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

Efficacy of a Triticum vulgare Extract as a Treatment of Cervical Ectropion: A Prospective Observational Cohort Study

OBJECTIVES

To assess the effectiveness of a topical treatment for cervical ectropion with vaginal ovules containing aqueous extract of Triticum vulgare .

METHODS

Prospective observational cohort study conducted between November 2020 and November 2022 at the colposcopy clinics of 2 different hospitals. Sexually active patients with a colposcopic diagnosis of cervical ectropion, awaiting ablative procedure, were included in the study and prescribed medical therapy with vaginal T. vulgare ovules (group 1) or wait-and-see therapy (group 2). At both enrollment and 2-month follow-up, a symptomatologic evaluation recording the intensity of postcoital bleeding, leucorrhea, and dyspareunia was performed with a Visual Analog Scale (VAS) questionnaire, and a colposcopic examination was performed, calculating the size of the ectropion area.

RESULTS

A total of 116 patients (58 in group 1 and 58 in group 2) were included. Topical treatment with vaginal ovules containing aqueous extract of T. vulgare for 2 months resulted in significant decrease of symptoms related to cervical ectropion and significant reduction of the size of the ectropion area.

CONCLUSIONS

Our results support the efficacy of topical treatment with vaginal ovules containing aqueous extract of T. vulgare for symptomatic cervical ectropion; our study also suggests that expectant management, despite being widely practiced, seems to lead to a worsening of the natural history of ectropion.

Colposcopic outcomes for symptomatic patients with a negative oncogenic human papillomavirus test

This study assesses outcomes of colposcopy referrals for post‐coital, intermenstrual, or other abnormal bleeding with negative oncogenic human papillomavirus and negative to low‐grade cytology. Of 112 cases with median age of 34.5 years, cervical biopsy occurred in 19%, treatment of ectropion in 19%, endometrial sampling in 8%, polypectomy in 4%, and contraceptive change in 2%. No cervical or endometrial neoplasia was detected. Patients with bleeding symptoms and reassuring co‐test may instead attend a general gynaecology clinic.

Recurrent post-coital bleeding: Should colposcopy still be mandatory?

BACKGROUND

Colposcopy has been recommended for all women with recurrent post-coital bleeding (PCB) even if their cervical cytology or co-test (involving oncogenic human papillomavirus (HPV) DNA testing and cytology) are negative.

AIMS

To determine the risk of cervical cancer and its precursors among women with recurrent PCB with negative cytology or co-test.

MATERIALS AND METHODS

A retrospective analysis of two cohorts of women with PCB referred to a tertiary colposcopy clinic. Cohort (1) (n = 1846) between 1 January 2000 and 31 December 2016 (cytology-based screening) and Cohort (2) (n = 215) from 1 January 2018 to 31 December 2019 after introduction of primary HPV screening.

RESULTS

In 1217 (65.9%) women in Cohort (1) referred with negative cytology, there was one cancer (0.08%) and 22 high-grade squamous intraepithelial lesions (HSIL (cervical intraepithelial neoplasia 2/3)) on histopathology. In Cohort (2), there was no cancer or HSIL in 83 women with negative co-tests (negative for oncogenic HPV and cytology). False-negative cytology after a negative referral cytology or co-test was low with 2% of repeat cytology at initial colposcopy showing possible HSIL or worse.

CONCLUSIONS

Women presenting with PCB and negative cytology alone have a low risk of cancer and could have HPV testing before being triaged to colposcopy. We showed that with the assurance of a negative co-test and the low likelihood of false-negative cytology, these women could avoid colposcopy unless cervical cancer is clinically suspected. There is a need for a larger cohort study to substantiate our findings with more precision.

Postcoital bleeding is a predictor for cervical dysplasia

Background

Postcoital bleeding (PCB) is a common gynecological symptom that may cause concern among both patients and physicians. Current literature is inconclusive regarding management recommendations.

Objective

To identify risk-factors for dysplasia/cancer among patients presenting post-coital bleeding (PCB).

Methods

Using large health maintenance organization (HMO) database, all women reporting PCB in 2012–2015 were identified. PCB patient records in a single colposcopy center were reviewed. Age, marital status, ethnicity, gravidity, parity, BMI, smoking, PAP smear result (within 1 year of PCB presentation), colposcopy and biopsy results were recorded. Cases were matched by age and socio-economic enumeration area to controls accessing primary care clinics for routine care.

Results

Yearly incidence of PCB ranged from 400 to 900 per 100,000 women; highest among patients aged 26–30 years. Among the sample of 411 PCB cases with colposcopy, 201 (48.9%) had directed biopsy. Biopsy results included 68 cervicitis (33.8%), 61 koilocytosis/CIN 1/condyloma (30.3%), 44 normal tissue (21.9%), 25 cervical polyp (12.4%), 2 CIN 2/3 (1%) and 1 carcinoma (0.5%). Positive predictive value for koilocytosis/CIN 1 or higher pathology was 15.6% (64/411) and 0.7% for CIN 2 or higher grade pathology (3/411). In conditional logistic regression, multiparty was a protective factor: OR 0.39 (95% CI 0.22–0.88, P = 0.02), while pathological PAP smear was a related risk-factor: OR 3.3 (95% CI 1.31–8.35, P = 0.01). When compared to controls, PCB patients were significantly (P = 0.04) more likely to present CIN 1 or higher grade pathology (OR 1.82, 95% CI 1.02–3.33).

Conclusions

Study results indicate that PCB may require colposcopy, especially for nulliparous women with an abnormal PAP smear.

ASCCP Colposcopy Standards: Role of Colposcopy, Benefits, Potential Harms, and Terminology for Colposcopic Practice

OBJECTIVES

The American Society for Colposcopy and Cervical Pathology Colposcopy Standards address the role of and approach to colposcopy and biopsy for cervical cancer prevention in the United States. Working Group 1 was tasked with defining the role of colposcopy, describing benefits and potential harms, and developing an official terminology.

METHODS

A systematic literature review was performed. A national survey of American Society for Colposcopy and Cervical Pathology members provided input on current terminology use. The 2011 International Federation for Cervical Pathology and Colposcopy terminology was used as a template and modified to fit colposcopic practice in the United States. For areas without data, expert consensus guided the recommendation. Draft recommendations were posted online for public comment and presented at an open session of the 2017 International Federation for Cervical Pathology and Colposcopy World Congress for further comment. All comments were considered for the final version.

RESULTS

Colposcopy is used in the evaluation of abnormal or inconclusive cervical cancer screening tests. Colposcopy aids the identification of cervical precancers that can be treated, and it allows for conservative management of abnormalities unlikely to progress. The potential harms of colposcopy include pain, psychological distress, and adverse effects of the procedure. A comprehensive colposcopy examination should include documentation of cervix visibility, squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), lesion(s) visibility, size and location of lesions, vascular changes, other features of lesion(s), and colposcopic impression. Minimum criteria for reporting include squamocolumnar junction visibility, presence of acetowhitening, presence of a lesion(s), and colposcopic impression.

CONCLUSIONS

A recommended terminology for use in US colposcopic practice was developed, with comprehensive and minimal criteria for reporting.

Follow-up of Women With Negative Pap Test Results and Abnormal Clinical Signs or Symptoms

OBJECTIVES

Abnormal signs or symptoms recorded on Papanicolaou (Pap) test requisitions may reflect disease not detected with Pap testing. Since 2009, these cases have been reviewed in our laboratory by a second cytotechnologist and a cytopathologist. The objective of this study was to document follow-up findings on these patients.

METHODS

A search for Pap test results of "Negative for intraepithelial lesion or malignancy, abnormal clinical signs or symptoms" was performed for cases from January 1, 2009, to October 10, 2013. Clinical information and follow-up findings were documented.

RESULTS

1,104 cases were identified. Signs and symptoms were abnormal bleeding 897 (81%), polyps 83 (8%), pelvic mass 54 (5%), visible cervical lesions 48 (4%), vaginal lesions 17 (2%) and endometrial masses 6 (0.5%). Six hundred sixty-seven (60%) had follow-up results, including 517 with histopathologic diagnoses. Two-hundred thirty-three (45%) had nonspecific benign diagnoses, 216 (42%) had benign tumor-like conditions, 28 (4%) had insufficient specimens, 16 (3%) had precancerous diagnoses and 23 (4%) had malignancies. Endometrial malignancy was identified in 14 (61%), ovarian in 6 (26%), and miscellaneous in 3 (13%). No cervical cancers were identified.

CONCLUSIONS

We report follow-up findings from patients with abnormal clinical signs or symptoms, negative Pap test results, and follow-up recommendations highlighting reported abnormal signs or symptoms. Abnormal clinical signs and symptoms should routinely be considered in assessment and management of patients with negative cervical screening test results.

Is Cryotherapy Friend or Foe for Symptomatic Cervical Ectopy?

OBJECTIVE

To evaluate the success rates and clinical outcomes of cervical cryotherapy applied to cervical ectopy for symptomatic relief.

SUBJECTS AND METHODS

A total of 124 women who underwent cryotherapy for symptomatic treatment of cervical ectopy were included in this study. Indications for treatment were: abundant leucorrhoea (n = 114), post-coital bleeding (n = 22), recurrent cervicitis (n = 30) and pelvic pain (n = 12). Cryotherapy consisted of the use of carbon dioxide at -89°C to destroy the ectopic columnar epithelium by freezing, and it was transmitted to the ectopy through a flat cryoprobe. No routine anaesthesia or analgesia was administered. All patients were questioned about the status of their symptoms after 6 weeks of treatment.

RESULTS

The highest success rate was obtained in patients with abundant leucorrhoea (n = 102; 89.5%), while the lowest success rate was achieved in subjects with pelvic pain (n = 7; 58%). After treatment, no severe complications were observed, except for hydrorrhoea for a few days. Success rates were 9 times lower in patients who had 3 or more cervicitis episodes per 6 months.

CONCLUSION

In this study, the success rate of cryotherapy was highest in patients with abundant leucorrhoea and lowest in patients with pelvic pain and recurrent cervicitis. Hence, we recommend that clinicians perform the procedure in such patients without much delay.

Is colposcopic evaluation necessary in all women with postcoital bleeding?

OBJECTIVE

To evaluate what extent postcoital bleeding (PCB) is an indicator of cervical cancer (CIN2 (+)).

METHODS

This is a retrospective cohort study. Between 2007 and 2013, amongst all referred patients, a total of 1491 consecutive women who had both conventional cytology and cervical biopsy were enrolled in the study. Of those 237 women have PCB, according to biopsy results, subjects were divided into two groups: CIN1 (-) and CIN2 (+). Multiple logistic regressions was used to construct a model to predict the occurrence of CIN 2 (+) based on age, menopause, marriage status, smoking, PCB, HPV and cytology.

RESULTS

Among the all women with CIN 2 (+) colposcopy guided biopsy result, PCB was 13.1% (53/406). The relationship between biopsy results and age, parity, menopausal status, marital status, smoking, presence of PCB, HPV DNA, and cytology is statistically significant (p=0.012, p=0.001, p=0.023, 0.013, p>0.001, p=0.038, p<0.001, p<0.001, respectively). According to regression analysis only smoking, HPV (+) and abnormal cytology increase the probability of CIN2 (+); 1.687 times (p=0.018), 4.065 times (p<0.001), 5.787 times (p=0.001) respectively. Having PCB only does not indicate an increased risk of CIN2 (+).

CONCLUSION

Colposcopic examination and biopsy should be performed only in the situation where women have PCB and any of the following: smoking, positive HPV, or abnormal cytology.

Abnormal cervical appearance: what to do, when to worry?

Many clinicians encounter cervical lesions that may or may not be associated with cytologic abnormalities. Such abnormalities as ectropion, Nabothian cysts, and small cervical polyps are quite benign and need not generate concern for patient or clinician, whereas others, including those associated with a history of exposure to diethylstilbestrol, cervical inflammation, abnormal cervical cytology, and postcoital bleeding, should prompt additional evaluation. Further, in some patients, the cervix may be difficult to visualize. Several useful clinical suggestions for the optimal examination of the cervix are presented.

Managing women with post-coital bleeding: a prospective observational non-comparative study

The management of post-coital bleeding (PCB) is inconsistent in the UK and there are no guidelines to ensure good practice. This prospective study was conducted to review the management and identify the diagnostic outcome of 137 women treated according to a locally devised protocol based on the best available evidence. Women underwent smear testing, taking triple swabs and colposcopy. The endometrium was investigated in postmenopausal women and in those aged >35 years with associated intermenstrual bleeding. Of those who had PCB for >4 weeks, only 8/124 (6.5%) were referred urgently. Twenty eight (20.4%) women were found to have significant pathology; 14 (50%) were <35 years of age, 26 (92.8%) had PCB for >4 weeks, whereas seven (25 %) suffered severe episodes, suggesting that the duration, but not age or severity, is relevant. A large multi-centre study is needed to provide more information in order to optimise the management.

Prevalence of human papillomavirus genotypes, and mucosal IgA anti-viral responses in women with cervical ectopy

BACKGROUND

Data on the prevalence of different human papillomavirus (HPV) genotypes and the associated mucosal immune response in women with cervical ectopy are scarce.

OBJECTIVE

To assess the prevalence of different HPV genotypes and the mucosal anti-viral immune response in cervical ectopy.

STUDY DESIGN

Detection and typing of HPV DNA was determined in 141 women with cervical ectopy, 272 cytologically normal controls and 98 low-grade squamous intraepithelial lesions (LSIL) by PCR and direct sequencing. Mucosal IgA antibodies to HPV16 and HPV18 were evaluated in cervical mucus by ELISA.

RESULTS

The prevalence of HPV in cervical ectopy was higher (73.7%) than that observed in control samples (30.5% in endocervix, and 1.8% in exocervix), but similar to the prevalence in LSIL (62.2%). Typing showed that the overall distribution frequency concerned 14 different genotypes, with HPV18 being the most prevalent in cervical ectopy (53.9%), whereas HPV16 predominated in LSIL (38.7%). High-risk HPV genotypes were 2.2 times more frequent in cervical ectopy than in the normal endocervix (p<0.0001). HPV infection in cervical ectopy patients was accompanied by a mucosal IgA-antibody response. Antibody reactivity to HPV18 was significantly higher than the response to HPV16.

CONCLUSION

Cervical ectopy is a risk factor for infection with high-risk HPV genotypes, in particular HPV18. Our results emphasize the need of further studies to clarify the oncogenic potential of this virus in cervical ectopy.

Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom

OBJECTIVES

To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

STUDY DESIGN

A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

RESULTS

Six hundred and fourteen (60%) replies were received. Three hundred and thirty-seven (59.8%) of the respondents agree that PCB is a significant clinical issue that requires developing national guidelines for management, 452 (80.1%) do not have local guidelines in their departments, 336 (59.6%) agree with The Department of Health guidelines for referral. Two hundred and eighty-one (49.8%) respondents see women in gynaecology clinic, 94 (16.7%) in colposcopy clinic, while 163 (28.9%) see them in either clinics depending on the workload. Only 275 (48.8%) respondents repeat the cervical smear for those with negative smear history who are still within the national screening interval. Chlamydia testing is performed by 450 (79.8%) respondents, whereas 68 (12.1%) consider investigating the endometrium in selected cases.

CONCLUSION

The results highlight the wide variations in managing women with PCB. Given the well-reported association with serious pathology, it may be prudent to standardise the management in the UK based on the best available evidence.

Evaluation of women presenting with postcoital bleeding by cytology and colposcopy

OBJECTIVE

To evaluate women with postcoital bleeding (PCB) by clinical examination, cytology, colposcopy, and histopathology.

METHODS

A cross-sectional study of 123 women with PCB, who were referred to the Colposcopy Clinic of Arash Hospital, Tehran, over a 2-year period.

RESULTS

Clinical examinations revealed cervical polyps in 18 women and ectropion in 14. Cervical cytology identified 13 patients with atypical squamous cells of undetermined significance, 2 with atypical glandular cells, 4 with low-grade squamous intraepithelial lesions, and 3 with high-grade squamous intraepithelial lesions. Colposcopy indicated invasive cancer in 1 patient. Transitional zones appeared normal in 39.8% of the cohort, were atypical grade 1 in 33.3%, and atypical grade 2 in 4.9%. Fourteen abnormalities were detected at histology, including 1 squamous cell carcinoma, 1 low-grade glandular neoplasm, 9 cervical intraepithelial neoplasia (CIN) grade 1, 2 CIN grade 2, and 1 CIN grade 3. The sensitivity and specificity of cytology were 50% and 86.5%, respectively. A total of 21.4% of abnormal pathologies were missed using colposcopy, which had a sensitivity of 79%.

CONCLUSION

Because of its higher sensitivity, colposcopy can be recommended for the investigation of persistent PCB, even in the presence of normal cytology.