Pap smear screening in an urban STD clinic. Yield of screening and predictors of abnormalities

Risk of CIN2+ following a diagnosis of genital warts: a nationwide cohort study

OBJECTIVES

Individuals with genital warts may be particularly susceptible to human papillomavirus since they have failed to clear the virus. Consequently, women with genital warts could be at increased risk of cervical dysplasia. In this cohort study we aimed to compare the incidence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in women with a diagnosis of genital warts with that of the general female population without genital warts.

METHODS

Using the Danish nationwide population-based health data registers, we identified women between 15 and 45 years and followed them for diagnoses of CIN2+ from 1995 to 2006. Genital wart diagnoses were recorded from birth, and Cox regression with attained age as underlying scale was used to estimate age-dependent HRs for the risk of CIN2+ with genital warts as a time-varying exposure.

RESULTS

Among 918 609 women without genital warts and 32 218 women with genital warts, 30 209 and 1533 women, respectively, had a subsequent diagnosis of CIN2+. A significantly higher risk of CIN2+ was found among women with genital warts relative to those without (HR, 2.43; 95% CI 2.30 to 2.56). Treatment-resistant genital warts posed a significantly higher risk of CIN2+ than did transient genital warts (HR, 1.20; 95% CI 1.01 to 1.43). The risks remained elevated more than 4 years after the genital wart diagnosis.

CONCLUSION

Clinicians should ensure that women with genital warts are screened for cervical cancer after the genital wart diagnosis and that they continue to be screened on time.

Number of external anogenital warts is associated with the occurrence of abnormal cervical cytology

BACKGROUND

Anogenital warts (AGWs) are common results of sexually transmitted infection (STI). Human papillomavirus (HPV) types 6 and 11, which are non-oncogenic types, account for 90% of the clinical manifestations. Although the quadrivalent HPV vaccine has been launched, AGW remains prevalent in some countries and shows association with abnormal cervical cytology.

OBJECTIVES

To study the prevalence of abnormal cervical cytology (low grade squamous intraepithelial lesions or worse; LSIL+) in immunocompetent Thai women newly presenting with external AGWs.

MATERIALS AND METHODS

Medical charts of all women attending Siriraj STI clinic during 2007-2011 were reviewed. Only women presenting with external AGWs who were not immunocompromised (pregnant, human immunodeficiency virus positive or being on immunosuppressant drugs) and had not been diagnosed with cervical cancer were included into the study. Multivariate analysis was used to determine the association between the characteristics of the patients and those of AGWs and LSIL+.

RESULTS

A total of 191 women were eligible, with a mean age of 27.0±8.9 years; and a mean body mass index of 20.6±8.9 kg/m2. Half of them finished university. The most common type of AGWs was exophytic (80.1%). The posterior fourchette appeared to be the most common affected site of the warts (31.9%), followed by labia minora (26.6%) and mons pubis (19.9%). The median number of lesions was 3 (range 1-20). Around 40% of them had recurrent warts within 6 months after completing the treatment. The prevalence of LSIL+ at the first visit was 16.3% (LSIL 12.6%, ASC-H 1.1%, HSIL 2.6%). After adjusting for age, parity and miscarriage, number of warts ≥ 5 was the only factor associated with LSIL+ (aOR 2.65, 95%CI 1.11-6.29, p 0.027).

CONCLUSIONS

LSIL+ is prevalent among immunocompetent Thai women presenting with external AGWs, especially those with multiple lesions.

Cervical cancer screening among women who attend sexually transmitted diseases (STD) clinics: background paper for 2010 STD Treatment Guidelines

BACKGROUND

In April 2008, experts reviewed updates on sexually transmitted disease (STD) prevention and treatment in preparation for the revision of the Centers for Disease Control and Prevention (CDC) STD Treatment Guidelines. This included a review of cervical cancer screening in the STD clinical setting.

METHODS

Key questions were identified with assistance from an expert panel. Reviews of the literature were conducted using the PubMed computerized database and shared with the panel. Updated information was incorporated in the 2010 CDC STD Treatment Guidelines.

RESULTS

We recommend that STD clinics offering cervical screening services screen and treat women according to guidelines by the American College of Obstetrics and Gynecology, the American Cancer Society, the US Preventive Services Task Force, and the American Society for Colposcopists and Cervical Pathologists. New to the 2010 guidelines are higher age for initiating cervical screening (age ≥ 21 years) and less frequent intervals of screening (at least every 3 years). New recommendations include new technologies, such as liquid-based cytology and high-risk human papillomavirus (HPV) DNA tests. Liquid-based technologies are not recommended over conventional testing. HPV DNA tests are recommended as adjunct tests and with new indications for use in cervical screening and management. Stronger recommendations were issued for STD clinics offering cervical screening services to have protocols in place for follow-up of test results and referral (eg, colposcopy).

CONCLUSIONS

Important additions to the 2010 STD Treatment Guidelines include information on updated algorithms for screening and management of women and recommendations for use of liquid-based cytology and high-risk HPV testing.

Effect of specimen order on Chlamydia trachomatis and Neisseria gonorrhoeae test performance and adequacy of Papanicolaou smear

STUDY OBJECTIVE

To evaluate the effect of specimen collection order on the performance of diagnostic tests for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), and the specimen adequacy of ThinPrep Papanicolaou (Pap) smears.

DESIGN

Prospective cohort study.

SETTING

Public adolescent clinic.

POPULATION

313 women.

INTERVENTIONS

The order of five cervical testing specimens was randomized for (1) ligase chain reaction (LCR) and (2) polymerase chain reaction (PCR) for both CT and GC; (3) transcription-mediated amplification (TMA) for CT; (4) culture for CT; and (5) cytology and LCR for GC and CT performed on ThinPrep Pap specimens. For CT and GC, a reference standard was based on three different tests performed on separate specimens. Generalized estimating equations were used to account for repeated measures.

MAIN OUTCOME MEASURE

Sensitivity and specificity of diagnostic tests.

RESULTS

The proportion of inadequate Pap smears was independent of specimen order. As a group, nucleic acid amplification test (NAAT) sensitivity and specificity for GC and CT were similar in the first two (early) and last three (late) swabs. Although point estimates for sensitivity were higher in the early swabs compared to the late swabs for GC LCR (13% difference), GC PCR (13%), and CT TMA (10%), these differences were not statistically significant. Their clinical significance warrants further investigation.

CONCLUSIONS

In clinical settings where both Pap smears and STI testing are performed in adolescents, clinical considerations can influence the order of specimen collection, since neither Pap specimen adequacy nor test performance of NAAT for CT and GC were significantly associated with swab order.