Barrier methods of contraception and the risk of cervical neoplasia

The Correlation of Papanicolaou Smears and Clinical Features to Identify the Common Risk Factors for Cervical Cancer: A Retrospective and Descriptive Study from a Tertiary Care Hospital in Trinidad

Background: Cervical cancer, the fourth most frequent cancer in women, is associated with the human papillomavirus (HPV). This study identifies risk factors and clinical findings for abnormal cervical cytology and histopathology in the Trinidad and Tobago populations. Some risk factors include early age of first coitus, a high number of sexual partners, high parity, smoking, and using certain medications, such as oral contraception. This study aims to identify the significance of Papanicolaou (pap) smears and the common risk factors that contribute to the development of premalignant and malignant cervical lesions. Method: A three-year retrospective, descriptive study of cervical cancer was conducted at the Eric Williams Medical Sciences Complex. The subject population included 215 female patients aged 18 years and older with the following documented abnormal cervical cytology: (ASCUS), ASC-H, LSIL, HSIL, Atypical Glandular cells, HPV, Adenocarcinoma, and Invasive Squamous Cell Carcinoma. Histopathology records were analysed for thirty-three of these patients. Patients’ information was recorded on data collection sheets adapted from the North Central Regional Health Authority’s cytology laboratory standardised reporting format request form. Results and Findings: The data were analysed via Statistical Package for Social Sciences (SPSS) software edition 23 using frequency tables and descriptive analysis. The mean sample age of the population was 36.7 years, the first age of coitus was 18.1 years, the number of sexual partners was 3.8, and the number of live births was 2. LSIL was the most popular abnormal finding, 32.6%, followed by HSIL, 28.8%, and ASCUS, 27.4%. Most histopathological reports resulted in CIN I and II. Conclusions: The significant risk factors observed for cytology abnormalities and premalignant lesions were early age of coitus, a high number of sexual partners, and no use of contraception. Patients mostly presented as asymptomatic despite obtaining abnormal cytology results. Hence, regular pap smear screening should continue to be highly encouraged.

Condom and oral contraceptive use and risk of cervical intraepithelial neoplasia in Australian women

Objective

To assess the association between condom use and oral contraceptive consumption and the risk of cervical intraepithelial neoplasia (CIN).

Methods

A cross-sectional study was conducted in Perth clinics. A total of 348 women responded to the structured questionnaire. Information sought included demographic and lifestyle characteristics such as the use of condom for contraception, consumption of oral contraceptive, and duration of oral contraceptive usage. Crude and adjusted odds ratio (OR) and associated 95% confidence interval (CI) were calculated using unconditional logistic regression models and reported as estimates of the relative risk.

Results

The prevalence of CIN was found to be 15.8%. The duration of oral contraceptive consumption among women with abnormal Papanicolaou (Pap) smear result indicating CIN was significantly shorter than those without abnormal Pap smear result (mean±SD, 5.6±5.2 years vs. 8.2±7.6 years; p=0.002). Comparing to ≤3 years usage, prolonged consumption of oral contraceptive for ≥10 years reduced the risk of CIN (p=0.012). However, use of condom for contraception might not be associated with a reduced risk of CIN after accounting for the effects of confounding factors (adjusted OR, 0.52; 95% CI, 0.05 to 5.11; p=0.577).

Conclusion

Use of oral contraceptives, but not condoms, for contraception appeared to be inversely associated with CIN. Prolonged use of oral contraceptive demonstrated its benefits of reducing the risk of CIN.

Effect of diaphragm and lubricant gel provision on human papillomavirus infection among women provided with condoms: a randomized controlled trial

OBJECTIVE

To estimate the effect of providing women with a latex diaphragm, lubricant gel, and male condoms (intervention) compared with condoms alone (control) on human papillomavirus (HPV) incidence and clearance.

METHODS

Participants were 2,040 human immunodeficiency virus (HIV)-negative Zimbabwean women enrolled in a randomized trial estimating the effect of the intervention on HIV acquisition. Clinicians collected cervical samples for HPV testing at baseline, 12 months, and exit. L1 consensus polymerase chain reaction primers were used to determine HPV presence and type.

RESULTS

We found no differences in the following outcomes: HPV prevalence at the time of the first postenrollment HPV test (intention-to-treat analysis, relative risk [RR] 1.02, 95% confidence interval [CI] 0.90-1.16); HPV incidence at 12 months among women HPV-negative at baseline (RR 0.95, 95% CI 0.80-1.14); and HPV clearance at 12 months among women HPV-positive at baseline (RR 0.80, 95% CI 0.61-1.05). Clearance of HPV type 58 was lower in the intervention group at 12 months (RR 0.67, 95% CI 0.48-0.92), but not at exit (RR 0.93, 95% CI 0.75-1.16); clearance of HPV type 18 was lower in the intervention group at exit (RR 0.55, 95% CI 0.33-0.89), but not at 12 months (RR 0.55, 95% CI 0.29-1.05). Women reporting diaphragm/gel use at 100% of prior sex acts had a lower likelihood of having one or more new HPV types detected at 12 months (RR 0.75, 95% CI 0.58-0.96) and exit (RR 0.77, 95% CI 0.59-0.99).

CONCLUSION

Among women receiving risk reduction counseling and condoms in an HIV prevention program, diaphragm plus lubricant gel provision did not affect HPV incidence or clearance.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00121459

LEVEL OF EVIDENCE

I.

Effect of Replens Gel Used with a Diaphragm on Tests for Human Papillomavirus and Other Lower Genital Tract Infections

OBJECTIVE

Little is known about effects of vaginal lubricants with barrier contraceptives on detection of sexually transmissible infections. We hypothesized that Replens gel used with a diaphragm would neither inhibit human papillomavirus (HPV) detection in cervical samples and chlamydia (CT) and gonorrhea (GC) detection in urine samples, nor affect cervical cytology quality.

MATERIALS AND METHODS

After a clinician-collected cervical sample and a self-collected vaginal sample for HPV detection ("pregel" specimens), women placed a diaphragm containing Replens gel into the vagina. Participants (n = 77) removed the diaphragm after 6 hours and performed vaginal HPV self-sampling at several time points thereafter. Clinicians performed cervical cytology sampling and HPV testing ("postgel" specimens) 24 hours after diaphragm removal. Pregel and postgel specimens were analyzed with and without added SiHa cells (source of defined numbers of HPV16 genomes). HPV was detected by polymerase chain reaction using MY09/11 primers. Urine samples were obtained for CT and GC testing. Proportions of samples testing positive were compared using relative risk (RR) regression models.

RESULTS

Proportions with detectable HPV in the clinician-collected cervical pregel and postgel samples were not statistically different for samples with added SiHa cells (88.3% vs 93.2%, RR = 1.06, 95% confidence interval = 0.96-1.14) or for native HPV infection (32.9% vs 28.2%, RR = 0.87, 95% confidence interval = 0.71-1.06). In self-collected vaginal postgel samples, there was no trend for decreased HPV detection after gel exposure. Gel affected neither urine tests for CT and GC nor cytological quality.

CONCLUSIONS

Recent Replens gel use with a diaphragm does not inhibit cervical HPV testing, urine testing for CT and GC, or cervical cytology quality.

Primary prevention of human papillomavirus-dependent neoplasia: No condom, no sex

Cervix cancer is one of several neoplastic disorders that arise following transfer of human papillomavirus (HPV) during unprotected sexual intercourse, and like most other sexually transmitted diseases (STDs), is largely preventable by consistent condom use. This primary prevention strategy has received little support, however, when compared with massive secondary prevention initiatives involving cervical screening. The reasons for this anomalous situation are complex, and include: (i) the asymptomatic nature of most primary HPV infections; (ii) widespread ignorance concerning the venereal aetiology of HPV-related cancers; (iii) the common but incorrect belief that condom use does not reduce HPV transmission; (iv) the perceived irrelevance of safe sex campaigns based on reducing transmission of human immunodeficiency virus (HIV) in high-HPV but low-HIV countries such as the Philippines; (v) the promotion of oral contraception by the medical and pharmaceutical sectors as the sexual prophylaxis of choice; and (vi) the assumption that HPV vaccines will solve the problem. Here it is proposed that the high prevalence of non-HIV STDs, including distressing disorders such as genital warts and herpes simplex, can be exploited with greater efficacy as a public health deterrent to unsafe sex and HPV transmission. Targeting a "mutually assured infection" campaign at vulnerable subgroups such as teenagers and oral contraceptive users could help reverse the global expansion of HPV-related cancers.

Contraception during perimenopause

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.

Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic

BACKGROUND AND OBJECTIVES

Human papillomavirus (HPV) is the primary cause of cervical, anal, and other anogenital cancers, but risk factors for penile HPV detection in men have not been well-characterized.

GOAL

The goal of this study was to identify correlates of penile HPV detection in ethnically diverse men attending a sexually transmitted disease clinic.

STUDY

A cross-sectional investigation was conducted among 393 men. Participants completed a risk-factor questionnaire and underwent testing for penile HPV DNA. Presence of HPV DNA was assessed using polymerase chain reaction with PGMY primers and reverse line blot genotyping. Logistic regression analyses were conducted to identify variables associated with any-type, oncogenic, and nononcogenic HPV.

RESULTS

Circumcision was associated with reduced risk for oncogenic, nononcogenic, and overall HPV. Regular condom use was associated with reduced risk for oncogenic and overall HPV.

CONCLUSION

These findings, if confirmed by other studies, could impact public health practices and messages regarding HPV.

Costs and net health effects of contraceptive methods

BACKGROUND

Pregnancy and contraceptive methods both have important health effects that include risks and benefits. The net impact of contraception on women's health has not been reported previously.

STUDY DESIGN

This is a cost-utility analysis using a Markov model evaluated by Monte Carlo simulation using the societal perspective for costs. The analysis compared 13 methods of contraception to nonuse of contraception with respect to healthcare costs and quality-adjusted life years (QALYs). Discounting was applied for future costs and health effects. The base-case analysis applies to women of average health and fertility, ranging from 15 to 50 years of age, who are sexually active in a mutually monogamous relationship; smoking rates observed in women of reproductive age were used. Sensitivity analysis extended the analysis to nonmonogamous status and smoking status.

RESULTS

Compared with use of no contraception, contraceptive methods of all types result in substantial cost savings over 2 years, ranging from US$5907 per woman for tubal sterilization to US$9936 for vasectomy and health gains ranging from 0.088 QALYs for diaphragm to 0.147 QALYs for depot medroxyprogesterone acetate. Compared with nonuse, even with a time horizon as short as 1 year, use of any method other than sterilization results in financial savings and health gains. Most of the financial savings and health gains were due to contraceptive effects. In a population of patients, even modest increases in the use of the most effective methods result in financial savings and health gains.

CONCLUSIONS

Every method of contraception dominates nonuse in most clinical settings. Increasing the use of more effective methods even modestly at the expense of less effective methods will improve health and reduce costs. Methods that require action by the user less frequently than daily are both less costly and more effective than methods requiring action on a daily basis.

Comparison of Sexually Transmitted Disease Prevalence by Reported Level of Condom Use Among Patients Attending an Urban Sexually Transmitted Disease Clinic

BACKGROUND

There is controversy as to the protective effect of condoms in preventing various sexually transmitted diseases (STDs).

GOAL

The goal of this study was to assess the association of various levels of condom use with a variety of STD.

STUDY DESIGN

We conducted a cross-sectional study of female and heterosexual male visits to an urban STD clinic between 1990 and 2001.

METHODS

Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, recent-onset genital warts, first-episode herpes, and molluscum contagiosum by reported level of condom use over the past 4 months, with adjusted odds ratios (AOR) calculated by logistic regression.

RESULTS

Among 126,220 patient visits (39% women and 61% men), condom use over the past 4 months was reported by 54%, with 38% reporting inconsistent use and 16% consistent use. Condom users reported greater sexual risk in the past 4 months than nonusers (ie, new sex partners: 63% vs. 41%, P <0.001; multiple sex partners: 60% vs. 36%, P <0.001). When all condom users were compared with nonusers, there was limited evidence of protection against specific STD. However, when the analysis was restricted to condom users, infection rates were significantly lower in consistent than inconsistent users for both men and women for gonorrhea (AOR, 0.87 and 0.71, respectfully) and chlamydia (AOR, 0.66 and 0.74, respectfully), for trichomonas in women (AOR, 0.87), and for genital herpes in men (AOR, 0.73).

CONCLUSIONS

Comparisons of STD between condom users and nonusers are confounded by greater sexual risk in users. Comparing consistent with inconsistent users reduces this confounding, revealing protection for both men and women for nonviral STD and for genital herpes for men.

Sexual relationships, condom use, and concerns about pregnancy, HIV/AIDS, and other sexually transmitted diseases

As we move further into the 21st century, there are increasing numbers of teenagers and young adults infected with sexually transmitted diseases and acquired immunodeficiency syndrome. Aside from sexual abstinence, condom use is the best way to protect oneself from sexually transmitted diseases, including human immunodeficiency virus/acquired immunodeficiency syndrome. Participants in this study were predominantly female, predominantly Caucasian psychology students who experienced sexual intercourse with an opposite sex partner in the past year. Slightly fewer than half of these participants reported condom use at their last episode of vaginal intercourse and type of partner did not affect their condom use, nor did concern about human immunodeficiency virus/acquired immunodeficiency syndrome and sexually transmitted diseases. Findings such as these challenge advanced practice nurses to generate innovative strategies to promote condom use in all types of relationships. We propose that teaching about the link between cervical cancer and lack of condom use could be one of these new strategies.

Strategies for HPV prevention

The HPV types that cause cervical cancer are sexually transmitted, but there is little evidence that infection can be avoided by behavioral change, such as condom use. In contrast, prophylactic vaccines against HPV infection are likely to have high efficacy. In principle, the effectiveness of HPV vaccination as a strategy for cervical cancer control can be measured either by monitoring secular trends in cervical cancer incidence or by conducting randomized trials. The former approach is unlikely to provide convincing evidence of effectiveness, since cervical cancer rates are subject to strong secular trends that are independent of intervention measures. A few phase III trials of HPV prophylactic vaccines are being started. Such trials are very expensive studies involving frequent and complicated investigations. It is important, however, to start as soon as possible simpler trials which may demonstrate the effectiveness of HPV vaccine in field conditions, i.e. in developing countries which do not have the resources to mount effective cytology-based screening programs, yet suffer the major burden of mortality from cervical cancer. Such trials may capture a difference in the most severe, and rarest, preinvasive cervical lesions. The design of such studies is briefly considered for two areas: Southern India and South Korea. Finally, projections of the number of cases of cervical cancer following the introduction of mass vaccination are given for developed and developing countries.

Hormonal and barrier methods of contraception, oncogenic human papillomaviruses, and cervical squamous intraepithelial lesion development

We assessed the influence of hormonal (oral, injectable, or levonorgestrel [Norplant, Wyeth-Ayerst, Philadelphia, PA]) and barrier methods of contraception on the risk of cervical squamous intraepithelial lesions (SIL), while adjusting for high-risk (HR) HPV infection. Subjects were women receiving family planning services through the state health department clinics from 1995 to 1998. We selected 60 cases with high-grade cervical/SIL (HSIL) and 316 with low-grade cervical/SIL (LSIL) and controls (427 women with normal cervical cytology) and analyzed cervical DNA for HR-HPV, using Hybrid Capture I (Digene; Gaithersburg, MD). When assessing ever use, duration, recency, latency, and age at first use, neither oral contraceptives (OC), Norplant, nor injectable use was associated with an increased risk of SIL development after adjusting for age, age at first sexual intercourse, and HR-HPV positivity. Among HR-HPV-positive women, longer duration barrier method use was associated with a reduced risk of SIL. This finding has important clinical implications for SIL prevention among HR-HPV-infected women.

Oral contraceptives and cervical cancer--further findings from the Oxford Family Planning Association contraceptive study

In 1983, we reported results from the Oxford Family Planning Association contraceptive study regarding the association between oral contraceptives (OCs) and cervical neoplasia, after a 10 year follow-up of a cohort of 17,000 women. Further findings from this study are reported here after an additional 12 years of follow-up. A nested case--control design was used in which cases were all women diagnosed under 45 years of age with invasive carcinoma (n = 33), carcinoma in situ (n = 121) or dysplasia (n = 159). Controls were randomly selected from among cohort members and matched to cases on exact year of birth and clinic attended at recruitment to study. Conditional logistic regression analysis was used to determine odds ratios (ORs) and 95% confidence intervals (CIs) associated with various aspects of OC use relative to never users adjusted for social class, smoking, age at first birth and ever use of diaphragm or condom. Ever users of OCs had a slightly elevated OR for all types of cervical neoplasia combined (OR = 1.40, 95% CI 1.00-1.96). Odds ratios were highest for invasive carcinoma (OR = 4.44, 95% CI 1.04-31.6), intermediate for carcinoma in situ (OR = 1.73, 95% CI 1.00-3.00) and lowest for dysplasia (OR = 1.07, 95% CI 0.69-1.66). The elevated risk associated with OC use appeared to be largely confined to current or recent (last use in the past 2 years) long-term users of OCs. Among current or recent users, ORs for all types of cervical neoplasia combined were 3.34 (95% CI 1.96-5.67) for 49-72 months of use, 1.69 (95% CI 0.97-2.95) for 73-96 months and 2.04 (95% CI 1.34-3.11) for 97 or more months. These results suggest a possible effect of OC use on later stages of cervical carcinogenesis, although residual confounding due to sexual factors or human papillomavirus (HPV) infection cannot be ruled out.

Primary prevention of gynecologic cancers

A shift from treatment to prevention of the three major gynecologic cancers is overdue. The traditional approach to cervical, endometrial, and ovarian cancers has been secondary or tertiary prevention--early detection and treatment or mitigation of damage, respectively. We reviewed the literature on these cancers to identify strategies for primary prevention. Cervical cancer behaves as a sexually transmitted disease. As with other such diseases, barrier and spermicidal contraceptives lower the risk of cervical cancer; the risk reduction approximates 50%. Combination oral contraceptives help prevent both endometrial and epithelial ovarian cancers. The risk of endometrial cancer among former oral contraceptive users is reduced by about 50% and that of ovarian cancer by about 30% to 60%. Weight control confers strong protection against endometrial cancer. Breast-feeding and tubal sterilization also appear to protect against ovarian cancer. Although women have a range of practical, effective measures available to reduce their risk of these cancers, few are aware of them. Without this information, women cannot make fully informed decisions about their health.

Pap smear screening for adolescents: rationale, technique, and follow-up

Cervical cytologic abnormalities are increasingly prevalent in teenagers. Adolescents are at greater risk for cervical neoplasia than adult women because of the biologic changes occurring in the cervix during puberty, the prevalence of human papillomavirus, and the behavioral risk factors in this age group. Two behavioral risk factors are early age at first coitus and multiple sex partners. Human papillomavirus is widely believed to be the etiologic agent associated with the spectrum of cervical neoplasias. Papanicolaou smear technique, reporting, and management of abnormal smears in teens is explained.

Abnormal cervical cytology in adolescents: a literature review

This article reviews the literature on the subject of cervical cytological abnormalities in teenagers, defined as a Papanicolaou (Pap) smear result more severe than inflammation. There is discussion of the increasing prevalence of this problem in adolescents. Behavioral and biologic risk factors are examined. The role of the human papillomavirus, widely believed to be the etiologic agent, is addressed. Atypia, its relationship to cervical malignancies, and its management are reviewed. The possible role of the human immunodeficiency virus in the increasing prevalence of cytological abnormalities in teens is considered.

Risk factors for cervical intraepithelial neoplasia

To evaluate risk factors for cervical intraepithelial neoplasia (CIN), data were collected in a case-control study based on 366 patients (58 with CIN class 1, 70 with CIN class 2, and 238 with CIN class 3) and 323 control subjects with normal cervical smears interviewed on selected days at the same screening clinics where cases had been identified. No relationship emerged between indicators of socioeconomic status (education and social class) and risk of mild/moderate (considered together) and severe dysplasia. A total of 55 (43%) patients with CIN class 1 or 2, 107 (45%) patients with CIN class 3, and 94 (29%) controls were current smokers. The corresponding relative risk (RR) estimates for current versus never smokers were 1.9 (95% confidence interval [CI] 1.2 to 3.0) for patients with CIN class 1 or 2 and 2.5 (95% CI 1.7 to 3.6) for patients with CIN class 3, and the risk increased with the number of cigarettes smoked per day. No relationship was observed between oral contraceptive use, parity, spontaneous or induced abortions and the risk of CIN, but patients tended to report earlier age at first birth than control subjects. Compared with women reporting their first birth before the age of 20 years, the risk estimates were 0.5 and 0.4, respectively, for patients with CIN 1 or 2 and patients with CIN 3 in women reporting first birth at 20 to 24 years of age. The risk estimates were 0.5 and 0.6 for those reporting their first birth at age 25 or later, but the trends in risk were not statistically significant. The number of sexual partners was directly associated with the risk for both histopathologic subgroups. Compared with women reporting no intercourse or their first intercourse after 22 years of age, women with first intercourse before the age 18 had a RR estimate of CIN class 1 or 2 of 2.3 and of CIN class 3 of 2.4, with the trends in risk being statistically significant. This study confirms considerable similarities in the epidemiology of mild/moderate and severe cervical dysplasia. In addition, it suggests consistency between the epidemiology of intraepithelial and invasive cervical neoplasia for risk factors that are likely to act on one of the first stages of the process of carcinogenesis (i.e., indications of sexual habits) but differences for hormone-mediated factors (i.e., reproductive variables or oral contraceptives).

Cervical cancer and methods of contraception

When evaluating whether the use of a particular method of contraception is associated with an increased or decreased risk of cervical cancer, it is important to be aware of the epidemiological factors which might lead to incorrect conclusions. After careful consideration of the issues, and examination of the available data, it is concluded that women who use oral contraceptives are possibly at increased risk of invasive cervical cancer; users of barrier methods probably have a decreased risk (although the protective effect may differ between the various types of barrier method); and that users of other methods of contraception do not have an altered risk.