Health-related quality of life in women after colposcopy: results from a longitudinal patient survey.

BACKGROUND: Information concerning the health-related quality-of-life (HRQoL) consequences of colposcopy is limited, particularly over time. In a longitudinal study, we investigated women's HRQoL at 4, 8 and 12 months post colposcopy and the factors associated with this. METHODS: Women attending colposcopy at two large hospitals affiliated with the national screening programme in Ireland were invited to complete questionnaires at 4, 8 and 12 months post colposcopy. HRQoL was measured using the EQ-5D-3L and compared across a range of socio-demographic, clinical and attitudinal variables. A mixed-effects logistic multivariable model was employed to investigate associations between these variables and low HRQoL. RESULTS: Of 584 women initially recruited, 429, 343 and 303 completed questionnaires at 4, 8 and 12 months, respectively. The mean overall HRQoL score for the sample across all time points was 0.90 (SD 0.16). Approximately 18% of women experienced low HRQoL at each of the three time points. In multivariable testing, over the entire 12-month follow-up period, non-Irish nationals (OR 8.99, 95% CI 2.35-34.43) and women with high-grade referral cytology (OR 2.78, 95% CI 1.08-7.13) were at higher odds of low HRQoL. Women who were past (OR 0.20, 95% CI 0.07-0.58) or never (OR 0.42, 95% CI 0.16-1.12) smokers were at lower odds of low HRQoL than current smokers. As women's satisfaction with their healthcare increased their odds of experiencing low HRQoL fell (OR per unit increase 0.51, 95% CI 0.34-0.75). CONCLUSIONS: Women's HRQoL did not change over the 12 months post colposcopy, but some subgroups of women were at higher risk of experiencing low HRQoL. These subgroups may benefit from additional support.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey.

OBJECTIVE: To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress. DESIGN: Longitudinal survey. SETTING: Two hospital-based colposcopy clinics. POPULATION: Women with abnormal cytology who underwent colposcopy (±related procedures). METHODS: Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables. MAIN OUTCOME MEASURES: Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress. RESULTS: Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up. CONCLUSIONS: The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress. TWEETABLE ABSTRACT: Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Triage of LSIL/ASC-US with p16/Ki-67 dual staining and human papillomavirus testing: a 2-year prospective study.

OBJECTIVE: To investigate human papillomavirus (HPV) DNA testing and p16/Ki-67 staining for detecting cervical intraepithelial grade 2 or worse (CIN2+) and CIN3 in women referred to colposcopy with minor abnormal cervical cytology low-grade squamous intraepithelial lesions (LSIL) and atypical squamous cells of undermined significance (ASC-US). The clinical performance of both tests was evaluated as stand-alone tests and combined, for detection CIN2+ and CIN3 over 2 years. METHODS: ThinPrep(®) liquid-based cytology (LBC) specimens were collected from 1349 women with repeat LSIL or ASC-US. HPV DNA was performed using Hybrid Capture. Where adequate material remained (n = 471), p16/Ki-67 overexpression was assessed. Clinical performance for detection of histologically diagnosed CIN2+ and CIN3 was calculated. RESULTS: Approximately 62.2% of the population were positive for HPV DNA, and 30.4% were positive for p16/Ki-67. p16/Ki-67 showed no significant difference in positivity between LSIL and ASC-US referrals (34.3% versus 28.6%; P = 0.189). Women under 30 years had a higher rate of p16/Ki-67 compared to those over 30 years (36.0% versus 26.6%; P = 0.029). Overall HPV DNA testing produced a high sensitivity for detection of CIN3 of 95.8% compared to 79.2% for p16/Ki-67. In contrast, p16/Ki-67 expression offered a higher specificity, 75.2% versus 40.4% for detection of CIN3. Combining p16/Ki-67 with HPV DNA improved the accuracy in distinguishing between CIN3 and

Age related influence on screening coverage and satisfaction. with CervicalCheck.

The aim of this study was to evaluate levels of satisfaction of women attending the CervicalCheck programme and reasons for the age differential in screening uptake. A questionnaire was sent to 5,000 randomly selected attenders with a normal smear test (3,500 aged 25-44, 1,500 aged 45-60). Almost all in both age groups said they would return to CervicalCheck if invited (98.5%; 98.5%) and recommend the service to family/friend (99.6%; 99.5%). The single independent predictor of 'would recommend to family/friend' was willingness to return to CervicalCheck (OR = 31 (5.2-183.7)). Predictors of 'would return if invited' were knowledge of when due to return (OR = 2.5 (1.3-5.0)) and having contacted or having received a letter of invitation from CervicalCheck (OR = 3.1 (1.6-6.1)). Independent predictors of 'knowledge of when due to return' were older age group (OR = 0.5 (0.4-0.7)) and willingness to return to CervicalCheck (OR = 3.2 (1.2-6.3)). The GP is particularly important in informing older women and encouraging attendance.

Apparent improvement in survival for carcinoma of the cervix following the introduction of chemoradiation--a Will Rogers phenomenon.

The improved survival for bulky cervical cancers (> 4cm) reported with combination platinum based chemoradiation (1999) prompted a move away from surgery as these cases frequently received adjuvant radiotherapy and were exposed to the morbidity of multimodality treatment. The period pre-1999 (Group 1) was compared with post-1999 (Group 2) when chemoradiation was the preferred treatment for bulky operable cervical cancer. Significantly more cases were treated surgically among Group 1 compared with Group 2 (79% vs. 62%; P < 0.001). Switching from surgery to radiotherapy improved survival in both treatment categories (73% vs. 78% and 37% vs. 44%, respectively) but with no improvement in overall survival (70%/ov.s 70%). Survival (86%) was similar in both groups among surgically treated women with tumors < 4 cm, but significantly more in Group 2 with negative nodes received postoperative adjuvant chemoradiotherapy (Groups 1 vs. 2; 16% vs.37.5%: P < 0.001) and overall the surgically treated patients received more not less multimodality treatment (46.5% vs. 59%; P = 0.7).

Diagnostic and therapeutic dilemma associated with atypical glandular cells on liquid-based cervical cytology.

BACKGROUND: In 2008, the management of women in Ireland with atypical glandular cells changed to immediate referral to colposcopy. The optimal management of these women is unclear. A balance between the detection of occult disease and overtreatment is required. METHODS: Our study aim was to document the experience of this policy at the National Maternity Hospital, Dublin. Information from the computerized data management system was analysed with the statistical package SPSS. RESULTS: In 2009, 156 women attended colposcopy following a single atypical glandular cell diagnosis on liquid-based cytology. The mean age was 41 years. Thirty (19.2%) women had abnormal vaginal bleeding, 31 (19.9%) were smokers and 34 (21.8%) had received previous treatment. The colposcopy was satisfactory in 125 (80.1%) and unsatisfactory in 31 (19.9%). Cervical histology was available for 146 (93.6%) women: 57 excisional procedures and 89 diagnostic biopsies. Abnormal histology was detected in 46 women (31.5%). Four women (2.7%) had invasive cancer, five (3.4%) had adenocarcinoma in situ, 21 (14.4%) had cervical intraepithelial neoplasia (CIN) grade 2 or 3 and 16 (11.0%) had CIN1. No abnormality was detected in 100 women (68.5%), including 35 (61.4%) of those who had undergone excisional procedures. The colposcopic impression in this group was unsatisfactory in 10 women (28.6%), glandular abnormalities in six (17.1%), high- and low-grade changes in 12 (34.2%) and six (17.1%) women, respectively, and normal in one (2.9%). The findings were essentially negative in the remaining 10 women: overall, 30 (19.2%) of the 156 women referred to colposcopy had at least CIN2. CONCLUSION: This study confirmed significant levels of high-grade disease in women referred to colposcopy with atypical glandular cells on cytology. Concerns about undetected endocervical disease resulted in high levels of negative excisional biopsies. Alternative strategies, including endometrial sampling, human papillomavirus testing and discussion at clinicopathological meeting, should be considered.

Survival in women with ovarian cancer before and after the introduction of adjuvant paclitaxel; a 25-year, single institution review.

Adjuvant chemotherapy regime for ovarian cancer patients remains to be a contentious issue. The aim of this study was to compare the overall and progression-free survival of women with ovarian cancer before and after introduction of paclitaxel in our unit in 1992. A sample of 112 women who received adjuvant therapy following surgery for ovarian cancer was collected, 68 (61%) received platinum+alkylating agent before 1992 and later 44 (39%) received platinum+paclitaxel. Five-year survival was same in both treatment groups when there was no macroscopic disease after surgery (78% versus 70%) and when residual disease was <2 cm (50% versus 40%). Survival was greater in women with residual disease >2 cm in the platinum+paclitaxel group (50% versus 24%), (p = 0.04). However, progression-free survival was similar in both groups irrespective of stage or residual volume of disease. Therefore consideration to selective use of paclitaxel could reduce patient morbidity and costs significantly.

Lymphovascular space involvement in early stage well-differentiated endometrial cancer is associated with increased mortality.

OBJECTIVE: To study the relationship between lymphovascular space involvement (LVSI) in stage 1a or 1b well-differentiated endometrial cancer and survival. DESIGN: Retrospective study consisting of a search of an oncology database to identify women with endometrial cancer between January 1990 and December 2004. SETTING: Tertiary referral centre, Dublin, Ireland. SAMPLE: Women who had well-differentiated stage 1a or 1b endometrial cancer. METHODS: During the period 1990-2004, 226 patients with endometrial cancer were treated in the National Maternity Hospital, Dublin. We looked at all patients who had well-differentiated endometrioid adenocarcinoma of the endometrium with invasion of <50% thickness of the myometrium. Forty-one patients fulfilled these inclusion criteria. The presence or absence of LSVI was determined by review of haematoxylin and eosin sections. Patients were followed for 5 years or till death if earlier. Mortality was calculated. Statistical analysis was performed using Fisher's exact test. An odds ratio and 95% confidence interval was calculated using fixed effect Mantel-Haenszel model. MAIN OUTCOME MEASURES: Death from recurrence of endometrial cancer. RESULTS: Of the 41 patients, five (12%) were found to have (LVSI). Of the five patients with LVSI, three (60%) patients died of recurrence. All patients with recurrence died of disease and none of the patients without LVSI died (0 of 36). Overall, the survival rate was 92.7%. The presence of LVSI was a highly significant predictor of recurrence (P < 0.001). CONCLUSION: In patients with early stage well-differentiated adenocarcinoma of the endometrium, the presence of LVSI is associated with a high risk of death.

Management of minor cervical cytological abnormalities: a systematic review and a meta-analysis of the literature.

BACKGROUND: A significant number of women are diagnosed with a low grade cytological abnormality on cervical screening. Many authorities recommend surveillance as spontaneous regression might occur. However, protracted attendance for cytological follow-up decreases with time and might put some women at risk of developing invasive disease. The aim of this review was to assess management options for women with minor cervical disease. METHODS: An electronic literature search was conducted. All randomised controlled studies comparing immediate colposcopy to cytological surveillance in women with cervical atypia/borderline nuclear changes or low-grade lesions were included. The main outcomes studied were the default rates from the colposcopy clinic and the histological status of biopsies within immediate management protocols compared to biopsies taken on completion of surveillance. Pooled relative risks and 95% confidence intervals were calculated using a random-effect model and inter-study heterogeneity was assessed with Cochrane's Q-test. RESULTS: Three randomised controlled trials identified from the literature search with different surveillance periods were combined. The analysis revealed that compliance with follow-up declines over time and reaches significance at the end of 24 months of surveillance (RR: 74.10 [10.36, 529.79]). There was a significantly higher incidence of HPV and CIN 1 in those women referred to immediate colposcopy/treatment compared to those at the end of 24 months surveillance period (32% vs 21%) (RR 1.49, 95% CI 1.17-1.90) and (21% vs 8%) (RR 2.58, 95% CI 1.69-3.94), respectively, possibly explained by spontaneous regression of clinically non-important lesions. Finally, there was no significant difference in the incidence of CIN2 or worse at initial colposcopy compared with the observation group (24 months) (RR 1.72, 95% CI 0.85-3.48). CONCLUSION: Cytological surveillance puts women at risk as many show poor compliance and such women might have occult high grade abnormalities. A general policy should be immediate colposcopy for all women after a single low grade cervical smear.

Early stage endometrial carcinoma--a study of management and outcome.

The surgical management of early stage endometrial carcinoma is controversial. The benefits of pelvic lymphadenectomy and administration of radiotherapy in this group have been disputed. We aimed to document the experience of stage 1 endometrial carcinoma at the National Maternity Hospital during the 10 year period 1989-1998 and to evaluate and compare clinical outcomes between retrospectively-assigned low and high-risk tumour groups. Seventy seven women were diagnosed with Stage 1 endometrial carcinoma in this period. Thirty-nine women had low-risk and 38 had high-risk tumours. Women with high-risk tumours were older and had a higher rate of lymph-vascular space invasion by tumour on histological examination. Three women (3.9%) developed disease recurrence and died of their disease; one low-risk and two high-risk tumour patients. Survival without recurrence did not differ between the two risk groups. No consistent pattern existed in surgical staging between the two risk groups. A prospectively-assigned definition of risk would minimise variations in clinical practice by providing a basis for a more tailored approach to adjuvant treatments.

Cervical screening history in patients with early stage carcinoma of the cervix.

This study aimed to examine whether a decade of heightened publicity on issues relating to cervical screening has changed the screening profile of women presenting with cervical cancer at the National Maternity Hospital. The screening history of 100 women diagnosed with early/surgically treated cervical cancer between 1998 and 2002 was compared with a similar study conducted in 1982 /1990. The percentage of women never screened was similar - 24 %( 2002) and 23% (1990). The interval between last recorded smear and diagnosis of disease was greater than 5 years in 45.6% and 41.7% respectively. Overall 60% of women in the recent period had either failed to avail of screening or were not screened within 5 years of diagnosis compared with 64% in 1990. Multiparous women comprised 90% of the study group and 50% of those inadequately screened were attending their general practitioner on a regular basis - therefore affording a potential for opportunistic screening The current method of screening has failed in this group and has not improved in 10 years despite of increased population awareness and greater opportunities for screening than ever before and would support an argument for a National Screening Program.

Ischemic fasciitis: an unusual vulvovaginal spindle cell lesion.

Ischemic fasciitis is a benign reactive lesion that most commonly occurs in elderly, immobile patients in weight-bearing areas that are subject to intermittent ischemia with subsequent tissue breakdown and regenerative changes. The lesion can be clinically and pathologically mistaken for malignancy. Here we describe the first reported case of ischemic fasciitis of the vulvovaginal region in a 20-year-old paraplegic woman who presented with a clinically suspicious vulvar swelling. Histologic examination showed surface ulceration and underlying fibrinoid necrosis with surrounding reactive atypical fibroblast-like cells and small blood vessels, the characteristic histologic features of ischemic fasciitis.

Follow up after LLETZ: could schedules be modified according to risk of recurrence?

OBJECTIVES: To document the pattern of recurrence of disease following large loop excision of the transformation zone (LLETZ) to identify a low risk group of women who might benefit from less intensive cytological surveillance. DESIGN: Analysis of prospectively collected information with retrospective review of follow up smears. POPULATION: Three thousand, five hundred and sixty women who underwent LLETZ (median age 31 years; IQR 12 years). SETTING: Colposcopy clinic at Northern Gynaecological Oncology Centre, Gateshead. METHODS: Women treated with LLETZ from 1988 to 1995 were reviewed. Information on the pathology from LLETZ was collected prospectively and information on the subsequent smears was obtained from the family health authorities. RESULTS: Invasive cancer was detected on the original LLETZ in 134 women who were excluded from the study. Of the remaining 3,426 women, histology of LLETZ showed high grade CIN (II and III) in 2,371 (69%). At least one follow up smear was undertaken in 3,385 women (99%). This constituted 9,765 women years of follow up with a mean duration of 35 months. Four hundred and seventeen women (12.2%) had a dyskaryotic follow up smear. Incomplete excision of the lesion and an age of > or = 50 years at the time of the LLETZ were associated with an increased risk of recurrent CIN. Based on these risk factors the study group was divided into three risk groups: 1. women aged < 50 with no disease at the margins (n = 1680); 2. women aged > or = 50 with disease at the margins (n = 93); and 3. women aged < 50 with positive margins, or aged > or = 50 with negative margins (n = 1653). The cumulative survival without recurrent CIN at five years for these groups were 92%, 57% and 86%, respectively. CONCLUSION: Women aged > or = 50 with CIN at the margins of excision constituted a small minority high risk group (3%). Consideration should be given to repeat treatment of these women rather than surveillance. Women aged < 50 with complete excision of low grade CIN comprised 51% of the study group. These women were at low risk of recurrent CIN and might benefit from less intensive cytological surveillance following LLETZ.

Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes.

Comerci G, Bolger BS, Flannelly G, Maini M, de Barros Lopes A, Monaghan JM. Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes. Int J Gynecol Cancer 1998; 8: 23-26. Two hundred and seventy-five females with stage IB-IIB negative lymph node cervical cancer, treated between January 1988 and December 1994 by radical hysterectomy and pelvic lymph node dissection, form the basis of this analysis. The clinical records were reviewed for all patients including histopathology, clinical features at presentation, and follow-up. Tumors were re-staged according to the 1995 FIGO classification. Median follow-up was 55 months and 85.8% were followed for longer than two years. There were 21 recurrences, 12 of which were true central recurrence (disease-free survival at 5 years: 91.66%). Fifteen of 25 deaths were due to cervical cancer (crude survival at 5 years: 93.27%). In univariate log-rank analysis, stage (P = 0.005), tumor size (P = 0.0002), and lymph-vascular space involvement (LVSI) (P = 0.01) appeared to be statistically significant factors for tumor recurrence. Other factors including age, histology type, differentiation, adjacent cervical intraepithelial neoplasia or cervical glandular intraepithelial neoplasia, and presence of intraepithelial disease at resection margin were not found to be statistically significant. In multivariate analysis (Cox regression) tumor size (P = 0.02) and LVSI (P = 0.03) were the only independent variables. In the presence of negative lymph nodes and complete surgical excision, tumor size and LVSI are important predictors of local recurrence.

A study of treatment failures following large loop excision of the transformation zone for the treatment of cervical intraepithelial neoplasia.

OBJECTIVE: To examine the long term efficacy of large loop excision of the transformation zone (LLETZ) in the treatment of cervical intraepithelial neoplasia (CIN) and to evaluate the relative diagnostic merits of colposcopy and cytology in the follow up of these women. DESIGN: A retrospective examination of cytology, colposcopy and histology records of the first 1000 women treated with LLETZ in Aberdeen from 1989 to 1991. SETTING: Colposcopy Clinic Aberdeen Royal Infirmary, Grampian Region, Scotland. RESULTS: Nine hundred and seventy-seven women (97.7%) were seen for follow up at least once and 317 were followed for as long as four years. This comprises 2812 woman years of follow up. The incidence of recurrent CIN was 27/1000 woman years and the cumulative rate of recurrence at four years was 10.1 per 100 women. Twenty-eight of the 59 women (47%) with abnormal colposcopy and proven CIN had a concurrent smear that did not show dyskaryosis. CONCLUSIONS: LLETZ is an effective from of treatment for CIN. Colposcopy was useful in the follow up of these women and expedited the treatment of persistent disease. We recommend that any follow up protocol should include a colposcopic assessment and cytological follow up for at least four years following treatment. Further data are required to determine the risk of recurrence beyond this time.

Immediate colposcopy or cytological surveillance for women with mild dyskaryosis: a cost effectiveness analysis.

BACKGROUND: The aim of the study was to compare the cost effectiveness of immediate diagnosis and treatment of mild dyskaryosis compared with the usual policy of cytological surveillance. METHODS: A cost effectiveness analysis was carried out alongside a randomized clinical trial. RESULTS: Immediate diagnosis and treatment increased total costs by 50 per cent from 54.42 pounds per treated woman [95 per cent confidence interval (CI) 48.85 pounds-59.98 pounds] in the surveillance group to 82.02 pounds per woman in the immediate diagnosis and treatment group with an incremental cost of 27.60 pounds (95 per cent CI 22.04 pounds-33.17 pounds). However, the number of cases of CIN III detected increased by 69 per cent for the policy of immediate diagnosis and treatment. This led to an average cost effectiveness ration of 180.18 pounds for the immediate diagnosis and treatment group and 199.94 pounds per case of CIN III detected for the surveillance group, with a marginal cost effectiveness ratio of 148.22 pounds (95 per cent CI 94.01 pounds-309.33 pounds) for the immediate diagnosis and treatment group. CONCLUSION: Immediate diagnosis and treatment increases the total cost of managing mildly dyskaryotic smears but this increased cost is offset by a sharp increase in the number of cases of CIN III detected.

Serial quantitation of HPV-16 in the smears of women with mild and moderate dyskaryosis.

The aim of this study was to examine the efficacy of semi-quantitative polymerase chain reaction (PCR) testing in cervical smears as an adjunct to cytological surveillance in a cohort of women with mild or moderate dyskaryosis. The study population comprised a group of 62 women who underwent twelve months of cytological and colposcopic surveillance as part of a larger randomised prospective study of women with mild and moderate dyskaryosis. Semi-quantitative PCR for HPV-16 DNA was carried out on the initial and twelve month study smears before a large loop excision of the transformation zone (LLETZ) was carried out. Smears from a control population which comprised 167 women without a history of abnormal cervical cytology who were attending family planning and general practitioner clinics for routine cervical smears were tested similarly. The presence of high or intermediate levels of HPV-16 DNA on both the initial and twelve month study smear was positively associated with the identification of cervical intraepithelial neoplasia (CIN) grades II or III in the LLETZ specimen (P = 0.01). While the combination of HPV-16 DNA testing with cytology on a repeat cervical smear improved the selection of women with underlying CIN II/III, there was still a false negative rate of 53%. Twenty-nine women had 'low risk' levels of HPV-16 DNA and mild dyskaryosis or less on both repeat smears indicating suitability for surveillance, but in fact 34% of them had CIN II/III. This study supports the finding reported previously of an association between high and intermediate levels of HPV-16 DNA and CIN II/III.(ABSTRACT TRUNCATED AT 250 WORDS)

Every woman with an abnormal cervical smear should be referred for treatment: debate.

No dispute exists regarding the optimal management of women with moderate or severe dyskaryosis (high grade SIL). These women should have a colposcopic assessment and biopsy. Women with borderline nuclear abnormalities should have a repeat smear and undergo colposcopy only if the abnormality persists. Low-grade abnormalities (low-grade SIL) are common, and their management is relevant. We suggest that these women be referred for an immediate colposcopic assessment for the following reasons: a. a policy of cytologic surveillance allows an opportunity for default, and these women are at an increased risk of invasive cancer. b. a significant proportion of these women will have underlying CIN grade III that should be treated. c. a minority of these women revert to cytologic normality without a recurrent dyskaryotic smear and, therefore, eventually will be referred to colposcopy. d. a policy of immediate referral to colposcopy may be financially less expensive and avoid unnecessary anxiety to the woman during the period of undergoing repeated smears.

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. DESIGN: A case-control study. SETTING: A teaching hospital serving a regional population. SUBJECTS: One thousand women who had undergone large loop excision of the transformation zone (LLETZ) for the treatment of cervical intraepithelial neoplasia (CIN) between 1989 and 1991. Two controls were matched for each of the 149 women who had a singleton pregnancy progressing beyond 20 weeks of gestation following treatment, with regard to age, parity, height, husband's or partner's social class and smoking habits to account for common independent risk factors for adverse obstetric outcome and cervical intraepithelial neoplasia. MAIN OUTCOME MEASURES: Intention to conceive, number of pregnancies, gestation, low birthweight, mean birthweight, mode of delivery, and duration of labour. RESULTS: Out of a cohort of 1000 women who underwent LLETZ for the treatment of CIN, 653 women replied to a postal questionnaire. When asked up to 54 months after treatment, 130 women (19.9%) had become pregnant and 47 (7.2%) had tried to become pregnant. A total of 199 pregnancies from 178 women was identified from the cohort of women. For the 149 women from the case cohort, the mean birthweight was 3380 g compared with 3373 g in the control group (P = 0.88). The incidence of low birthweights in pregnancies progressing to at least 37 weeks of gestation was 3.1% in the treated group, compared with 3.2% in the control group (P = 0.98). Following LLETZ, 9.4% of deliveries were preterm (< 37 weeks of gestation), compared with 5.0% in the control group (p = 0.12). There was no significant difference in mean gestation, mode of delivery, indication for caesarean section or duration of labour between the women who had undergone LLETZ and the controls. CONCLUSION: When socio-epidemiological factors associated with the development of cervical intraepithelial neoplasia are controlled for, LLETZ does not appear to exert an independent adverse effect on subsequent pregnancy outcome.

Management of women with mild and moderate cervical dyskaryosis.

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 colposcopy.