Cervical Ectopy Research Articles

Auditing the Use of Colposcopy Versus General Gynecology Clinics to Investigate Women With Postcoital or Intermenstrual Bleeding

The aim of this audit was to determine whether initial referral to a general gynecology clinic (GOPD) or a colposcopy clinic is the most efficient means of managing women with postcoital (PCB) or intermenstrual (IMB) bleeding. A prospective audit of women with PCB or IMB was conducted. Sixty referrals from primary care were note-logged and alternatively allocated to either clinic. Data were collected by case note review. Sixty women were referred for abnormal bleeding, 33 (55%) of which were seen at the GOPD and 27 (45%) at the colposcopy clinic. Investigations included Chlamydia testing, which was deficient in both settings, whereas ultrasound scans and hysteroscopies were performed in 9% of patients attending the GOPD compared with none in the colposcopy clinic. The most common finding at the GOPD was cervical ectopy in 14 (42%) patients. No abnormality was found in 9 (28%) patients. At colposcopy, 14 (52%) had no abnormality detected, whereas 8 (30%) had cervical ectopy and 3 (11%) had cervical intraepithelial neoplasia. There were no cases of malignancy found in this study. Most patients with PCB and IMB will not have a serious abnormality. Our study proposes that a new PCB/IMB outpatient service can improve the efficiency of treatment of these women by providing appropriate guidelines to standardize their care.

Nested Case–Control Study of Cervical Mucosal Lesions, Ectopy, and Incident HIV Infection Among Women in Cape Town, South Africa

The objective of this study was to test whether cervical mucosal lesions and ectopy increase women's susceptibility to HIV infection. HIV-seronegative women ages 35 to 65 years (n = 5773) enrolled into a cervical cancer screening trial were followed for up to 36 months. All HIV seroconverters (n = 86) in the cohort were compared with randomly selected controls (n = 324) who did not seroconvert. Magnified photographs of the cervix taken during speculum examination at enrollment were evaluated for cervical mucosal lesions and ectopy using standard criteria. The presence of mucosal lesions (observed among 19% of controls) was associated with increased risk of HIV seroconversion (adjusted odds ratio [AOR] = 1.93; 95% confidence interval [CI] = 1.07-3.48). Ectopy extending over >20% of the cervix was also associated with HIV seroconversion (AOR = 2.18; 95% CI = 1.01-4.69). Visible lesions of cervical mucosa and cervical ectopy may be markers of increased susceptibility to HIV infection among women. Protection of the mucosa of the cervix may provide an important approach for new HIV prevention technologies.

Should Women with Postcoital Bleeding Be Referred for Colposcopy?

This study was to determine the risk of finding significant cervical pathological abnormality in women referred to the colposcopy clinic primarily because of postcoital bleeding. We evaluated the cervical smear history of such women and correlated this with any colposcopic or pathological abnormality. There were 142 women seen over a period of 12 months. The age range of the study population was 16 - 61 years (mean age of 34.1 years). There was no case of lower genital tract invasive neoplasia. Out of the 142 cases, 56 women (39.4%) had normal findings at colposcopy and 44 (31%) were secondary to cervical ectopy. A total of 27 (19%) had cervical intraepithelial neoplasia (CIN) out of which there were 15 (10.6%) cases of high-grade disease (CIN II and CIN III); and, 20 (74%) out of the 27 women with CIN had a recently negative cervical smear (within the previous 36 months). Seven women (4.9%) had benign cervical polyps that were removed during colposcopy. The frequency of finding invasive lower genital tract neoplasia in women with postcoital bleeding is low. However, a good proportion of them would have a diagnosis of cervical intraepithelial neoplasia even with a recently negative cervical smear. Therefore, postcoital bleeding should remain an indication for referral to the colposcopy clinic for a detailed evaluation of the lower genital tract.

Relationship of cervical ectopy to chlamydia infection in young women

ObjectiveGenital Chlamydia trachomatis infection is the most common bacterial sexually transmitted infection (STI) in the UK. Behaviours including multiple sex partners and inconsistent condom use, and biological factors such as...

Post-coital bleeding: a rare and unusual presentation of cervical endometriosis

Often due to benign conditions such as cervical ectopy, post-coital bleeding is a distressing symptom for the patient. However, for the clinician, the identification of the etiology is important in order to effect proper treatment. We present a case referred to the colposcopy clinic because of post-coital bleeding and a smear report of 'groups of benign glandular cells of endometrial origin'. Colposcopy was normal but histology of an excised haemorrhagic nodule revealed endometriosis with resolution of symptoms. Cervical endometriosis should be considered in the differential diagnosis of post-coital bleeding with no obvious ectopy or malignancy.

Age-Related Changes of the Cervix Influence Human Papillomavirus Type Distribution

Approximately 15 human papillomavirus (HPV) types cause virtually all cervical cancer whereas other HPV types are unrelated to cancer. We were interested in whether some noncarcinogenic types differ from carcinogenic in their affinity for the cervical transformation zone, where nearly all HPV-induced cancers occur. To examine this possibility, we tested cervical specimens from 8,374 women without cervical precancer and cancer participating in a population-based study in Guanacaste for >40 HPV types using PCR. We compared age-group specific prevalences of HPV types of the alpha9 species, which are mainly carcinogenic and include HPV16, to the genetically distinct types of the alpha3/alpha15 species (e.g., HPV71), which are noncarcinogenic and common in vaginal specimens from hysterectomized women. We related HPV detection of each group to the location of the junction between the squamous epithelium of the ectocervix and vagina and the columnar epithelium of the endocervical canal. Models evaluated the independent effects of amount of exposed columnar epithelium (ectopy) and age on the presence of alpha9 or alpha3/alpha15 types. Prevalence of alpha9 types (7.6%) peaked in the youngest women, declined in middle-aged women, and then increased slightly in older women. By contrast, prevalence of alpha3/alpha15 types (7.6%) tended to remain invariant or to increase with increasing age. Detection of alpha9 infections increased (P(trend) < 0.0005) but alpha3/alpha15 infections decreased (P(trend) < 0.0005) with increasing exposure of the columnar epithelia. Older age and decreasing cervical ectopy were independently positively associated with having an alpha3/alpha15 infection compared with having an alpha9 infection. These patterns need to be confirmed in other studies and populations. We suggest that these genetically distinct groups of HPV types may differ in tissue preferences, which may contribute to their differences in carcinogenic potential.

Should women with postcoital bleeding be referred for colposcopy?

SummaryThis study was to determine the risk of finding significant cervical pathological abnormality in women referred to the colposcopy clinic primarily because of postcoital bleeding. We evaluated the cervical smear history of such women and correlated this with any colposcopic or pathological abnormality. There were 142 women seen over a period of 12 months. The age range of the study population was 16 – 61 years (mean age of 34.1 years). There was no case of lower genital tract invasive neoplasia. Out of the 142 cases, 56 women (39.4%) had normal findings at colposcopy and 44 (31%) were secondary to cervical ectopy. A total of 27 (19%) had cervical intraepithelial neoplasia (CIN) out of which there were 15 (10.6%) cases of high-grade disease (CIN II and CIN III); and, 20 (74%) out of the 27 women with CIN had a recently negative cervical smear (within the previous 36 months). Seven women (4.9%) had benign cervical polyps that were removed during colposcopy. The frequency of finding invasive lower genital tract neoplasia in women with postcoital bleeding is low. However, a good proportion of them would have a diagnosis of cervical intraepithelial neoplasia even with a recently negative cervical smear. Therefore, postcoital bleeding should remain an indication for referral to the colposcopy clinic for a detailed evaluation of the lower genital tract.

Young age is a risk factor for HIV among female sex workers—An experience from India

A cross-sectional community-based study was conducted among brothel-based sex workers of West Bengal, eastern India, to study the prevalence of HIV and associated risk factors. Unlinked anonymous HIV testing was performed on 2076 sex workers. Of these, 558 were interviewed using a pre-tested questionnaire to study their risk factors. Overall HIV sero-prevalence was 5.9%. All infections were HIV-1, except that four sex workers from Kolkata were infected with HIV-2. Surprisingly, HIV infection was much higher (12.5%) in younger sex workers (age < or =20 years) compared with older age groups (5.4%) (P=0.002; odds ratio 2.40, 95% CI: 1.29-4.38). This could be associated with larger areas of cervical ectopy of younger sex workers who are subjected to repeated trauma during sexual intercourse, facilitating higher HIV transmission. Behavioral factors may increase a young sex worker's risk of acquiring HIV infection, including professional immaturity with clients, which might lead to more unprotected sex. HIV status was associated with other sexually transmitted infection in the previous year but was not associated with literacy status, daily income, duration of sex work, number of clients entertained per day, entertaining clients outside a brothel (in a hotel), and reported condom use.

Prospective Clinical Trials Designed to Assess the Use of Hormonal Contraceptives and Risk of HIV Acquisition

Prospective Clinical Trials Designed to Assess the Use of Hormonal Contraceptives and Risk of HIV Acquisition

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

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

Human papillomavirus infection and cervical ectopy

Objectives: To investigate the prevalence of human papillomavirus (HPV), and HPV type 16 (HPV16) infection in cervical ectopy, and the presence of anti-HPV16 secretory IgA (sIgA) antibodies. Methods: DNA from patients with cervical ectopy ( n=218), HPV-associated lesions ( n=111), and controls without evidence of cervical ectopy or HPV infection ( n=93) were analyzed by PCR for the presence of HPV and HPV16. The presence of mucosal sIgA antibodies against HPV16 capsid antigens (VLP) was assayed in cervical mucus by ELISA. Results: Prevalence of HPV DNA was higher in cervical ectopy than in controls ( P=0.04; OR=2.06; 95% CI 0.99–4.33). HPV16 was 6.3 times more prevalent in cervical ectopy than in controls. Anti-HPV16 sIgA were detected more frequently in cervical ectopy patients than in controls ( P=0.0004). Conclusions: Cervical ectopy correlates with HPV infection. HPV16 is highly prevalent in cervical ectopy. sIgA antibodies against HPV16 capsids are generated in patients with cervical ectopy.

A clinico-pathological study of postcoital bleeding.

To undertake a clinical study of postcoital bleeding (PCB) in a district general hospital we retrospectively reviewed the records of 248 patients referred to the gynaecology department over a 5-year period. 63% were in the 21-40-year age group and 80% were multiparous. Seventy per cent were referred to the gynaecology out patients' clinic and 28% to the colposcopy clinic. Associated symptoms included menstrual abnormalities (39%) and dyspareunia (13%). Twenty per cent had benign polyps, including endometrial polyps and 25% had cervical ectropion. Cervical intraepithelial neoplasia was detected in 6.8% of cases. There was no case of invasive cancer of the lower genital tract. This is the first report of associated endometrial polyps contributing to PCB. We conclude that CIN may not always be asymptomatic and the incidence of cervical or endometrial cancer is low in women with PCB.

Nongonococcal and Nonchlamydial Cervicitis.

Cervicitis encompasses a variety of gynecologic conditions. Although inflammation on a Papanicolaou smear may be indicative of true cervical inflammation, establishing a diagnosis of mucopurulent cervicitis (MCP) is more clinically useful. MCP seems to be analogous to nongonococcal urethritis in men. Many cases of MCP are related to Chlamydia trachomatis infection, but the majority of cases have other potential causes. Other possible pathogens include Neisseria gonorrhoeae, Trichomonas vaginalis, Ureaplasma urealyticum, Mycoplasma genitalium, herpes simplex virus, and cytomegalovirus. Many cases may be related to cervical ectopy. MCP is a marker for endometritis, salpingitis, and adverse pregnancy outcomes. Given the current shortcomings in our understanding of this disease, an empiric approach to evaluation and treatment is suggested.

Histologic development of cervical ectopy: relationship to reproductive hormones.

Cervical ectopy has been proposed as a risk factor for chlamydial infection, HIV, and other sexually transmitted diseases (STDs). Ectopy is a histologic phenomenon resulting from a complex interplay of morphologic and hormonal processes. Reproductive hormones influence the production of ectopy during late fetal life, puberty, pregnancy, and with use of oral contraceptives. Ectopy is modified over time by squamous metaplasia and epitheliazation, low pH, trauma, and possibly by cervical infection. The authors review the histologic development of ectopy from late fetal life to menopause to understand STD risk. Ectopy is often assessed and quantified by direct, unaided observation during speculum examinations. This method may result in inaccurate estimates and misclassification with the transformation zone. Valid, reproducible measures of ectopy are necessary for epidemiologic studies to examine the impact of exogenous hormonal contraceptives on the development of ectopy and on potential infection risk.

The measurement of cervical ectopy: Computerized planimetry verus clinical assessment

The measurement of cervical ectopy: Computerized planimetry verus clinical assessment

High prevalence of genital Chlamydia trachomatis infection in women presenting in different clinical settings in Jamaica: implications for control strategies.

OBJECTIVE: To determine the prevalence of genital Chlamydia trachomatis infection and risk factors in women attending family planning, gynaecology, and sexually transmitted disease (STD) clinics in Jamaica. METHODS: Endocervical specimens...

Effect of intrauterine device use on cervical shedding of HIV-1 DNA.

Hormonal contraception has been associated with an increased prevalence of cervical shedding of HIV-1 DNA among infected women. We conducted this study to evaluate the effect of the use of an intrauterine device (IUD) on the detection of HIV-1 DNA in cervical secretions. A prospective study of HIV-1-seropositive women undergoing IUD insertion at two public family planning clinics in Nairobi, Kenya. Cervical swab samples were collected before IUD insertion and approximately 4 months thereafter for the detection of HIV-1-infected cells using polymerase chain reaction (PCR) amplification of HIV-1 gag DNA sequences. Ninety-eight women were enrolled and followed after IUD insertion. The prevalence of HIV-1 DNA cervical shedding was 50% at baseline and 43% at follow-up [odds ratio (OR) 0.8, 95% confidence interval (CI) 0.5-1.2]. There was no statistically significant difference between the baseline and follow-up shedding rates in a multivariate model that controlled for previous hormonal contraceptive use, condom use, cervical ectopy, friable cervix, cervical infections at an interim visit, and CD4 lymphocyte levels (OR 0.6, 95% CI 0.3-1.1). The insertion of an IUD did not significantly alter the prevalence of cervical shedding of HIV-1-infected cells. The use of IUDs, in conjunction with condoms, may be an appropriate method of contraception for HIV-1-infected women from the standpoint of potential infectivity to the male partner through exposure to genital HIV-1.

The effect of one injection of Depo-Provera® on the human vaginal epithelium and cervical ectopy

Two studies in rhesus monkeys have shown that progesterone implants, Depo-Provera® and Norplant®, were associated with vaginal thinning. Progesterone implants have also been associated with an increased risk of simian immunodeficiemcy virus (SIV) acquisition. This study in 16 women was done to assess vaginal epithelial thickness and number of cell layers from biopsies taken in the untreated follicular and luteal phases, and at 1 month and 3 months after administration of Depo-Provera. There was no significant change over time in either parameter from biopsies obtained in the luteal phase compared with those at either time after Depo-Provera administration. There was also no change in the mean number of Langerhans cells in vaginal wall specimens and no change in cervical ectopy. It appears that women do not respond to exogenous progestins with the dramatic vaginal thinning seen in rhesus monkeys.

Cervical ectopy and the transformation zone measured by computerized planimetry in adolescents

Objective: To determine whether cervical ectopy and the transformation (T) zone were larger in adolescents using oral contraceptives (OCs) compared to depot medroxyprogesterone acetate (DMPA). Method: Cervical photographs were taken on 91 adolescents in Baltimore, Maryland. Ectopy and T zone size were measured using computerized planimetry. Patients provided reproductive and sexual history. Correlates of ectopy and T zone size were identified by proportional odds and linear regression models, respectively. Result: Twenty-five women had no ectopy. Parity was independently associated with greater ectopy (OR 3.9, 95% CI 1.37–11.11). Predictors of smaller ectopy were douching (OR 0.23, 95% CI 0.09–0.65), and shorter sexual history (OR 0.20, 95% CI 0.05–0.74). Neither OC or DMPA were associated with ectopy. Predictors of greater T zone size were years since menarche (13.8 mm 2/year, P=0.003) and OCs (54.7 mm 2, P=0.05). DMPA predicted a smaller T zone (−67.0 mm 2, P=0.01). Conclusion: Computerized planimetry provides standardized measurements. Douching and sexual activity may decrease ectopy through increased squamous metaplasia. Hormonal contraceptives were not associated with ectopy in adolescents. However, long-term progestin use may decrease T zone size.

Prevalence of visible disruption of cervical epithelium and cervical ectopy in african women using depo-provera®

Associations between Depo-Provera® (injectable, progesterone-only contraceptive) use and visible disruption of cervical epithelium and cervical ectopy were investigated using data collected as part of a cervical cancer screening study in periurban Cape Town, South Africa. Women were interviewed about their contraceptive use, and underwent a gynecologic examination that included two 35-mm photographs of the cervix after application of 5% acetic acid. Photographs of 723 subjects were reviewed (blind to clinical information and using systematic criteria developed before review) for evidence of atrophy and epithelial disruption, including inflammation and ulceration. The percentage of the cervix covered with columnar epithelium (ectopy) was also estimated from the photographs. A random sample of 85 photographs was reviewed again for reliability. A total of 121 current users of Depo-Provera were no more likely to have evidence of epithelial disruption (38%) than 574 nonusers (39%), odds ratio (OR) = 1.37, 95% CI: 0.89–2.11 adjusting for age and parity. The prevalence of significant ectopy (columnar epithelium covering >10% of the cervix) was also no different among current Depo-Provera users (OR = 1.22, 95% CI: 0.80–1.86 adjusting for age and parity). Reliability of visual scoring of epithelial disruption and ectopy was excellent (κ = 0.8). Although the underlying prevalence of visible disruption of cervical epithelium was very high, current use of Depo-Provera was not associated with increased prevalence of visible disruption of the cervical epithelium or with ectopy in this sample of African women.