Pregnancy outcome after loop electrosurgical excision procedure for cervical intraepithelial neoplasia.

OBJECTIVE: To determine pregnancy outcomes among women who underwent loop electrosurgical excision procedure (LEEP). METHODS: In a case-control study in Italy, 475 pregnant women who underwent LEEP and 441 untreated pregnant women were enrolled between January 2003 and January 2007. Outcome measures were spontaneous abortion, preterm delivery, and at-term delivery rates. Continuous and discrete variables were analyzed via t, χ(2), and Fisher exact tests. Groups were compared by analysis of variance and Tukey HSD test. RESULTS: The spontaneous abortion rate was 14.5% and 14.1% in the LEEP and untreated groups, respectively. The preterm delivery rate was 6.4% and 5.0% in the LEEP and untreated groups, respectively. The number of women with a cervical length of less than 30mm was higher in the LEEP group, but this did not influence preterm delivery rate (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.53-1.95). Among women with a cervical length of less than 15mm, those treated with a wider removal of cervical tissue showed increased risk of preterm delivery (OR, 5.31; 95% CI, 1.01-28.07). CONCLUSION: The preterm delivery rate was not higher among women who underwent LEEP than among untreated women. Preterm delivery was associated with cone size and cervical length in the second trimester.

The re-infection rate of high-risk HPV and the recurrence rate of vulvar intraepithelial neoplasia (VIN) usual type after surgical treatment.

BACKGROUND: VIN usual type appears to be related to the HPV's oncogenic types. The aim of this prospective multicenter study was to evaluate the re-infection rate of high-risk HPV and the recurrence rate of VIN usual type after surgical treatment. MATERIAL/METHODS: The study enrolled 103 women affected by VIN usual type. They underwent wide local excision by CO2 laser. The patients were investigated by clinical evaluation and HPV DNA test 6 months after surgical treatment, and then were followed-up at 12, 18, 24, and 36 months. The recurrences were treated with re-excision. RESULTS: The rate of HPV infection after surgical treatment was 34% at 6 months, 36.9% at 12 months, 40% at 18 months, 41.7% at 24 months and 44.7% at 36 months. The mean time from HPV infection to the development of VIN was 18.8 months. CONCLUSIONS: HPV testing in the follow-up of VIN usual type patients might be useful for identifying those patients with a higher risk of recurrence after surgical treatment, although more studies are needed. These preliminary data suggest that the test, in addition to clinical examination, can improve the efficacy of the follow-up.

Impact of human papillomavirus infection on the neovaginal and vulval tissues of women who underwent surgical treatment for Mayer-Rokitansky-Kuster-Hauser syndrome.

OBJECTIVE: To evaluate the impact of human papillomavirus (HPV) infections on the neovaginal and vulval tissues of women who underwent surgical treatment for Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. DESIGN: Multicenter observational study. SETTING: University and community hospitals. PATIENT(S): Thirty-three women who had previously undergone neovagina reconstruction due to MRKH and who were referred to our centers for the evaluation and treatment of HPV neovaginal/vulval-related lesions. INTERVENTION(S): HPV infections were confirmed by polymerase chain reaction analysis or hybrid capture 2 tests; the patients underwent vaginoscopy, pap smear, and biopsy of the lesion and were treated by laser vaporization. Follow-up was conducted for 5 years. MAIN OUTCOME MEASURE(S): HPV-related neovaginal/vulval lesions, HPV testing, follow-up, recurrence rate. RESULT(S): Seventeen patients showed vulval lesions, and 16 patients neovaginal lesions. HPV testing results were positive for low-risk HPVs in 27 patients and high-risk HPVs in six patients. All the vulval lesions were condylomata, whereas 10 neovaginal lesions were condylomata, three were vaginal intraepithelial neoplasia (VAIN) degree 1, two were VAIN degree 2, and one was an adenocarcinoma. Eight patients were lost to follow-up. Twenty patients tested positive for an HPV infection, and seven patients (28%) had a recurrence of the lesion in the follow-up time. CONCLUSION(S): Patients who underwent neovagina reconstruction have sexual relationships and are HPV exposed. These patients should be evaluated after surgery for HPV infections to prevent HPV-related diseases and cancers.

Clinical management and follow-up of squamous intraepithelial cervical lesions during pregnancy and postpartum.

BACKGROUND: The incidence of cervical cancer in pregnancy is estimated to be 1-10/10000 pregnancies. Approximately 3% of cervical cancers are diagnosed during pregnancy. The incidence of abnormal Pap smears has been reported to be 5%-8%. Data on the spontaneous evolution of an intraepithelial neoplasia during pregnancy are quite diverse. Of dysplasia cases diagnosed during pregnancy, 10%-70% regress and sometimes even disappear postpartum, while persistence in the severity of cervical neoplasia is reported in 25%-47% and progression occurs in 3%-30%. However, adequate follow-up and definitive management in the postpartum period is important. The objective of the study was to assess proper management of squamous intraepithelial lesion (SIL) during and after pregnancy, to assess regression, persistence and risk of progression and the predictive role of HPV tests. MATERIALS AND METHODS: Thirty-one out of 721 pregnant women with a diagnosis of low- and high-grade SIL were observed. All patients were triaged using standard colposcopy. The histological diagnosis was assessed by colposcopic direct biopsies. In patients affected by high-SIL with colposcopic findings of suspected micro-invasive lesions, a loop electrosurgical excisional procedure (LEEP) was carried out in pregnancy. High risk HPV tests were performed using PCR. The patients were followed up with cytology and colposcopy every 6-8 weeks during gestation and nine weeks postpartum. They were re-evaluated using cytology, colposcopy and histology for a final diagnosis and, when necessary, submitted to treatment. The patients were followed up for a minimum of 5 years. The HPV test was performed once at 6-8 weeks during gestation and annually during the follow-up. RESULTS: Of the 31 patients with abnormal cytology, histological analysis revealed 10 cervical intraepithelial neoplasia (CIN) 1, 5 CIN 2 and 16 CIN 3. The HPV test at diagnosis was positive for HPV 16 type in 22 cases and negative in 9. Five patients with CIN 2 and 11 with CIN 3 were followed up; 5 patients with CIN 3 with colposcopic findings of suspected microinvasive lesions were submitted to an excisional procedure with LEEP before the 16th week of pregnancy. CONCLUSION: Performing high-risk HPV tests may improve the follow-up of patients with SIL in pregnancy and postpartum in addition to cytology and colposcopy to indicate persistence/progression of the lesions. Proper management and adequate follow-up could be proposed in pregnancy and postpartum.

Hormonal replacement therapy after stem cell transplantation.

OBJECTIVE: To evaluate HRT compliance and efficacy in the treatment of symptomatic ovarian failure in pre-menopausal women after stem cell transplantation (SCT) for malignancies. METHODS: Thirty-one females were selected and prospectively followed in a university bone marrow transplantation unit and gynecologic outpatient clinic in a university teaching hospital. The patients received regular gynecological examinations, hormonal assessment every 6 months including plasma levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), 17-beta estradiol (E2), and transvaginal pelvic ultrasonography, mammography, and computerized bone mineralometry every 12 months. Self-assessment form of menopausal symptoms perception was filled in by all patients before HRT and during the observation period. RESULTS: All patients developed gonadal failure after SCT. The menopausal symptoms more frequently reported were: vasomotor (90%), muscleskeletal symptoms (61%), vulvo-vaginal atrophy (54%), and mood changes (54%). Fifteen premenopausal women out of 31 (51.6%) received systemic HRT on the basis of age (<45 years), absence of medical contraindication or subjective refusal, and complete remission of underlying malignancies post-SCT. The remaining patients (48.4%) did not receive HRT mainly for patient's refusal (29%), relapse of malignancy (13%) or liver toxicity (9.6%). HRT was effective in HRT treated patients promptly relieving unpleasant symptoms of gonadal failure. HRT was tolerated without minimal complications or serious side effects. CONCLUSIONS: Dramatic improvement in menopausal symptoms was observed in women on HRT although treatment was feasible only in nearly half of the patients. HRT alleviates unnecessary discomfort and improves the well-being of female patients post-transplant also by preventing menopause related complications. Feasibility and patients' compliance of HRT should be carefully evaluated in long-term survivors after stem cell transplantation.