Journal of Lower Genital Tract Disease最新文献

Objective: To identify barriers and facilitators to transitioning to primary human papillomavirus (HPV) testing from current cervical cancer screening practices among community OB/GYN physicians.

Methods: We conducted an exploratory qualitative study with in-depth interviews of 10 community-based OB/GYNs. Interviews were semistructured, utilizing an interview guide informed by the Consolidated Framework for Implementation Research, designed to explore current screening practices, perceptions of cytology versus primary HPV testing, recommended screening intervals, patient and physician acceptance of HPV-based testing, and anticipated changes in practice. Interviews were coded for recurring themes and organized into provider-, patient-, and system-level domains.

Results: Identified barriers included interprovider variability in cervical cancer screening practices, fear of missing a cancer, concerns about loss of follow-up, patient preferences for more frequent screening, and talking about HPV with patients as a stressful/difficult process. Identified facilitators included awareness of possible upcoming changes in cervical cancer screening recommendations and previous adjustments in approach to cervical cancer screening.

Conclusions: Transitioning to this evidence-based cervical cancer screening modality will require targeted, multilevel strategies to address physician concerns and to promote the acceptability and adoption of primary HPV testing.

This study reports follow-up rates for abnormal Pap test results among inpatients screened through the Johns Hopkins Cervical Cancer Screening Program (CCSP). Between 2018 and 2023, 997 patients underwent screening in the CCSP. Of that total, 20.7% (206/997) had abnormal Pap tests warranting further care, and of these individuals, 54.5% did not follow-up. Individuals with a history of homelessness were significantly less likely to follow up (OR: 0.35). Those who had documented assistance for transportation were more likely to return for care (OR: 2.98), especially amongst individuals with a history of homelessness (OR: 4.84). The findings highlight potential targeted interventions based on housing and transportation assistance. Such interventions have been added to our inpatient protocol, with the goal of improving care continuity and effective screening.

Cervical cancer screening in under-resourced areas presents significant challenges. Our project evaluated the integration of an HPV-based screening protocol in low resource clinics in Tijuana, Mexico. Our protocol featured point-of-care High Risk HPV (HR-HPV) screening through self- or provider collection, based on patient preference. HR-HPV positive patients were offered same or subsequent day colposcopy. Treatment was provided with thermal ablation. 62 patients were screened with 31% HR-HPV positivity rate. 60% preferred self-collection, and 40% preferred provider collection. Among test-positives, 53% underwent colposcopy, with a loss to follow up of 47%. 96% of respondents expressed willingness to recommend the program, Our conclusion is that HPV screening can be effectively implemented in low-resource clinics, with attention to logistical issues associated with new technology and specific social barriers.

Objectives: Persistent infection with high-risk human papillomavirus (HR-HPV) is a major cause of cervical precancerous lesions and cervical cancer. This study aimed to evaluate the effectiveness of Qingdu Suppository (QDS) in promoting HPV clearance and to identify predictors of treatment response.

Methods: This was a prospective observational cohort with retrospective analysis. A total of 60 patients with persistent HR-HPV infection were included (30 QDS and 30 non-QDS). The primary endpoint was HPV clearance, defined as 2 consecutive negative PCR results ≥6 months apart. Intention-to-treat (ITT, n=66, with lost-to-follow-up treated as persistent infection) and per-protocol (PP, n=60) analyses were performed. Inverse probability of treatment weighting (IPTW) was applied, and robust (sandwich) variance estimators were used to obtain valid confidence intervals.

Results: In the IPTW-weighted analysis, QDS was associated with higher HPV clearance than non-QDS (55.2% vs. 3.4%, p<.001). HPV clearance was significantly higher in the QDS group than in the non-QDS group (55.2% vs. 3.4%, p<.001). QDS remained an independent predictor of clearance (adjusted OR=33.1, 95% CI: 4.5-243.6, p=.001), with consistent benefits across subgroups.

Conclusions: Using a strict endpoint of 2 consecutive negatives, QDS was associated with higher HPV clearance. Results were consistent across analytic approaches but should be interpreted with caution, given the limited sample size and nonrandomized design. QDS may represent a promising adjunctive therapy, but its efficacy and long-term benefits require confirmation in larger multicenter randomized controlled trials.

Objective: Vulvodynia is chronic vulvar pain frequently associated with other comorbid chronic pain conditions. However, it is unclear whether women with vulvodynia experience higher rates of non-pain-related disorders after first onset of vulvar pain relative to unexposed women.

Methods: Women born in Sweden between 1981 and 1996 were identified from Sweden's Medical Birth Register (N=832,276) and assigned "exposed" if diagnosed with localized provoked vulvodynia (n=4,787), vaginismus (n=2,063), or both (n=867) between 2001 and 2018. Two women with no vulvar pain were matched to women with vulvar pain by birth year and assigned a reference year aligned with women's vulvar pain diagnosis. We assessed the cumulative incidence of new-onset conditions 1 year or later after vulvodynia diagnosis and comparable time periods among unexposed women. We further assessed the risk difference among all new-onset global ICD-10-recorded diagnostic codes, and risk difference, relative risks, and attributable fraction among highly observed new-onset ICD-10 codes.

Results: Among all ICD-10-coded global categories, we observed 4 to 5 more new-onset infectious disease codes (95% CI: 3.7-5.3) per 100 women, and 3 to 4 more new-onset global mental health (95% CI: 3.0-4.5), genital tract (2.6-4.5), and skin condition (95% CI: 2.7-4.2) codes per 100 women exposed to vulvar pain relative to those unexposed. New-onset conditions with the largest relative risks and attributable fractions included candidiasis, STDS, mood/anxiety disorders, dermatitis, and irregular menstruation.

Conclusions: Women with vulvodynia may have a compromised immune system that increases the risk of a wide spectrum of other health-related conditions after a vulvodynia diagnosis.

Objectives: Incompletely treated vulvar lichen sclerosus can lead to major complications and reduced quality of life. Limited treatment options beyond super-potent topical steroids are available for these recalcitrant cases.

Methods: In this descriptive, retrospective case series, 3 female patients ages 36-63 presenting with recalcitrant, biopsy-proven vulvar lichen sclerosus were treated with oral upadacitinib at a dosage of 15 mg daily and monitored at 1-2 month intervals.

Results: All 3 patients experienced clinical improvement in signs of lichen sclerosus and a decrease in symptom severity with minimal side effects.

Conclusions: Upadacitinib may be an effective treatment option for recalcitrant vulvar LS. More robust studies are needed to fully evaluate the efficacy and limitations of JAK inhibitors in treating lichen sclerosus.

Objective: We evaluated the adherence of cervical cancer screening (CCS) to ASCCP guidelines in the United States within a single hybrid community-academic institution.

Methods: In this retrospective cohort study, pap smears from October 2022 through December 2023 were abstracted from the electronic medical record. Adherence with CCS was determined by collecting tests ordered, the interval between tests, and subsequent result management. The findings were classified as adherent (appropriate order, interval, and management) or nonadherent. Descriptive statistics were employed.

Results: Three hundred and forty-eight pap smears were included; 225 (65%) were normal and 123 (35%) were abnormal. Two hundred thirty-two (67%) were nonadherent with ASCCP guidelines, while 116 (33%) were adherent. Of the nonadherent pap smears, 71 (31%) were ordered incorrectly, most commonly due to lack of HPV cotesting (87%); 190 (55%) were performed at an incorrect interval, most commonly due to an inappropriately short interval (89%); and 63 (18%) were managed inappropriately, most commonly due to lack of indicated colposcopy (57%) or unnecessary colposcopy (33%). Based on specific cytology results, overall adherence, appropriateness of interval, and order type did not vary between results (p=.18, p=.71, p=.23, respectively); however, the subsequent management was significantly different based on the cytology (p<.001). There were significant differences among provider type (p=.01) and practice (p<.001), but no difference by age, BMI, or medical comorbidity.

Conclusions: In this cohort, the majority of pap smears were nonadherent, largely due to underutilization of HPV cotesting, overscreening, and lack of indicated colposcopy. With clear guidelines available, there is significant room for improvement.

Objectives: The aims of the study were to describe clinicopathologic features of vulvar biopsies diagnostic for vitiligo and assess the link between vitiligo and genital symptoms.

Methods: The pathology database identified vulvar biopsies showing vitiligo, defined as absent or rare melanocytes on HMB-45, Sox-10, or Melan-A stains. Inclusion criteria were age 18 or over and availability of slides and medical records. Clinical data included demographics, comorbid conditions, symptoms, examination, treatment, and response. Histopathologic review documented site, epidermal characteristics, dermal collagen change, and lymphocytic infiltrate. Cases were stratified by histologic evidence of lichenoid dermatosis.

Results: Vulvar biopsies demonstrated vitiligo in 36 women with a median age of 56 years. Simultaneous histologic diagnosis of lichen sclerosus (LS) or lichenoid dermatitis was present in 23 (64%). Seven (19%) showed otherwise normal skin, while 5 (14%) had lichen simplex chronicus and 1 (3%) had spongiotic dermatitis. Itch was more frequent in the lichenoid group [21/23 (91%) vs 6/13 (46%); p = .005], while asymptomatic status was more likely in the normal/dermatitis group [5/13 (38%) vs 2/23 (9%); p = .001]. Three of 7 (43%) women with isolated histologic vitiligo reported pain and/or itch; 2 of their clinicians provided topical steroid maintenance and follow-up for presumed LS. Of 19 women with histologic LS, 11 (58%) lacked basal layer degeneration, of whom 6 (54%) reported concurrent topical steroid or calcineurin inhibitor use.

Conclusions: Symptomatic women with biopsy-proven vulvar vitiligo usually have an additional dermatologic condition, but histopathologic diagnosis of overlapping conditions is complicated by basal layer assessment and nonsclerotic LS.

Objective: The aim of this study was to evaluate the clinical performance of 2 DNA-based assays (DNA-xGT, DNA-lGT) and 1 RNA-based assay (mRNA), using specimens from women with cervical carcinoma or high-grade cervical lesions (≥CIN3).

Methods: Liquid-based cytology samples collected from 154 patients with ≥CIN3 histology results were tested with DNA-xGT, DNA-lGT, and mRNA assays. The clinical sensitivities of the HPV testing for disease detection were evaluated. Genotype-specific agreement was also assessed between the assays.

Results: The clinical sensitivity of the DNA-xGT, DNA-lGT, and mRNA in detecting ≥CIN3 were 96.8%, 96.1%, and 91.6%, respectively. The overall high-risk HPV positive percent agreement ranged from 92.6% to 99.3% across different assay pairs analyzed. Composite comparator analysis demonstrated no significant difference between the DNA assays; however, a significant difference was observed between the RNA assay and the DNA assays.

Conclusions: While no statistically significant difference was observed between DNA-xGT and DNA-lGT assays in disease detection rate, the mRNA test showed a significantly lower detection rate when compared to the DNA-xGT assay. Most of the missed infections (8/13) were identified as HPV16 or HPV18.

Objective: Multicentric, human papillomavirus (HPV) associated lower genital tract disease includes preinvasive and invasive lesions at multiple anatomic sites and can be synchronous or metachronous. Identifying patients with multicentric disease is crucial because of associated high treatment failure and recurrence. This study evaluates clinicopathologic patterns in immunocompetent and immunocompromised patients with multicentric lower anogenital disease.

Methods: Two-hospital retrospective study of 36 patients with histologic diagnoses of multicentric anogenital HPV-associated dysplasia was identified over a 25-year period. Patients were classified based on immune status: immunocompetent without HIV, immunocompetent with HIV, and immunocompromised. Histologic diagnoses, p16 immunohistochemistry (IHC), and in situ hybridization (ISH) for high-risk (HR) and low-risk (LR) HPV were reviewed.

Results: The most common sites of dysplasia were the anus (25%) and vulva (25%), with high-grade squamous intraepithelial lesions (HSIL) being the most frequent diagnosis (50%). Positive p16 IHC and HR-HPV ISH staining occurred in 71% and 81% of specimens, respectively. One-third of patients revealed a variation in IHC/ISH expression in lesions at the same anatomic sites at different time points. A significantly higher frequency of variation occurred in individuals living with HIV and immunocompromised individuals when compared to immunocompetent individuals.

Conclusions: This study supports the theory that some multicentric disease may arise from repeated infections with various HPV genotypes. The findings highlight the need for further research into genetic predispositions and other factors influencing the development of multicentric HPV-associated lesions in both immunocompetent and immunocompromised individuals.