Lori A. Boardman

The accuracy of colposcopic grading for detection of high-grade cervical intraepithelial neoplasia

Objective. To relate aspects of online colposcopic image assessment to the diagnosis of grades 2 and 3 cervical intraepithelial neoplasia (CIN 2+). Methods: To simulate colposcopic assessment, we obtained digitized cervical images at enrollment after acetic acid application from 919 women referred for equivocal or minor cytologic abnormalities into the ASCUS-LSIL Triage Study. For each, 2 randomly assigned evaluators from a pool of 20 colposcopists assessed images using a standardized tool online. We calculated the accuracy of these assessments for predicting histologic CIN 2+ over the 2 years of study. For validation, a subset of online results was compared with same-day enrollment colposcopic assessments. Results. Identifying any acetowhite lesion in images yielded high sensitivity: 93% of women with CIN 2+ had at least 1 acetowhite lesion. However, 74% of women without CIN 2+ also had acetowhitening, regardless of human papillomavirus status. The sensitivity for CIN 2+ of an online colpophotographic assessment of high-grade disease was 39%. The sensitivity for CIN 2+ of a high-grade diagnosis by Reid Index scoring was 30%, and individual Reid Index component scores had similar levels of sensitivity and specificity. The performance of online assessment was not meaningfully different from that of same-day enrollment colposcopy, suggesting that these approaches have similar utility. Conclusions. Finding acetowhite lesions identifies women with CIN 2+, but using subtler colposcopic characteristics to grade lesions is insensitive. All acetowhite lesions should be assessed with biopsy to maximize sensitivity of colposcopic diagnosis with good specificity.

Topical gabapentin in the treatment of localized and generalized vulvodynia.

OBJECTIVE: To evaluate the clinical efficacy and tolerability of topical gabapentin in the treatment of women with vulvodynia. METHODS: A retrospective study was designed to ascertain clinical responses to topical gabapentin. Patient demographic and medical characteristics, including present and prior treatment for vulvodynia, were routinely collected. The final outcome was defined by a comparison between pretreatment and posttreatment mean pain scores based on a discrete visual analog scale of 0 to 10. Categorical data were compared by Fisher exact test, continuous variables between groups by the Wilcoxon rank sum test, and mean change in pain score between pretreatment and posttreatment by paired Student t test. RESULTS: Between January 2001 and December 2006, 51 women with vulvodynia (19 or 37% with generalized vulvodynia, 32 or 63% with localized) were treated with 2% to 6% gabapentin. After a minimum of 8 weeks of therapy, the mean pain score among the 35 evaluable women was significantly reduced from 7.26 to 2.49 (mean change –4.77, 95% confidence interval –5.47 to –4.07). Overall, 28 of 35 (80%) demonstrated at least a 50% improvement in pain scores. Among patients with localized vulvodynia, sexual function improved in 17 of 20 with evaluable results (6 of 9 reinstituted vaginal intercourse, whereas all 11 patients experiencing decreased frequency of intercourse reported increased frequency after treatment). Discontinuations occurred in 7 of 50 (14%) treated. CONCLUSION: Topical gabapentin seems to be well-tolerated and associated with significant pain relief in women with vulvodynia. LEVEL OF EVIDENCE: III

Abortion training in United States obstetrics and gynecology residency programs

OBJECTIVE: To identify characteristics of programs which provide training in abortion, to calculate the number of procedures done during training, and to compare the availability of abortion training in 2004 with that of prior national surveys. METHODS: An investigator-designed questionnaire about abortion training in obstetrics and gynecology residency programs was mailed to all U.S. residency directors. Collected data included program information, abortion training, and numbers of residents trained. Data were analyzed to estimate differences in abortion training by region, program size, and type of training offered. RESULTS: Of the 252 questionnaires mailed, 185 (73%) were returned. Of the 185, 94 (51%) program directors reported routine instruction in elective abortion, 72 (39%) optional training, and 19 (10%) no training. Large programs and programs located in the Northeast and West Coast were significantly more likely to offer routine training in terminations (P < .01). In the programs offering routine training, more than 50% of residents received instruction in termination practices. Of those practices, the most common were first-trimester surgical abortion (85% of programs), followed by medical abortion (59%), second-trimester induction (51% of programs), and dilation and extraction (36%). As compared with those in programs with optional training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first- and second-trimester terminations (P < .01). CONCLUSION: Routine training in elective abortion resulted in greater exposure to abortion practices and greater experience in more complicated abortion techniques during residency. LEVEL OF EVIDENCE: III

Laboratory evaluation of acute upper genital tract infection

Objective To evaluate the diagnostic test charactersitic of common tests used to diagnose upper genital tract infection. Methods Subjects included women who either met the Centers for Disease Control and Preventions minimal criteria for acute pelvic inflammatory disease or who had other signs of upper genital tract infection (ie, atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview, comprehensive laboratory testing, and either an endometrial biopsy of laparoscopy for definitive diagnosis or upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of acute endometritis or salpingitis, 2) laparoscopic visualization of purulent exudate in the pelvis without another source, or 3) positive testing for Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium, fallopian tubes, or pelvis. Results One hundred twenty women with adequate endometrial samples were evaluated between August 1993 and September 1995. The median age of the study population was 24 years; 38% were white, 52% were smokers, 81% were insured by medicaid or were uninsured, and 67% were single. Sensitivities for elevated white blood cell count (WBC), erythrocyte sedimentation rate, C-reactive protein, and increased vaginal white blood cells are 57, 70, 71 and 78%, respectively. If any one test is abnormal, the sensitivity is 100% and specificity is 18%. If all four tests are abnormal, sensitivity, is 29% and specificity is 95%. Conclusion Testing for incresaed vaginal white blood cells was found to be the most sensitive laboratory indicator for upper genital tract infection, whereas serum WBC was the most specific. NO one diagnostic laboratory test is pathognomonic for upper genital tract infection. Combinations of positive tests can improve diagnostic specificity and positive predictive value, but with a diminution of sensitivity and negative predictive value. Combinations of negative tests can reliably exclude upper genital tract infection.

Endovaginal sonography for the diagnosis of upper genital tract infection

Objective To determine the clinical utility of transvaginal sonography for the diagnosis of upper genital tract infection. Methods Fifty-five women who either met the Centers for Disease Control and Preventions minimal criteria for acute pelvic inflammatory disease or were being seen for non-classic signs of upper genital tract infection were evaluated. During abdominal and endovaginal ultrasound testing, fluid in the cul-de-sac, discrete tubes with or without tubal fluid, multicystic ovaries, and adnexal masses were noted. Upper genital tract infection was confirmed by laparoscopic visualization or histologic or microbiologic evidence of salpingitis or endometritis. Results The specificity of identifying fallopian tubes with or without intraluminal fluid on ultrasound was 97% (35 of 36); the sensitivity, however, was only 32% (six of 19). Calculated using Bayes theorem and based on a prevalence rate of 50%, the positive predictive value of visualizing fallopian tubes was 91%. The sensitivities associated with the visualization of a multicystic ovary or tubo-ovarian abscess were 42% (eight of 19) and 32% (six of 19), with specificities of 86% (31 of 36) and 97% (35 of 36), and positive predictive values of 75% and 91%, respectively. Cul-de-sac fluid was associated with low sensitivity (37%; seven of 19), low specificity (58%; 21 of 36), and the lowest positive predictive value (47%). Conclusion Endovaginal sonography has limited clinical utility in the diagnosis of upper genital tract infection due to its low sensitivity.

Atypical squamous cells of undetermined significance: human papillomavirus testing in adolescents.

OBJECTIVE: To estimate the age-stratified prevalence of oncogenic human papillomavirus (HPV) infection and to evaluate risk factors for HPV acquisition among women with atypical squamous cells of undetermined significance (ASC-US). METHODS: This was a chart review of all women with ASC-US smears who underwent oncogenic HPV testing between July 2002 and February 2004. To be eligible, HPV DNA results had to be available. Data extracted from charts included demographic information as well as certain patient characteristics historically associated with HPV acquisition or carriage. RESULTS: Of 527 eligible women with ASC-US, 357 (68%, 95% confidence interval [CI] 64–72%) tested positive for oncogenic HPV. As compared with women who tested negative, this population was significantly younger and less likely to be married. When stratified by age, 77% of the women aged younger than 20 years were positive for high-risk subtypes, compared with 58% of women aged older than 25 years (P < .01). In the multivariate analysis, young age (relative risk [RR] 1.30, 95% CI 1.14.–1.49), current smoking (RR 1.14, 95% CI 1.03–1.25) and a history of chlamydial infection (RR 1.20, 95% CI 1.09–1.32) were associated with an increased likelihood of HPV infection, while oral contraceptive use (RR 0.86, 95% CI 0.72–1.03) had a marginal protective effect. The protective effect of oral contraceptives was most pronounced among adolescent women (RR 0.57, 95% CI 0.31–1.03). CONCLUSION: Given that the rate of oncogenic HPV infection approached 80% in our population of adolescent women with ASC-US, the usefulness of HPV testing in this age group requires further investigation. LEVEL OF EVIDENCE: II-3

Microflora changes with the Use of a vaginal microbicide

Background The rate of HIV transmission is increasing more in women than in any other group. There is an urgent need for the development of microbicides with activity against this virus that women can use during intercourse. These products must be convenient, effective, and safe, and ideally they will cause minimal disruption in the normal vaginal ecosystem. Goal The objective of this study was to evaluate changes in vaginal microflora, specifically Lactobacillus species, with the use of BufferGel. Study Design A prospective cohort study was performed to evaluate the change in vaginal flora before and after BufferGel use. BufferGel was applied vaginally once or twice daily for 14 days by low-risk abstinent and monogamous women. Results There was no change in frequency of Lactobacillus species after BufferGel use. However, there was a decrease in H2O2-producing lactobacilli (from 4.9 × 107 to 1.1 × 107 cfu;P = 0.001). The proportion of facultative gram-negative rods present increased from 27% to 65% after BufferGel use, whereas obligately anaerobic microbes decreased from 62% to 38%. Conclusion Use of BufferGel once or twice daily for 14 days resulted in no clinically significant change in Lactobacillus colonization.

Screening for Anal Cancer in Women.

Objective The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women. Methods A group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women. Results Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus–infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population. Conclusions While there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus–infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.

Positive cone biopsy specimen margins in women infected with the human immunodeficiency virus.

OBJECTIVES The purpose of this study was to compare the positive margin rate associated with cervical conization among women who are seropositive for human immunodeficiency virus with that among women who are seronegative. STUDY DESIGN This was a cross-sectional study of 245 women who underwent cervical conization for the following indications: biopsy-proven cervical intraepithelial neoplasia grade 2 or 3, abnormal endocervical curettage specimen, cytologic-histologic examination discrepancy, persistent cervical intraepithelial neoplasia grade 1, or abnormal cytologic characteristics with inadequate colposcopic examination. RESULTS Twenty-two (47.8%) of 46 women who were seropositive for human immunodeficiency virus and 65 (32.7%) of 199 women who were seronegative had positive cone biopsy specimen margins. In a multivariable logistic regression the human immunodeficiency virus-seropositive women had a 2-fold increased risk of having a positive cone biopsy margin (odds ratio, 2.25; 95% confidence interval, 1.07-4.76). CONCLUSION If the presence of positive cone biopsy specimen margins represents the potential for disease progression, then our findings of a positive margin rate of nearly 50% in a human immunodeficiency virus-positive population may argue against the kind of conservative management of colposcopic follow-up that has been proposed for immunocompetent women.

Clinical Recommendation: Pediatric Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, labial adhesions, and loss of pigmentation. Treatment includes topical anti-inflammatory agents and long-term follow-up as there is a high risk of recurrence and an increased risk of vulvar cancer in adult women with history of lichen sclerosus. These recommendations are intended for pediatricians, gynecologists, nurse practitioners and others who care for pediatric/adolescent girls in order to facilitate diagnosis and treatment.