Cervical intraepithelial neoplasia: risk factors for persistence and recurrence in adolescents

One of the most common sexually transmitted infections in adolescents is human papillomavirus. These infections can occur in one or multiple areas of the female genitalia but the vulva is usually the initial site of implantation for HPV. We carried out a long-term follow-up study of adolescents to evaluate the incidence of single or multiple lesions in the lower genital tract, the correlation between sexual behaviour and their localisation and behavioural risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN). We interviewed 268 women aged 12-21 years who had previously had cytology and/or physical examination suspicious for HPV infection. We asked them information about their lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. Those who smoked more than five cigarettes a day were considered "smokers". We have no specific data about oral contraception although we know that none of the patients had used oral contraceptives for more than two years. Two hundred and thirty-four young women between the ages of 12 and 21 years were included in the study. The diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy and directed biopsy. We found that in 126 out of 234 (53.8%) adolescents using contraceptives, only 85 (36.3%) had used a condom. The sites most frequently affected by lesions were the vulva, perianus and perineum (194/234; 82.9%), and the cervix (125/234; 53.4%). Vaginal lesions were detected in only 29/234 patients (12.3%). In 161 patients, sexual habits, age at first intercourse (p = 0.68), frequency of intercourse (p = 0.49) and number of lifetime partners (p = 0.27) as well as age (p = 0.26) played a role in transmission and incidence of HPV infection but not in the location of the lesions. This could be due to coexistent clinical and subclinical multiple infections as well as transmission via intercourse or from other sources, including tampons. HPV infection is detected by abnormal pap test, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover more attention should be paid to the psychological aspect of diagnoses and treatment of adolescents compared to older women as there was a high rate of patients lost in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. Only 12-45% of sexually active adolescent girls had obtained Pap smear screening. In our study we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER surgery.

Cervical intraepithelial neoplasia; HPV; Recurrence; Adolescents

[1] Moscicki A.B.: "Human pap仆lomavirus infection in adolescents" Pediatr. Clin. North Am., 1999. 46. 783.

[2] Mount S.L., Papillo J.L.: "A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern New England" Pediatrics, 1999, 103, 539.

[3] Edelman M., Fox A.S., Alderman E.M., Neal W., Shapiro A., Silver E.J. et al.: "Cervical Papanicolaou smear abnormalities in inner city Bronx adolescents: prevalence, progression, and immune modifiers". Cancer, 1999, 87, 184.

[4] Crowther M.E.: "Is the nature of cervical carcinoma changmg in young women?". Obstet. Gynecol. Surv., 1995, 50, 71.

[5] Schiffman M.H., Brinton L.A.: "The epidemiology of cervical carcinogenesis". Cancer, 1995, 76, 1888.

[6] Burk R.D., Ho G.Y., Beardsley L., Lempa M., Peters M., Bierman R.: "Sexual behavior and partner characteristics are the predominant risk factors for genital human papillomavirus infection in young women". J. Infect. Dis., 1996, 174, 679.

[7] Kotloff K.L., Wasserman S.S., Russ K., Shapiro S., Daniel R., Brown W. et al.: "Detection of genital human papillomavirus and associated cytological abnormalities among college women". Sex Transmit. Dis., 1998, 25. 243.

[8] Ludicke F., Stalberg A., Vassilakos P., Major A.L., Campana A.: "High- and intermediate-risk human papillomavirus infection in sexually active adolescent females". J. Pediatr. Adolesc. Gynecol., 2001, 14, 171.

[9] Moscicki A.B., Winkler B., Irwin C.E. Jr, Schachter J.: "Differences in biologic maturation, sexual behavior, and sexually transmilted disease between adolescents with and without cervical intraepithelial neoplasia". J. Pediatr., 1989, 115, 487.

[10] Shew M.L., Fortenberry J.D., Miles P., Amortegui A.J.: "Interval between menarche and first sexual intercourse, related to risk of human papillomavirus infection". J. Pediatr., 1994, 125, 661.

[11] Moscicki A.B., Shiboski S., Broering J., Powell K., Clayton L., Jay N. et al.: "The natural history of human papillomavirus infection as measured by repeated DNA testing in adolescent and young women". J. Pediatr., 1998, 132, 277.

[12] Nobbenhuis M.A., Walboomers J.M., Helrnerhorst T.J., Rozendaal L., Rernrnink A.J., Risse E.K. et al.: "Relation of human papillarnavirus status to cervical lesions and consequences for cervicalcancer screening: a prospective study". Lancet, 1999, 354, 20.

[13] Stafl A., Wilbanks G.D.: "An international terminology of colposcopy: report of the Nomenclature Committee of the International Federation of Cervical Pathology and Colposcopy". Obstet. Gynecol., 1991, 77, 313.

[14] Pace S., Labi G.L., Figliolini M., Stentella P., De Falco V., Mastrone M. et al.: "Intraepithelial cervical lesions: colpo-microcolposcopic diagnosis". Minerva Ginecol., 1993, 45, 9.

[15] Woodman C.B., Collins S., Winter H., Bailey A., Ellis J., Pnor P. et al.: "Natural history of cervical human papillomavirus infection in young women: a longitudinal cohort study". Lancet, 2001, 357, 1831.

[16] Kahn J.A., Colditz G.A., Frazier L.: "Factors associated with pelvic examinations in sexually active adolescent girls". J Adolesc. Health, 2001, 28, 130.

[17] Kurman R.J., Henson D.E., Herbst A.L., Noller K.L., Schiffman M.H.: "Interim guidelines for management of abnormal cervical cytology, the 1992 National Cancer Institute Workshop". J. Am. Med. Assoc., 1994, 271, 1866.

[18] Koss L.G.:'The Papanicolaou test for cervical cancer detection. A triumph and a tragedy". J. Am. Med. Assoc., 1989, 261, 737.

[19] Hassan E.A., Creatsas G.K., Diakomanolis E.S., Sakellaropoulos G.G., Rodolakis A.J., Konidaris S.D., Michalas S.P.: "Colposcopically directed biopsy findings in the young female". J. Pediatr. Adolesc. Gynecol., 2001, 14, 35.

[20] Evander M.. Edlund K., Gustafsson A., Jonsson M., Karlsson R,, Rylander E., Wadell G.: "Human pap仆lomavirus infection is transient in young women: a population-based cohort study". J. Infect Dis., 1995, 171, 1026.

[21] Wilcox L.S., Mosher W.D.: "Factors associated with obtammg health screening among women of reproductive age". Public Health Rep., 1993, 108, 76.

[22] Igra V., Millstein S.G.: "Current status and approaches to tmproving preventive services for adolescents". J. Am. Med. Assoc., 1993, 269, 1408.

[23] Lavin C., Goodman E., Perlman S., Kelly L.S., Emans S.J. "Follow-up of abnormal Papanicolaou smears in a hospital based adolescents clinic". J. Pediatr. Adolesc. Gynecol., 1997, 10, 141.