Cervical Cytologic and Colposcopic Changes in Cases Using Intrauterine Devices for Along Time

INTRODUCTION

Intrauterine Contraceptive Devices (IUCDs) are a sort of long-acting reversible contraception, the most effective reversible birth control method. IUCDs are reversible, long-acting, safe, cost and effective. IUCD is one of the most commonly used family planning method after voluntary female sterilization.¹

Intrauterine devices are reversible, long-lasting, and the most commonly used birth control method worldwide. It is still unclear how IUDs work. It is believed that it has various effects on sperm, ovum, fertilization, implantation, and endometrium. The optimal time for IUD insertion is the menstrual period. Postpartum IUD insertion can be performed during the postpartum control visits 4-8 weeks after delivery. Studies could not prove the fact that IUDs

increased the risk of pelvic infection and caused an ectopic pregnancy, of all other female genital organ cancers, cervical cancer is the most common cancer type for women worldwide.²

Cervical cancer, with an ever-increasing incidence rate in younger females worldwide, has been one of the major causes of morbidity in women below 40 years of age. Cervical cancer is seen at lower rates in developed countries where the public health is improved, while it is more prevalent in less developed countries. Although Israel is not a developed country; women have the lowest incidence rates of cervical cancer since sexual behaviors, circumcision, and hygiene habits have an important place in the etiological causes.³

Cervical cancer doesn’t progress suddenly and remains as precancerous lesions over the course of many years. This allows for an early diagnosis through some methods of cytologic and clinical diagnosis and creates a window of opportunity for a curative treatment.  Cytology and colposcopy are the most advantageous techniques used in the diagnoses of cervical cancer and preinvasive lesions. However; cytology doesn’t provide the last finding of the disease, it is a screening method that should be performed with others for further examination (Colposcopy, Histo-Pathology). It is acknowledged that colposcopy and cytology are mutually complementary methods. Cytology examines exfoliated cells, while colposcopy examines the changes occur in the vascular structure of the cervix.⁴

According to some research, endocervical curettage (ECC) should be performed routinely in all cases with abnormal cytologic findings. ECC is performed when colposcopic examination is unsatisfactory or fails to provide any finding that explains the abnormal cytology during a colposcopic examination. Patients with an abnormal pap smear result or patients with a suspicious-looking cervix even they had a (-) pap smear should be evaluated by colposcopy and colposcopy directed biopsy. The false-negative rate of the Pap smear test is about 20%-40%. These rates also cover the patients diagnosed with cervical cancer shortly after a normal cytology.⁵

The aim was to investigate cervical cytologic and colposcopic changes in patients using IUCDs for a long period of time and to create awareness among the IUCD users for regular follow up.

PATIENTS AND METHODS

The Obstetrics and Gynecology Department of Al-Hussein University Hospital conducted this cross-sectional study. 200 patients in the study group (Group 1) were monogamous, without a history of STDs, and had been using an IUCD for three to five years. On the other hand, and Control Group (Group 2) included 200 patients without a previous anamnesis of any contraception method.

Inclusion criteria: Ladies of age above 35 years and bellow 40 years, of party 3 to 5 time, subjects using intrauterine contraceptive device for 3 to 5 years, the subjects were chosen irrespective of their socio-demographic profile, and never on any other contraceptive method.

Exclusion criteria: Subjects not do early entercors befor 18 years, subject with missing IUCD, subjects with pregnancy with IUCD in situ, and patients with HPV.

All patients were subjected to:

Complete history taking: (1) A person's name, age, marital status, and residence. (2) A person's menstrual history, which includes the age at menarche, menstrual disturbances, dysmenorrhea, and associated symptoms. (2) Previous obstetric history, including parity and delivery method. (3) Current history: pharmaceutical use and chronic illnesses. (4) Previous HTN and DM history. (5) A history of diabetes or a related illness in the family. (6) A history of drug allergies. (7) Laparoscopic interference in the operation's surgical history.

Examination:

General examination: measurement of weight, height, and the evaluation of vital signs (BMI).

Abdominal and local clinical examination: to evaluate fundal level and gestational age, previous surgery scar, mass, soreness or rigidity, and any abdominal or pelvic pathology that can be clinically detected

Bimanual pelvic examination of both adenexa, uterus to look for any abnormalities in the female genitalia.

Routine trans-vaginal examination.

Examination for any visible lesions or secretions.

Vaginal Pap smear was taken.

Colposcopic examination

All cases had been undergoing a colposcopic examination performed by the same gynecologist with the same colposcopic device and a smear was obtained from all patients.Age, Parity, Gravida, The histories of the patients had been used to determine the number of births and the age at first coitus. A smear had been obtained prior to the examination. The cervix had been examined with the naked eye before applying Acetic Acid (AA) and the presence of displaced endocervical epithelium (Ectropion or Ectopy) had beennoted. Ectropion and/or ectopy had been classified as mild (Periorificial), moderate, and severe (reaching to Fornix zone) according to the area occupied in the cervix.

The presence or absence of atypical vascularization had been recorded using a green filter by wiping the cervix with serum physiologic. Following this procedure, cervical mucus had been removed with a 3% of AA solution and after waiting for about a minute, Squamo-columnar Junctions (SCJ) and Transformation Zone (TZ) had been observed. The response of the cervix to AA had been evaluated as mild and dense according to the severity of whitening. Mosaic and punctuation patterns had been described as course and fine.

Colposcopy will be considered satisfactory in cases where SCJ can be observed clearly and continuously and the entire TZ and any extent of a lesion, if present, will be visible. On the other hand, colposcopy will be considered unsatisfactory in cases where SCJ will not be observed clearly and TZ can not be seen fully and in cases with a lesion extending into the cervix canal where the upper limit can not be seen clearly. ECC will be performed with the Novak curette in patients with unsatisfactory colposcopy in order to determine the treatment protocols and to examine the endocervical canal, as well.

Punch biopsy will be performed on mild dense Aceto White (AW) areas, Schiller positive areas and areas with fine or coarse mosaics and punctuations. Before obtaining the cytology and histo-pathology results, IUCDs will be not removed from any of the patients, including those diagnosed with lesions. Biopsy specimens fixed in 10% formaldehyde will be sent to pathology. After a routine histo-pathological examination, 5-micron tissue sections stained with Hematoxylin Eosin will be examined under a light microscope at 40x, 100x, and 400x magnifications.

Ethical Consideration: The Al Azhar University faculty of medicine's Institutional Review Board (IRB) had requested clearance of the study plan. All study participants received an explanation of the procedure before beginning the trial, and all patients provided counselling regarding the study's risks and benefits before providing their written consent. At every stage of the study, confidentiality and personal privacy have been protected.

Statistical analysis:

Microsoft Excel 2016 and the SPSS programme (Statistical Package for Social Sciences) version 26.0 will be used to tabulate and statistically analyse the obtained data, and MedCalC programme software version 19. When analysing numerical non-parametric data, descriptive statistics were carried out using the mean, SD (standard deviation), minimum, and maximum of the range., they were performed using the median and first and third interquartile ranges; and for categorical data, they were performed using the number and percentage. For quantitative variables, inferential analyses were performed using the independent t-test when there were two independent groups and parametric data, when there were two independent groups with non-parametric data, and the Mann Whitney U. For inferential analysis of qualitative data, the chi square test for independent groups was used. P values under 0.05 were used to determine significance; values beyond this threshold are non-significant. The p-value is a statistical indicator of the likelihood that the findings of a study may have been the result of chance.

RESULTS

p≤0.05 is considered statistically significant, p≤0.01 is considered high statistically significant, SD= standard deviation, IQR= Interquartile range,

-comparison between groups done by **Mann-Whitney U test, § Chi-Square Test

Table 1: Clinico-demographic characteristics among the studied groups

According to Table 1, there was no statistically significant difference in age between the two groups (p=0.498). In the two groups, gravida and parity were comparable and didn't differ significantly (p=0.638 & 0.367, respectively). The age at first coitus in group 1 was, however, noticeably younger than it was in the control group (p 0.001).

p≤0.05 is considered statistically significant, p≤0.01 is considered high statistically significant, SD= standard deviation, IQR= Interquartile range, comparison between groups done by § Chi-Square Test

Table 2:Comparison between the studied groups regarding pathological findings

Table (2) indicates that there was a statistically significant difference between group (1) and group (2) patients in the prevalence of abnormal cervical cytology (p=0.02). When compared to group 1, group 2 was shown to have a higher incidence of inflammatory and infectious disorders, but group 1 had a higher incidence of abnormal ectopic changes (2). Regarding the degree of ectopy, there was a statistically significant difference between group (1) and group (2).  (p=0.005).

p≤0.05 is considered statistically significant, p≤0.01 is considered high statistically significant, SD= standard deviation, IQR= Interquartile range, comparison between groups done by § Chi-Square Test

Table 3: Comparison between the studied groups regarding colposcopic findings

Table (3) shows there were high statistically significant difference colposcopy findings between the participants in group (1) and group (2) (p< 0.001).

p≤0.05 is considered statistically significant, p≤0.01 is considered high statistically significant, SD= standard deviation, IQR= Interquartile range, comparison between groups done by § Chi-Square Test

Table 4: Comparison between the studied groups regarding F mosaic and biopsy findings

According to Table (4), Regarding F mosaic, there was a statistically significant difference between the participants in groups (1) and (2) (p=0.003). The biopsy results showed a highly statistically significant difference between group (1) and group (2). (p 0.001).