR 7.561, 95% CI: 2.787-20.514). HPV16 and HPV18 serostatus were the most significant predictors of each other (p=0.0001), and the life-time number of sexual partners was more significant (p=0.001) predictor of HPV16 than HPV18 serostatus (p = 0.049). CONCLUSION: These data are useful in evaluating the exposure status of the women to the risk factors of cervical cancer in south of Brazil.     

Genetic polymorphisms of GSTM1, p21, p53 and HPV infection with cervical cancer in Korean women

OBJECTIVES: The aim of this study was to determine whether GSTM1 or GSTT1 might be associated with risk of cervical cancer development in Korean women. The multiplicative interaction of GSTM1 and GSTT1 genotype with p21, p53 polymorphism, and HPV genotype was also investigated. METHODS: From 1997 to 1999, uterine cervical carcinoma was diagnosed in 215 Korean women at the Department of Obstetrics and Gynecology of Seoul National University Hospital. None of the women in the control groups (n = 98) had any evidence of cervical lesions, which were confirmed by Pap smear. Finally, 81 cases and 86 controls were genotyped for p21, p53, and GSTM1 and T1 and HPV infection. A multiplex PCR method was used for the genotyping of GSTM1 and GSTT1; direct sequencing for p53 codon 72, high-risk HPV, and PCR-RFLP (BsmAI) for p21 codon. The unconditional logistic regression analysis was used to calculate ORs and 95% CI. RESULTS: Although the GSTM1 and GSTT1 genotype was not significantly associated with cervical cancer development for all women, the GSTM1 null genotype was significantly associated with an increased risk of cervical cancer development in women with high-risk HPV infection (OR = 2.9, 95% CI: 1.0-8.2). Although the frequency of overall GSTT1 null genotype was significantly lower in cervical carcinoma patients with high-risk HPV infection (OR = 0.3, 95% CI: 0.1-1.0), almost 2-fold increased risk was observed among women with GSTT1 null and Arg/Arg genotype (OR = 1.9, 95% CI: 0.7-5.4). Although the cervical cancer risk was 3.3-fold increased in women with null and Arg/Arg genotype compared to women with GSTM1 present and p21 Ser-containing genotype, there was no significant multiplicative interaction between GSTM1 and p21 (P for interaction = 0.785) or p53 (P for interaction = 0.815). CONCLUSIONS: These findings suggest that the risk of cervical cancer may be related to GSTM1 genotype in women with high-risk HPV infection and that there is a possible gene-gene interaction in the incidence of cervical cancer.     

Impact of prolonged referral interval on colposcopic outcomes in women with moderate or severe dysplasia

OBJECTIVE: To ascertain the impact of long referral to first colposcopy interval on disease outcome in women with high-grade cervical smear tests. METHODS: Data from 316 women categorized into Group 1 (seen 180 days after referral) and Group 2 (seen within 180 days of referral) were analyzed using chi2 test with Yates correction. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Women in Group 1 were less likely to need treatment (33.8% [25/74] vs 55.8% [135/242]; OR=0.45; 95% CI, 0.25-0.78; P=0.0004) and less likely to have high-grade disease (24.3% [18/74] vs 45.9% [111/242]); OR=0.37; 95% CI, 0.21-0.68; P=0.001) than women in Group 2. There was no significant difference between the groups in proportion of women with invasive disease. CONCLUSION: In women with high-grade smears the need for excisional treatment and the risk of invasive disease may be reduced by prolonged referral interval.     

Glucose challenge test: screening threshold for gestational diabetes mellitus and associated outcomes.

OBJECTIVE: To examine whether women with an 1-hour 50-g glucose challenge test (GCT) for gestational diabetes mellitus (GDM) between 120 and 140 mg/dL and >or=140 mg/dL are at risk of perinatal complications. STUDY DESIGN: A retrospective cohort study of women with singleton pregnancies screened for GDM between 1988 and 2001 with a 1-hour 50-g GCT. Values of GCT were stratified into four subgroups: <120, 120-129, 130-139, and >or=140 mg/dL. Perinatal outcomes were compared using the Chi-square test and multivariable logistic regression analysis. RESULTS: There were 13 901 women meeting the study criteria. Compared to women with a GCT of <120 mg/dL, women with a GCT of 130-139 mg/dL and >or=140 mg/dL were more likely to have preeclampsia and operative vaginal or cesarean deliveries. Neonates born to women with a GCT of 130-139 mg/dL also had higher odds of having a 5-minute Apgar score <7 (odds ratio (OR) = 1.51, 95% confidence interval (CI) 1.01-2.29), shoulder dystocia (OR = 2.02, 95% CI 1.16-2.55), birth trauma (OR = 1.47, 95% CI 1.06-2.02), and composite morbidity (OR = 1.25, 95% CI 1.03-1.51). Women with a GCT of >or=140 mg/dL had higher odds of macrosomia (OR = 1.32, 95% CI 1.13-1.54) and shoulder dystocia (OR = 1.68, 95% CI 1.11-2.55). CONCLUSION: Women with GCT results of 130-139 mg/dL appear to be at increased risk for perinatal morbidity. Thus, utilizing a diagnostic test in women with a GCT above 130 mg/dL should be considered.     

Postoophorectomy Estrogen Use and Breast Cancer Risk

OBJECTIVE:: To estimate whether the protective effect of premenopausal bilateral oophorectomy on breast cancer risk is mitigated by estrogen therapy use after surgery. METHODS:: In pooled data from four population-based case-control studies spanning 1992-2007, we examined estrogen use after total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) and subsequent breast cancer risk. We identified cases of postmenopausal invasive breast cancer in women (n=10,449) aged 50-79 years from three state tumor registries and age-matched control group participants without breast cancer (n=11,787) from driver's license and Medicare lists. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and estrogen use were queried during structured telephone interviews. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated with multivariable logistic regression. RESULTS:: Breast cancer risk comparisons were made relative to women who experienced natural menopause and never used hormones. Overall, breast cancer risk increased 14% among women currently using estrogens after TAHBSO (OR 1.14, 95% CI 1.03-1.28), 32% for estrogen durations less than 10 years (OR 1.32, 95% CI 1.11-1.57), and 22% for estrogen initiation within 5 years of TAHBSO (OR 1.22, 95% CI 1.09-1.37). Among women who underwent early TAHBSO (younger than 40 years), 24-30% decreases in breast cancer risk were observed among both never (OR 0.70, 95% CI 0.55-0.88) and current (OR 0.76, 95% CI 0.61-0.96) estrogen users. CONCLUSION:: Unopposed estrogen use does not negate the reduction in breast cancer risk associated with early (younger than 40 years) bilateral oophorectomy. However, initiating estrogen therapy after TAHBSO at ages 45 and older can increase breast cancer risk and should be considered carefully. LEVEL OF EVIDENCE:: II.     

The significance of peripartum fever in women undergoing vaginal deliveries

We investigated whether patients undergoing vaginal delivery who developed peripartum fever (PPF) had increased rates of other gestational complications. A retrospective study was undertaken comparing pregnancy complications of patients who developed PPF with those who did not. A multivariable logistic regression model was constructed to control for confounders. To avoid ascertainment bias, the year of birth was included in the model. Women who underwent cesarean delivery and those with multiple pregnancies were excluded from the study. During the study period, there were 169,738 singleton vaginal deliveries, and 0.4% of the women suffered from PPF. Hypertensive disorders, induction of labor, dystocia of labor in the second stage, suspected fetal distress, meconium-stained amniotic fluid, postpartum hemorrhage, manual lysis of a retained placenta, and revision of the uterine cavity and cervix were found to be independently associated with PPF by multivariable analysis. Year of birth was found to be a risk factor for fever. Apgar scores lower than 7 at 1 but not 5 minutes were significantly higher in the PPF group. Perinatal mortality rates were significantly higher among women with PPF (6.7% versus 1.3%, odds ratio [OR] = 5.4; 95% confidence interval [CI] 3.9 to 7.3; P < 0.001). Using another multivariable analysis, with perinatal mortality as the outcome variable, PPF was found as an independent risk factor for perinatal mortality (OR = 2.9; 95% CI 1.9 to 4.6; P < 0.001). PPF in women undergoing vaginal deliveries is associated with adverse perinatal outcomes and specifically is an independent risk factor for perinatal mortality.     

Impact of hormone replacement therapy on the histologic subtype of breast cancer

OBJECTIVE: Postmenopausal hormone replacement therapy (HRT) is associated with an increase in breast cancer risk, which correlates to the duration of HRT use. We wanted to investigate a possible association between HRT use and the risk of a histologic subtype of breast cancer. PATIENTS AND METHODS: From 1995 until 2004, 497 cases of primary ductal, lobular or ductulolobular breast cancer in postmenopausal women were diagnosed at the Department of Gynecology and Obstetrics, University Hospital Basel, Switzerland. The data was derived from patient's records. HRT ever use was defined as HRT use for > or =6 months. RESULTS: Of the 99 cases of lobular cancer 72.7% were invasive lobular cancers, 21.2% were invasive ductulolobular cancers and 6.1% were lobular cancers in situ. Of the 398 cases of ductal cancer, 90.5% were invasive ductal cancers and 9.5% were ductal cancers in situ. Totally 144 women were HRT ever users, and 341 women were HRT never users. HRT status could not be defined in 12 women. HRT ever use was associated with an increased risk for lobular cancer (OR 1.67; 95% CI 1.02-2.73). Also, menopause due to bilateral oophorectomy was associated with an increased risk for lobular cancer (OR 2.42; 95% CI 1.06-5.54). CONCLUSIONS: There is evidence that HRT as well as menopause due to bilateral oophorectomy may be associated with an increased risk for lobular cancer. This association is of major clinical relevance, since lobular breast cancer is more difficult to diagnose clinically and radiologically than ductal breast cancer.     

Racial/ethnic differences in perineal, vaginal and cervical lacerations

OBJECTIVE: To determine if variation exists between ethnicities for risk of perineal, vaginal, and cervical laceration at vaginal delivery. STUDY DESIGN: Retrospective cohort study of nulliparous women who underwent vaginal delivery of a vertex presentation. Predictor variable was ethnicity with outcome variables cervical, vaginal, and second-, third-, or fourth-degree perineal laceration. Logistic regression analysis was conducted to control for confounders. RESULTS: Of the 17,216 who met criteria, Filipino (OR = 1.92, 95% CI 1.64-2.25) and Chinese (OR = 1.60, 95% CI 1.33-1.92) women were at greatest risk for third- and fourth-degree laceration. Only Filipino (OR = 1.32, 95% CI 1.10-1.57) and other Asian (OR = 1.23, 95% CI 1.08-1.41) women were at slightly increased risk of vaginal laceration. No differences were seen for cervical laceration. CONCLUSION: Different ethnicities are at widely varying risk of perineal laceration, but little difference exists for vaginal or cervical lacerations. Research into the mechanisms behind this should investigate differences in perineal anatomy.     

A PCR study on the coexistence of herpes simplex virus, cytomegalovirus and human papillomavirus DNAs in cervical neoplasia

There is strong epidemiological and biological evidence that the development of squamous cell carcinoma of the cervix is a multistep process in which human papillomaviruses (HPVs) play a crucial but not total role and where the synergistic effect of herpes simplex virus (HSV) and human cytomegalovirus (HCMV) has been suggested. The presence of HPV, HSV and HCMV deoxyribonucleic acids (DNAs) was assessed by a polymerase chain reaction (PCR) in cervical biopsies obtained from 41 women with cervical neoplasia (21 high-grade cervical intra-epithelial neoplasia (CIN) and 20 squamous cell cancers) and 33 controls. Human papillomavirus 16 DNA was significantly more common in high-grade CIN (57%) and cancer (50%) than in normal cervix (9%). Herpes simplex virus and HCMV DNAs were present in 12% and 21% of normal cervices, 19% and 24% of high-grade CIN, and 25% and 25% of cancers, respectively. After adjustment for patients' age, coinfection associating high-risk HPVs (HPV 16 and/or HPV 18) and herpes viruses (HCMV and/or HSV) were observed in cervical neoplasia (odds ratio (OR) = 19.11; 95% confidence interval (CI): 2.14–170.36). Conversely, the OR for infection by HPV 16 and/or HPV 18 alone did not reach statistical significance (OR = 7.22; 95% CI: 0.85–61.16). Moreover infection by HCMV and/or HSV alone (OR = 0.89; 95% CI: 0.33–2.24) was not associated with cervical neoplasia. Our results support the role of HSV and HCMV as cofactors of HPV 16 and HPV 18 in cervical neoplasia.     

Knowledge of cervix cancer,human papilloma virus (HPV) and HPV vaccination at the moment of introduction of the vaccine in women in Belgium

Aim To test the knowledge of women, attending a gynecology clinic, on HPV, cervix cancer awareness and the knowledge and willingness to use HPV vaccine for themselves or their children. Setting Routine gynecological and obstetrical care with ambulatory service in a medium-sized general hospital in a small town in Belgium (Heilig Hart Hospital, Tienen). Methods Questionnaire to be filled out by 381 consecutive women while in the attendance room for consultation with one of the four gynecologists. Fisher T or Chi2 were used as statistical methods. Results Knowledge about HPV as a cause of cervix cancer and the existence of a vaccine was roughly 50%. Women with lower education were more likely to know nothing about the cause of cervix cancer than women with higher education (54 versus 39%, P = 0.016). Half of the women were willing to accept the vaccine, whatever the cost price, and 40% required more information or refunding. Compared to women above 40, young age (25 years or less) was a risk factor for poor knowledge of HPV (P = 0.007), cervix cancer (P = 0.016) and the HPV vaccine (P = 0.07), regardless of a higher degree of education (79% postgraduate degree versus 43.4% in the 40+-year-old women, P = 0.006). Women with a daughter (64.7%) or a son (69.2%) were more inclined to vaccinate their daughter than women without children (46.3%, P < 0.0001). None of the women declined the vaccination because it was meant to protect against a sexually transmitted disease (STD). Conclusion Upon introduction and marketing of the first HPV vaccine, only 50% of women attending a routine gynecology clinic were aware of the role of HPV in cervix cancer and the possibility of getting a vaccination against it. Unexpectedly, despite a high degree of education, young women seem to have a low awareness of cervix cancer, its cause and the preventive measures. Contrary to some women in the USA, Western European women are less likely to decline the HPV vaccine because it will protect them against STD. In Belgium, women who are childless or poorly educated and especially young women should be the targets of campaigns that motivate them to prevent HPV-induced cervix cancer.