Syringe or mask? Loop electrosurgical excision procedure under local or general anesthesia: a randomized trial.

BACKGROUND: Loop electrosurgical excision procedure may be performed under local anesthesia or general anesthesia, and practice patterns differ worldwide. No randomized head-to-head comparison has been published to confirm or refute either practice. OBJECTIVE: This study aimed to compare loop electrosurgical excision procedure under local anesthesia vs general anesthesia regarding patient satisfaction and procedure-related outcomes such as rates of involved margins, complications, pain, and blood loss. STUDY DESIGN: Consecutive women referred to our colposcopy unit were recruited. Loop electrosurgical excision procedure was performed under local anesthesia with 4 intracervical injections of bupivacaine hydrochloride 0.5% or under general anesthesia with fentanyl, propofol, and a laryngeal mask with sevoflurane maintenance. The primary endpoint was patient satisfaction assessed on the day of surgery and 14 days thereafter using a Likert scale (score 0-100) and a questionnaire. Secondary endpoints included rates of involved margins, procedure-related complications, pain, blood loss, and surgeon preference. Results were compared using nonparametric and chi-square tests. RESULTS: Between July 2018 and February 2020, we randomized 208 women, 108 in the local anesthesia arm and 100 in the general anesthesia arm. In the intention-to-treat analysis, patient satisfaction did not differ between the study groups directly after surgery (Likert scale 100 [90-100] vs 100 [90-100]; P=.077) and 14 days thereafter (Likert scale 100 [80-100] vs 100 [90-100]; P=.079). In the per-protocol analysis, women in the local anesthesia arm had significantly smaller cone volumes (1.11 cm3 [0.70-1.83] vs 1.58 cm3 [1.08-2.69], respectively; P<.001), less intraoperative blood loss (Δhemoglobin, 0.2 g/dL [-0.1 to 0.4] vs 0.5 g/dL [0.2-0.9]; P<.001), and higher satisfaction after 14 days (100 [90-100] vs 100 [80-100]; P=.026), whereas surgeon preference favored general anesthesia (90 [79-100] vs 100 [90-100], respectively; P=.001). All other secondary outcomes did not differ between groups (resection margin status R1, 6.6% vs 2.1% [P=.26]; cone fragmentation, 12.1% vs 6.3% [P=.27]; procedure duration, 151.5 seconds [120-219.5] vs 180 seconds [117-241.5] [P=.34]; time to complete hemostasis, 60 seconds [34-97] vs 70 seconds [48.25-122.25] [P=.08]; complication rate, 3.3% vs 1.1% [P=.59]). In a multivariate analysis, parity (P=.03), type of transformation zone (P=.03), and cone volume (P=.02) and not study group assignment, age, body mass index, and degree of dysplasia independently influenced the primary endpoint. CONCLUSION: Loop electrosurgical excision procedure under local anesthesia is equally well tolerated and offers patient-reported and procedure-related benefits over general anesthesia, supporting the preferred practice in some institutions and refuting the preferred practice in others.

Management and treatment of cervical intraepithelial neoplasia in the Netherlands after referral for colposcopy.

INTRODUCTION: The aim of this study was to describe trends in the diagnosis and treatment of women referred from the national screening program with cervical intraepithelial neoplasia (CIN) in the Netherlands, and to compare these trends with national guidelines and identify potential areas for improvement for the new primary high-risk HPV screening program. MATERIAL AND METHODS: We conducted a population-based cohort study using data from the Dutch pathology archive. Women aged 29-63 years who took part in the Dutch cervical screening program between 1 January 2005 and 31 December 2014 were selected. Three referral groups were identified: direct referrals and those referred after either one (first indirect referrals) or two (second indirect referrals) repeat cytology tests, totaling 85 239 referrals for colposcopy. The most invasive management technique and the most severe diagnosis of each screening episode was identified. Rates of management techniques were calculated separately by referral type, highest CIN diagnosis and age group. RESULTS: In all, 85.1% of CIN 3 lesions were treated with excision (either large excision or hysterectomy) and 26.4% of CIN 1 lesions were treated with large excision. Rates of overtreatment (CIN 1 or less) in see-and-treat management were higher for indirect referrals than for direct referrals and increased with age. Large excision rates increased with CIN diagnosis severity. CONCLUSIONS: Despite guideline recommendations not to treat, CIN 1 lesions were treated in just over 25% of cases and approximately 15% of CIN 3 lesions were possibly undertreated. Given the expected increase in CIN detection in the new primary high-risk HPV screening program, reduction in CIN 1 treatment and CIN 2 treatment in younger women is needed to avoid an increase in potential harm.

Estrategias para la implantación del cribado poblacional de cáncer de cuello uterino con test VPH-AR / Strategies for the implementation of population-based screening for cervical cancer with the HR-HPV test

Introducción: desde el año 2005 se trabaja coordinadamente Atención Primaria y especializada para revertir el cribado de cáncer de cuello de útero de oportunista a poblacional. En 2011 se añadió el test de virus de papiloma humano de alto riesgo a la citología (co-test) como cribado primario. Objetivo: potenciar el cribado poblacional de cáncer de cuello de útero. Material y métodos: captación activa de la población a través de las matronas de Atención Primaria y atención en ginecología de las mujeres positivas a virus de papiloma humano de alto riesgo. En Anatomía Patológica se realiza control de calidad de las pruebas y se monitorizan los resultados. Resultados: se ha duplicado la cobertura poblacional, el 80,7% de las pruebas de cribado se realiza en Atención Primaria y el número de neoplasias intraepiteliales cervicales se ha quintuplicado. Conclusiones: la implicación de todos los profesionales en el cribado ha permitido conseguir una cobertura del 66,6% y la introducción del test de virus de papiloma humano de alto riesgo ha incrementado los diagnósticos de neoplasias intraepiteliales cervicales (AU)

Introduction: Since 2005, a coordinated effort by primary care and gynaecology services has shifted screening from an opportunistic setting to a population-based strategy. High-risk Human papilloma viruses testing was added to the Papanicolau smear (co-testing) as the primary screening test in 2011. Objective: To implement population-based cancer screening. Material and methods: Primary care midwives arrange appointments for women and, if tested positive, they are then attended in gynaecology services. Quality control and the monitoring of results is carried out by the pathology service. Results: Coverage has doubled, 80% of screening tests are performed in primary care and the number of CIN 2/3 intraepithelial neoplasia cases have increased 5 fold. Conclusion: The participation of the entire health screening team has increased coverage to 66%. The introduction of the human papilloma viruses test has increased the detection of intraepithelial neoplasia cases (AU)

Pain relief for obstetric and gynecologic ambulatory procedures.

As minor gynecologic procedures move from the operating room to the office, providers need to ensure that patients are comfortable and that procedures are performed safely. Although local anesthesia is commonly used for gynecologic procedures, a multimodal approach may be more effective. If necessary, sedation can be safely provided in an office setting with the correct tools and training. This article reviews evidence-based approaches to pain management for gynecologic procedures in the ambulatory setting.

Comparison between trans-obturator trans-vaginal mesh and traditional anterior colporrhaphy in the treatment of anterior vaginal wall prolapse: results of a French RCT.

INTRODUCTION AND HYPOTHESIS: To compare the efficacy of a collagen-coated polypropylene mesh and anterior colporrhaphy in the treatment of stage 2 or more anterior vaginal wall prolapse. METHODS: Prospective, randomized, multicenter study conducted between April 2005 and December 2009. The principal endpoint was the recurrence rate of stage 2 or more anterior vaginal wall prolapse 12 months after surgery. Secondary endpoints consisted of functional results and mesh-related morbidity. RESULTS: One hundred and forty-seven patients were included, randomized and analyzed: 72 in the anterior colporrhaphy group and 75 in the mesh group. The anatomical success rate was significantly higher in the mesh group (89%) than in the colporrhaphy group (64%) (p = 0.0006). Anatomical and functional recurrence was also less frequent in the mesh group (31.3% vs 52.2%, p = 0.007). Two patients (2.8%) were reoperated on in the colporrhaphy group for anterior vaginal wall prolapse recurrence. No significant difference was noted regarding minor complications. An erosion rate of 9.5% was noted. De novo dyspareunia occurred in 1/14 patients in the colporrhaphy group and in 3/13 patients in the mesh group. An analysis of the quality of life questionnaires showed an overall improvement in both groups, with no statistical difference between them. Satisfaction rates were high in both groups (92% in the colporrhaphy group and 96% in the mesh group). CONCLUSION: Trans-obturator Ugytex mesh used to treat anterior vaginal wall prolapse gives better 1-year anatomical results than traditional anterior colporrhaphy, but with small a increase in morbidity in the mesh group.

A comparative study of efficacy and outcomes of large loop excision of the transformation zone procedure performed under general anaesthesia versus local anaesthesia.

BACKGROUND: Although Australian National Health and Medical Research Council (NHMRC) guidelines do not specify targets for mode of anaesthesia for large loop excision of the transformation zone (LLETZ) procedures, UK NHS Cervical Screening Programme (NHSCSP) guidelines recommend that >80% of LLETZ procedures be performed under local anaesthesia. There is a paucity of clinical data regarding both the proportion of women receiving general anaesthesia for treatment, factors underpinning this choice and the impact of mode of anaesthesia on treatment outcomes. AIMS: To identify the proportion of women who have a LLETZ under general anaesthesia and to establish the impact of mode of anaesthesia on outcomes including treatment efficacy, overtreatment (negative histology), short-term morbidity and attendance for follow-up. METHODS: Single-centre retrospective analysis of all women treated with LLETZ for suspected cervical dysplasia between 1, May 2005 and 1, May 2009. RESULTS: Thirty-three percent of a total 465 LLETZ procedures were carried out under general anaesthesia, although the reason for anaesthesia choice was not recorded in 52% of cases. There were no significant differences in the primary outcomes of unclear LLETZ margins or negative LLETZ histology, or in the secondary outcomes of depth and surface area of LLETZ specimen, short-term morbidity or rates of incomplete follow-up. CONCLUSIONS: Although reasons underpinning selection of anaesthesia mode remain elusive, at this centre, outcomes following LLETZ procedure for the management of suspected cervical dysplasia are not affected by the mode of anaesthesia used.

Non-uptake of colposcopy in a resource-poor setting.

OBJECTIVE: To determine the rate of acceptance/refusal of colposcopy and the reasons for refusal by women referred for the procedure in southeast Nigeria. METHODS: An audit was performed of the computerized database for all women referred for colposcopy at the University of Nigeria Teaching Hospital, Enugu, from August 1, 2009, to July 31, 2010. The characteristics of those who accepted colposcopy were compared with those who refused the procedure. An interviewer-administered questionnaire was used to assess reasons for refusal and the subsequent treatment chosen. RESULTS: During the study period, 154 women were referred for colposcopy: 103 (66.9%) accepted and 51 (33.1%) refused. Those who refused were younger and tended to be nulliparous (P=0.029 and P=0.004, respectively). The most common reasons for refusal were fears of possible diagnosis of cervical cancer and compromise of future fertility. Most women who refused resorted to spiritual healing. CONCLUSION: The rate of refusal of colposcopy in southeast Nigeria was high, indicating an urgent need for appropriate remedial measures instituted through intensive education of women regarding cervical cancer and its prevention. Targeted counseling should be initiated early as part of prescreening counseling.

The colposcopic examination.

Colposcopy is used to evaluate women with genital tract abnormalities and abnormal cervical cytology. It is an office-based procedure during which the cervix is examined under illumination and magnification before and after application of dilute acetic acid. Colposcopy may include a biopsy of lesions with characteristics of malignancy and premalignancy, such as acetowhite changes, abnormal vascular patterns, and failure to uptake iodine stain. Endocervical sampling may accompany colposcopy, particularly in the evaluation of nonpregnant women with cytology results of atypical glandular cells and adenocarcinoma in situ. Satisfactory colposcopy requires visualization of the entire squamocolumnar junction and margins of any visible lesions. While most midwives do not perform colposcopy, they will provide the pre- and postprocedure education, counseling, and evaluation of patients undergoing the procedure. This paper reviews essential information and gives special consideration to colposcopic examination in adolescent women, pregnant women, and postmenopausal women.

Vaginal distribution of Replens and K-Y Jelly using three imaging techniques.

BACKGROUND: Determination of vaginal distribution is important to the development of potential vaginal microbicidal or spermicidal products. STUDY DESIGN: This was a descriptive study of three imaging techniques with a randomized crossover assignment of two gels and activity status within each technique. METHOD: Each of three sites utilized one technique. Three nulligravid women and three parous women were to be enrolled at each site. We studied the effects of time, ambulation, parity and body mass index on vaginal spreading of two commonly used gels, K-Y Jelly and Replens. Imaging by magnetic resonance imaging and gamma scintigraphy was performed at 5, 20, 35 and 50 min after insertion of 3.5 mL of gel. Imaging with a fiberoptic probe was performed at 5 and 20 min after insertion. RESULTS: Initial application of the gel resulted in approximately two thirds of maximum coverage possible, both in linear extent along the vaginal axis and in surface area covered. Over the next 45 min, spreading increased to about three quarters of the maximum possible. Ambulation generally increased linear spreading and the proportions of women with gel at the introitus and os. Effects of parity and body mass index (BMI) were similar on most measures of gel spreading, with nulligravid women tending toward greater spread than parous women and women of high BMI usually showing somewhat greater spread than women of normal weight. Differences between the two gels were not seen when all conditions of application were considered together. CONCLUSION: In vivo imaging of gel distribution demonstrated that ambulation, parity and BMI affect vaginal gel spreading. The three imaging techniques have advantages and disadvantages and provide complementary information for microbicide development.

Graft interposition colpocleisis, perineorrhaphy, and tension-free sling for pelvic organ prolapse and stress urinary incontinence in elderly patients.

STUDY OBJECTIVE: We sought to describe the outcome of combined colpocleisis, perineorrhaphy, and tension-free sling procedure for advanced uterovaginal prolapse and stress urinary incontinence in patients who are elderly and medically compromised. DESIGN: Prospective analysis. SETTING: University hospital. PATIENTS: Thirty-nine women were enrolled. Median age of patients was 82 years (76-94 years). INTERVENTIONS: All patients had advanced uterovaginal prolapse with perineal relaxation and incontinence and each wore a large pessary. MEASUREMENTS AND MAIN RESULTS: Median estimated blood loss was 42 mL (range 10-65 mL), median operating time was 58 minutes (range 45-76 minutes), and median hospital stay was 8 hours (range 0-3 days). Thirty procedures were accomplished without general anesthesia. Le Fort colpocleisis was reinforced with excessive mesh strips from the sling by placing mesh between anterior and posterior vaginal walls at the time of closure. No intraoperative complications occurred and none had postoperative voiding difficulty or significant discomfort. One patient required hospitalization for cardiac arrhythmias and 3 others for observation purposes only. Median follow-up has been 24 months. Follow-up physical examinations were performed for postoperative evaluation. One patient required reoperation for minor posterior compartment prolapse and another has started to show some apical prolapse again. Neither patient had a perineorrhaphy at the time of initial procedure. Two patients required some graft excision as a result of exposure from the side without any loss of support or discomfort. In all, 37 patients (37 of 39) are extremely pleased with the prolapse repair and 35 patients (35 of 39) report significant improvement of stress incontinence. CONCLUSION: Concomitant severe pelvic organ relaxation and stress urinary incontinence can be surgically treated safely and rapidly using a tension-free sling and colpocleisis with perineorrhaphy under local anesthesia and sedation, thereby eliminating potential risks of general anesthesia and invasive surgery. A novel technique of graft interposition colpocleisis has been used.

Music or guided imagery for women undergoing colposcopy: a randomized controlled study of effects on anxiety, perceived pain, and patient satisfaction.

OBJECTIVE: It was hypothesized that music or guided imagery versus usual care would result in less anxiety and perceived pain for colposcopy patients. MATERIALS AND METHODS: Patients were randomized to music, guided imagery, or usual care after completing a baseline questionnaire. All patients completed a postprocedure questionnaire. RESULTS: Study participants (N=170) had a mean age of 28.4 years (SD=9.6; range 18-60) and formed a racially diverse group. Education/income levels were low. No between-group differences were found for postprocedure anxiety or pain rating. CONCLUSIONS: Mind-body interventions had no statistically significant impact on reported anxiety, perceived pain, or satisfaction with care, even for those who anticipated the most pain or started with high anxiety.

Colposcopic management of high-grade referral smears: a retrospective audit supporting 'see and treat'?

OBJECTIVE: The National Health Service Cervical Screening Programme monitors the quality of colposcopy services through the annual KC65 returns. The 2002 returns demonstrated that Standard 7c, which specifies a biopsy rate > or = 90% at first colposcopy visit for high-grade referrals, was not met in the assessed 3-month period. This was investigated along with the other standards. METHODS: Retrospective colposcopy records were accessed for the 597 new referrals, excluding 10 pregnant patients, seen at the colposcopy clinic at the Royal Victoria Infirmary between 1 July 2001 and 31 December 2002, following an abnormal high-grade smear. Cytology and histopathology computer records were checked for confirmation. The results were assessed against the colposcopy standards applicable at that time and the revised standards (2004). RESULTS: Biopsies were taken from 94.47% (Standard > or = 90%) of women at index colposcopy visit including wire loop excision biopsies from 66.16% (87.97% of high-grade colposcopic appearances). Cervical intraepithelial neoplasia (CIN) on histology was found in 91.79% in the study group (Standard > or = 85%) and in 96.71% of index visit biopsies (Standard > or = 90%), meeting the applicable colposcopy standards. The revised 2004 standards specify a biopsy in > or = 95% of high-grade referrals and excision biopsies in 95% if colposcopic appearances are also high-grade, if colposcopy is low grade but the smear is severely dyskaryotic, or when the lesion extends into the canal. The positive predictive value of high-grade cytology for this entire group was 75.54% with CIN present in 90.95%. CONCLUSION: From this study it appears that high-grade cytology in this centre reliably indicates high-grade CIN. Therefore, in women referred for colposcopy following a high-grade smear, excision biopsies should be performed in a higher proportion at the first visit to comply with the revised standards.

Quality control assurance in national screening programmes for cervical cancer.

The United Kingdom established a centrally controlled formal screening programme for cervical cancer in 1988. The programme has been an unprecedented success, with the incidence of cervical cancer falling by an accelerated rate of 7% a year. Underlying the success of the programme is a rigorous system of quality assurance at all levels of activity. Quality assurance assessment in performed for coverage of the target population, cytology reporting laboratories and colposcopy services. Each component in the system is examined annually by mandatory returns, and by regular on-site review of the clinical services by independent authorities. Processes also exist to establish and maintain the competency of all clinical and non-clinical staff involved in the programme. Using nationally published figures from the financial year 2001/2002, the different quality assurance strategies are described. The future development of quality assurance in the programme is then discussed.

The use of music to reduce anxiety for patients undergoing colposcopy: a randomized trial.

OBJECTIVE: The goal of this work was to investigate the impact of music on women's anxiety and perceived pain during colposcopy examination. METHODS: This was a prospective randomized study. Two hundred and twenty women referred for colposcopy for the first time were recruited. They were randomized to either the music or no-music group. Before colposcopy examination, each subject completed a Chinese version of the state anxiety questionnaire (STAI) and assessed the anticipated pain for colposcopy with a visual analog scale (VAS). Slow-rhythm music was played during colposcopy examination in the music group. Subjects in the no-music group were examined in the same setting without music. After colposcopy, each subject completed the STAI form again and assessed their pain during examination by the VAS. RESULTS: Women in the music group experienced significantly less pain (mean VAS 3.32 [95% CI 2.86-3.78] vs 5.03 [4.54-5.52], P<0.001) and lower anxiety (mean STAI 39.36 [95% CI 37.33-41.39] vs 44.16 [41.82-46.49], P = 0.002) during colposcopy examination than women in the no-music group. On linear regression analysis, the factors significantly affecting anxiety during colposcopy were anxiety score at enrollment, pain score during colposcopy, and whether or not the women had listened to music during the colposcopy examination. The factors significantly affecting the pain scores were whether the women had listened to music during the procedure and the final anxiety scores. CONCLUSIONS: Music is a simple, inexpensive, and easily used strategy to minimize anxiety and pain during colposcopy examination.

Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia.

STUDY OBJECTIVE: To describe the technique, complications, and outcomes of vaginal repair of concomitant advanced uterine and vaginal prolapse and stress urinary incontinence using colpocleisis and tension-free vaginal tape (TVT) and pubovaginal sling under intravenous sedation and local anesthesia in elderly and/or medically compromised patients. DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: Large tertiary care hospital with university affiliation. PATIENTS: Thirty consecutive women. INTERVENTION: Colpocleisis and TVT-pubovaginal sling. MEASUREMENTS AND MAIN RESULTS: Data were obtained by retrospective chart review of office and surgical records and follow-up physical examinations. All 30 patients had the procedure completed without general anesthesia. Mean estimated blood loss was 56 ml (range 10-150 ml), mean operating time 97.3 minutes (range 65-135 min), and mean hospital stay 1.62 days (range 1-12 days). No intraoperative complications occurred, although one woman experienced a postoperative myocardial infarction. Average follow-up was 19.1 months. Three women required reoperation for minor prolapse (2 posterior repairs, 1 anteroposterior repair) and 94% were cured of stress incontinence. CONCLUSION: Preliminary data suggest that surgical correction of concomitant severe pelvic organ relaxation and stress urinary incontinence using a proved procedure (pubovaginal sling) coupled with colpocliesis can be performed rapidly and safely with local anesthesia and mild sedation, thus limiting the potential risks of general anesthesia and more invasive surgical procedures.

Design and methods of the evaluation of an HPV-based cervical cancer screening strategy in Mexico: The Morelos HPV Study.

OBJECTIVE: The purpose of this paper is to describe the design and methodology of the Morelos HPV Study. The main objective of this study is to examine the use of two different methods for obtaining HPV DNA specimens, self-collected vaginal and clinician-collected cervical, to detect pre-invasive cervical lesions and cancer. MATERIAL AND METHODS: This study was conducted within the regular population-based framework of the Mexican Institute of Social Security (IMSS) cervical cancer screening program in Morelos. A total of 7,868 women were recruited between May and October 1999 and are representative of the population of women attending cervical cancer screening services at the 23 IMSS clinics in the state of Morelos in 1999. Women were provided with a detailed description of the study before signing an informed consent form. Basic data were obtained from all participants using a standard IMSS registration form. During the initial recruitment visit, a randomly selected subsample of 1,069 participants were interviewed to collect additional information about cervical cancer risk factors, acceptability of the HPV and Pap tests, as well as patient costs. Before the pelvic exam, participants were asked to provide a self-collected vaginal specimen for HPV testing. All participants underwent a pelvic examination that involved collecting a cervical sample for the Pap smear and a clinician-collected HPV specimen. Data were evaluated from 7,732 women with complete information for the three tests. The 1,147 women who received at least one positive result (Pap, self- and/or clinician-HPV tests) were invited to return for a colposcopic examination. During colposcopy, biopsies were taken as appropriate, to histologically confirm a diagnosis of cervical intraepithelial neoplasia (CIN) 2/3 or invasive cancer. A total of 1,015 women attended colposcopy, and 101 women received a histologically-confirmed CIN 2/3 or cervical cancer diagnosis. CONCLUSIONS: The initial enrollment activities of the Morelos HPV study are the basis for a prevalent case-control study and a prospective cohort study that will investigate the natural history of HPV infections and determine if an HPV-based screening strategy is a safe and cost-effective alternative to Pap screening. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.

Colposcopia digital en la neoplasia cervical intraepitelial. Correlación histológica y utilidad clínica / Digital colposcopy in cervical intraepithelial neoplasia. Histological correlation and clinical utility

Objetivo: Determinar, en la neoplasia cervical intraepitelial (CIN), la correlación histológica de la información morfométrica obtenida mediante un sistema original de colposcopia digital, y establecer sus posibles aplicaciones clínicas.Métodos: En 101 pacientes con colposcopia valorable se midió el área de la zona de transformación y de las lesiones colposcópicas. En 62 casos, en los que se practicó exéresis de la lesión con asa, estos datos se correlacionaron con la extensión de las lesiones histológicas.Resultados: A mayor grado histológico las lesiones cervicales incrementan significativamente su tamaño colposcópico (CIN-I, CIN-II, CIN-III: 90 mm2, 134 mm2, 265 mm2, respectivamente) y ocupan una disposición más central en el cérvix. Existe una muy buena correlación, cercana al 85 por ciento, con el tamaño medido mediante morfometría histológica.Conclusiones: El tamaño de la lesión colposcópica de la CIN es un buen indicador del verdadero tamaño lesional. Estos resultados abren una nueva perspectiva en la conducta a seguir en las lesiones de bajo grado, al ofrecer un método objetivo y fiable para controlar su evolución. (AU)

Prevention of cervix cancer.

Cervix carcinoma is an important health problem world-wide, being the second most common cancer among women, ranking first in many developing countries. A number of important epidemiological risk factors have been identified as contributing to the development of CIN and invasive cervix carcinoma. Of key importance is infection with human papillomavirus (HPV), which is the primary risk factor. There are evolving primary and secondary preventive strategies that could further reduce the burden from cervical carcinoma. The possible primary preventive strategies include risk reduction, diet or dietary supplements, HPV vaccines, and other chemopreventive agents. The possible advances in secondary preventive strategies include new technologies for Pap smears, HPV typing triage, and other adjuvant screening procedures. The impact of these strategies will depend upon evidence to support their use along with the characteristics of the population and environment in which they are used.