Effects of depot medroxy progesterone acetate use on cervical cytology of HIV positive women at a comprehensive care clinic in Kisumu, Kenya
Abstract
Background: The use of the long acting hormonal contraceptive Depot Medroxy-Progesterone
Acetate (DMPA) has been increasing in the last decade. The hormonal effects of this
contraceptive agent on human cervical epithelium have been under reported in the literature
especially for the women infected with the Human Immune-deficiency Virus (HIV). Of concern
is the increased risk of developing pre-malignant lesions that lead to cervical cancer if not
detected early. Contraception in HIV -infected women can decrease the number of unintended
pregnancies and thus reduce maternal death and vertical transmission of HIV. The relationship
between DMP A, HN and cervical cytology is unclear.
Objective: This study set out to determine the hormonal effects of DMPA on cervical smears
among HIV positive women by determining cervical changes and lesions of HIV positive
women on DMPA. These were compared with cervical changes seen in HIV positive women
who were not on hormonal contraception. The relative risk of abnormal cytology associated with
the DMP A use for at least 6 months in HfV positive women was estimated.
Design: This was a case control study where cases were selected from among HIV positive
women using Dl'vfPA while controls were selected from HIV positive women who were not
using any method of contraception.
Setting: The study was carried out at the research training and care programme/Comprehensive
Care Centre (CCC) clinics at Lumumba Health Centre and Kisumu District hospital sites where
HIV positive women receive treatment and follow up. Cytomorphological changes and
cytohormonal changes were interpreted at the University of Nairobi (UON) laboratory.
Materials and Methods: HN positive women who sought services from CCC's clinics were
recruited during the study period. A total of 126 HIV positive women were included in the final
statistical analysis and were grouped into women who were using DMPA (63 cases) and those
who were not on any contraceptive method (63 controls). Structured questionnaires were used to
collect clinical and demographic data while CD4 counts data was obtained from participants'
files. Cervical smears were then collected and processed for cytological examination and
classified according to the Bethesda system 2001. Smears were further examined for squamous
cell folding and clustering, intermediate cells predominance, lactobacilli amounts, atrophic
pattern, navicular cells and premalignant lesions.
Results: The mean age of DMPA users group (cases) was 27.5 years while that of the DMPA
non-users (control) group was 29.5 years. There was a statistically significant difference of
progesterone dependent changes observed in DMP A users and non users, P=0.023 OR 2.4(1.1-
51). Progesterone pattern was seen in 45.0% of DMPA users and 25.4% in DMPA non users.
For pattern description, increased amounts of Lactobacilli (28.0.%) were observed more in
DMPA users while folding of the cytoplasm was described more in non- users (313%).
Generally there was no statistically significant difference of abnormal cytology in DMPA users
and non users P=0.080, OR 2.7 (09-8.2) when compared to normal cytology. The prevalence of
High grade squamous intraepithelial lesion (HGSIL) was 6.3% in DMPA users and 3.2% nonusers,
P=0.680, Low grade intraepithelial lesion with HPV effect (LGSIL andHPV) was 6.3% in
DMPA users and 11.1% in non-users, P=0.344 OR 0.5 (0.2-2.0) and Atypical squamous cells of
undetermined significance (ASCUS) 6.3% in DMPA users and 1.6% in non-users, P=')365,
OR4.2 (95% CI 0.5-38.7. Atypical glandular cells of undetermined significance (AGUS) were
reported in DMPA users was 3.2% only, P=0.496, OR 2.2 (Cl 0.2-25.3).
Conclusion Certain progesterone-dependent effects like squamous folding of the cytoplasm,
crowding, presence of lactobacilli and intermediate predominance were identified more in
DMPA users while squamous crowding and folding of the cytoplsmic edges of cells were
identified more in the non users. There is no increased risk of cervical intraepithelial neoplasia in
patients using DMP A
Recommendations
I. Further evaluation of abnormal cytology in HIV positive women on DMP A using other
methods of cervical cancer screening like liquid based cytology and HPV- DNA testing
strategies should be explored.
2 Family Planning services and cervical smear screening should fully be integrated into
Comprehensive Care Centre's.
Citation
Masters of science in clinical cytologySponsorhip
University of NairobiPublisher
Department of human pathology University of Nairobi