Computerized planimetry versus clinical assessment for the measurement of cervical ectopia

Risk-based screening to identify reproductive tract infection among HIV-infected women desiring use of intrauterine contraceptives

BACKGROUND

Reproductive tract infections (RTIs) are a major cause of morbidity and mortality, yet RTI testing remains limited in resource-constrained settings. We assessed performance of an existing RTI risk assessment screening tool among women living with HIV (WLHIV) considering intrauterine contraceptive (IUC) use.

METHODS

We conducted a cross-sectional analysis among WLHIV screened for participation in an IUC trial in Cape Town, South Africa (NCT01721798). RTI testing included Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and bacterial vaginosis. Tool scoring was based on five separately scored criteria: (1) age under 25 years, (2) cohabitation with a partner, (3) secondary education, (4) self-reported intermenstrual bleeding and (5) number of current sexual partners and condom use frequency (score 0-5). We assessed tool performance in detecting RTI at 0 vs 1-5, 0-1 vs 2-5 and 0-2 vs 3-5 score thresholds.

RESULTS

Of 303 women, 52% (n=157) reported antiretroviral therapy use and median age was 31 years. The prevalence of any RTI was 38% (gonorrhoea=7%, chlamydia=11%, trichomoniasis=12% and bacterial vaginosis=18%) and 8% of women had multiple RTIs. Overall, 4%, 27% and 69% of women had screening tool scores of 0, 1 or 2+, respectively. At a threshold of at least one scored criterion, the tool demonstrated high sensitivities (95%-97%) but low specificities (3%-4%) for detecting any RTI. Increasing the score threshold and/or inclusion of abnormal vaginal discharge marginally improved specificity.

CONCLUSION

The prevalence of RTIs observed in this population was high, and the screening tool had no discriminatory power to detect prevalent RTIs.

Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa

OBJECTIVES

It has been hypothesised that ectopy may be associated with increased susceptibility to sexually transmitted infections (STIs). In this cross-sectional study, we wanted to explore the association between STIs (including HIV) and cervical ectopy.

METHODS

We included 700 sexually active young women attending randomly selected high schools in a rural district in KwaZulu-Natal, South Africa. The district is endemic of HIV and has a high prevalence of STIs. We did computer-assisted measurements of the ectocervical area covered by columnar epithelium (ectopy) in colposcopic images and STI analyses on cervicovaginal lavage and serum samples. All participating women answered a questionnaire about sexual behaviour and use of contraceptives.

RESULTS

The mean age was 19.1 years. Ectopy was found in 27.2%, HIV in 27.8%, chlamydia in 25.3% and gonorrhoea in 15.6%. We found that age, parity, chlamydia and gonorrhoea, years since menarche, years since sexual debut and number of sexual partners were associated with ectopy. In multivariate analysis with chlamydia infection as the dependent variable, women with ectopy had increased odds of having chlamydia infection (adjusted OR 1.78, p=0.033). In women under 19 years of age, we found twofold higher odds of being HIV-positive for those with ectopy (OR 2.19, p=0.014).

CONCLUSIONS

In conclusion, cervical ectopy is associated with Chlamydia trachomatis infection and HIV in the youngest women.

Therapeutic effects of focused ultrasound in 4014 patients with symptomatic cervical ectopy

This study aimed to explore the therapeutic effect of focused ultrasound (FU) therapy in patients with symptomatic cervical ectopy. 4677 patients with symptomatic cervical ectopy were enrolled and treated with FU. Three months after treatment, we analyzed the therapeutic effects and the adverse reactions in 4014 cases with complete records. All influential factors were also analyzed with logistic regression analysis. For the treatment of symptomatic cervical ectopy, the effective rate of FU was 99.8%, and the cure rate was 72.52%. Bleeding that either reached or exceeded normal menstrual volume occurred in 12 cases. Logistic regression analysis showed that the degree of illness, vaginal cleanliness, economic level, occupation, age and artificial abortion frequency were all influential factors. Focused ultrasound is a promising new therapeutic option for the treatment of symptomatic cervical ectopy. Additionally, it can be widely used for a variety of patients.

Immunomodulatory factors in cervicovaginal secretions from pregnant and non-pregnant women: a cross-sectional study

BACKGROUND

Pregnant women are at an increased risk for HIV infection due to unknown biological causes. Given the strong effect of sex-hormones on the expression of immunomuodulatory factors, the central role of mucosal immunity in HIV pathogenesis and the lack of previous studies, we here tested for differences in immunomuodulatory factors in cervico-vaginal secretions between pregnant and non-pregnant women.

METHODS

We compared concentrations of 39 immunomodulatory factors in cervicovaginal lavages (CVL) from 21 pregnant women to those of 24 non-pregnant healthy women from the US. We used Bonferroni correction to correct for multiple testing and linear regression modeling to adjust for possible confounding by plasma cytokine concentration, cervical ectopy, total protein concentration, and other possible confounders. Cervical ectopy was determined by planimetry. Concentration of immunomodulatory factors were measured by a multiplex assay, protein concentration by the Bradford Method.

RESULTS

Twenty six (66%) of the 39 measured immunomodulatory factors were detectable in at least half of the CVL samples included in the study. Pregnant women had threefold lower CVL concentration of CCL22 (geometric mean: 29.6 pg/ml versus 89.7 pg/ml, p = 0.0011) than non-pregnant women. CVL CCL22 concentration additionally correlated negatively with gestational age (Spearman correlation coefficient [RS]: -0.49, p = 0.0006). These associations remained significant when corrected for multiple testing. CCL22 concentration in CVL was positively correlated with age and negatively correlated with time since last coitus and the size of cervical ectopy. However, none of these associations could explain the difference of CCL22 concentration between pregnant and non-pregnant women in this study, which remained significant in adjusted analysis.

CONCLUSIONS

In this study population, pregnancy is associated with reduced concentrations of CCL22 in cervicovaginal secretions. The role of CCL22 on HIV transmission should now be investigated in prospective studies.

Hormonal contraception and area of cervical ectopy: a longitudinal assessment

BACKGROUND

The effect of combined oral contraceptives (COCs) and depot-medroxyprogesterone acetate (DMPA) on the area of cervical ectopy is not well understood.

STUDY DESIGN

From 1996 to 1999, we recruited women not using hormonal contraception from two family planning centers in Baltimore, MD. Upon study entry and 3, 6 and 12 months after the initial visit, participants were interviewed and received visual cervical examinations with photography. Ectopy was measured from digitized photographs and was analyzed both continuously and categorically (small [≤0.48 cm(2)] vs. large [>0.48 cm(2)]).

RESULTS

Of 1003 enrolled women, 802 returned for at least one follow-up visit. At 12 months, the numbers of women using COCs, DMPA or no hormonal method at least 50% of the time since the prior visit were 230, 76 and 229, respectively. After multivariable adjustment, COC use (vs. no hormonal use) was associated with large area of ectopy (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.0-3.3). No significant relationship was observed between DMPA and large area of ectopy (OR: 0.5, 95% CI: 0.2-1.3). The incidence of large area of ectopy by contraceptive exposure (COC, DMPA or no hormonal method) was 17.4 (CI: 11.8-24.6), 10.9 (CI: 4.4-22.4) and 4.6 (CI: 2.2-8.4) per 100 woman-years, respectively.

CONCLUSIONS

Use of COCs, but not DMPA, was associated with large area of cervical ectopy. Area of ectopy at baseline was the strongest predictor of area of ectopy at follow-up.

Colposcopically observed vascular changes in the cervix in relation to the hormonal levels and menstrual cycle

OBJECTIVE

We assessed colposcopically observed vascular changes occurring in the cervix in relation to cyclical hormonal variation in healthy women.

MATERIALS AND METHODS

Thirty women with regular menstrual cycles and willing to remain sexually abstinent during a menstrual cycle were enrolled. Colposcopy was performed during the peak of the estrogen and progesterone levels.

RESULTS

The mean (+/-SD) diameter of the largest visible blood vessel differed significantly between the estrogenic phase (0.38 +/- 0.14 mm) as compared with the progestogenic phase (0.47 +/- 0.12 mm; p <.01). The blood vessels were more prominent and dense and had a well-defined outline during the progestogenic phase than the estrogenic phase; however, these differences were not statistically significant. There was borderline increase in the interleukin 8 level during the estrogenic phase.

CONCLUSIONS

Physiological changes of increased vascularity of the cervix observed colposcopically during the progestogenic phase are normal. If such changes do not correspond to the menstrual cycle phase in women using vaginal microbicides in early-phase clinical trials, presence of inflammatory markers should be evaluated. Elevated interleukin 8 during the estrogenic phase needs further evaluation.

Identifying appropriate IUD candidates in areas with high prevalence of sexually transmitted infections

BACKGROUND

The IUD is a highly effective, safe, inexpensive and long-lasting contraceptive. However, IUDs may increase PID risk during the early postinsertion period when inserted in women with cervical infections. We developed a simple algorithm to identify women at low risk of current sexually transmitted infection (STI) who are appropriate IUD candidates in regions with moderate or high STI prevalence.

METHODS

We used data sets from family planning populations in Kenya, Zimbabwe, Jamaica and the United States to develop optimum algorithms. We then validated these algorithms using data sets from family planning populations in Thailand and Uganda.

RESULTS

A simple unweighted algorithm based on age, living with partner, education, bleeding between periods and a behavioral risk score (number of sex partners, condom use) was the most useful. Adding clinical signs did not improve algorithm performance. Women categorized at low risk by this algorithm were at substantially reduced risks of cervical infection. Women identified at high STI risk had at least twice the risk as the overall clinic populations. Women in the moderate-risk group had STI risks similar to the overall clinic populations.

CONCLUSION

Women categorized as low risk by the algorithm can be referred for IUD insertion while women categorized at high risk should not receive an IUD without further testing or treatment. Women in the moderate-risk group should be triaged based on the STI prevalence of the overall clinic population. A simple checklist has been developed to help providers estimate a client's risk of current STI and to guide appropriate triage.

Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections

BACKGROUND AND OBJECTIVES

Several previous studies have suggested that hormonal contraception could be associated with increased risk of cervical infections. However, few high-quality prospective studies have examined this relationship.

GOAL

The goal of this study was to measure the effect of oral contraceptives (OC) and depot-medroxyprogesterone acetate (DMPA) on the acquisition of cervical chlamydial and gonococcal infections.

STUDY

Women attending 2 reproductive health centers in Baltimore, MD, were enrolled into a prospective cohort study. Participants were 15 to 45 years and were initiating OCs or DMPA or not using hormonal contraception. Interviews, physical examinations, and testing for incident cervical infections were conducted at 3, 6, and 12 months.

RESULTS

The analysis included 819 women. Most were single (77%) and nulliparous (75%); 43% were black. Median age was 22 years. During the study, 45 women acquired a chlamydial or gonococcal infection (6.2 per 100 women-years). DMPA use (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.6-8.5), but not OC use (HR, 1.5; 95% CI, 0.6-3.5), was significantly associated with increased acquisition of cervical infections after adjusting for other risk factors. Cervical ectopy was not an important mediator of cervical infection risk.

CONCLUSIONS

DMPA use, but not OC use, appeared to be significantly associated with increased acquisition of cervical chlamydial and gonococcal infections.