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.