Recent intrauterine device use and the risk of precancerous cervical lesions and cervical cancer

Effect of contraceptive methods on the vaginal microbiome and host immune factors

OBJECTIVE

The objective of this study was to assess alterations in vaginal microbiota and immune markers over the first three months following initiation of copper intrauterine device (copper IUD), levonorgestrel (LNG) implant, and intramuscular depot medroxyprogestone acetate (DMPA-IM).

STUDY DESIGN

We included 162 participants from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial, which enrolled healthy, HIV-negative women seeking contraception and randomized them to a copper IUD, LNG implant, or DMPA-IM. Microbiome and immune profiles in vaginal swab samples collected at enrollment, 1 month and 3 months were analyzed. We categorized microbiome profiles as 'optimal', 'intermediate', or 'non-optimal' based on established criteria [1]. We compared microbiome and immune markers across contraceptive groups and evaluated changes to 1 and 3 months.

RESULTS

Copper IUD users had a more diverse vaginal microbiome and generally increased inflammatory cytokines and antimicrobial peptides over the 3-month follow-up, compared to LNG-implant and DMPA-IM users [2]. LNG-implant users had less complex vaginal microbiomes with reduced inflammation, while DMPA-IM showed little change in either microbiome composition or inflammatory markers. Copper IUD users exhibited lower microbiome stability and a higher likelihood of transitioning to less optimal profiles. In contrast, LNG-implant users showed greater stability and a higher probability of transition to optimal microbiome and immune marker profiles.

CONCLUSIONS

Contraceptive methods affect the vaginal microbiome differently. Copper IUD use may lead to less favorable profiles and increased levels of some immune markers, indicating potential adverse health effects. Conversely, LNG-implant usage promotes a more favorable microbiome and immune marker balance.

IMPLICATIONS

Our findings suggest that copper IUDs are associated with decreased prevalence of Lactobacillus-dominated microbiomes, higher transition rates towards less optimal microbiome and increased inflammatory profiles, which may lead to negative implications for gynecologic and reproductive health, the LNG-implant may offer positive health benefits with increased prevalence of L. crispatus-dominated microbiomes.

Association of intrauterine device use and risk of abnormal cervical cytology

OBJECTIVE

To determine whether intrauterine device (IUD) use is associated with a significantly increased risk of abnormal cervical cytology.

METHODS

A retrospective cohort study was carried out at the University of Campinas, Campinas, SP, Brazil. Data came from medical records of 2,963 women from a family planning clinic who had undergone at least one cervical cytology for screening between 1990 and 2017. Women were split into three groups: users of either copper (Cu)- or the levonorgestrel 52 mg-IUD (2,305) and users of other contraceptive methods (658). The dependent variable was the cytological results as normal and abnormal, based on the Bethesda System. The most severe cytological result of each participant was considered and when all her results were normal, the last one was considered.

RESULTS

IUD use was associated with a lower risk of abnormal cervical cytology after adjusting for the number of cytology assessments per participant (RR 0.74; 95% CI 0.55;0.99; p = 0.049). Abnormal cervical cytology was more common in women with multiple cytology assessments and a longer duration since sexual debut. For each additional cytology test, the risk increased by 33.8% (p < 0.001), and for every additional year since sexual debut, the risk increased by 6.2% (p < 0.001). A lower incidence of abnormal cervical cytology was observed among women with a history of caesarean delivery, with a 24.9% reduction in risk per additional caesarean (p < 0.001). IUD users underwent more cervical cytology assessments than non-IUD users.

CONCLUSION

We identified low risk of abnormal cervical cytology among IUD users.

Prevalence of cervical intraepithelial lesions and associated factors among women attending a cervical cancer clinic in Western Uganda; results based on Pap smear cytology

Introduction

There are high incidence and mortality rates of cervical cancer among females in East Africa. This is exacerbated by limited up-to-date data on premalignant lesions and associated factors in this setting. In this study, we determined the prevalence of cervical intraepithelial lesions and associated factors among women attending the Mbarara Regional Referral Hospital cervical cancer clinic in Southwestern Uganda.

Methods

In this cross-sectional study, 364 participants were recruited from among women attending the Mbarara Regional Referral Hospital cervical cancer clinic from 1 April to 30 June 2023. On consent, the study nurse collected demographic data and Pap smears, which were microscopically examined and reported by a laboratory scientist and a pathologist following the Bethesda grading system (2014). Statistical analyses were done in STATA version 17, using proportions, Chi-square, bivariate, and multivariate logistic regression analysis to determine associated factors at ⩽0.05 significance level.

Results

The mean age of participants was 41.9 years. A third of all study participants (37.6%, 132/351) were contraceptive users, mostly hormonal contraceptives (87.1%, 115/132). Almost 88% (307/351) had an unknown Human Papilloma Virus status. The prevalence of cervical intraepithelial lesions among our study participants was 6.6% (23/351), of which 73.9% (17/23) were low-grade squamous intraepithelial lesions. More than half (9/17, 52.9%) of low-grade squamous intraepithelial lesions were active hormonal contraceptive users. Use of hormonal contraceptives (OR: 3.032, p: 0.0253), use of intrauterine devices (OR: 6.284, p: 0.039), and any family history of cervical cancer (OR: 4.144, p: 0.049) were significantly associated with cervical intraepithelial lesions.

Conclusion

The prevalence of cervical intraepithelial lesions was 6.6%, lower than global estimates. Use of hormonal and intrauterine device contraceptives, as well as family history of cervical cancer, were significantly associated with cervical intraepithelial lesions among our study population. Prospective studies are recommended to further understand associations between different types of intrauterine devices and hormonal contraceptives, and cervical lesions.

Copper in Gynecological Diseases

Copper (Cu) is an essential micronutrient for the correct development of eukaryotic organisms. This metal plays a key role in many cellular and physiological activities, including enzymatic activity, oxygen transport, and cell signaling. Although the redox activity of Cu is crucial for enzymatic reactions, this property also makes it potentially toxic when found at high levels. Due to this dual action of Cu, highly regulated mechanisms are necessary to prevent both the deficiency and the accumulation of this metal since its dyshomeostasis may favor the development of multiple diseases, such as Menkes' and Wilson's diseases, neurodegenerative diseases, diabetes mellitus, and cancer. As the relationship between Cu and cancer has been the most studied, we analyze how this metal can affect three fundamental processes for tumor progression: cell proliferation, angiogenesis, and metastasis. Gynecological diseases are characterized by high prevalence, morbidity, and mortality, depending on the case, and mainly include benign and malignant tumors. The cellular processes that promote their progression are affected by Cu, and the mechanisms that occur may be similar. We analyze the crosstalk between Cu deregulation and gynecological diseases, focusing on therapeutic strategies derived from this metal.

Risk of precancerous cervical lesions in women using a hormone-containing intrauterine device and other contraceptives: a register-based cohort study from Denmark

STUDY QUESTION

Is the risk of high-grade precancerous cervical lesions and/or is the risk of lesion progression increased in users of a hormone-containing intrauterine device (HIUD) compared with users of other contraceptive methods.

SUMMARY ANSWER

Women starting use of HIUD had the same subsequent risk of cervical intraepithelial neoplasia 3+ (CIN3+) as copper IUD (CIUD) users, and both groups tended to have lower risks than oral contraceptives (OC) users.

WHAT IS KNOWN ALREADY

HIUDs may cause inflammatory and immunosuppressive changes that may potentially affect the risk of persistent human papillomavirus infection and precancerous cervical lesions.

STUDY DESIGN, SIZE, DURATION

A Danish population-based cohort study was conducted using register data from 2008 to 2011 on 26–50-year-old users of HIUD (n = 60 551), CIUD (n = 30 303), or OC (n = 165 627).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Within each user group, women were divided into two groups; normal cytology or abnormal diagnosis before start of contraceptive use (baseline). Follow-up histology and cytology diagnoses were registered during the 5 years after baseline. Adjusted relative risks (aRR) and 95% CI were calculated for precancerous cervical lesions in HIUD users compared with CIUD and OC users.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with normal cytology at baseline: at follow-up HIUD users had the same risk of CIN3 or higher (3+) as CIUD users; aRR 1.08 (95% CI 0.94–1.22). For the HIUD and CIUD groups compared with OCs, the risks of CIN3+ were lower: aRR 0.63 (95% CI 0.57–0.69) and aRR 0.58 (95% CI 0.52–0.65), respectively. The same was observed for CIN2 risks: aRR 0.86 (95% CI 0.76–0.96) and aRR 0.68 (95% CI 0.58–0.79) for HIUD and CIUD groups, respectively. Women with abnormal diagnosis at baseline: a lower progression risk, except for CIN2+ at baseline, was observed in HIUD users compared with OC users. Similar progression risks were found in HIUD and CIUD users. There were no differences between the three contraceptive groups in persistence or regression of present lesions.

LIMITATIONS, REASONS FOR CAUTION

We adjusted for age, education, and region of residence as a proxy for socio-economic factors. Data on smoking and sexual behavior were not available thus we cannot exclude some differences between the three user groups.

WIDER IMPLICATIONS OF THE FINDINGS

These findings suggest that women may safely use HIUDs.

STUDY FUNDING/COMPETING INTEREST(S)

A.P. Møller Foundation for the Advancement of Medical Science, Else and Mogens Wedell-Wedellborgs Fund, Direktør Emil C. Hertz og Hustru Inger Hertz Fund, and the Fund for Development of Evidence Based Medicine in Private Specialized Practices. EL is principle investigator for a study with HPV-test-kits provided by Roche. The other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Distribution of HPV Genotypes Differs Depending on Behavioural Factors among Young Women

Risk factors for the different human papillomavirus (HPV) genotypes are not well understood, although the risk of cancer is known to vary among them. Our aim was to evaluate the association of diverse behavioral and reproductive factors with genotype-specific HPV prevalence among 879 unvaccinated women aged 18–75 years referred to the colposcopy clinic at Helsinki University Hospital in Finland. Cervical swabs for HPV genotyping were collected in the first visit and assessed for 34 high-risk (hr) and low-risk (lr) HPV genotypes. Participants completed a questionnaire on behavioral, reproductive, and lifestyle factors. Differences in genotype-specific HPV prevalence were analyzed overall and in age groups using binary logistic regression. Smoking was associated with higher prevalence in HPV16 compared with other hrHPV genotypes together with decreasing age, being highest among younger women <30 years old, odds ratio (OR) 3.74 (95% CI 1.42–9.88). The later the sexual debut, the more it seemed to protect from HPV16 infection. The best protection was achieved when the sexual debut took place at >20 years of age, with an OR of 0.43 (95% CI 0.23–0.83). This association was not seen with other hrHPV genotypes. Methods of contraception seemed not to have an effect on hrHPV positivity, regardless of the HPV genotype. The genotype specific hrHPV prevalence differs, depending on behavioral factors, especially among younger women referred to colposcopy.

A Systematic Review and Meta-analysis of the Adverse Effects of Levonorgestrel Emergency Oral Contraceptive

INTRODUCTION

The levonorgestrel oral emergency contraceptive is well tolerated and effective, however its use is still limited, mainly due to safety concerns.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize current evidence regarding the adverse events, and their prevalence, reported during the use of oral levonorgestrel emergency contraceptives.

METHODS

Four electronic databases and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched. Studies that reported or investigated safety outcomes or adverse reactions during the use of levonorgestrel as an emergency oral contraceptive were included. Data on study design, demographics of levonorgestrel and the control cohort, and reported adverse effects were extracted.

RESULTS

A total of 47 articles were included in this systematic review, from which it was shown that most of the adverse reactions were common and not serious. Uncommon adverse reactions identified included anorexia, ectopic pregnancy, exanthema, chloasma, miscarriage, and weight gain. Multiple serious adverse events, including convulsion, ectopic pregnancy, febrile neutropenia, stroke, abdominal hernia, anaphylaxis, cancer, ovarian cyst rupture, serious infections, and suicidal ideation, were reported. In addition, the prevalence of adverse events after a levonorgestrel 0.75 mg two-dose regimen and a levonorgestrel 1.5 mg single-dose regimen were not statistically different (p > 0.05).

CONCLUSIONS

The most common adverse effects of levonorgestrel were not serious. This systematic review shows that data regarding the adverse reactions of repeated use of levonorgestrel are scarce. Studies on the multiple uses of levonorgestrel emergency contraception are still required to ensure its safety.

Relationship between contraceptive methods and human papillomavirus positivity

PURPOSE

Understanding the effect of contraceptive use on high-risk human papillomavirus (HPV) positivity may provide information that is valuable to women in contraceptive decision-making. This study includes women aged 30-65 years who admitted to Family Planing outpatient clinic and have hrHPVDNA positivity.

METHODS

We included a total of 801 women. All participants underwent national cervical cancer screening using HPV screening test conducted by the Cancer Control Department of the Ministry of Health. They completed a questionnaire on demographic information and potential risk factors.

RESULTS

The HPV DNA positivity rate among all participants was 8.4%. The two most common HPV genotypes were HPV16 and HPV51. Meanwhile, hrHPV infection was associated with age, marital status, smoking status, and contraceptive method.

CONCLUSION

HPV is the most common cause of sexually transmitted diseases. Understanding about the reproductive and demographic characteristics affecting HPV persistence is crucial. The effect of contraceptive methods on HPV positivity is important information that is necessary to be relayed to women by healthcare professionals.

The effect of age On cervical cancer screening in women aged 20-29

No definite consensus exists currently regarding the appropriate age at which to start cervical cancer screening. We analyzed the effectiveness of age in abnormal histology outcomes in women aged 20-29. Data on women aged 20-29 having undergone opportunistic cervical cancer screening with cytology during the 2014-2019 period were retrospectively reviewed. Based on cytology outcomes, human papillomavirus test results (if present), age and clinical decision, patients underwent either colposcopy or observation. The effects of age and other epidemiologic factors on histologic diagnoses of cervical intraepithelial neoplasia (CIN) or cancer [CIN (+)] were analyzed in univariate and binomial logistic regression analyses. Among 1649 women, CIN (+) lesions were observed in 61 (3.7%) women. The occurrence of CIN (+) lesions increased 1.149 times each year; thus, women aged 25-29 were more likely to have CIN (+) than those aged 20-24 (4.4% vs. 2.1%; p=0.019). A significant determinant of CIN (+) was the increase in age, i.e. women aged 20-29. Accordingly, considering age is crucial for the diagnosis of CIN (+) in cancer screening.

Oral contraceptive and intrauterine device use and the risk of cervical intraepithelial neoplasia grade III or worse: a population-based study

OBJECTIVE

Hormonal contraceptive use has been associated with the development of cervical cancer, although inconsistent results are reported on the association with intrauterine device (IUD) use. The aim of this study was to evaluate the association between the type of contraceptive use and the development of cervical intraepithelial neoplasia grade III or worse (CIN3+).

METHODS

A retrospective population-based cohort study including women aged 29-44 years attending the cervical cancer screening program with normal cytology between 2005 and 2009 identified from the Dutch Pathology Registry. Subgroups with at least 5 years registered use of an oral contraceptive (OC) or IUD were compared with non-users. Risk ratios of CIN3+ were estimated per contraceptive type.

RESULTS

702,037 women were included with a median follow-up of 9.7 years, of which 6705 (0.96%) and 559 (0.08%) women developed CIN3 and cervical cancer, respectively. IUD use was associated with an increased risk of developing CIN3+ (risk ratio (RR) 1.51, 95% confidence interval (CI) 1.32-1.74), and OC use was associated with an increased risk of developing CIN3+ (RR 2.77, 95%CI 2.65-3.00) and cervical cancer (RR 2.06, 95%CI 1.52-2.79). The risk of developing CIN3+ and cervical cancer was higher for OC users compared with IUD users (RR 1.83, 95%CI 1.60-2.09 and RR 1.70, 95%CI 1.00-2.90, respectively).

CONCLUSIONS

Both OC use and IUD use were associated with an increased risk of developing CIN3+. However, for women with a contraceptive wish, an IUD seems safer than an OC as the risk of developing CIN3+ and cervical cancer was higher for OC users.

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Contraception in cancer survivors - an expert review Part I. Breast and gynaecological cancers

Objective: The efficacy of treatment for many cancers has increased dramatically in recent decades and there are a growing number of cancer survivors who need effective contraception. In this paper, a group of experts from the European Society of Contraception set out to define the most frequent cancers in women and summarise the guidelines, reviews and studies that provide information and guidance on contraception for each cancer. Methods: Epidemiological studies were analysed to determine the frequency of cancers in women of reproductive age. A narrative review was performed for each cancer, collecting data about the treatment of the disease, its impact on fertility, and the efficacy, health risks, possible benefits and contraindications of the contraceptive methods available. The recommendations were then summarised. Results: Owing to a large amount of information, the results are presented in two parts. Part 1 includes contraception after breast and gynaecological cancers. Part 2 summarises the findings and recommendations regarding contraception in women with skin, gastrointestinal, haematological and endocrine cancers.