H. C. Kitchener

Management of women with mild and moderate cervical dyskaryosis.

Abstract Objective : To compare the outcomes in women with mild and moderate dyskaryosis after increasing periods of surveillance and thereby to define a rational protocol for managing such women. Design - Prospective study with randomisation of women to one of four treatment groups, each with a different period of surveillance; one group in which the women were given immediate treatment and three other groups in which the women were under surveillance for six, 12, and 24 months. Setting : A dedicated colposcopy clinic in Aberdeen, Scotland. Subjects : 902 women who presented with a mildly or moderately dyskaryotic smear for the first time. Interventions : Cytological and colposcopic examinations at intervals of six months until the allocated period of surveillance was completed, at which time biopsy was performed. Women with severe dyskaryosis were withdrawn from surveillance and a biopsy was performed. Main outcome measures - The histological findings after punch biopsy or large loop excision of the transformation zone, and the trends in cytological appearances of serial cervical smears. Results - 793 women completed the study. In all, 769 women had an adequate final smear, of which 197 were normal cytologically, 328 were still mildly or moderately dyskaryotic, and 244 were severely dyskaryotic. Seventeen of the 67 (25%) women with one repeat smear showing non-dyskaryosis had cervical intraepithelial neoplasia grade III compared with only one of the 31 (3%) women with no dyskaryosis in four repeat cervical smears (P <0.0001). None of the women had invasive cancer. Of 158 women whose index smear showed mild dyskaryosis and who were allocated to the group under surveillance for two years, only 40 had not defaulted or still had dyskaryotic smears by the end of the two years. Conclusion : Cytological surveillance, although safe, is not an efficient strategy for managing women with mildly abnormal smears. Women with any degree of dyskaryosis in a smear should be referred for colpscopy.

Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects

Abstract Objective: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. Design: Prospective randomised controlled trial. Setting: Obstetrics and gynaecology department of a large teaching hospital. Subjects: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women)). Main outcome measures: Mental state, marital relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. Results: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss of sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. Conclusions: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness. Key messages Key messages Hitherto hysterectomy has been the preferred procedure, though women may be ill postoperatively The introduction of hysteroscopic procedures demands an evaluation of different surgical methods according not only to gynaecological criteria but also in terms of their psychiatric and psychosocial outcome This randomised trial of hysterectomy and hysteroscopic surgery found that both methods had satisfactory outcomes in terms of anxiety, depression, and psychosocial adjustment

Fertility and pregnancy outcome following large loop excision of the cervical transformation zone

Objective To determine if large loop excision of the transformation zone affects subsequent fertility and pregnancy outcome.

A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia

Objective To compare endometrial laser ablation (ELA) with transcervical resection of the endometrium (TCRE) in the treatment of menorrhagia.

The 1993 British Society for Colposcopy and Cervical Pathology/national coordinating network United Kingdom colposcopy survey : comparison with 1988 and the response to introduction of guidelines

Objective To evaluate colposcopic practice over a 12-month period in the UK, April 1993 to March 1994, to compare this with 1988, and to test penetration and acceptance of previously introduced national guidelines. Design A nationwide survey of colposcopy practice by postal questionnaire, including referral criteria, diagnosis and treatment, follow up, waiting times and information and counselling. Setting All gynaecology clinics in the United Kingdom. Results Returns were obtained from 215 clinics (78%), that saw an average of 434 new women per year. Seventy percent of clinics follow the current national guideline for cytological referral criteria for colposcopy. Diathermy loop excision is now by far the most popular treatment method for CIN. The majority of clinics employ both colposcopy and cytology for follow up. A total of 103 invasive cancers following treatment for CIN were reported during the 12-month period of the survey. Most clinics provide new patients with both information and counselling. Conclusions Colposcopy practice has undergone considerable changes in the last five years. There has been a good response to the introduction of a national guideline for referral for colposcopy. While local audits are necessary to identify improvements that need to be made to individual clinical services, this national audit has shown some trends over the past five years, has highlighted the problem of invasive cancer following treatment for CIN and has assessed the impact of a national guideline.

A population-based study of microinvasive disease of the cervix--a colposcopic and cytologic analysis.

A study of 61 cases of microinvasion of the cervix occurring in our population between 1980 and 1989 is reported. The mean age of the women was 39 years, compared with 30 years for cervical intraepithelial grade 3 (CIN III) and 47 years for frank invasion, respectively. Colposcopic suspicion of microinvasion was present in 31 cases, giving a sensitivity of colposcopic diagnosis of 50% and a specificity of 91%. In 21 cases (34%) there was no suspicion either cytologically or colposcopically of microinvasion. Colposcopy predicted microinvasion more accurately with increasing depth of invasion. In 28 women there had been previous smears within 10 years available for review. The time interval between the first abnormal smear and the histological diagnosis ranged from 1 month to 9.8 years (mean, 4 years).

A prospective randomised study of the effects of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery.

OBJECTIVE To study the effect of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery. DESIGN Prospective randomized study. SETTING Aberdeen Royal Infirmary. SUBJECTS One hundred and sixteen women about to undergo either endometrial laser ablation (ELA) or transcervical resection of the endometrium (TCRE). INTERVENTION Fifty-five women were randomised to receive 1.2 g of Augmentin (co-amoxiclav) i.v. at induction of anaesthesia. Sixty-one women received no antibiotic prophylaxis. Blood cultures were obtained at the end of the surgical procedure. RESULTS Incidence of bacteraemia in the non-antibiotic group (16%) was significantly higher than that in the antibiotic group (2%) (95% confidence interval for difference from 5% to 25%). The majority of organisms were of dubious clinical significance and contamination could not be excluded in 7 cases out of 10. CONCLUSION There is no convincing evidence that antibiotics are of value in this clinical setting.

Mild and moderate dyskaryosis: can women be selected for colposcopy on the basis of social criteria?

OBJECTIVE--To describe the distribution of cervical intraepithelial neoplasia grades among women with mild and moderate dyskaryosis after a single cervical smear and to determine whether social criteria could help identify women who are at increased risk of grade II or III disease. DESIGN--Cross sectional analysis within a randomised prospective study. Subjects had a repeat smear, a colposcopic examination, and an excision biopsy of the transformation zone. In addition, women were asked to complete a social questionnaire. SETTING--Colposcopy clinic, Aberdeen. SUBJECTS--228 women with a single smear test showing mild or moderate dyskaryosis. MAIN OUTCOME MEASURES--Histology, age, sexual and contraceptive history, cigarette smoking. RESULTS--159 (70%) women had cervical intraepithelial neoplasia grades II or III. Among current smokers the prevalence of grade II and III disease was higher in women who smoked greater than or equal to 20 cigarettes a day (84%) than among those who smoked less (66%; p less than 0.04). Women with more than one sexual partner also had a higher prevalence (75%) than women with only one partner (50%; p = 0.0028). Use of oral contraceptives and younger age were not significantly associated. The prevalence of grade II or III disease was up to 66% in the lower risk groups. CONCLUSIONS--Because of the high prevalence of cervical intraepithelial neoplasia grades II and III in both the high and the low risk groups social factors are not useful for selecting women with mild or moderate dyskaryosis for either early referral to colposcopy or cytological surveillance.

Admission-discharge policies for hysteroscopic surgery: a randomised comparison of day case with in-patient admission.

OBJECTIVE To study the effectiveness and acceptability of day case hysteroscopic surgery. DESIGN Prospective randomised controlled trial. SETTING Aberdeen Royal Infirmary. SUBJECTS One hundred and ninety four consecutive women who underwent hysteroscopic endometrial ablation. INTERVENTION Seventy three women were allocated to day case surgery and 37 to inpatient admission; 84 women though otherwise fit for day case surgery were scheduled for in-patient admission as they lived more than 20 miles away. All women completed a questionnaire 24 h after their operations. Readmission rates were obtained from case notes. Satisfaction rates 12 months after the operation were recorded by means of a follow-up questionnaire. RESULTS Post-operative pain was absent or slight in 48 (75%) of the women in the day case group 27 (84%) of women in the in-patient group, and 55 (82%) in the non-randomised in-patient group. Post-operative analgesia was necessary in 34 (52%) women in the day case group, 24 (75%) women in the in-patient group and 36 (53%) women in the non-randomised in-patient group. Hospital costs were significantly less in the day case group. Satisfaction with stay 92% in the day case group, and 100% in the other two groups. CONCLUSION In this setting, day care is a safe acceptable and less expensive alternative to in-patient care for hysteroscopic endometrial ablation.

Does HPV cause cervical cancer

The relation between human papillomavirus (HPV) and cervical cancer is unquestionably one of the ‘hot topics’ in current gynaecological research. The issue is important and part of its importance is that it bears on a high profile aspect of our practice. As usual in a controversy of this nature we have a spectrum of opinions from the enthusiasts for HPV causation through the baffled observer to the cynics who regard the association as purely casual. The fact is, that at the moment we simply do not know whether or not HPV causes cervical cancer. What we can do, however, is to review the data and attempt to develop a reasoned assessment. Epidemiological studies indicate that the principal risk factors which have so far been identified for cervical neoplasia are early onset sexual activity, multiple partners and cigarette smoking. The obvious interpretation of these data is that there requires to be the opportunity for one or more mutagens to be sexually transmitted and that long-term exposure to a carcinogen such as cigarette tar encourages promotion through precancer to invasive disease. This is over-simplistic as many women who develop cervical cancer are non-smoking and have had only one sexual partner; indeed the connotation of cervical cancer as an affliction of promiscuous women has been unfortunate and has resulted in some women feeling that they have ‘caught’ the disease. Within a hypothesis of this nature HPV appears an excellent candidate as a causative agent in cervical neoplasia. It is sexually transmitted, commonly causes infection of the lower genital tract and its stigmata are frequently seen in association with pre-invasive neoplasia (Meisels et al. 1981). The advent of recombinant DNA technology in molecular biology, with its ability to identify viral DNA in host tissues spotlighted HPV as a possible progenitor of cervical cancer. Not only were HPV genomes discovered in cervical intraepithelial neoplasia (CIN) and cancers but different subtypes were discovered in different grades of the disease. HPV-6, originally isolated from the classical genital wart condyloma acuminatum, appeared to be associated with CIN I whereas a majority of CIN 111 and invasive disease appeared to contain HPV-16 genomes (Crum et al. 1984). This finding was confirmed by McCance et al. (1985) who also suggested that whereas HPV-6 was extrachromosomal, IIPV-16 was integrated into the host cell genome. More recently, study of HPV gene expression has shown that HPV-16 encodes a protein mapped in the region of the E6/E7 open reading frames which will co-operate with an activated ras oncogene to transform primary cells (Matlashewski et al. 1987). Integration of a papillomavirus in the host chromosomes, by a subtype known to be associated with high-grade CIN and invasive cancer, and with expression of transforming viral genes, which in addition satisfied some of the epidemiological requirements for the disease, is regarded by some as sufficient evidence to incriminate HPV-16 as the cause. This concept of a sexually transmitted virus causing cervical cancer, which itself ‘enjoys’ a high political profile (dwarfed only by AIDS), has bcen seized upon by the popular press and has pre-empted more considered appraisal of the data. Rather neglected until recently has been the question of HPV in control tissues in studies of this type. In trying to assess the relevance of HPV in cervical neoplastic tissues it is important to have knowledge of its presence both in normal areas of the affected cervix and the cervical tissues of women who have never had cervical disease and whose cervix is histologically normal. Recently published data from Glasgow (Murdoch et al. 1988) have indicated that 60% of biopsies from normal areas of the transformation zone of women with CIN contained HPV 16 genomes; moreover, this DNA was frequently