Can vaginal misoprostol effectively increase rate of a satisfactory colposcopy? A randomized double-blind placebo-controlled trial

Transformation zone types: a call for review of the IFCPC terminology to embrace practice in low-resource settings

Most cervical cancers develop in the transformation zone (TZ). Type 3 TZs, where the full circumference of the squamocolumnar junction (SCJ) is not visible pose problems during cervical screening with visual inspection methods, as (pre)cancerous lesions may be missed. Several practical strategies can be implemented to convert type 3 TZs into TZ 1 or TZ 2, including the use of an endocervical speculum or hygroscopic cervical dilators, opening the vaginal speculum more widely, skillful use of cotton-tipped applicators, performing colposcopy in midcycle, and use of oral or vaginal misoprostol and estrogen to 'ripen' the cervix. With the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) terminology, settings with better resources to manipulate the cervix for a better view of the endocervical canal may assign patients to different categories from those in low-resource settings during a colposcopic examination. Here, we propose a colposcopic revision to the current IFCPC classification by segregating TZ 2 according to the extent of endocervical involvement and TZ 3 according to whether any attempt is made to open the endocervical canal, if such attempt(s) were successful, and the extent to which the practitioner can visualise parts of the uterine cervix beyond the border of the SCJ in the endocervical canal. In this proposed reclassification, TZ 2A has no part of the SCJ extending beyond 5 mm into the endocervical canal, whereas TZ 2B has part or all of the SCJ extending beyond 5 mm into the endocervical canal. TZ 3 is further subclassified into TZ 3A if the practitioner does not attempt to open the endocervical canal or the endocervical canal is opened, but not beyond 5 mm and TZ 3B if the full circumference cannot be visualised after opening the endocervical canal beyond 5 mm. We believe this revision will improve and better standardise the classification of TZ types, with huge implications for practice in low-resource settings, due to limited options for referral and treatment, to reduce the risk of missed cervical cancers and suboptimal treatment resulting from ablating lesions that extend too far into the endocervical canal.

Misoprostol and estradiol to enhance visualization of the transformation zone during cervical cancer screening: An integrative review

The purpose of this integrative literature review was to appraise studies conducted worldwide using misoprostol and estradiol in converting Type 3 transformation zone (TZ) of the cervix into Types 1 or 2 and to assess which regimen could be more feasible in low-and-middle-income countries (LMICs). We reviewed the English language literature for peer-reviewed studies that evaluated strategies to convert Type 3 TZs to Types 1 or 2 for cervical cancer screening. Web of Science and PubMed searches were performed up to July 2020. Search terms included: "cervical colposcopy," "inadequate colposcopy", "cervical cancer screening", "transformation zone," "estrogen", "estradiol", and "misoprostol." Inclusion criteria were articles published in the English language, original research, and peer reviewed articles. A total of 127 articles were abstracted, 24 articles were reviewed, and 9 articles met all inclusion criteria. We found that intravaginal misoprostol, intravaginal estradiol, and oral estradiol can successfully convert Type 3 TZ to Types 1 or 2. A single dose of vaginal misoprostol had a similar maximum response rate (20-80%) to a multi-dose regimen over several days or weeks of both intravaginal estradiol (64-83%) and oral estradiol (50-70%). Misoprostol administration was associated with more side effects such as abdominal cramping and vaginal bleeding compared to estradiol, although these were generally mild. In conclusion, Oral estradiol, intravaginal estradiol, and intravaginal misoprostol can be used to convert Type 3 TZ to Types 1 or 2. Intravaginal misoprostol is well tolerated and more feasible in LMICs due to availability and shorter treatment schedule compared to oral or intravaginal estradiol.

Endocervicoscopy with office hysteroscope for complete visualization of transformation zone in cases of invisible squamocolumnar junction on colposcopy

Aim:

To evaluate the role of endocervicoscopy for the visualization of the T3 transformation zone (TZ) on colposcopy.

Materials and Methods:

Forty patients with either abnormal Pap smear or positive VIA-VILI and T3 TZ on colposcopy were recruited from the colposcopy clinic and subjected to endocervicoscopy with a 4-mm office hysteroscope. The view of the endocervical canal was recorded before and after the application of 5% acetic acid and the squamocolumnar junction was identified in its entirety. An endocervical curettage was taken in all the cases and compared with the final histopathology report.

Results:

Squamocolumnar junction was visible in all the 40 cases; however, in two patients (5%), cervical dilatation had to be done. The positive predictive value (PPV) of endocervicoscopy in our study was 33.3% and negative predictive value (NPV) was 100%. Dense acetowhitening/irregular polypoidal endocervical mucosa with dilated blood vessels was significant in predicting the premalignant and malignant lesions with PPV of 67% and NPV of 100%.

Conclusion:

Endocervicoscopy allows a panoramic view of the endocervical canal. It is a safe, effective, and feasible technique for visualization of squamocolumnar junction with 5% acetic acid in cases of T3 TZ on colposcopy.

Abnormal cervicovaginal cytology, unsatisfactory colposcopy and the use of vaginal estrogen cream: an observational study of clinical outcomes for women in low estrogen states

AIM

To determine the effectiveness of vaginal estrogen cream to improve the rate of satisfactory colposcopy and subsequent smear result in patients in a hypoestrogenic state and an abnormal Papanicolaou smear. To delineate between abnormal smears secondary to atrophy and inflammation from preneoplastic change and suggest an effective treatment strategy to deal with this challenging situation.

METHODS

Patients with abnormal cervicovaginal smears who were in a low estrogen state (postmenopausal or amenorrheic postnatal) undergoing colposcopy were identified. All patients had an unsatisfactory colposcopy and were treated with vaginal estrogen cream twice per week for 6 weeks and underwent repeat colposcopy, smear and targeted biopsy where required.

RESULTS

Fifty-four patients had an abnormal smear and were clinically in a low estrogen state, with four having previously had a hysterectomy. After 6 weeks of vaginal estrogen therapy, 32 out of 50 patients' colposcopic examinations were satisfactory. Also, 40 out of 54 patients' smears returned to normal after treatment. Of the 14 patients with persistent smear abnormalities, only three were diagnosed with true high-grade pre-invasive disease.

CONCLUSION

The use of vaginal estrogen cream for patients with smear abnormalities and a low estrogen status improves the satisfactory colposcopy rate and improves the accuracy of the prediction of true high-grade pre-invasive disease. This treatment may then reduce the number of patients that require definitive treatment for their screen-detected abnormalities in this patient population.

Vaginal Misoprostol for Overcoming Inadequate Colposcopies: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Inadequate colposcopic results due to inadequate visualization of the cervical transformation zone is a diagnostic problem that is encountered in approximately 10% to 15% of these procedures. The objective of the present systematic review and meta-analysis was to investigate whether misoprostol effectively converts inadequate colposcopic examinations to adequate.

MATERIALS AND METHODS

We searched MEDLINE (1966-2014), Scopus (2004-2014), Popline (1974-2014), ClinicalTrials.gov (2008-2014), CENTRAL (1999-2014), and Google Scholar (2004-2014) search engines along with reference lists of all electronically retrieved articles. For the meta-analysis of selected indices, we used the RevMan 5.2 program.

RESULTS

Treatment with misoprostol significantly increases the rates of adequate colposcopic examinations (odds ratio [OR] = 6.78, 95% confidence interval [CI] = 2.94-15.61). Its principal adverse effect is abdominal pain (OR = 10.19, 95% CI = 2.19-47.45). Neither nausea (105 women, random effects model [REM], OR = 4.99, 95% CI = 0.54-45.71) nor fever (111 women, REM, OR = 3.90, 95% CI = 0.59-25.56) or diarrhea (111 women, REM, OR = 2.21, 95% CI = 0.49-10.00) was found increased among women receiving misoprostol. The conversion rates toward an adequate examination ranged between 55.5% and 78.9% in the misoprostol group.

CONCLUSIONS

According to our meta-analysis, misoprostol seems to improve the conversion rates from inadequate colposcopic examinations to adequate diagnoses. However, firm results to generalize our findings among specific populations, such as those already having a previous conization, are precluded by the small number of enrolled studies. Thus, future research in the field becomes necessary.