TABLE 2
Likelihood of inadequate follow-up colposcopic examination*
| Characteristics | Adjusted OR | 95% CI |
|---|---|---|
| Cryotherapy | 18.66 | 6.99–49.81 |
| Cone or LEEP | 3.01 | 0.78–11.58 |
| Cervical dysplasia | ||
| Mild | NA | |
| >Mild | NA | |
| ECC | NA | |
| HPV | NA | |
| Glandular atypia | NA | |
| *Logistic regression model included the clinic of colposcopy (not shown). Age (years) and duration (days; from treatment or first colposcopy to second colposcopy) were removed from the model by backward elimination. | ||
| CI, confidence interval; ECC, endocervical curettage ; HPV, human papilloma virus; LEEP, loop excision of the ectocervical portion; NA, not applicable; OR, odds ratio. | ||
Discussion
Undergoing cryotherapy of the uterine cervix increases the risk that a follow-up colposcopic examination will be inadequate. This agrees with the findings of Jobson and Homesley’s 1984 study,6 which looked at the efficacy of cryotherapy vs carbon dioxide laser ablation in the treatment of cervical dysplasia. Although it was not the focus of their study, a high rate of inadequacy was noted on follow-up colposcopic examinations after cryotherapy.
Because of the retrospective design of this study, we could not randomly assign women to a treatment group. However, the study groups were similar with respect to other variables potentially associated with the outcome measure. In addition, we attempted to control confounding variables by using multivariable analysis. By including the clinic where the examination was performed, we attempted to limit the effect of the subjective assignment of adequacy by the physician. This is a limitation of this study.
We found an association between the clinics where the follow-up colposcopist’s examinations were performed and whether a follow-up examination was adequate or inadequate. The determination of adequacy depends on the physician’s observations during the colposcopic examination. We were unable to measure the intra- or interobservation variation between the examinations. However, we attempted to control for this effect by including the clinic site in the multivariable analysis.
The current standard of care for inadequate colposcopic examination recommends more invasive evaluation with a procedure such as cervical conization or LEEP. This allows clarification of discordance between cytology, histology, and the colposcopist’s impression; sampling of any lesion that may extend past the view of standard colposcopy; and histologic evaluation of the entire transformation zone. Given the reported high rates of spontaneous regression of mild and moderate cervical dysplasias with a watchful waiting approach,8 12 we wonder whether we are performing unnecessary procedures (LEEP and conization) after cryotherapy as a result of inadequate follow-up colposcopic examinations. A study evaluating the pathologic findings of cone or LEEP specimens from inadequate colposcopic examinations after cryotherapy would help answer these questions. If there is no persistence or progression of dysplasia, then this would support the hypothesis that cryotherapy leads to unnecessary, invasive procedures. Further controlled trials are required to answer these questions.
ACKNOWLEDGMENTS
The authors acknowledge the assistance of Adeline Yerkes, of the Chronic Disease Division, Oklahoma State Department of Health, in facilitating access to the county clinic records.