Acceptability of unsupervised HPV self-sampling using written instructions

Objectives

The study measured the acceptability of self-sampling for human papillomavirus (HPV) testing in the context of cervical cancer screening. Women carried out self-sampling unsupervised, using a written instruction sheet.

Setting

Participants were women attending either a family planning clinic or a primary care trust for routine cervical screening.

Methods

Women (n = 902) carried out self-sampling for HPV testing and then a clinician did a routine cervical smear and HPV test. Immediately after having the two tests, participants completed a measure of acceptability for both tests, and answered questions about ease of using the instruction sheet and willingness to use self-sampling in the future.

Results

The majority of women found self-sampling more acceptable than the clinician-administered test, but there was a lack of confidence that the test had been done correctly. Significant demographic differences in attitudes were found, with married women having more favourable attitudes towards self-sampling than single women, and Asian women having more negative attitudes than women in other ethnic groups. Intention to use self-sampling in the future was very high across all demographic groups.

Conclusion

Self-sampling for HPV testing was highly acceptable in this large and demographically diverse sample, and women were able to carry out the test alone, using simple written instructions. Consistent with previous studies, women were concerned about doing the test properly and this issue will need to be addressed if self-sampling is introduced. More work is needed to see whether the demographic differences we found are robust and to identify reasons for lower acceptability among single women and those from Asian background.

Public awareness of human papillomavirus

Objectives

The main objective of this study was to review the evidence relating to the level of awareness of human papillomavirus (HPV) in the general population and the implications for the potential introduction of HPV vaccination and HPV testing as part of screening.

Methods

PubMed search performed on terms: ‘HPV education’, ‘HPV awareness’ ‘Genital Warts Awareness’

Results

Public awareness of HPV is generally very low, particularly with respect to its relation to abnormal smears and cervical cancer although knowledge levels vary to some extent according to sociodemographic characteristics. There is also much confusion around which types cause warts and the types that can cause cancer. The sexually transmissible nature of the infection is of major concern and confusion to women.

Conclusions

Due to the lack of current awareness of HPV, significant education initiatives will be necessary should HPV vaccination and/or HPV testing be introduced. Organized edification of healthcare workers and the media, who constitute the two most preferred sources of information, will be crucial.

Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women aged 15-25 years with and without serological evidence of previous exposure to HPV-16/18

In the Phase III PATRICIA study (NCT00122681), the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine (Cervarix(®), GlaxoSmithKline Biologicals) was highly efficacious against HPV-16/18 infections and precancerous lesions in women HPV-16/18 deoxyribose nucleic acid (DNA) negative and seronegative at baseline. We present further data on vaccine efficacy (VE) against HPV-16/18 in the total vaccinated cohort including women who may have been exposed to HPV-16/18 infection before vaccination. In women with no evidence of current or previous HPV-16/18 infection (DNA negative and seronegative), VE was 90.3% (96.1% confidence interval: 87.3-92.6) against 6-month persistent infection (PI), 91.9% (84.6-96.2) against cervical intraepithelial neoplasia (CIN)1+ and 94.6% (86.3-98.4) against CIN2+ [97.7% (91.1-99.8) when using the HPV type assignment algorithm (TAA)]. In women HPV-16/18 DNA negative but with serological evidence of previous HPV-16/18 infection (seropositive), VE was 72.3% (53.0-84.5) against 6-month PI, 67.2% (10.9-89.9) against CIN1+, and 68.8% (-28.3-95.0) against CIN2+ [88.5% (10.8-99.8) when using TAA]. In women with no evidence of current HPV-16/18 infection (DNA negative), regardless of their baseline HPV-16/18 serological status, VE was 88.7% (85.7-91.1) against 6-month PI, 89.1% (81.6-94.0) against CIN1+ and 92.4% (84.0-97.0) against CIN2+ [97.0% (90.6-99.5) when using TAA]. In women who were DNA positive for one vaccine type, the vaccine was efficacious against the other vaccine type. The vaccine did not impact the outcome of HPV-16/18 infections present at the time of vaccination. Vaccination was generally well tolerated regardless of the woman's HPV-16/18 DNA or serological status at entry.

Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women

BACKGROUND

The human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine was immunogenic, generally well tolerated, and effective against HPV-16 or HPV-18 infections, and associated precancerous lesions in an event-triggered interim analysis of the phase III randomised, double-blind, controlled PApilloma TRIal against Cancer In young Adults (PATRICIA). We now assess the vaccine efficacy in the final event-driven analysis.

METHODS

Women (15-25 years) were vaccinated at months 0, 1, and 6. Analyses were done in the according-to-protocol cohort for efficacy (ATP-E; vaccine, n=8093; control, n=8069), total vaccinated cohort (TVC, included all women receiving at least one vaccine dose, regardless of their baseline HPV status; represents the general population, including those who are sexually active; vaccine, n=9319; control, n=9325), and TVC-naive (no evidence of oncogenic HPV infection at baseline; represents women before sexual debut; vaccine, n=5822; control, n=5819). The primary endpoint was to assess vaccine efficacy against cervical intraepithelial neoplasia 2+ (CIN2+) that was associated with HPV-16 or HPV-18 in women who were seronegative at baseline, and DNA negative at baseline and month 6 for the corresponding type (ATP-E). This trial is registered with ClinicalTrials.gov, number NCT00122681.

FINDINGS

Mean follow-up was 34.9 months (SD 6.4) after the third dose. Vaccine efficacy against CIN2+ associated with HPV-16/18 was 92.9% (96.1% CI 79.9-98.3) in the primary analysis and 98.1% (88.4-100) in an analysis in which probable causality to HPV type was assigned in lesions infected with multiple oncogenic types (ATP-E cohort). Vaccine efficacy against CIN2+ irrespective of HPV DNA in lesions was 30.4% (16.4-42.1) in the TVC and 70.2% (54.7-80.9) in the TVC-naive. Corresponding values against CIN3+ were 33.4% (9.1-51.5) in the TVC and 87.0% (54.9-97.7) in the TVC-naive. Vaccine efficacy against CIN2+ associated with 12 non-vaccine oncogenic types was 54.0% (34.0-68.4; ATP-E). Individual cross-protection against CIN2+ associated with HPV-31, HPV-33, and HPV-45 was seen in the TVC.

INTERPRETATION

The HPV-16/18 AS04-adjuvanted vaccine showed high efficacy against CIN2+ associated with HPV-16/18 and non-vaccine oncogenic HPV types and substantial overall effect in cohorts that are relevant to universal mass vaccination and catch-up programmes.

FUNDING

GlaxoSmithKline Biologicals.

Prophylactic HPV vaccines

Infection with human papillomavirus (HPV), in particular HPV 16 and HPV 18, is the main cause of cervical cancer. Two prophylactic vaccines against types 6, 11, 16 and 18 have shown great promise in clinical trials, with recent results demonstrating 100% efficacy against persistent HPV infection and development of CIN up to five years of follow-up. One of these (Gardasil, recently licensed) contains all four HPV types, offering protection against genital warts (types 6 and 11) as well as cervical cancer. The other (Cervarix) contains types 16 and 18, targeting cervical cancer alone. Recent data suggest a degree of cross-protection, against types 31 and 45; this could significantly increase the level of protection afforded by the vaccines. It is envisaged that girls between 11 and 12 will be the target, and this is what has been recommended in the United States. There is still debate about the issue of vaccinating boys. A fundamental issue is the lack of education of both the public and health professionals about HPV. In theory, an HPV vaccine could prevent almost all cervical cancer, eventually removing the need for cervical smears. However, there is at least one whole generation of women for whom the vaccine will come too late, and who will continue to require screening.

Attitudes to self-sampling for HPV among Indian, Pakistani, African-Caribbean and white British women in Manchester, UK

Objective: To examine attitudes to self-sampling for human papillomavirus (HPV) testing among women from contrasting ethnic groups.

Setting: Manchester, UK.

Methods: Two hundred women of Indian, Pakistani, African-Caribbean and white British origin were recruited from social and community groups to participate in a questionnaire survey. The questionnaire included items on attitudes to self-sampling and intention to use the test.

Results: Willingness to try to use the test was high, and women did not foresee religious or cultural barriers to self-sampling; however, a large proportion of women were concerned about doing the test properly. This concern was greatest in the Indian and African-Caribbean groups.

Conclusions: Although women's willingness to try self-sampling for HPV is encouraging, worries about carrying out the procedure correctly must be addressed if women are to feel confident about the results of self-sampling methods and reassured by a negative result.

Management of women who test positive for high-risk types of human papillomavirus: the HART study

BACKGROUND

Certain types of human papillomavirus (HPV) are the primary cause of almost all cervical cancers. HPV testing of cervical smears is more sensitive but less specific than cytology for detecting high-grade cervical intraepithelial neoplasia (CIN2+). HPV testing as a primary screening approach requires efficient management of HPV-positive women with negative or borderline cytology. We aimed to compare the detection rate and positive predictive values of HPV assay with cytology and to determine the best management strategy for HPV-positive women.

METHODS

We did a multicentre screening study of 11085 women aged 30-60 years. Women with borderline cytology and women positive for high-risk HPV with negative cytology were randomised to immediate colposcopy or to surveillance by repeat HPV testing, cytology, and colposcopy at 12 months.

FINDINGS

HPV testing was more sensitive than borderline or worse cytology (97.1% vs 76.6%, p=0.002) but less specific (93.3% vs 95.8%, p<0.0001) for detecting CIN2+. Of 825 randomised women, surveillance at 12 months was as effective as immediate colposcopy. In women positive for HPV at baseline, who had surveillance, 73 (45%) of 164 women with negative cytology and eight (35%) of 23 women with borderline cytology were HPV negative at 6-12 months. No CIN2+ was found in these women, nor in women with an initial negative HPV test with borderline (n=211) or mild (32) cytology.

INTERPRETATION

HPV testing could be used for primary screening in women older than 30 years, with cytology used to triage HPV-positive women. HPV-positive women with normal or borderline cytology (about 6% of screened women) could be managed by repeat testing after 12 months. This approach could potentially improve detection rates of CIN2+ without increasing the colposcopy referral rate.

Awareness of human papillomavirus among women attending a well woman clinic

OBJECTIVES

To assess the level and accuracy of public understanding of human papillomavirus (HPV) in the United Kingdom.

METHODS

Women attending a well woman clinic were asked to complete a questionnaire assessing HPV awareness and specific knowledge about the virus.

RESULTS

Questionnaires were completed by 1032 women, of whom 30% had heard of HPV. Older women, non-smokers, and those with a history of candida, genital warts, or an abnormal smear result were more likely to have heard of HPV. Even among those who had heard of HPV, knowledge was generally poor, and fewer than half were aware of the link with cervical cancer. There was also confusion about whether condoms or oral contraceptives could protect against HPV infection.

CONCLUSIONS

In this relatively well educated sample, awareness and knowledge of HPV were poor. Public education is urgently needed so that women participating in cervical cancer screening are fully informed about the meaning of their results, especially if HPV testing is soon to be introduced.

Attitudes towards HPV testing: a qualitative study of beliefs among Indian, Pakistani, African-Caribbean and white British women in the UK

This study examined attitudes to human papillomavirus (HPV) testing among a purposively selected sample of women from four ethnic groups: white British, African Caribbean, Pakistani and Indian. The design was qualitative, using focus group discussion to elicit women's attitudes towards HPV testing in the context of cervical cancer prevention. The findings indicate that although some women welcomed the possible introduction of HPV testing, they were not fully aware of the sexually transmitted nature of cervical cancer and expressed anxiety, confusion and stigma about HPV as a sexually transmitted infection. The term 'wart virus', often used by medical professionals to describe high-risk HPV to women, appeared to exacerbate stigma and confusion. Testing positive for HPV raised concerns about women's sexual relationships in terms of trust, fidelity, blame and protection, particularly for women in long-term monogamous relationships. Participation in HPV testing also had the potential to communicate messages of distrust, infidelity and promiscuity to women's partners, family and community. Concern about the current lack of available information about HPV was clearly expressed and public education about HPV was seen as necessary for the whole community, not only women. The management of HPV within cervical screening raises important questions about informed participation. Our findings suggest that HPV testing has the potential to cause psychosocial harm to women and their partners and families.

High acceptability and satisfaction with NuvaRing use

NuvaRing is a combined contraceptive vaginal ring that releases constant low doses of ethinylestradiol and etonogestrel. One cycle consists of 3 weeks of ring use followed by a 1-week ring-free period and the ring can easily be inserted and removed by the women themselves. Acceptability and satisfaction were determined by a questionnaire in two large, multicenter, open, 1-year studies conducted in a total of 2393 women, of whom 1950 (82%) completed cycle 3 questionnaires. Overall, 53% of participants switched to NuvaRing from other hormonal contraception; the main reason given for deciding to use NuvaRing (47%) was that it appeared to be a new and attractive method of contraception. Nearly all users considered the ring easy to insert and remove. Although 15% of women and 30% of their partners reported feeling the ring at least occasionally during intercourse, very few partners objected to women using the ring and the majority of women felt comfortable with it during intercourse. Reductions in menstrual pain and the length of the menstrual period were reported during ring use. More than 90% of women were satisfied or very satisfied with the ring at each assessment and 97% of those who completed the studies said they would recommend the method to others. At baseline, the preferred contraceptive method was the pill (66% of users). However, more than 80% of women at each assessment said they would use NuvaRing as their first-choice method. High satisfaction at cycle 3 was a good predictor of low subsequent discontinuation risk. In conclusion, this analysis shows that users express good acceptability and a high level of satisfaction with NuvaRing.

The effect of stopping smoking on cervical Langerhans' cells and lymphocytes

OBJECTIVE

To investigate the effects of stopping smoking on cervical Langerhans' cells and lymphocytes.

DESIGN

Prospective intervention study.

SETTING

A large family planning clinic in central London.

POPULATION

Women volunteers prepared to attempt to give up smoking for six months. Their most recent cervical smear showed no abnormality greater than mild dyskaryosis.

METHODS

The women were seen at three-month intervals for six months. Reduction in smoking was assessed by self-reporting and validated by salivary cotinine concentrations. Colposcopy and a biopsy of a normal area were performed at the first and last visits. Any area of abnormality was also biopsied at the final visit. Langerhans' cells and lymphocytes were counted.

MAIN OUTCOME MEASURES

Proportional changes in counts of Langerhans' cells and lymphocytes with reduction in smoking.

RESULTS

Reduction in smoking by 20 to 40 cigarettes per day was significantly associated with a reduction of between 6% and 16% in counts of Langerhans cells, CD8 and total lymphocytes. Heavy smoking was significantly associated (P = 0.02) with an increased chance of persistent human papillomavirus infection. The presence of candida was associated with significantly higher counts of between 41% and 47% in total lymphocytes and CD8 lymphocytes. In contrast, the presence of anaerobic vaginosis was associated with significantly lower counts of between 16% and 30% in Langerhans cells, CD4 and CD8 lymphocytes.

CONCLUSIONS

This large intervention study has demonstrated a clear relationship between reduction in smoking and changes in cervical immune cell counts. Future studies need to take into account cytokine interactions, which recent studies suggest may be significant in the immune response to both human papillomavirus and cervical intraepithelial neoplasia and the ever-increasing complexity of the cell-mediated immune system of the cervix.

The 'pill scare': the responses of authorities, doctors and patients using oral contraception

In October 1995, the regulatory authority in the UK issued a warning about an increased risk of venous thromboembolism in women taking third-generation combined oral contraceptives. This was done before publication of the scientific papers involved, and resulted in a huge media 'pill scare'. The manner in which the information was released has been criticised, as many doctors did not receive their 'Dear Doctor' letter from the regulatory authority until after media reporting. The result of the scare has been a loss of confidence in the oral contraceptive pill in general, and a rise in abortion rates.

Depo Provera. Position paper on clinical use, effectiveness and side effects

Depo Provera (medroxyprogesterone acetate, DMPA) when given as 150 mg by deep intramuscular injection every 12 calendar weeks (84 days+5 days), is a highly effective contraceptive with a very low failure rate comparable to modern copper IUDs and lower than many other methods. It should be available as a first line method to all who wish to make an informed choice about reversible methods of contraception. Pre-use counselling is essential to minimise the effect of menstrual change which occurs in most patients. However there is great patient variability. Use of DMPA is independent of intercourse and also independent of the user's memory (and thus of continuing motivation), other than remembering the 12 weekly appointments. For many women this is a great advantage. Oral contraceptive methods involve remembering to take a pill each day, in the case of the progestogen only pill within the same three hours each day. This places considerable strain on women who lead irregular lifestyles, who are very busy or travel frequently. Such women often describe a constant 'fear of forgetting', especially with the POP. The main potential disadvantage of DMPA in this country are likely to be menstrual disturbance and weight gain. The combined oral contraceptive pill gives the appearance of excellent cycle control because it removes the natural cycle altogether and replaces it with an artificial one. All progestogen-only methods, whether low or high dose, lead to menstrual disturbances, so in this respect DMPA is not unique. Although troublesome, the menstrual disturbances which occur in DMPA users very rarely require operative medical intervention, and can often be improved simply by short courses of oestrogen or shorter injection intervals. Again, women need to know what can be done so that they are aware that they should seek advice early, rather than miserably waiting.for their 12 week appointment. DMPA has no appreciable effects on blood pressure or thrombosis risk. In this it has an advantage over the combined oral contraceptive pill, and provides a simple, effective alternative for women who cannot use the pill for these reasons. Similarly, it has been suggested that women who suffer from focal migraine and are therefore advised against use of the combined oral contraceptive pill can still use progestogen-only contraceptives. Although the POP is medically safe in these circumstances, in young women it is less effective, and involves strict time keeping, which will be disadvantageous for some women. Side effects, long term use and schedules of administration are also discussed. The use of local protocols to allow nurse administration is to be supported both in general practice and the clinic situation. Perhaps the most important issue surrounding the use of DMPA is that of patient information. The method has had a particularly bad public image, which naturally makes potential users anxious and subject to misinformation from poorly informed or biased sources. Also, it is temporarily irreversible during its three months duration, so the duration of any problems or anxieties resulting from side effects may be longer than for other methods. It is of paramount importance that easily understood, accurate patient information leaflets are available, since biased and inaccurate information is readily available from women's magazines, perpetuating the myths surrounding the method.

Differential expression of keratins 10, 17, and 19 in normal cervical epithelium, cervical intraepithelial neoplasia, and cervical carcinoma

AIM

To examine the value of immunohistochemistry in defining a keratin profile to aid cervical histopathological diagnosis.

METHODS

Immunohistochemical localisation of keratins 17, 10, and 19 was studied in 268 cervical biopsies from 216 women including normal epithelia (with and without human papilloma virus), low and high grade cervical intraepithelial neoplasia, and invasive carcinoma. The percentage of positive immunostaining was scored using a Kontron MOP videoplan image analyser.

RESULTS

All major categories of cervical epithelia expressed these keratins to varying degrees. The median percentage of immunostaining for keratin 10 was 40% in normal tissue compared with just 1% in invasive carcinoma (p < 0.0001). The medians for keratin 17 were 0% in the normal group and 80% in carcinomas (p < 0.0001). By contrast, there was no significant difference in staining for keratin 19. Using a combination of the keratin 10 and 17 percentages, it was possible to separate the carcinomas from the benign conditions with a sensitivity of 100% and a specificity of 93%. Further analyses within the groups revealed more extensive staining for keratins 10 and 19 in reserve cell hyperplasia, immature squamous metaplasia, and congenital transformation zone.

CONCLUSIONS

The morphological variety within the cervix is reflected, in part, by distinct keratin patterns. There are striking differences in the patterns of keratins 10 and 17 between infiltrating squamous carcinoma and normal cervical epithelia.

Effect of smoking cessation on cervical lesion size

BACKGROUND

Cigarette smoking has been postulated as a cofactor in the aetiology of cervical cancer, but a causal role is difficult to establish because of potential confounding by sexual behaviour. We have investigated the effect of cessation or reduction of cigarette smoking on the course of minor-grade cervical lesions.

METHODS

In this intervention study 82 women volunteers with minor-grade lesions on colposcopy (cervical intraepithelial neoplasia grade 1 or less) attempted to give up smoking for 6 months. Smoking histories were taken at 3-monthly clinic visits and verified by measurement of salivary cotinine concentrations. At each clinic visit, a photograph of the cervix was taken; the image was digitised and computer-aided image analysis was used to assess lesion size, by investigators unaware of smoking status.

FINDINGS

Of the 82 women, 17 stopped smoking completely for at least 6 months and 11 others reduced their smoking consumption by more than 75%. Of these 28 women, 23 (82%) showed a reduction in lesion size of at least 20% or 4 mm2 compared with 13 (28%) of the 47 non-quitters (odds ratio 12.0 [95% Cl 3.9-32.7]). The remaining seven women had unconfirmed smoking histories. There was a significant correlation between the extent of smoking reduction and the change in lesion size (chi2 for trend=31.55, p<0.0001). Adjustment for social class, method of contraception, and stage of menstrual cycle did not affect the results.

INTERPRETATION

Our findings support a link between smoking and cervical disease and suggest that smoking cessation could have a beneficial effect on early cervical abnormalities.

Human papillomavirus testing in primary cervical screening

Several studies have examined the role of tests for human papillomavirus (HPV) in screening for cervical cancer but as yet the relevance is unclear. We looked at HPV testing for types 16, 18, 31, and 33 on material taken at the time of a cervical smear in 2009 eligible women having routine screening. Women with any degree of dyskaryosis or high levels of one of these HPV types were referred for colposcopy. 44% of the cervical intraepithelial neoplasia (CIN) lesions of grade 2/3 detected had negative cytology and were found only by HPV testing. A further 22% of the CIN 2/3 lesions were positive for HPV but showed only borderline or mild cytological changes. The positive predictive value of HPV testing was 42%, which was similar to that for moderate dyskaryosis. HPV types 16 and 31 were more sensitive and specific for CIN 2/3 than were types 18 or 33. However, 25% of the CIN 2/3 lesions were not detected by these four HPV tests. We suggest that HPV testing could usefully augment but not replace conventional cytology. These results should stimulate a much larger randomised trial to assess the impact of these improved CIN 2/3 detection rates on the subsequent incidence of invasive cancer.

Semiautomated detection of human papillomavirus DNA of high and low oncogenic potential in cervical smears

Detection of DNA from human papillomaviruses (HPV) of high and intermediate oncogenic risk in cervical smears may predict the presence of cervical cancer or may indicate precancerous changes. Here we describe a semiautomated polymerase chain reaction system for the detection and classification of HPV DNA that is present in clinically significant amounts in routine cervical scrapes.

Semiautomated detection of human papillomavirus DNA of high and low oncogenic potential in cervical smears

Detection of DNA from human papillomaviruses (HPV) of high and intermediate oncogenic risk in cervical smears may predict the presence of cervical cancer or may indicate precancerous changes. Here we describe a semiautomated polymerase chain reaction system for the detection and classification of HPV DNA that is present in clinically significant amounts in routine cervical scrapes.

Cytokeratin expression and acetowhite change in cervical epithelium

AIM

To investigate the distribution of cytokeratins 10, 13, 14 and 19 in biopsy specimens taken from acetowhite and non-acetowhite areas of the cervix.

METHOD

Cervical biopsy specimens were taken from both acetowhite and non-acetowhite areas from 44 patients who presented with abnormal cervical cytology. The specimens were snap frozen in liquid nitrogen and multiple sections taken from each specimen. Staining was performed for cytokeratins 10, 13, 14, 19 and NADPH diaphorase enzyme. The areas of each section positive for the various markers were measured.

RESULTS

Cytokeratin 10 positive cells were greatly increased in number in acetowhite biopsy specimens compared with non-acetowhite samples (45.1% v 2.8%; p < 0.0001). Cytokeratin 19 was also increased, but to a lesser extent (17.8% v 5.5%; p < 0.0001). In contrast, the almost universal expression of cytokeratin 13 was reduced in acetowhite biopsy specimens (86.2% v 96.9%; p < 0.0001). Cytokeratin 14 was found diffusely in the basal region of the stratified squamous epithelium and was marginally more apparent in the acetowhite biopsy specimens (p = 0.04).

CONCLUSION

It is suggested that the presence of cytokeratin 10 may be an essential requirement for the formation of acetowhite change in association with the cellular swelling caused by acetic acid.

Comparison of four cytologic sampling techniques in a large family planning center

In recent years, several new cervical sampling techniques have been introduced to try to improve the accuracy of the cervical smear. In the present study four such techniques were compared: the Aylesbury spatula, Rolon spatula, Cervex device and Aylesbury spatula used in conjunction with a Cytobrush. The total number of smears collected was 14,172, 80% of which were from women under age 35. Despite large differences between the techniques with regard to the presence of endocervical cells in smears, no differences were found in the detection of dysplasia. Endocervical cells were seen significantly more often in dysplastic smears than in negative smears. There was little difference in the rate of unsatisfactory samples. It appears that in a young population, the instruments used for cervical sampling are not likely to significantly influence the detection of dysplasia if skilled personnel take the smears.

Preliminary report of unexpected local reactions to a progestogen-releasing contraceptive vaginal ring

This is the first report of vaginal erythematous areas associated with the use of a levonorgestrel-releasing contraceptive ring. Of 139 female subjects, 48 developed lesions of varying size and degrees of redness. Sixteen of these have undergone serial colposcopy and thirteen have also had biopsy examinations, which revealed acetowhite areas and, histologically, chronic inflammation with widely dilated vessels and frequently with thinning of the epithelium. The cause remains uncertain but hormonal, chemical and physical effects might all have a role.

Use of the Cytobrush for concurrent cytology and chlamydia sampling: a comparison of immunofluorescence and culture for detection of chlamydia

Five hundred and thirty-three women attending a genitourinary medicine clinic underwent concurrent cytology and Chlamydia trachomatis screening using a Cytobrush (Medscand AB). In each case, the same Cytobrush was used to give a sample for direct immunofluorescence and culture. 11.1% of samples were positive by immunofluorescence, while 10.6% were positive by culture. This was a close agreement (Kappa = 0.875). The ability of the same instrument to be used for both cytology and chlamydial screening, where direct immunofluorescence is used for detection of chlamydiae, may allow more widespread screening for chlamydia to be practical.

The use of cervicography in a primary screening service

The cervicography and concurrent endocervical brush smear results obtained in 1162 women screened at the Marie Stopes Clinic were analysed. Colposcopy and biopsy results were obtained for positive cases. A comparison was made with a group of 1007 women attending the same clinic for routine cytology only. Nearly 10% of women who were screened by cervicography had a technically defective cervicogram, the main single reason being that the view was obscured by blood. Routine cytology was positive in 1%, while cervicography was positive in 13%, where positivity was defined as a result leading to a recommendation for colposcopy. The false positive rate for cervicography was 26%. Even after adjustment, this difference was highly significant (P less than 0.0001).

Cervical smears following laser treatment. Comparison of Cervex brush versus Cytobrush-Ayre spatula sampling

For 802 women at initial follow-up after laser treatment of cervical lesions, 421 smears prepared using the Cervex brush were compared with 381 smears prepared using the combination of a Cytobrush plus an Ayre spatula. The smears were graded for adequacy, the presence of endocervical or metaplastic cells and the presence and degree of epithelial abnormalities. Endocervical or metaplastic cells were seen more often in Cytobrush-Ayre spatula smears (94.5%) as compared with Cervex brush smears (88.8%; P = .004). Also, the number of samples classed as inadequate was significantly greater with Cervex brush smears (4.0%) than with Cytobrush-Ayre spatula smears (0.3%; P = .0003). The number of smears showing dysplasia was too small to detect realistic differences between the two sampling methods. These findings suggest that, in women who have had laser treatment of the cervix, Cytobrush plus Ayre spatula sampling produces better-quality smears than does Cervex brush sampling, with regard to both adequacy and the presence of endocervical cells.

A comparison of four cytological sampling techniques in a genitourinary medicine clinic

Four cytological sampling techniques (the Ayre's spatula alone, the Ayelesbury spatula, the Ayre's spatula in conjunction with a Cytobrush (Medscand), and the Cervex (Steriseal] were compared when used in a genitourinary medicine clinic. Over a period of two years 6991 smears were taken. No difference was found between the methods with regard to detection of dyskaryosis, although there were significant differences in the percentage of smears containing endocervical cells.

Use of the Cytobrush for concurrent endocervical cytology and chlamydia sampling

In 899 women attending a genitourinary medicine clinic Chlamydia trachomatis was tested for using both a Cytobrush and a conventional swab. In 425 cases, the Cytobrush was used for concurrent cytology and chlamydia sampling. Both methods were equally effective in the detection of chlamydia, and, in addition, the Cytobrush gave a higher yield of inclusion bodies per sample. The use of the same instrument for both cytology and chlamydia screening may represent a saving in time and money.