Loris Y. Hwang

Factors that influence the rate of epithelial maturation in the cervix in healthy young women.

PURPOSE To examine the longitudinal changes in the epithelial topography of the cervix in healthy young women; and to determine the sociodemographic, behavioral, and biological factors associated with the rate of cervical epithelial maturation. METHODS Healthy young women were enrolled from October 2000 to September 2002 as part of a larger study of human papillomavirus (HPV). At interval visits, interviews, infection testing, and colpophotography (3% acetic acid; 10x, 16x magnifications) were performed. Areas of total cervical face and cervical immaturity, defined as columnar and early squamous metaplasia, were quantitatively measured using computerized planimetry. Cervical immaturity was expressed as percentage of total cervical face. This analysis includes the first consecutive 145 women with greater than 10% immaturity at baseline. The rate of cervical maturation was defined as change in percent-immaturity. Predictors included sociodemographics, sexual behaviors, and infections. Data analyses included multivariate generalized linear models with repeated measures. RESULTS The baseline mean age was 17.8 years. Colpophotographs were available from 815 total visits, representing 2.7 years mean follow-up per woman and 5.9-month mean intervals. Women began the study with a median of 39% immaturity and ended with 8% immaturity. After adjusting for time and baseline percent-immaturity, an increased rate of cervical maturation was associated with oral contraceptive pill use (parameter estimate -.023, p =.04) and smoking (-.039, p =.01). CONCLUSIONS Cervical maturation was documented during relatively short time periods for the vast majority of these women. Oral contraceptive pills and smoking may accelerate the maturational process, representing increased cell proliferation and thus a possible greater vulnerability to HPV.

Higher levels of cervicovaginal inflammatory and regulatory cytokines and chemokines in healthy young women with immature cervical epithelium

Young women aged 15-24 years have the highest rates of sexually transmitted infections (STIs). The vulnerability of adolescents is often attributed to risky sexual behaviors, whereas biological factors affecting mucosal immunity are poorly understood. The objective of this cross-sectional study was to examine associations between the type of cervical epithelium and protein levels of 11 cervicovaginal cytokines and chemokines in non-pregnant healthy young women. Cervical epithelial types were viewed on colpophotography and measured quantitatively using computerized planimetry. We selected 16 women with immature epithelium (predominantly columnar and early/mid squamous metaplasia), and 16 women with mature epithelium (predominantly squamous epithelium). Cytokine levels were measured in cervicovaginal lavage samples by MILLIPLEX™ MAP Human Cytokine/Chemokine multiplex immunoassay. Bivariate Box-Cox regression models compared cytokine levels between immature and mature groups. Multivariate Box-Cox models adjusted separately for age, years since menarche, days since last menses, years of sexual activity, number of lifetime sexual partners, HPV infection, hormonal contraceptive use, smoking, bacterial vaginosis by Nugents criteria, and polymorphonuclear cells on wet prep. The mean age was 19.2 years. Women with immature epithelium demonstrated significantly higher levels of IL-1α, IL-1β, IL-6, IL-8, MIP-1α, RANTES, TNFα, IL-10, IL-12 and IFNγ (each p<0.01), compared to women with mature epithelium. Results remained highly significant in the multivariate models. Cytokine profiles in the healthy state may foreshadow differential responses to pathogens. Cervical epithelial type should be measured in clinical studies involving cervicovaginal immune markers.

Adolescent contraception: review and guidance for pediatric clinicians.

The objectives of this article are to review current contraceptive methods available to adolescents and to provide information, guidance, and encouragement to pediatric clinicians to enable them to engage in informed up-to-date interactions with their sexually active adolescent patients. Pregnancy prevention is a complex and dynamic process, and young people benefit from having a reliable authoritative source for information, counseling, and support. Clinicians who provide services for adolescents have a responsibility to develop their skills and knowledge base so that they can serve as that source. This review begins with a discussion about adolescent sexuality and pregnancy in the context of the adolescent developmental stages. We discuss approaches to introduce the topic of contraception during the clinic visit and contraceptive counseling techniques to assist with the discussion around this topic. In addition, information is included regarding confidential services, support of parental involvement, and the importance of male involvement in contraception. The specific contraceptive methods are reviewed in detail with the adolescent patient in mind. For each method, we discuss the mechanism of action, efficacy, contraindications, benefits and risks from the medical perspective, advantages and disadvantages from the patients perspective, side effects, patient adherence, patient counseling, and any medication interactions. Furthermore, we have included a section that focuses on the contraceptive management for the adolescent patient with a disability and/or chronic illness. The article concludes with an approach to frequently asked or difficult questions. This section largely summarizes subsections on specific contraceptive methods and can be used as a quick reference on particularly challenging topics. Finally, a list of useful contraceptive management resources is provided for both clinicians and patients.

Active Squamous Metaplasia of the Cervical Epithelium Is Associated With Subsequent Acquisition of Human Papillomavirus 16 Infection Among Healthy Young Women

BACKGROUND Vulnerability of younger women to human papillomavirus 16 (HPV16) infection has been attributed to the predominance of ectocervical columnar epithelia in this age group. However, squamous metaplastic tissue may be more influential. We examined the extent of ectopy and metaplastic activity as risks for HPV16 acquisition in a prospective cohort. METHODS Participants were HPV16 negative at the first two visits. Follow-up occurred every 4 months. Ectopy was quantitatively measured on colpophotographs. We calculated metaplastic rate as the difference in ectopy between visits. Cox proportional hazards models were constructed, adjusting for several covariates. RESULTS Analyses included 198 women (mean baseline age 17 years) for 1734 visits. Mean follow-up was 4.4 years. Incident HPV16 was detected in 36 (18%) women. Metaplastic rate between the two visits before HPV16 detection was significantly associated with incident infection (hazard ratio [HR], 1.17; confidence interval [CI], 1.02-1.33; P = .02). However, ectopy was not significant, whether measured before or concurrent to HPV16 detection (HR range, 0.99-1.00; CI range, .97-1.02; P range, .47-.65). CONCLUSIONS Dynamic metaplasia rather than the sheer extent of ectopy appears to increase risk for incident HPV16 in healthy young women. This in vivo observation is consistent with the HPV life cycle, during which host cell replication and differentiation supports viral replication.

Sexual behaviors after universal screening of sexually transmitted infections in healthy young women.

OBJECTIVE: To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation. METHODS: Of all women entering recruit training (June 1999–June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation. RESULTS: The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10–6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19–21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12–5.50). CONCLUSION: Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors. LEVEL OF EVIDENCE: II

Biological and Behavioral Risks for Incident Chlamydia trachomatis Infection in a Prospective Cohort

OBJECTIVE: To identify biological and behavioral risks for incident Chlamydia trachomatis among a prospective cohort of young women followed frequently. METHODS: Our cohort of 629 women from two outpatient sites was seen every 4 months (October 2000 through April 2012) for behavioral interviews and infection testing. C trachomatis was tested annually and any time patients reported symptoms or possible exposure using commercial nucleic acid amplification tests. Analyses excluded baseline prevalent C trachomatis infections. Risk factors for incident C trachomatis were assessed using Cox proportional hazards models. Significant risks (P<.10) from bivariate models were entered in a multivariate model adjusted for four covariates chosen a priori (age, race or ethnicity, condom use, study site). Backward stepwise elimination produced a final parsimonious model retaining significant variables (P<.05) and the four adjustment variables. RESULTS: The 629 women attended 9,594 total visits. Median follow-up time was 6.9 years (interquartile range 3.2–9.8), during which 97 (15%) women had incident C trachomatis. In the final multivariate model, incident C trachomatis was independently associated with human papillomavirus at the preceding visit (P<.01), smoking (P=.02), and weekly use of substances besides alcohol and marijuana (P<.01) since the prior visit. Among 207 women with available colpophotographs (1,742 visits), cervical ectopy was not a significant risk factor (P range=.16–.39 for ectopy as continuous and ordinal variables). CONCLUSION: Novel risks for C trachomatis include preceding human papillomavirus, smoking, and substance use, which may reflect both biological and behavioral mechanisms of risk such as immune modulation, higher-risk sexual networks, or both. Improved understanding of the biological bases for C trachomatis risk would inform our strategies for C trachomatis control. LEVEL OF EVIDENCE: II

Cervical ectopy and the acquisition of human papillomavirus in adolescents and young women.

OBJECTIVE: Higher rates of human papillomavirus (HPV) in adolescents and younger women have been attributed to their greater extent of “cervical ectopy,” defined as columnar and metaplastic epithelia on the ectocervix. Our objective was to estimate associations between ectopy and incident HPV in healthy adolescents and young women. METHODS: Enrolled between October 2000 and October 2002, this prospective cohort included women aged 13–21 years who were sexually active, without previous cervical intraepithelial neoplasia, cervical procedures, or immunosuppression, with menarche within 6 years before enrollment, and negative for HPV DNA at baseline. Every 4 months, extent of ectopy was quantitatively measured using colpophotography and computerized planimetry. Cox proportional hazards models examined associations between ectopy and incident HPV, defined as the first positive HPV result during follow-up. RESULTS: The 138 women attended 509 total visits. At baseline, mean age was 16.7 years and mean extent of ectopy was 25% of the total cervical face. Incident HPV of any type was detected in 42 (30%) women and was not significantly associated with baseline ectopy (hazard ratio 1.09, 95% confidence interval 0.96–1.25; P=.20; ectopy in units of 10%), or with ectopy measured 4 months before HPV detection (hazard ratio 1.09, confidence interval 0.94–1.26; P=.25). Our sample size had 80% power to detect a hazard ratio of 1.9 (with two-tailed &agr;=0.05). Results were similarly insignificant for HPV subgroupings of incident high-risk, low-risk, &agr;9, and &agr;3/&agr;15 types, and when adjusted for new sexual partners. CONCLUSION: Extent of cervical ectopy was not associated with HPV acquisition in healthy adolescents and young women. Biological vulnerabilities may lie in immune function or other characteristics of the cervical epithelium. LEVEL OF EVIDENCE: II

Feasibility of clinical detection of cervical dysplasia using angle‐resolved low coherence interferometry measurements of depth‐resolved nuclear morphology

This study sought to establish the feasibility of using in situ depth‐resolved nuclear morphology measurements for detection of cervical dysplasia. Forty enrolled patients received routine cervical colposcopy with angle‐resolved low coherence interferometry (a/LCI) measurements of nuclear morphology. a/LCI scans from 63 tissue sites were compared to histopathological analysis of co‐registered biopsy specimens which were classified as benign, low‐grade squamous intraepithelial lesion (LSIL), or high‐grade squamous intraepithelial lesion (HSIL). Results were dichotomized as dysplastic (LSIL/HSIL) versus non‐dysplastic and HSIL versus LSIL/benign to determine both accuracy and potential clinical utility of a/LCI nuclear morphology measurements. Analysis of a/LCI data was conducted using both traditional Mie theory based processing and a new hybrid algorithm that provides improved processing speed to ascertain the feasibility of real‐time measurements. Analysis of depth‐resolved nuclear morphology data revealed a/LCI was able to detect a significant increase in the nuclear diameter at the depth bin containing the basal layer of the epithelium for dysplastic versus non‐dysplastic and HSIL versus LSIL/Benign biopsy sites (both p < 0.001). Both processing techniques resulted in high sensitivity and specificity (>0.80) in identifying dysplastic biopsies and HSIL. The hybrid algorithm demonstrated a threefold decrease in processing time at a slight cost in classification accuracy. The results demonstrate the feasibility of using a/LCI as an adjunctive clinical tool for detecting cervical dysplasia and guiding the identification of optimal biopsy sites. The faster speed from the hybrid algorithm offers a promising approach for real‐time clinical analysis.

Diversity of Cervicovaginal Cytokine Response to Incident Chlamydia trachomatis Infection Among a Prospective Cohort of Young Women.

Animal, in vitro, and ex vivo studies have identified several cytokines involved in host immunity to genital Chlamydia trachomatis (CT) infection. However, in vivo cytokine responses are not well described. Our objectives were to document cervicovaginal cytokine levels and intrawoman cytokine changes during incident CT in a prospective cohort.

P4-S1.10 Longitudinal changes in cervicovaginal cytokine levels upon incident Chlamydia trachomatis infection among young women

Background Highest rates of genital Chlamydia trachomatis (CT) infection are found in 15–24-year-old women. Animal, in vitro, and ex vivo studies have identified several inflammatory and regulatory cytokines that impact infection clearance, recurrence, and immunopathology. However, the in vivo natural history of the cytokine response is not well-described. Our study aim was to characterise the cytokine levels in the cervicovaginal secretions of young women with incident CT. Methods Women were eligible to enrol (as part of a prospective HPV Natural History Study) who were 13–21 years old, sexually active (5 years maximum), and had no history of cervical neoplasia or procedures, or immunosuppression. Women were seen every 4 months for interviews, infection tests, and cervicovaginal lavage samples for cytokine measurement by Luminex® multiplex assay. CT was detected by nucleic-acid amplification. This prospective study selected women (N=64) who had incident CT infection, defined as a negative CT result followed by a positive CT result at a later visit. Cytokine levels were tested at each womans pair of negative and positive visits. Each sample was run in duplicate wells. To address assay variation among our samples, per cent-differences between duplicate wells were calculated. A womans cytokine response was defined as positive” if the per cent-increase from her negative visit to her positive visit exceeded the [mean+2 SD] of the inter-well per cent-difference for that cytokine. Similarly, “negative” was defined as an inter-visit per cent-decrease that exceeded the [mean+2 SD] of the inter-well per cent-difference. The remaining women were defined as having “no response”. Results The mean age at incident infection was 19 years. Infections concurrent to the positive CT were detected for HPV in 24 (38%) women; yeast in 10 (16%); bacterial vaginosis in 5 (8%); Neisseria gonorrhoeae in 3 (5%); and Trichomonas vaginalis in 1 (2%). Abstract P4-S1.10 table 1 shows the distribution of cytokine responses. Response status was not significantly associated with age or other genital infections (HPV, yeast, bacterial vaginosis, N gonorrhoeae, T vaginalis) detected at either the negative CT or positive CT visits. Abstract P4-S1.10 Table 1 Longitudinal changes in cervicovaginal cytokine levels upon incident Chlamydia trachomatis infection among young women (N=64 women) Cytokine Median cytokine level at negative CT visit (pg/ml) Median cytokine level at subsequent positive CT visit (pg/ml) Women with positive response, n (%) Women with no response, n (%) Women with negative response, n (%) IL-6 30.3 30.3 23 (36) 19 (30) 22 (34) IL-8 1855.5 1832.6 8 (16) 30 (60) 12 (24) IL-1α 345.3 316.1 23 (36) 14 (22) 27 (42) IL-1β 29.0 43.3 31 (48) 14 (22) 19 (30) MIP-1α 14.1 19.6 28 (44) 16 (25) 20 (31) RANTES 3.2 5.1 30 (47) 22 (34) 12 (19) IFNγ 3.2 3.2 16 (25) 43 (67) 5 (8) CT, Chlamydia trachomatis. Conclusions In young women with incident CT, the in vivo cytokine responses measured in the cervicovaginal fluid compartment are heterogeneous. Differences in the cytokine milieu between individuals may have implications for immune defense and immunopathology.