[Revision of the French colposcopic terminology]. / Nouvelle classification française des images colposcopiques.

OBJECTIVES: To revise the 1983 colposcopic terminology form the French Society of Colposcopy and cervicovaginal pathology (SFCPCV). METHODS: All the three following steps of colposcopic examination were considered for the description of various colposcopic features: inspection without coloration, followed by the application of acetic acid and iodine staining. This revised terminology now includes the different possible colposcopic aspects of the normal cervix, including the ectropion and the normal transformation zone. It also includes colposcopic appearance of abnormal glandular cervical epithelium and of vaginal epithelium. The revised nomenclature was reviewed by all the board of the SFCPCV and was finally approved during the 45th annual conference of the SFCPCV. RESULTS: Abnormal transformation zone grade (TAG) 1a and 1b have been brought together under the sole TAG1 designation. TAG2a and TAG2b now correspond to TAG2, whereas TAG2c corresponds to TAG3. Colposcopic report should mention the interpretability of the colposcopic examination, with the precise type of the squamocolumnar junction (1, 2 or 3), the colposcopic impression, the size of any TAG and finally mention whether one or multiple biopsies were taken and their precise location. Colposcopic impression must give priority to the most pejorative colposcopic aspect which takes precedence over others. CONCLUSION: When performing colposcopy, one should keep in mind that this examination only relies on the interpretation of various colposcopic signs and images with this not guaranteeing for diagnosis. Only histological analysis of a possible guided cervical biopsy provides for a precise diagnosis.

[Management of HPV-induced cervical lesions in immunosuppressed patients - Review of the literature]. / Prise en charge des lésions cervicales HPV induites chez les patientes immunodéprimées ­ Revue de la littérature.

INTRODUCTION: Current French recommendations for the management of cervical lesions related to human papilloma virus (HPV) infection are limited to general population. Patients who are immunocompromised appear to be at increased risk of induced HPV lesions. The objective of this review is to summarize the various existing data about risk of induced HPV lesions in immunocompromised patients to specify the management. METHODS: The Medline database was searched through the Pubmed portal, as well as the recommendations of various international learned societies. RESULTS: Situations with an increased risk are regardless of treatment: Human Immunodeficiency Virus (HIV) infection, transplants, lupus. Patients with chronic inflammatory bowel disease (IBD) and rheumatoid arthritis are at increased risk only when immunosuppressive therapy is required. Screening for dysplasic intraepithelial lesions in HIV+ patients should be more sustained than in the general population. Due to lack of data, recommendations for other conditions have been extrapolated from the management of HIV+ patients. HPV vaccination is effective in these populations, particularly at times when the immune system is the most effective. DISCUSSION: Identified immunocompromised populations are at higher risk of induced HPV lesions due to an incomplete immune response and should be screened on a sustained basis. In addition, HPV vaccination should be encouraged.

Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms.

PURPOSE: The objective of this study was to evaluate the efficacy of fractional CO2 laser to manage vulvar and vaginal symptoms of Genitourinary Syndrome of Menopause (GSM) in postmenopausal women. METHODS: All postmenopausal women with symptoms of GSM undergoing fractional CO2 laser treatment in our centers were asked to fill out a validated quality of life questionnaire (Global Quality of Life Questionnaire), Visual Analog Scale (VAS) for symptoms, a questionnaire on overall discomfort related to pelvic floor symptoms, and the Female Sexual Function Index (FSFI) at several points: before each session (three sessions at monthly intervals) and one 3 months after treatment completion. Statistical analysis compared pre-therapy data and data at 3 months of treatment. RESULTS: Forty-six women were included with a mean age of 57.3 years (± 11.1 years). A significant improvement was demonstrated in vaginal dryness (p = 6.34 10-6) and for symptoms of stress urinary incontinence (p = 0.043). Among sexually active patients, there was a significant improvement in the degree of symptom discomfort affecting their satisfaction (p = 0.007), dyspareunia (p = 0.001) and sensitivity during sexual intercourse (p = 0.001). Significantly, more women were able to achieve (p = 0.026) and maintain (p = 0.018) lubrication during intercourse. CONCLUSION: CO2 laser treatment seems to improve the quality of life and sexual health of patients as well as GSM symptoms at 3 months of treatment; long-term reevaluation is necessary to demonstrate that improvement persists over time.

[HPV testing in the screening and follow-up of patients with cervical high-grade squamous intraepithelial lesions]. / Le test HPV dans le dépistage et le suivi des patientes présentant une lésion histologique de haut grade du col utérin.

OBJECTIVES: To evaluate the value of high-risk HPV (HR HPV) testing in screening and post-treatment follow-up of high-grade squamous intraepithelial cervical lesions (HSIL). METHODS: A systematic review of the literature from 2000 to 2019 was conducted including the following keywords: "human papilloma virus", "HPV testing", "cervical squamous intraepithelial lesion", "cervical cancer". RESULT: Numerous recent randomized studies and meta-analyzes have concordant results in favor of HR HPV superiority over cervical smear in the screening and post-treatment monitoring of HSIL. In screening, the sensitivity of the HR HPV tests is 63% to 98% whereas that of the cervical smear is only 38% to 65% for the detection of HSIL+ (HSIL and invasive cancers). A negative HR HPV test is associated with less than 5% risk of LIEHG+at 6 years. In addition, after removal of a LIEHG, HR HPV tests have a sensitivity>90% and specificity>80% to predict treatment failure. After surgicale exision, a negative HR HPV test is associated with a risk of failure<2% (negative predictive value of 98%), and 12-25% if it is positive. CONCLUSIONS: HR HPV tests are effective, allowing early detection of LIEHG+ identification of low-risk women in case of negative test, and a prediction of the risk of failure after treatment.

[CO2 LASER for the treatment of vaginal symptoms of genitourinary syndrome of menopause]. / Place du LASER au CO2 pour le traitement des symptômes vaginaux du syndrome génito-urinaire de la ménopause.

Genitourinary syndrome of menopause (GSM) brings together a collection of signs including vaginal dryness, burning sensation and itching discomfort as well as deterioration of sexual health, dysuria, urgenturia and repeated urinary infections and may be responsible for a significant impairment of quality of life in symptomatic postmenopausal women. The management of GSM therefore represents a public health issue. Systemic or local hormonal treatments are frequently offered, as well as non-hormonal treatments. The existence of contraindications to hormonal treatments and the constraints of using local treatments lead us to propose other therapeutic options. CO2 LASER is now part of the therapeutic arsenal for the treatment of vaginal dryness in the context of GSM. There is a growing interest in this technique, especially for women who have a contraindication to hormonal therapy, as it is a globally effective, long-acting alternative with very little adverse effect. Current evidence suggests that this tool could provide a quality of life benefit to many patients with minimal side effect exposure, if used in the respect of its indications and implementation protocols. However, clinical data based on high-level therapeutic trials remain absolutely essential for this treatment to be validated and recommended by health professionals.

[Should CIN 2 and 3 be treated the same way?]. / La CIN 2 merite-t-elle la même prise en charge que la CIN 3 ?

Although spontaneous regression of cervical intraepithelial neoplasia type 2 (CIN 2) occurs in 40% of cases over a 2 years period, such diagnosis commonly requires the use of excisional techniques exposing to genuine obstetrical and neonatal morbidity as well as the risk of unsatisfactory post-treatment colposcopy. Recent advances in knowledge about CIN 2 natural history and morbidity of conservative therapies brings out the need to optimize therapeutics indications and to reconsider the use of ablative techniques. In order to allow for the lack of histological analysis and final diagnosis, it is therefore crucial not to misdiagnose microinvasive cervical disease. The use of factors significantly related to the risk of microinvasion misdiagnosis allows for a simple and reliable risk assessment in decision-making regarding CIN 2 management. Thus, CIN 2 therapeutic abstention with simple follow up as well as ablative technique might be safely considered in women under 30 whose lesion involves only one cervical quadrant, with type one transformation zone, without any colposcopic sign of severity and whose cervical smear and biopsy results are concordant. Use of ablative techniques will be recommended in all other cases. If necessary, practice of large loop excision of the transformation performed under colposcopic vision by experienced practitioner should be preferred to all other excisional techniques.

[Modern management of cervical intraepithelial neoplasia: a proposal for a risk assessment method in colposcopic decision-making]. / Repenser la prise en charge des néoplasies intraépithéliales du col de l'utérus: proposition d'une méthode d'évaluation du risque et d'aide à la décision thérapeutique.

Recent improve in the understanding of the natural progression of cervical intraepithelial neoplasia (CIN) and in the knowledge of treatments pregnancy related morbidity in addition with progression in mean age of first pregnancy brings out the need to rethink CIN management. Efficient tools are therefore needed to optimize therapeutic indications and destructive techniques have to be reconsidered. Because there is no superior technique for treating CIN in terms of treatment failure, the choice of a treatment method will not depend on this criteria but on the overall consideration of its characteristics, advantages and limitations put in balance with age of women, plan of pregnancy as well as CIN severity, risk of progression and of microinvasion misdiagnosis. The use of a "risk assessment method" based on five criteria: colposcopic impression, transformation zone type and size, age and agreement between cytology and histology would allow for proper evaluation of the risk of microinvasion misdiagnosis. Depending on their severity, each of these five criteria would be graded from 1 to 3. The presence of at least one grade 3 criteria would warrant the need for excisional treatment, preferably large loop excision of the transformation zone, allowing for histological analysis and reliable diagnosis. Ablative technique could be reasonably considered for only one grade 2 criteria or if all criteria are grade 1, reflecting good prognosis. Such risk assessment method requires to be prospectively evaluated.

[Cervical screening: toward a new paradigm?]. / Un nouveau paradigme pour le dépistage du cancer du col utérin?

OBJECTIVES: Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening. MATERIAL AND METHODS: The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France. RESULTS: The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary. CONCLUSION: The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

[What kind of follow-up after surgical treatment for high-grade cervix lesion?]. / Quel suivi après traitement chirurgical dune lésion de haut grade du col utérin ?

The women treated for a high-grade cervical lesion (CIN2+) have a high and prolonged (beyond 25 years) risk of recurrence (x 5 compared to the general population) of cervical as well as extracervical lesion. The cytological and colposcopic protocols of follow-up raise the problem of their insufficient sensitivity, and the compliance of the patients to this prolonged follow-up is low. Test HPV seeking the presence of high-risk HPV benefits from a high sensitivity and presents altogether a very strong negative predictive value. The addition of this test to the cytological monitoring three to six months after the conization makes it possible to distinguish a group of patients with low risk (with both tests negative) being able to profit from a traditional follow-up, from a high-risk group having at least one positive test, whose surveillance must be reinforced (with triage by colposcopy), prolonged in time and extended beyond the cervix. Like as the primary screening of cervical lesions, the follow-up of the patients after conization must profit from the addition of test HPV and would deserve protocolization and organization.

[Guidelines for the follow-up of women treated for high-grade cervical neoplasia]. / Recommandations pour la surveillance des patientes traitées pour des lésions de haut grade du col utérin.

The women treated for CIN2-3 remain at a substantially increased risk of recurrences, which persists longer than 10 years. The women treated for a CIN2-3 are more likely to develop invasive cancer and the risk is two to five times greater than that of the general population. The main objective of the follow-up of patients treated for high-grade CIN is in one hand, to detect and treat the recurrences and on the other hand, to determine a subpopulation presenting a high risk of recurrence which should be followed-up more intensively. At present, frequent follow-up with cytology and colposcopic evaluation of the cervix is the preferred strategy recommended in France by Anaes. Both, the cytology and the colposcopy don't have a very good sensitivity. HPV test is more sensitive compared to cytology or colposcopy in detecting CIN treatment failures. It would be more prudent to use a strategy involving both the cytology and HPV test. Both the sensitivity and the negative predictive value of combined cytology and HPV testing in detecting a residual disease or recurrence are around 100%. Women presenting negative results of both tests, could, then be considered at a low risk of recurrence and their surveillance should be the same as that of the screening of the general population. In case of positivity a more intensive follow-up should be organized.

[Long-term results of hysteroscopic resection of endometrial polyps in 367 patients. Role of associated endometrial resection]. / Résultats à long terme de la résection des polypes endométriaux chez 367 patientes. Place de l'endométrectomie associée.

OBJECTIVE: To assess the results of hysteroscopic resection of endometrial polyps and the eventual role of associated endometrial resection. PATIENTS AND METHODS: Retrospective study. Between 1998 and 2001, 367 patients had hysteroscopic resection of endometrial polyps, which were initially confirmed by diagnostic hysteroscopy. Fifty-four percent of these had associated endometrial resection. RESULTS: Five intraoperative complications and/or incidents were noted, but there was no major complication. 83% of patients were followed up and the median follow-up period was 40 months (range 17-66 months). The success rate in this study was 96.4%. This is higher in the group of patients that had associated endometrial resection: 98.3 vs 93.7%. DISCUSSION AND CONCLUSION: Hysteroscopic resection is the optimal method for treatment of benign endometrial polyps. Associated endometrial resection in older patients or in patients not desiring to conserve their fertility potential improves the success rate and decreases the rate of recurrences.

[Menorrhagia after age 40. Contribution of ultrasonic examination]. / Les ménorragies après 40 ans. Apport des examens ultrasonores.

Menorrhagia after age 40 can have functional, general, local, or organic reasons. The most frequent are: submucous myomas, adenomyosis, polyps. Submucous myomas: a transvaginal scan (TVUS) specifies the type of myoma according to its situation within the uterine cavity: intracavitary myoma or submucous. A transvaginal scan is performed to assess myomas before operative HSC. There are three criteria to check: myomas diameter must be less than 5 cm; 5 mm or more of normal myometrium should be present between myoma and external wall; the myoma must not be in contiguity with a subserosal myoma. Uterine adenomyosis is a common gynecologic condition that is characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. Pathology may be proximal or distal, focal or diffuse. Transvaginal US shows: cystic dilatation of heterotopic glands, heterogeneity of the myometrial echotexture, antero-posterior asymmetry of the uterus. TVUS has a sensitivity of 62 to 89% and a specificity of 89 to 96%. Polyps are most often hyperechoic: this makes the diagnosis more difficult in luteal phase; Power Doppler shows the vascular central pedicle. TVUS has a sensitivity of 75%. The polyps smaller than 3 mm are not visible in a reliable way without the help of a contrast media in the cavity.

[Role of hysteroscopy in the diagnosis and treatment of infertility]. / Place de l'hystéroscopie dans le diagnostic et le traitement de l'infertilité.

UTERINE DISORDERS: Because they can prevent implantation, anomalies within the uterine cavity play an important role in fertility. The uterine disorders most often observed during hysteroscopy and implicated in infertility are adhesions, septa, polyps, submucous myomas, adenomyosis, endometritis, anomalies of the cervical canal, and lesions of the uterotubal junction. EXPLORATIONS: Hysterosalpingography can be used to evaluate tubal permeability but provides inadequate information about the uterine cavity (numerous false-positives and false-negatives). Pelvic ultrasound is especially helpful for diagnosing interstitial anomalies in the uterus. HYSTEROSCOPY: Diagnostic hysteroscopy also has a place in infertility investigations, for it allows direct visualization of the uterine cavity, the endometrial mucus (endometritis, adenomyosis), and the cervical canal. The examination is practiced on a out-patient basis, without anesthesia, using appropriate small-caliber instruments and irrigation with physiological saline. Surgical hysteroscopy is used to treat these anomalies. Patients receive general anesthesia. A high-frequency, low-voltage electric current is used, and glycine for irrigation. This procedure allows resection of submucous myomas and polyps and of septa and adhesions. Some groups use laser beams and irrigation by physiological saline for these treatments. Coagulation of a superficial focal spot of adenomyosis is not useful in infertility therapy. RESULTS: As assessed by the percentage of patients with each indication who subsequently became pregnant, the results of surgical hysteroscopy have been satisfactory: 62 per cent (%) of cases after myomectomy, 66% after section of uterine septa, and 61% after treatment of complicated adhesions. A new exploration of the uterine cavity will be necessary sometime after the surgery to verify the absence of any iatrogenic disorders (adhesions, myomatous fragments).