األية البقرة األية 32سورة البقرة 32سورة

A Comparative Study A Comparative Study Between Colposcopy Between Colposcopy and Cytopathology in and Cytopathology in Women With Contact Women With Contact

BleedingBleeding

AcknowledgementAcknowledgement

Supervised ByProf. Dr. Ahmad Amin SalehProfessor of Obstetrics and Gynaecology

Prof. Dr. Ahmad Hamza SolimanProfessor of Obstetrics and Gynaecology

Prof. Dr. Ahmad Altaf AbbasProfessor of Obstetrics and Gynaecology

Prof. Dr. Ibrahim Hassan MohammadProfessor of Pathology

Dr. Mohammad Salah Eldein HassaninAssistant Professor of Obstetrics and Gynaecology

Faculty of Medicine - Al-Azhar UniversityFaculty of Medicine - Al-Azhar University

AcknowledgementAcknowledgementDiscussed By

Prof. Dr. Mahmoud El-ShourbagyProfessor of Obstetrics and Gynaecology

Faculty of Medicine - Ain Shams University

Prof. Dr. Ahmad Altaf AbbasProfessor of Obstetrics and Gynaecology Faculty of Medicine - Al-Azhar University

Prof. Dr. Mohamed Taher IsmailProfessor of Obstetrics and Gynaecology Faculty of Medicine - Al-Azhar University

IntroductionIntroduction

Contact bleeding is an uncommon gynecologic symptom although abnormal vaginal bleeding presents as the most common gynecologic complaint.

Contact bleeding is an alarming symptom and all women with contact bleeding should be seen in the colposcopy clinic even, those who referred with negative cytology.

Nowadays, there has been a dramatic reduction in the incidence of invasive carcinoma of the cervix with introduction of widespread screening programs using vaginal cytology, colposcopy and histopathology in positive cases.

The principal goal of cervical cytology is to detect precancerous lesions and asymptomatic preclinical cancer. Colposcopy could have an important place in evaluation of the patients; colposcopically guided biopsies may clarify in concise cytologic findings and give an assessment of location, size and extent of a lesion

Aim of the Aim of the WorkWork

Evaluation of women with contact bleeding by cytological examination, colposcopy and histopathology and comparison between three parameters were be carried and results were be statistically analyzed.

SubjectSubject

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MethodsMethods

This study was performed for women attending the Outpatient Clinic of Obstetrics and Gynecology Department of Al-Azhar University Hospitals (Sayed Galal and El-Hussein) and covered 2 years period from May 2004 to April 2006.

61 patients with contact bleeding were reviewed, but only 50 non pregnant women, without age or parity limits and complaining of contact bleeding were enrolled in the study.

Every patient was informed about the study and procedure was explained and an oral consent was obtained.

Each woman was asked about the following through full history taken :

1. Personal history, including :

- Age of the patient.

- Age of marriage and its duration.

- Age of first intercourse.

- Life time number of partners.

2.Main complaint and its duration.

3.Menstrual history.

4.Obstetric history.

5.Contraceptive history including the type and duration of use.

6.Past history of medical problems and surgical procedures she had, especially cervical surgery as previous cauterization.

7.Family history of similar condition or cancer cervix.

8.Husband history for smoking and venereal diseases.

9.History of sexually transmitted diseases.

10. Socioeconomic history. Standard cervical cancer risk factors could

be obtained in 35 of the 50 patients (70%) as age of first intercourse, life time numbers of partners.

Then every patient was submitted to the following :

1. General examination.2. Local gynecological examination.3. Cytological examination. Using the Bethesda system patients with

viral changes and mild dyskaryosis were grouped as low-grade squamous intra-epithelial lesion (LSIL) and those with moderate-to-severe dyskaryosis and carcinoma in situ were grouped as high-grade squamous intra-epithelial lesion (HSIL). Metaplastic changes, inflammatory smears and inflammatory atypia without viral changes were taken as negative cytology.

4. Colposcopy : All patients were evaluated colposcopically by using

Olympus Model OCS-2 Colposcope. We classified our patients into 3 groups according to

the colposcopic examination :1. Insignificant colposcopy:normal colposcopic

findings.2. Significant colposcopy, which showed different

colposcopic lesions, vascular changes may be present and gave the examiner the possibility that CIN lesions I, II and III will be found in biopsies.

3. Highly significant colposcopy : suspicious colposcopic lesion usually with vascular changes and gave the examiner the possibility that an early invasive or frank invasive carcinoma will be found in biopsies.

5. Colposcopic guided punch biopsy : It was obtained in total of 16 patients who had an

atypical transformation zone (N=14), a suspect invasive cancer (N=1) and unsatisfactory colposcopy (N=1).

Viral changes with atypia, cervical intraepithelial neoplesia (CIN) 1-3, carcinoma in situ and invasive cancers were consider positive on biopsy.

Women who were assessed as an abnormal data on colposcopy and confirmed by biopsies were referred for appropriate treatment and follow up according to Al-Azhar University Hospitals protocols.

Risk factors were assessed by correlating age, parity and duration of bleeding with the various finding obtained on histopathology, namely benign pathology (group 1) and invasive cancer (group 2).

ResultsResults

In this retrospective study, 61 patients with contact bleeding presented to colposcopy unit were reviewed, but a total of 50 patients were enrolled in the study and 11 patients were excluded.

The standard cervical risk factors as age at first intercourse, lifetime number of partners, parity, history of sexually transmitted diseases, family history of cancer cervix, smoking and history of methods of contraception were obtained in 35 patients (70%).

All patients had monogamous relationship non of patients had family history of cancer cervix or history of sexually transmitted diseases, all patients were non smoker, nor alcoholic.

Age No. %

< 20 years 2 4

21-30 years 18 36

31-40 years 22 44

41-50 years 7 14

> 50 years 1 2

Age of patients (in years).

40 Patients (80%) belonged to the sexually active reproductive age group, only 2 patients (4%) were below 20 years and 3 patients (6%) were post menopausal

Types of contraception.

Types of contraception No. %

No contraception methods 40 80

Tubal ligation 2 4

Condum 2 4

IUCD 6 12

40 patients (80%) did not use any contraception methods 2 patients (4%) were ligated, 2 patients (4%) used condum and 6 patients (12%) used intrauterine contraceptive devices (IUCD)

Parity.Parity No. %

Nullipara 2 4Para 1 4 8Para 2 17 34Para 3 14 28Para 4 13 26

Contact bleeding was infrequently seen in nulliparas, I.e. 2 patients (4%) and primiparas 4 patients (8%). 44 patients (88%) were multipara.

Duration of symptom.

Duration of symptom No. %0-3 months 23 464-6 months 11 227-9 months 2 410-12 months 7 14>12 months 7 14

Approximately two third of the patients I.e. 34 patients (68%) reported the symptom early, I.e. within 6 months of onset and 7 patients(14%) waited for more than one year.

Cytological findings No. %Normal 2 4Non specific inflammation 30 60Trichomanas vaginalis 3 6LSIL 6 12HSIL 2 4Invasive cancer 2 4Unsatisfactory 5 10

Cytology identified 2 patients (4%) only with invasive cancer and 8 Cytology identified 2 patients (4%) only with invasive cancer and 8 patients (16%) with SIL (6 patients [12%] LSIL and 2 patients (4%) HSIL)patients (16%) with SIL (6 patients [12%] LSIL and 2 patients (4%) HSIL)The majority of patients I.e., 33 patient (66%) had inflammatory smears. The majority of patients I.e., 33 patient (66%) had inflammatory smears. Trichomans vaginalis was seen in 3 smears (6%) and 30 smears (60%) Trichomans vaginalis was seen in 3 smears (6%) and 30 smears (60%) had non specific inflammation. Five patients (10%) had unsatisfactory had non specific inflammation. Five patients (10%) had unsatisfactory smears and 2 patients (4%) had normal smears.smears and 2 patients (4%) had normal smears.

Colposcopic findingColposcopic finding No. %

Typical transformation zone 34 68Atypical transformation zone(Grade I)

10 20

Atypical transformation zone(Grade II)

3 6

Atypical transformation zone(Grade III)

1 2

Suspect invasive 1 2Unsatisfactory 1 2

Colposcopy revealed atypical transformation zone in 14 patients (28%) and suspect invasive cancer in one patient (2%). Majrity of patients I.e. 34 patients (68%) had typical transformation zone and oly one patient (2%) had unsatisfactory colposcopic finding

Normal cervix with squamocolumner junction

Typical transformation zone.

Leukoplakia. Acetowhite change.

Unsatisfactory colposcopy. High-grade lesion with dense acetowhite epithelium on the posterior lip of the cervix.

Histopathological examination of obtained biopsies revealed that:3 patients (6%) had invasive cancer.3 patients (6%) had viral changes with CIN I.2 patients (4%) had CIN II and CIN III.1 patient (2%) had tuberculosis of the cervix.7 patients (14%) had chronic cervicitis.

Histopathological findingHistopathological finding No. %

Chronic cervicitis 7 14

Tuberculosis 1 2

Viral (HPV) 1 2

CIN I 2 4

CIN II 1 2

CIN III 1 2

Invasive cancer 3 6

Comparison between (group I) and (group II) as regard age and parity.

Patients with benign pathology (group I) had a mean age of 32,9 years compared to 41,3 years in patients with invasive cancer cervix (group II), the difference being statistically significant Patients with benign pathology (group I) had a mean parity 2.8 versus 4.2 in patients with invasive cancer, (group II) the difference being statistically insignificant.

Variable Group I Group II P. value

Age in years 32.9±7.2 41.3±6.2 0.036

Parity 2.8±1.4 4.2±1.5 0.074

Comparison between (group I) and (group II) as regard duration of contact bleeding.

Variable Group I Group II P. value

Duration of bleeding in months 7.9±9.7 7.2±5.8 0.045

The duration of contact bleeding did not correlate with pathology.

DiscussionDiscussion

In this study a total of 50 patients were enrolled, invasive cancer was seen in 6% of the patients and CINII and CINIII in 4%, thus the most alarming feature of frank malignancy and its precursor were seen in total of 10% patients with contact bleeding.

In study done by Shalini et al. (1998) for colposcopic and histopathological evaluation of 110 patients with contact bleeding, invasive cancer was seen in 5.5% of the patients, while CIN II and CIN III were seen in 3.6% of the patients.

To the best of our knowledge there is no enough studies in literature quoting the incidence of malignancy in contact bleeding. However in various studies, contact bleeding as the presenting symptom was seen in 6-10% of patients with invasive cancer (Pardnani et al., 1995)

Benign lesions of the cervix dominated the findings in our study accounting 84% which is similar in compared to 85.5% of the patients in the study done by (Shalini et al., 1998).

Tuberculosis of the cervix was seen in one patient (2%) which was comparable to 1.8% of patients in study done by Shalini et al. (1998).

Trichomanas vaginalis was diagnosed in total of 3 patients (6%) by cytology which is comparable to 6..4% of the patients in study done by Shalini et al. (1998).

The majority of the patients i.e. 30 patients (60%) had non specific inflammation on cytology versus 70% of the patients had non specific inflammation in study done by Shalini et al. (1998).

SummarySummary

Results of this study showed that : The standard risk factors were obtained in 35 patient

(70%) of total of 50 patients. All patients had a monogamous relationship, non of

patients had family history of similar condition or cancer cervix or history of sexually transmitted diseases, and all were non smoker nor alcoholic.

Cytology identified 2 patients (4%) only with invasive cancer and 8 patients (16%) with SIL [6 (12%) LSIL and 2 (4%) HSIL], while the majority of patients i.e. 33 patients (66%) had inflammatory smears. Trichomanas vaginalis was seen in 3 smears (6%) and 30 smears (60%) had non specific inflammation and 5 patients (10%) had unsatisfactory smears and 2 patients (4%) had normal smears.

Colposcopy revealed an atypical transformation zone in 14 patients (28%) and suspect invasive cancer in on patient (2%), while the majority of patients i.e. 34 patients (68%) had typical transformation zone and only one patient (2%) had unsatisfactory colposcopic findings.

Colposcopically guided punch biopsies were obtained in 16 patients (32%) and revealed the following on histopathological examination :

– 3 patients (6%) had invasive cancer.

– 3 patients (6%) had viral changes with CIN I.

– 2 patients (4%) had CIN II and CIN III.

– 1 patient (2%) had tuberculosis of the cervix.

– 7 patients (14%) had chronic cervicitis.

In this study, invasive cancer was seen in 3 patients (6%) and CIN II, III in 2 patients (4%), thus the most alarming feature of frank malignancy and its precursor were seen in total of 10% of patients with contact bleeding.

In another study for colposcopic and histopathological evaluation of 110 patients with contact bleeding, invasive cancer was seen in 5.5% of the patients while CIN II and CIN III were seen in 3.6% of the patients.

Vascular ectopy was the commonest benign lesion seen in colposcopy, about 66% of the patients had a vascular ectopy.

In this study, the mean age of patients with benign pathology was 32.9 years and the mean parity was 2.8.

While the mean age of patients with invasive cancer was 41.3 years and the mean parity was 4.17.

This results reiterate with time-honored teaching that cancer of the cervix is more common in multiparous women in their 5th decade of life.

In this group of women with contact bleeding that the index of suspicion of malignancy is high, investigation work-up through smears and colposcopy is mandatory in all cases.

The commonest cause of contact bleeding is a vascular ectopy. In the absence of neoplesia and infection, a vascular ectopy which is persistently symptomatic, may be treated by conservative measures such as cauterization, cryotherapy or laser evaporation.

Lastly, since the majority of cases showed inflammatory changes, effort must be made to look for specific infection specially. Chlamydia trachomatis and appropriate therapy instituted.

ConclusionConclusion

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RecommendationsRecommendations

Contact bleeding is an uncommon gynecologic symptom. Although, abnormal vaginal bleeding presents the most common gynecologic complaint.

Even in invasive cancer of the cervix, contact bleeding as the presenting symptom is infrequent.

Earlier diagnosis of CIN and of invasive cancer of the cervix in women with contact bleeding is a desirable goal.

The mean age of patient with invasive cancer was 41.3 year and parity 4.17 indicate that cancer of the cervix is more common is multiparous women in the 5th decade of life.

In this group of women with contact bleeding that the index of suspicion of malignancy is high, investigation work-up through smears and colposcopy is mandatory in all cases.

The commonest cause of contact bleeding in colposcopy was a vascular ectopy.

In the absence of neoplesia and infection, a vascular ectopy, which is persistently symptomatic may be treated by conservative measures as such as cauterization, cryotherapy and laser vaporization.

Every case with contact bleeding should be evaluated by cytology, colposcopy and histopathology wherever indicated.

Lastly, since the majority of cases showed inflammatory changes, effort must be made to look for specific infection specially Chlamydia trachomatis and appropriate therapy instituted.