ULTRASOUND DIAGNOSTICS OF CERVICAL CHANGES WITH DIFFERENT LOCALIZATION OF THE CERVICITIS IN WOMEN WITH THE ECTOPY OF THE VAGINAL PORTION OF THE CERVIX

The aim of the study was to improve the diagnosis of structural changes in all parts of the cervix depending on the preferential localization of the inflammatory process - in the ectocervix, endocervix, and also in the stroma in women with ectopia (pseudoerosis) of the vaginal part of the cervix. The study included women of predominantly early and middle reproductive age, as these women have inflammatory processes more often than in menopause. To perform the work, a transvaginal imaging method was used, which allowed us to see the smallest structures (up to 0.5-1.0 mm) of the cervix. We have previously developed a technique for visualizing the external part of the cervix and obtained a patent of Ukraine. The results of the ultrasound were compared with laboratory data, colposcopy and cervicoscopy. Traditionally, the diagnosis of cervicitis was made on the basis of clinical symptoms, smear results to determine the presence and type of pathogen. Endoscopic methods allowed visualization of only the mucous membrane of the cervical canal and external part of the cervix. The deep layers of the ectocervix, endocervix and cervical stroma can only be visualized using high-frequency ultrasound in a transvaginal way. According to the results of the study, it was possible to determine the preferential localization of the inflammatory process, to determine the nature of changes in different layers of the cervix. These changes were expressed in the presence of calcifications and cystic cavities of various sizes (1-6 mm), an increase or decrease in echogenicity, the degree of heterogeneity of the structure of the ecto-, endocervix and stroma.

Diagnosis of tuberculous cervicitis by Papanicolaou-stained smear

Tuberculosis (TB) is a common infection in the developing countries. It can involve most organs. Genital TB is usually secondary to pulmonary or extragenital TB. Tuberculosis most commonly involves the upper genital tract. Involvement of the cervix is rare. In countries like India, where carcinoma of cervix is very common, cervical TB may easily be mistaken clinically for malignancy. We report a case of tuberculosis cervicits (secondary to pulmonary tuberculosis) in a 54-year-old postmenauposal woman, who presented with a complaint of discharge per vaginum for a short duration. Per speculum examination showed an ulcerated lesion over anterior lip of cervix, clinically suggestive of malignancy. However, a Papanicolaou-smear showed features suggestive of tuberculosis which was confirmed by biopsy, resulting in early diagnosis and treatment of the patient. Hence, in a patient with a suspicious cervical lesion and a prior history of tuberculosis, a diagnosis of cervical tuberculoiss must be considered.

Noninvasive laser therapy for outpatients with chronic inflammatory disorders of cervix

Chronic inflammation of the cervix can develop cervical stenosis with infertility and cervical congestion is related with the cervical cancer. We create a review of main etiological agents and methods of screening and diagnosis. We also make a brief review of modern therapeutic approach.

CONCLUSIONS

We follow the utility of LLLT through the following aspects: evolution, indications, results of Babeş-Papanicolau screening, cytology, clinical aspects. The results of the study will allow the complex system of treatment to be used in a large category of women. We appreciate that the procedure (used in our center also) will decrease the cervical pathology, the morbidity inside the treatment, the mortality through the evolution of cervical cancer. We propose the applicability for outpatients first and then as an integrated treatment method inside hospitals for a wide access.

In infertile women, cells from Chlamydia trachomatis infected sites release higher levels of interferon-gamma, interleukin-10 and tumor necrosis factor-alpha upon heat-shock-protein stimulation than fertile women

BACKGROUND

The magnitude of reproductive morbidity associated with sexually transmitted Chlamydia trachomatis infection is enormous. Association of antibodies to chlamydial heat shock proteins (cHSP) 60 and 10 with various disease sequelae such as infertility or ectopic pregnancy has been reported. Cell-mediated immunity is essential in resolution and in protection to Chlamydia as well as is involved in the immunopathogenesis of chlamydial diseases. To date only peripheral cell mediated immune responses have been evaluated for cHSP60. These studies suggest cHSPs as important factors involved in immunopathological condition associated with infection. Hence study of specific cytokine responses of mononuclear cells from the infectious site to cHSP60 and cHSP10 may elucidate their actual role in the cause of immunopathogenesis and the disease outcome.

METHODS

Female patients (n = 368) attending the gynecology out patient department of Safdarjung hospital, New Delhi were enrolled for the study and were clinically characterized into two groups; chlamydia positive fertile women (n = 63) and chlamydia positive infertile women (n = 70). Uninfected healthy women with no infertility problem were enrolled as controls (n = 39). cHSP60 and cHSP10 specific cytokine responses (Interferon (IFN)-gamma, Interleukin (IL)-10, Tumor Necrosis Factor (TNF)-alpha, IL-13 and IL-4) were assessed by ELISA in stimulated cervical mononuclear cell supernatants.

RESULTS

cHSP60 and cHSP10 stimulation results in significant increase in IFN-gamma (P = 0.006 and P = 0.04 respectively) and IL-10 levels (P = 0.04) in infertile group as compared to fertile group. A significant cHSP60 specific increase in TNF-alpha levels (P = 0.0008) was observed in infertile group as compared to fertile group. cHSP60 and cHSP10 specific IFN-gamma and IL-10 levels were significantly correlated (P < 0.0001, r = 0.54 and P = 0.004, r = 0.33 respectively) in infertile group.

CONCLUSION

Our results suggest that exposure to chlamydial heat shock proteins (cHSP60 and cHSP10) could significantly affect mucosal immune function by increasing the release of IFN-gamma, IL-10 and TNF-alpha by cervical mononuclear cells.

Injuries to the cervix in sexual trauma

Research on genital injury in sexual assault is limited and few articles have documented injuries to the cervix in sexual assault victims. This review focuses on reviewing and critically evaluating available literature on injuries of the cervix associated with rape, sexual trauma, and some other circumstances. Based on this evaluation, topics for future research are suggested. Nursing and medical studies were examined for this review. The collective studies date from 1991 to 2004. Although multiple articles were identified pertaining to sexual assault and genital injury, only six articles that specifically referred to injuries associated with genital and cervical tissue were included.

A cross-sectional study of a prototype carcinogenic human papillomavirus E6/E7 messenger RNA assay for detection of cervical precancer and cancer

PURPOSE

To evaluate carcinogenic human papillomavirus (HPV) mRNA for E6 and E7 mRNA detection on clinical specimens to identify women with cervical precancer and cancer.

EXPERIMENTAL DESIGN

We evaluated a prototype assay that collectively detects oncogenes E6/E7 mRNA for 14 carcinogenic HPV genotypes on a sample of liquid cytology specimens (n=531), masked to clinical data and to the presence of HPV genotypes detected by PGMY09/11 L1 consensus primer PCR assay.

RESULTS

We found an increasing likelihood of testing positive for carcinogenic HPV E6/E7 mRNA with increasing severity of cytology (P(Trend) < 0.0001) and histology (P(Trend) < 0.0001), with 94% of cervical intraepithelial neoplasia grade 3 (CIN3) histology cases (46 of 49) and all five cancer cases testing positive for carcinogenic HPV E6/E7 mRNA. Overall, fewer specimens tested positive for carcinogenic HPV E6/E7 mRNA than for carcinogenic HPV DNA (P<0.0001, McNemar's chi(2) test), especially in women with <CIN1 (P<0.0001). We also found that using a higher positive cutpoint for detection of carcinogenic HPV E6/E7 mRNA improved the association of positive test results with cervical precancer and cancer by reducing the number of test positives in women without precancer without reducing clinical sensitivity for cervical precancer and cancer compared with detection of carcinogenic HPV E6/E7 mRNA using a lower positive cutpoint by the same assay and with detection of carcinogenic HPV DNA.

CONCLUSIONS

We found that carcinogenic HPV E6/E7 mRNA is a potentially useful biomarker for detection of cervical precancer and cancer and warrants further evaluation.

Could a cervical occlusion suture be effective at improving perinatal outcome?

Cervical weakness and infection have long been regarded as major causes of preterm birth. Cervical cerclage has been used extensively to reduce the risk of preterm birth arising as a result of cervical weakness, but increasing evidence suggests that the cervix plays more than just a mechanical role. Immunological function of the cervix and mucus plug is thought to be important in minimising the ingress of microbes, which can lead to chorioamnionitis and rupture of the amniotic membranes. In this review, we examine the background of traditional cervical cerclage and introduce the concept of the occlusion suture and its potential benefit in reducing the risk of recurrent preterm prelabour rupture of membranes.

Simultaneous detection of Neisseria gonorrhoeae and Chlamydia trachomatis by PCR in genitourinary specimens from men and women attending an STD clinic

Neisseria gonorrhoeae and Chlamydia trachomatis are the two most common bacterial sexually transmitted infections that manifest primarily as urethritis in males and endocervicitis in females, though the infection may be asymptomatic especially in women. Since complications may occur in untreated symptomatic and asymptomatic infected individuals, early diagnosis and treatment of infected individuals is required to prevent severe sequelae and spread of these diseases. Recently molecular amplification assays like Polymerase Chain Reaction (PCR) and Ligase Chain Reaction (LCR) have been found to be highly sensitive and specific methods for detection of N. gonorrhoeae and C. trachonmatis not only in urethral and cervical specimens but also in urine. The objective of this study was to screen male and female Sexually Transmitted Disease (STD) clinic attenders, with and without symptoms suggestive of urethritis and cervicitis for presence of N. gonorrhoeae and C. trachomatis using a multiplex PCR based assay, to compare its performance with culture for N. gonorrhoeae and Direct Fluorescent Antibody (DFA) staining for C. trachomatis and also to compare the efficacy of PCR test performed on urine and genital swab specimens collected from this high risk group. Genital specimens and urine was collected from STD clinic attenders. N. gonorrhoeae and C. trachomatis was detected in genital specimens by culture and DFA respectively. Multiplex PCR was used to detect N. gonorrhoeae and C. trachomatis infection in both genital and urine specimens. Among men with urethritis, N. gonorrhoeae was detected in 70% by culture and 77% by PCR, while C. trachomatis as detected in 7.5% by DFA and 17.5% by PCR. Among females with endocervicitis, N. gonorrhoeae was detected in 7.7% by culture and 30.7% by PCR, while C. trachomatis was detected in 7.7% by DFA and in 15.4% by PCR. None of the asymptomatic males were positive for N. gonorrhoeae and C. trachomatis by conventional methods, while 43.9% were positive for N. gonorrhoeae and 7.5% for C. trachomatis by PCR. Fifty per cent of asymptomatic women were positive for C. trachomatis by PCR alone. We encountered PCR positive but culture/DFA negative results and also PCR negative but culture/DFA positive results. In view of this a single PCR test cannot be used for diagnosis and treatment of N. gonorrhoeae and C. trachomatis infection unless confirmed by a second test.

[Female genital tuberculosis: about 11 cases treated in Antananarivo (Madagascar)]

A 5 year prospective study on genital tuberculosis, a rather uncommon localization, has been undertaken in 11 women treated at the DAT-HIS of Antananarivo, Madagascar Clinical diagnosis is problematic, if not unfeasible, due to the polymorphism of genital tuberculosis in women. Only histological and bacteriological examinations are, so far, confirmatory In the future, recourse to polymerase chain reaction will facilitate diagnosis and will allow a more accurate assessment of the incidence of this aspect of tuberculosis infection. Genital tuberculosis compromises women's fertility Even though the tuberculosis is cured, none of the 11 women of our research had carried their pregnancy to delivery, because artificial fertilization is not feasible here in Madagascar Screening of woman genital tuberculosis should be mandatory as regards gynaecological problems such as menstrual cycle disorders, sterility, abdominal pain, cyst of ovary ectopic pregnancy, spontaneous miscarriage in paraclinical investigations, especially in developing countries.

Cervicitis and Genitourinary Symptoms in Women Culture Positive for Mycoplasma genitalium

PROBLEM

Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women.

METHOD OF STUDY

We compared 26 culture-positive women (group 1), 257 additional polymerase chain reaction-positive women (group 2), and 107 negative control women. We used logistic regression to evaluate signs and symptoms, controlling for co-infections, pregnancy, age, and intervention group assignment.

RESULTS

Comparing group 1 with controls, we found significantly elevated odds ratios (ORs) for intermediate vaginal discharge (OR = 5.4; 95% confidence interval 1.01, 29.2) and action in response to discharge [3.9 (1.1, 13.5)]. Non-significant increases were observed for pathologic vaginal discharge [3.8 (0.78, 18.2)], pathologic dyspareunia [1.5 (0.25, 9.0)], vaginal odor [2.1 (0.75, 5.7)], and cervical mucopus [4.1 (0.74, 22.4)]. Group 2 results were similar, but showed no increase in cervical mucopus relative to controls.

CONCLUSION

Infection with M. genitalium in women is independently related to increased genitourinary symptomatology.

Risk factors for cervicitis among women with bacterial vaginosis

BACKGROUND

Cervicitis commonly occurs in women with bacterial vaginosis (BV), often without concomitant chlamydial or gonococcal infection. The risk factors for cervicitis have not been described.

METHODS

We characterized the risk factors for cervicitis, which is defined as endocervical mucopurulent discharge or easily induced bleeding, among women with BV who were 14-45 years of age. Associations between cervicitis and the characteristics of the subjects, including the presence of specific vaginal bacteria and chlamydial or gonococcal infection detected by strand displacement assay, were analyzed.

RESULTS

Of 424 women with BV, 63 (15%) had cervicitis. Of these 63 women, only 8 (13%) had chlamydia or gonorrhea. The risk factors for cervicitis, adjusted for variables, included older age (P<.001, for trend), <or=12 years of education (odds ratio [OR], 2.4 [95% confidence interval {CI}, 1.3-4.6]; P=.006), new male sex partner (OR, 2.7 [95% CI, 1.4-5.4]; P=.004), female sex partner (OR, 6.2 [95% CI, 1.3-28.3]; P=.02), recent oral sex (OR, 2.3 [95% CI, 1.2-4.2]; P=.008), and absence of vaginal H2O2-producing Lactobacillus species (OR, 2.7; 95% CI, 3.3-5.9; P=.01). No association with cervicitis was seen for current douching or smoking, race, time since or frequency of intercourse, or presence or quantity of vaginal bacteria other than H2O2-producing Lactobacillus species.

CONCLUSIONS

Cervicitis is common among women with BV and is associated with some risk factors that are distinct from those associated with endocervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis. Absence of H2O2-producing lactobacilli may contribute to the development of cervicitis.

Is Helicobacter pylori a pathogenic agent of the cervix uteri?

BACKGROUND

Helicobacter pylori is a gram-negative, microaerophilic rod-shaped bacterium that lives beneath the gastric mucosal layers, on the surface of epithelial cells. Gastric infection with this organism causes inflammation of the gastric mucosa, which can lead to gastritis, duodenal or gastric ulcers and even in rare cases to gastric carcinoma or MALT lymphoma. Approximately 50% of the population of the entire world is believed to be infected with H. pylori, but the exact route of transmission is still uncertain. It has been speculated that the cervix, with its endocervical columnar epithelium and acidic mucous layer, might provide a suitable environment for H. pylori. H. pylori might be a pathogenic agent for cervical infection. In order to address this issue we studied H. pylori in the endocervical tissue.

METHODS

To investigate our hypothesis, we examined cervical tissue using PCR, culture, and Gram-stain. Thirty-three cervices from women who underwent total hysterectomy for noninvasive non-cervical benign uterine diseases were analyzed in this study. Twenty-one patients had cervicitis and 12 patients were included as controls.

RESULTS

Of the 29 patients studied, none showed evidence of H. pylori infection. H. pylori was not detected by PCR, histology, or culture.

CONCLUSIONS

We could not detect H. pylori in the cervix of patients with cervicitis. H. pylori-infected patients' cervices remain to be investigated, and a larger study is needed to draw firm conclusions.

Removal of the retained cervical stump

OBJECTIVE

The purpose of this study was to identify indications for and complications of abdominal or vaginal surgical removal of the cervical stump after previous supracervical hysterectomy.

STUDY DESIGN

This was a retrospective chart review of trachelectomy patients at Mayo Clinic, Rochester, Minnesota, or Mayo Clinic, Scottsdale, Arizona, between January 1974 and December 2003.

RESULTS

Of 335 patients with a history of supracervical hysterectomy who subsequently required trachelectomy, 25 were excluded from study. Half of the remaining 310 patients had trachelectomy between 1974 and 1983, an average of 26 years after hysterectomy. The indication in three quarters of trachelectomies performed vaginally was prolapse. The vaginal approach had significantly fewer complications than the abdominal approach.

CONCLUSION

Removal of the cervical stump is infrequent and has declined over a 30-year period. The decline in trachelectomy may be because of a decreasing number of supracervical hysterectomies performed. When trachelectomy is performed vaginally, prolapse is the most common indication, and there are few complications.

Hormonal contraception and risk of cervical infections among HIV-1-seropositive Kenyan women

OBJECTIVE

To evaluate the relationship between hormonal contraceptive use and the acquisition of cervical sexually transmitted infections (STI) among HIV-1-infected women.

DESIGN

A prospective cohort study of 242 commercial sex workers in Mombasa, Kenya, followed from the time of HIV-1 infection.

METHODS

At monthly follow-up visits, sexual behavior and contraceptive use were recorded, and laboratory screening for STI was performed. Multivariate Andersen-Gill proportional hazards models were constructed to examine the association between the use of hormonal contraception and the occurrence of cervical STI.

RESULTS

The median duration of follow-up after HIV-1 acquisition was 35 months, and 799 person-years of follow-up were accrued. After adjustment for demographic factors and sexual behavior, women using the injectable contraceptive depot medroxyprogesterone acetate were at increased risk of Chlamydia trachomatis infection [hazard ratio (HR) 3.1, 95% confidence interval (CI) 1.0-9.4, P = 0.05] and cervicitis (HR 1.6, 95% CI 1.0-2.3, P = 0.03) compared with women using no contraception. The use of oral contraceptive pills was associated with an increased risk of cervicitis (HR 2.3, 95% CI 1.4-3.8, P = 0.001). Hormonal contraception was not associated with an increased risk of infection with Neisseria gonorrhoeae.

CONCLUSION

The use of hormonal contraception by HIV-1-infected women was associated with an increased risk of cervicitis and cervical chlamydia infection. HIV-1-seropositive women using hormonal contraception should be counseled about the importance of consistent condom use to prevent both STI and HIV-1 transmission.

[Mycoplasmal infection in patients with reactive arthritis and seronegative spondyloarthropaties]

After investigation of 150 patients with reactive arthritis and undifferentiated spondyloarthropathies, inflammation signs of urogenital tract (uretritis in men and endocervicitis in women) were found in about 2/3 of patients. In those patients with reactive arthritis and undifferentiated spondyloarthropathies Ureaplazma urealyticum was found in more than 1/4 of patients, Mycoplasma hominis - in 1/10 of patients, and both microbes appeared in 1/10 of patients. Micoplasmal infection occurred in equal frequency in patients with reactive arthritis and undifferentiated spondyloarthropathies with a tendency to appear more in women than in men.

Increased risk of cervical canal infections with intracervical Foley catheter

OBJECTIVE

To evaluate the effect of intracervical Foley catheter insertion, for the induction of labor, on cervical canal infection.

DESIGN

A prospective interventional study with paired analysis.

PLACE AND DURATION OF STUDY

The study was conducted in the department of Obstetrics and Gynecology at the Aga Khan University, Karachi, between June 1 and August 31, 2002. SUBJECTS AND METHODS In 45 women undergoing cervical ripening with intracervical Foley catheter for the induction of labour at term, cervical swabs were taken for culture and sensitivity before its insertion and again after its spontaneous expulsion or removal.

RESULTS

Intracervical Foley catheter was retained for mean duration of 8.1 +/- 1.7 hours. There was a significant change in the pathogenic organisms (0 % v 16.3 %; p 0.016) from pre-Foley to post-Foley catheter cervical swab cultures. Growth of beta-hemolytic Streptococcus group-B, Candida albicans, Candida glabrata and Gardnerella vaginalis on cervical swab were considered pathogenic. One woman (2.2 %) developed fever following insertion of intracervical Foley catheter. No statistically significant effect of potential confounding factors was observed on change in growth of pathogenic organisms.

CONCLUSION

Induction of labour at term with Foley catheter is associated with a significant increase in intracervical pathogenic organisms despite undertaking routine aseptic measures. We recommend evaluation of this technique for its potential infectious harm in larger studies. Meanwhile, extreme aseptic measures should be undertaken during its insertion to avoid maternal and possible neonatal infections.

Interrelationships of bacterial vaginosis and cervical inflammation

BACKGROUND

Women with cervicitis frequently have bacterial vaginosis (BV). Prior studies have suggested that BV is involved in the pathogenesis of cervicitis.

GOALS

To delineate the association of BV and cervicitis and to determine whether treatment of BV results in increased resolution of cervicitis.

STUDY DESIGN

Women with clinically diagnosed cervicitis and BV received doxycycline and ofloxacin and were randomized to treatment with metronidazole gel or placebo. Resolution of BV and cervicitis was assessed.

RESULTS

Metronidazole gel was associated with resolution of BV. Resolution of cervicitis was associated with use of metronidazole gel versus placebo (24/27 [88.9%] versus 15/24 [62.5%]; P = 0.03). When further stratified by resolution of BV, those whose BV resolved were more likely to have resolution of cervicitis than those with persistent BV. Although these trends persisted in multivariate analyses, they did not achieve statistical significance.

CONCLUSION

Univariate analyses suggest an association between BV and cervicitis. An association between the use of metronidazole gel and resolution of cervicitis was demonstrated. Hypotheses regarding the latter include nonspecific antiinflammatory effects of metronidazole, its effect on BV flora, and its effect on a specific unrecognized pathogen.

Demographic and behavioural profile of adults infected with chlamydia: a case-control study

OBJECTIVES

To determine which demographic and behavioural parameters are independently associated with chlamydial infection in adults.

METHODS

Subjects were recruited prospectively from male and female attendees at a large clinic for sexually transmitted infections (STI). All subjects were tested for chlamydia and gonorrhoea and asked to complete a questionnaire addressing demography, sexual and non-sexual (including drug taking) behaviour, and history of STI. Cases were those attending with a new clinical episode and found to be infected with chlamydia, but who did not have gonorrhoea. A control group was selected randomly from those found to be negative on screening for both infections.

RESULTS

986 cases and 1212 controls were recruited over one calendar year. The following were found to be independent risk factors for chlamydial infection on multivariate analysis (odds ratios with 95% confidence intervals in parentheses): being unmarried (1.8; 1.1-3.1); black Caribbean ethnicity (2; 1.5-2.7). Increasing age, fewer partners, and higher reported use of condoms were associated with a lower risk of infection.

CONCLUSION

Black Caribbeans are at increased risk from chlamydia after controlling for sexual behaviour and socioeconomic status. Future research should seek an explanation elsewhere-for example, in terms of differences in sexual mixing or effectiveness of healthcare interventions.

Diagnosing PID--getting the balance right

The objective of the study was to determine the clinical manifestations and diagnostic criteria used to diagnose presumptive pelvic inflammatory disease (PID) at the Sydney Sexual Health Centre (SSHC). The study was a retrospective, case-note review of all women diagnosed with presumptive PID between April 1991 and December 1997. Seven hundred and thirteen women were included. The commonest recorded symptoms were vaginal discharge (68%), lower abdominal pain (65%) and dyspareunia (57%), while adnexal tenderness (83%), cervical motion tenderness (75%) and cervicitis (56%) were the most frequently recorded examination findings. Sixty-two per cent were prescribed doxycycline and metronidazole. The recording of signs and symptoms in women with presumptive PID was poor and only 22% met the current Centers for Disease Control (CDC) diagnostic criteria. It is likely that PID is over diagnosed in this group of women. This may lead to under diagnosis of other conditions causing pelvic pain and may be detrimental to reproductive health.

[Microbiological approaches to the prognostication of inflammatory complications after intrauterine interventions]

The species composition and persistence parameters of vaginal microflora in women after intrauterine interventions (intrauterine contraception and artificial abortion) has been studied. The relationship between inflammatory complications after intrauterine interventions and previous changes in the microflora has been established. Criteria for the evaluation of vaginal microbiocenosis, making it possible to prognosticate the appearance of inflammatory complications after intrauterine interventions, have been worked out.

[The etiology of infectious cervicitis in women]

Infectious cervicitis is a common disease in women of reproductive age. A prospective study was carried out including 70 women with clinical manifestations of cervicitis during gynecological and colposcopic examination. In 19 women (27%), Chlamydia trachomatis was demonstrated by direct immunofluorescence in cervical smears. Neisseria gonorrhoeae was isolated in 2 women and 1 had a concomitant infection with Neisseria gonorrhoeae and Chlamydia trachomatis. Mycoplasma hominis and Ureaplasma urealyticum were isolated in 7 patients and 4 had cytological smears consistent with Human Papilloma Virus infection. In the rest 47 patients no etiological agent was found. The results of the present study indicate that the most common etiological cause for infectious cervicitis can be Chlamydia trachomatis and an examination for this organism should me mandatory in women with infectious cervicitis for guiding the correct diagnosis and treatment.

[Incidence and risk factors of papillomavirus infection and cervical dysplasia in sexually active adolescent girls]

A cytological examination of 425 sexually active females aged 13-17 established cervical HPV infection incidence at 30.3 +/- 2.2% while that of cervical dysplasia--4.5 +/- 1.0%. The risk factors for HPV infection included low education and income level (p < 0.05), number of sexual partners exceeding three (p < 0.05), poor hygienic standards of woman (p < 0.05) and those of partner (p < 0.001) and smoking of more than 5 cigarettes per day (p < 0.001). The risk factors of cervical epithelial dysplasia were number of partners of 5 or more (p < 0.001), poor hygienic standards of male partner (p < 0.001) and smoking of 10 cigarettes and more per day (p < 0.001), etc.

Molecular epidemiology of genital Chlamydia trachomatis infection in high-risk women in Senegal, West Africa

The prevalence and heterogeneity of Chlamydia trachomatis infections in a cohort of female sex workers in Dakar (Senegal) were determined by using endocervical-swab-based PCR DNA amplification assays. The overall prevalence of cervical chlamydial infection was 28.5% (206 of 722), and most of these infections were asymptomatic. An increased number of sexual partners was significantly associated with infection (adjusted odds ratio [AOR] = 1.37; 95% confidence interval [CI] = 1.06 to 1.77), while the presence of a yeast infection was negatively associated with chlamydial infection (AOR = 0.28; 95% CI = 0.10 to 0.83). Six different C. trachomatis genotypes were identified based on phylogenetic analysis of the omp1 gene sequences. Interestingly, genotype E predominated (47.6%) and was not associated with visible signs of cervical inflammation compared to non-E genotypes (P < 0.05). Overall, the high rate of asymptomatic C. trachomatis infection by genotype E may suggest genotype-specific properties that confer a transmission advantage in this high risk population.

Gynecologic conditions and bacterial vaginosis: implications for the non-pregnant patient

Bacterial vaginosis is characterized by a shift from the predominant lactobacillus vaginal flora to an overgrowth of anaerobic bacteria. Bacterial vaginosis is associated with an increased risk of gynecologic complications, including pelvic inflammatory disease, postoperative infection, cervicitis, human immunodeficiency virus (HIV), and possibly cervical intraepithelial neoplasia (CIN). The obstetrical risks associated with bacterial vaginosis include premature rupture of membranes, preterm labor and delivery, chorioamnionitis and postpartum endometritis. Despite the health risks associated with bacterial vaginosis and its high prevalence in women of childbearing age, bacterial vaginosis continues to be largely ignored by clinicians, particularly in asymptomatic women.

Urethritis and cervicitis

BACKGROUND

With sexually transmitted diseases (STDs) no longer on the decline, it is prudent to assume that all cases of non specific urethritis and cervicitis are caused by sexually transmitted infection. Specific infections of the urethra and cervix due to chlamydia and other non gonococcal organisms are common and because they are often not apparent clinically, are underdiagnosed.

OBJECTIVE

The aim of this paper is to provide a realistic approach to the management of urethritis and cervicitis by encouraging the performance of investigations and the instigation of treatment at the first consultation.

DISCUSSION

A knowledge of the patient's sexual history combined with a working knowledge of the new DNA based technologies should provide for the early assessment of and intervention with patients who are at risk of at least one STD infection.

Biological behavior and etiology of inflammatory cervical smears

Two hundred and fifty-seven consecutive women attending a major maternal and child health (MCH) center were studied clinically, colposcopically, cytologically, and microbiologically for different gynecologic infections. Out of 257 cases, 207 (80.5%) had inflammatory cervical smears, of which 183 (88.4%) were infected with one or more genital tract infections. Bacterial vaginosis (risk, 22.6-fold), chlamydia (risk, 21.6-fold), and human papillomavirus (HPV) (risk, 13.5-fold) were independently associated with inflammatory smears. In addition, significantly higher proportions of women with inflammatory smears had cervical ectopies (28.5% vs. 10.2%) and bleeding ectopies (30.9% vs. 4.1%) as compared to noninflammatory smears. Women infected with bacterial/parasitic genital infections were given specific treatment. These women were followed up at regular intervals to assess the efficacy of antimicrobial therapy. During follow-up examination, only 26 women (12.6%) showed negative smears. Sixteen women developed squamous intraepithelial lesions (SIL) during follow-up, and 163 women had persistent inflammatory smears. Multivariate analysis revealed that persistent inflammatory smears were associated with herpes simplex virus (HSV) infection, as revealed through detection of IgA antibodies to HSV (risk, 11.5-fold). Progression of SIL was associated with HPV infection (risk, 17.6 fold). Thus, inflammatory smears are associated with different types of infection, most of which do not respond to antimicrobial therapy.

[Mycoplasma hominis and Ureaplasma urealyticum in different gynecologic diseases]

The incidence of Mycoplasma hominis (M. hominis) y Ureaplasma urealyticum (U. urealyticum) was investigated in 113 endocervical samples obtained from women who were seen for different gynecological pathologies. Forty-seven (42%) patients were positive to these microorganisms; 26 cases (23%) were positive for M. hominis and 21 (19%; p = NS) for U. urealyticum. Average age was 32.1 +/- 7.7 years; the average number of sexual partners was 1.7 +/- 1.1. Eleven of 17 patients with 3 o more sexual partners were positive for Genital Mycoplasma (GM), and U. urealyticum was found more often in this group. A higher incidence of GM was found in women between 26 and 30 years (34%); 57.5% of the patients with positive cultures for GM had begun sexual activity before 20 years of age. M. Hominis was found in 61% of women with no parity and U. urealyticum in 71% of parous women. The cultures were positive in 10 of 14 patients with pelvic inflammatory diseases (PID). A cervical biopsy was taken from 52 cases and the diagnosis of cervical intraepithelial neoplasia (CIN) was made in 49 (94%) but only 24 of them were positive for GM (50%). Thirty-five patients suffered sterility, and 12 (34%) were positive for GM, however all positive cases consulted because of primary sterility. The conclusions obtained from this study are: 1) Near half of the patients was positive for GM and none of the species was predominant over the other. 2) The more sexual partners the higher was the incidence of GM, especially U. Urealyticum. 3) The lower the age of the first sexual intercourse the higher the probability of contamination with these microorganisms. 4) M. hominis was more common in nulliparous women and U. urealyticum was found more often in parous patients; the number of deliveries did not have influence in these findings. 5) A statistical significance between GM and PID was found (p = 0.03). 6) GM have no influence on spontaneous abortion. 7) No statistical significance was found between GM and the beginning and evolution of CIN. 8) No relation statistically significative was found between GM and sterility.

[Problems of diagnosis and treatment of cervicitis]

Infectious cervicitis is a common disease in women of reproductive age. The symptoms are not characteristic and they are often neglected by the patient and the physician. Cervicitis is a very important clinical entity, because the infection can ascend to the genital tract. The most common causes for the infectious cervicitis are Chlamydia trachomatic and Neisseria gonorrhoeae. A variety of methods for the precise diagnosis must be employed--gynecologic examination, colposcopy, pathomorphology and cytology and bacteriological examination as well. Therapeutic modalities must include coverage for both Chlamydia trachomatis and Neisseria gonorrhoeae. Bacteriological test of cure is mandatory.

Using age to predict cervical infection in women presenting with lower genital tract syndrome in Cape Town

In developing countries without access to laboratory testing, the syndromic management of cervicitis in women with lower genital tract symptoms results in overtreatment. We evaluated the validity of using different age cut-offs to predict the risk of cervical infection in women attending a clinic for sexually transmitted diseases in Cape Town. Specimens from 161 women with lower genital tract symptoms were examined microbiologically for evidence of cervicitis (gonorrhoea and/or chlamydial infection). Women with cervicitis (median 21 years) were significantly younger than those not infected (median 23 years). Retrospective simulation using the age cut-offs (< 45 years (current approach), < 30 years, and < 25 years) to predict cervicitis showed that specificity could be increased (overtreatment reduced) from 17% to 50% if presumptive diagnoses of cervicitis were restricted to women aged under 25 years. Lowering the age cut-off would severely limit sensitivity, however, and as many as 9% and 20%, respectively, of infected women would go untreated if the age cut-offs < 30 and < 25 years were used. The use of a lower age cut-off would therefore serve neither individual nor public health in the presumptive diagnosis and treatment of cervicitis in a high risk population, and would result in a substantially lower detection rate.

Twelve-month comparative multicenter study of the TCu 380A and ML 250 intrauterine devices in Bangkok, Thailand

The long-term effectiveness of the copper-bearing intrauterine device (IUD) has been documented. This paper reports 12-month results from a multiyear comparative study of the Copper T (TCu) 380A and Multiload (ML) 250 IUD in Bangkok, Thailand, among 1396 women. Continuation of the assigned IUD was relatively high after 12 months of use, with continuation rates of 90.17 and 87.54 per 100 women, respectively. Whereas the accidental pregnancy rate was higher for the ML 250 IUD than for the TCu 380A IUD (1.0 and 0.2 per 100 women, respectively), this difference was not considered statistically significant (p < 0.69). The rate of IUD expulsion was significantly higher among women using the ML 250 IUD than for women using the TCu 380A IUD (4.61 and 2.40 per 100 women, respectively, p = 0.05).

Factors related to cervicitis in Qashghaee nomadic women of southern Iran

In a survey of reproductive habits and cervical pathology in 1015 women of the Qashghaee nomadic tribe of southern Iran, a high prevalence (80%) of cervicitis was observed. The effects of reproductive and other habits on risk of cervicitis were therefore assessed using proportional odds modelling. Increased risks of a higher degree of cervicitis were associated with middle to late age (p = 0.02), a history of delivery of children (p = 0.001), intercourse during menses (p = 0.03) and a history of ever giving birth in a maternity hospital (p = 0.02). A lower risk was associated with increased duration of marriage (p = 0.05). The increased risk observed for history of birth in maternity hospital may reflect a prior obstetric problem which predisposes to both cervicitis and seeking the specialist obstetric care provided in the maternity hospital. Results suggest an infectious agent which may be transmitted in childbirth.

Use of wet mount to predict Chlamydia trachomatis and Neisseria gonorrhea cervicitis in primary care

BACKGROUND AND OBJECTIVES

Cervicitis is associated with salpingitis, infertility, and complications of pregnancy. Universal screening has been recommended for high-prevalence populations but may not be appropriate in the family practice setting. Leukocytes on an endocervical gram stain have been associated with infectious cervicitis due to Chlamydia trachomatis and Neisseria gonorrhea. This study sought to determine whether the finding of leukocytes in a vaginal wet mount could be used to screen for infectious cervicitis in an urban family practice.

METHODS

A consecutive sample of 357 women had cultures for C trachomatis and N gonorrhea and a standardized wet mount.

RESULTS

All women with infectious cervicitis were under age 35. Thirty-six percent of infected women had more leukocytes than epithelial cells in the wet mount, compared with 23% of women without these organisms.

CONCLUSIONS

Wet mount findings did not reliably predict infectious cervicitis. Study of a larger population is needed to confirm these findings.

[Analysis of obstructive dystocia due to cervical adhesion caused by gonococcal infection]

OBJECTIVE

To analyse the clinical manifestation and treatment of obstructive dystocia due to cervical adhesion.

METHOD

Ten cases of obstructive dystocia due to cervical adhesion were retrospectively analysed.

RESULTS

Gram's stain of the cervical smear was positive for gonococci in all of the 10 patients. Sites of the cervical adhesion were at external os in 5 cases, at internal os in 2 cases and in cervical canal in the other 3. The clinical manifestation varied with the site of the cervical adhesion. All the patients had spontaneous delivery after separating the adhesions.

CONCLUSION

As one of the factors of high-risk pregnancy, obstructive dystocia due to cervical adhesion caused by gonococcal infection should be considered seriously by the obstetricians.

Vaginal discharge. How to pinpoint the cause

Vaginal discharge is a common symptom of genital infection in women. Identifying its source can be challenging, because a large number of pathogens cause vaginal and cervical infection, and several infections may coexist. Patient history and physical examination findings may suggest a diagnosis. Useful tests for etiologic diagnosis include pH analysis of vaginal fluid, the "whiff" test, wet mount examination, culture, and Gram's stain. Once the source of infection has been identified, the patient can be treated, usually with oral antibiotics, oral antifungals, or topical vaginal preparations.

Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching

OBJECTIVE

Our purpose was to assess determinants of cervical ectopia and cervicitis, specifically after adjustment for cervical infection.

STUDY DESIGN

A cross-sectional study was conducted with colposcopic, cytologic, and microbiologic examination of 764 randomly selected women attending a sexually transmitted disease clinic and 819 consecutive college students undergoing routine annual examination.

RESULTS

After we controlled for potential confounders, cervical ectopia was positively associated with oral contraception and Chlamydia trachomatis infection and negatively associated with aging in both populations, with recent vaginal douching in patients with sexually transmitted diseases, and with current smoking in college students. Oral contraception wa also associated with the radius of ectopia, and among users of oral contraception ectopia was associated with duration of oral contraception. Cervicitis (evaluated by Gram stain, Papanicoloau smear, and colposcopy) was associated with cervical infection by C. trachomatis and cytomegalovirus (both populations) and with gonorrhea and cervical herpes simplex virus infection (patients with sexually transmitted diseases). Cervicitis was independently associated with ectopia but not with oral contraception after we adjusted for these four cervical infections. However, oral contraception was associated with edema and erythema of the zone of ectopia among women without cervical infection.

CONCLUSIONS

Oral contraception, aging, cervical infection, smoking, and douching have effects on cervical ectopia that may influence the acquisition, transmission, or effects of sexually transmitted agents. Ectopia is associated with young age, oral contraception, and cervical infection; cervicitis is associated with ectopia and cervical infection by C. trachomatis, Neisseria gonorrhoeae, herpes simplex virus, and cytomegalovirus. In women without cervical infection, edema and erythema of the zone of ectopia are associated with oral contraception.

[Modification of operative support methods for urinary stress incontinence in women using a free fascia band]

The author modified the sustaining methods applied until now for treatment of stress urinary incontinence (s.u.i.) in women by replacing the peduncular "supports" with a free fascial band. The surgeries by choice were performed on hard working manual female workers in which s.u.i. was associated with anterior colpoptosis. During 6-years observation, recovery (very good and good results) was found in 89.3% of cases.

[The enzymatic diagnosis of endocervicitis caused by Chlamydia trachomatis]

The authors compare the reliability of an enzyme method for diagnostics of chlamydial endocervicitis versus Clearview chlamydia test. The results suggest that the enzyme test may be applied with sufficient diagnostic reliability.

[Intrauterine device-associated genital actinomycosis. Diagnosis and therapy with reference to five case reports]

Between 1992 and the beginning of 1993, 5 patients attending the gynecological department of the Charité Hospital in Berlin were treated for IUP-associated actinomycosis. The IUP had been used by these women for periods of between five and sixteen years. The primary diagnosis was established on the basis of a histological examination in three cases. In two cases, dysplasias had been diagnosed on the basis of the cytological examination. In one case, the primary diagnosis was suspected by the finding of actinomycetes in the cytological preparation. The treatment of choice is high-dose intravenous penicillin administered over the long term.

[Actinomycosis and intrauterine spiral. 4 case reports]

Genital actinomycotic infections are relatively rare and show a strong coincidence with long term IUD application. Two patients without symptoms, where diagnosis was made by means of Papanicolaou smears, were compared with two patients, where removal of a tubovarian mass led to diagnosis. A general agreement about diagnosis and especially screening tests are still missing, but there seems to be a consensus regarding the types of IUD, the duration of use, and the sexual behaviour of the patients.