Analysis of the structure of gynecological diseases and extent of surgery in patients of different age groups supervised in the cervical and endometrial pathology office

The most effective methods for preventing cervical cancer are vaccination and the treatment of cervical precancerous diseases once detected [1]. Prompt and effective treatment of cervical intraepithelial neoplasia (CIN) can result in complete cure and prevent progression to malignancy [2].

Although cervical cancer is more common in older women, there has been an increase in cases of diagnosing early forms of reproductive system cancer in young women [3, 4]. Therefore, it is important to determine the incidence of cervical precancerous disease in women based on age. By analyzing these data, we can identify a specific age group of women who require closer screening for cervical cancer and justify the need for appropriate medical management [5].

Currently, there is a rising trend in the incidence of endometrial cancer among younger women. Researchers have emphasized the importance of preventive therapy, including the morphological control of the endometrium [6]. It is promising to gather high-risk patients for endometrial cancer in one institution to facilitate diagnosis, surgical treatment if necessary, and effective treatment prescriptions. The authors also highlight that after surgical treatment for abnormal uterine bleeding, hormone therapy is often prescribed for a short period or not at all, which is insufficient for preventing endometrial cancer in the future [7].

This study aimed to analyze the prevalence of gynecological diseases and the extent of surgeries performed in patients of different age groups under the supervision of cervical and endometrial pathology offices.

Materials and methods

This epidemiological descriptive study of the incidence and prevalence of gynecological diseases in patients at the cervical pathology office was conducted at the Yekaterinburg Clinical Perinatal Center (YCPC) between 2022 and 2023. The study analyzed the indicators of the adult female population.

In the cervical and endometrial pathology office of the YCPC, various manipulations were performed in 412 patients. For this study, the authors selected a group of women who had undergone a full range of diagnostic tests, including general clinical investigations, colposcopy in patients with cervical pathology, cervical cytology, and morphological examination of cervical, vaginal, endometrial, or vulvar tissues. A total of 369 patients were included in this study (n=369).                                          

Patients aged 18–20 years represented 7/369 (1.9%) of the cohort, those aged 21–30 years 73/369 (19.7%), and those aged 31–40 years 168/369 (45.5%). The 41-50 age group comprised 64/369 (17.3%) of the cohort, while the 51-60 age group comprised 22/369 (5.96%). The 61–70 age group comprised 23/369 (6.2%) of the cohort, and individuals 71 years of age or older comprised 12/369 (3.3%).

To make a comparative analysis of the structure of cervical and endometrial diseases, we divided the patients into three groups according to their age (based on the WHO classification):

Group 1 included women who received medical care in the cervical and endometrial pathology office, aged 18–44 years (young age according to the WHO), n=290.

Group 2 included women who received medical care in the cervical and endometrial pathology office, aged 45–59 years (WHO average age), n=44.

Group 3 included women who received medical care in the cervical and endometrial pathology office, aged 60–74 years (old age according to WHO), n=30.

All women who took part in the study were referred by doctors from antenatal clinics in the city of Yekaterinburg in accordance with order 521-p dated March 16, 2022 “On the organization of medical care for patients with pathology of the cervix and endometrium in the city of Yekaterinburg”. Medical care was provided in accordance with the order of the Ministry of Health of Russia dated October 20, 2020, N 1130n “On approval of the procedure for providing medical care in the field of obstetrics and gynecology”, as well as clinical recommendations.

All manipulations of the cervix, vagina, and vulva were carried out under the control of the MK-200 “Scanner” video colposcope with the ability to use the visual VIA method, archiving images on paper in color. Treatment with low-frequency ultrasound solutions was performed using an ultrasonic surgical device AUZH-100 “Fotek” (for carrying out cavity and extra-cavitary cavitation). Tissue biopsy, cervical excision (LLETZ), cervical electroconization, argon plasma coagulation of the cervix was performed on a high-frequency electrosurgical device with argon-enhanced coagulation EHVCha-140 “Fotek.” Smoke evacuation during manipulation was carried out using an ASD smoke aspiration device “Fotek.” Laser vaporization of tissues was performed using a laser surgical device with photodynamic and hyperthermic exposure modes (Lakhta-Milon). Office hysteroscopy was performed using the SOPRO-181 endoscopic video camera, which allows the procedure to be performed on an outpatient basis without instrumental dilation of the cervical canal or anesthesia. The authors analyzed the structure of gynecological diseases in patients of different age groups and the list of medical procedures in each group.

Statistical analysis

Statistical analysis was performed using descriptive statistics in an Excel spreadsheet. The arithmetic mean (M) and standard deviation (SD), presented as M (SD), were used to describe quantitative data with normal distribution.                                            

Results

The mean age of the patients in group 1 was 33.76 (6.07) years. After carrying out a full diagnostic investigation, including histological examination of the tissue of the cervix, vagina, or vulva, we obtained the following data on the structure of the disease. The incidence of CIN I was 69/290 (23.79%), whereas CIN II occurred in 139/290 (47.93%) patients. CIN III was found in of 41/290 (14.13%) patients. Benign conditions and normal cervical tissue (leukoplakia, true erosion, and normal cervical epithelium) were observed in 58/290 (20%) patients. Hyperplastic endometrial disease was found in 17/290 cases (5.86%). Cervical cancer was detected in 5/290 patients (1.72%), while vulvar intraepithelial neoplasia (VIN) was not detected.

The mean age of patients in group 2 was 50.89 (4.09) years. The structure of diseases of the cervix, vagina, vulva, and endometrium is presented as follows: incidence of CIN I, 13/44 (29.55%); CIN II, 18/44 (40.91%); CIN III, 7/44 (15. 91%), benign diseases of the cervix – 11/44 (25%), cervical cancer – 1/44 (2.27%), endometrial hyperplastic processes – 2/44 (4.55%), VIN – 1/44 (2.27 %).

The mean age of the patients in group 3 was 67.13 (3.86) years. The structure of diseases of the cervix, vagina, vulva, and endometrium is presented as follows: incidence of CIN I, 5/30 (16.67%); CIN II, 18/30 (60%); CIN III, 4/30 (13.33%); benign diseases of the cervix, 6/30 (20%); cervical cancer, 0; endometrial hyperplastic process, 0; VIN, 3/30 (10%).

Comparative analysis of the structure of cervical, vulvar, and endometrial diseases in women of different age groups revealed the following characteristics (Table 1): CIN I was more frequent in women in group 2, but CIN II was more frequent in women in group 3. CIN III occurred with almost the same incidence in all three groups (14.13, 15.91 %, and 13.33 %, respectively). The incidence of benign diseases, cervical cancer, and endometrial hyperplastic processes does not depend on patient age. VIN was not registered in group 1, but in group 3, it occurred at a frequency of 2.27% (Table 1).

A comparative analysis of the extent of surgical interventions in the cervical and endometrial pathology office revealed the following features (Table 2). In group 1, the genital tract was treated with low-frequency ultrasound (LFUS) cavitated solutions in 289/290 (99.66%) cases. The following procedures were performed on the cervix for therapeutic and diagnostic purposes: 153/290 (52.76%) underwent point/multifocal biopsy, and 25/290 (8.62%) patients received LLETZ treatment. Additionally, 81 patients (27.93%) underwent cervical electroconization, while 200 patients (69%) were treated with argon plasma coagulation (APC). Laser vaporization (LV) was performed in 58 patients (20%), and 5/290 (1,72%) patients underwent diathermoelectrocoagulation (DEC). Three patients (1.03%) underwent cervical polypectomy and 109 patients (37.59%) underwent endocervical curettage. Operations on the body of the uterus included aspiration from the uterine cavity (pipelle biopsy) in 27/290 (9.31%), office hysteroscopy in 19/290 (6.55%), and insertion and removal of an intrauterine device (IUD) in 0. Patients in group 1 did not undergo a single biopsy of the vaginal vault.

In 44/44 (100%) cases in group 2, the genital tract was treated with solutions cavitated using LFUS. Therapeutic and diagnostic procedures of the cervix: point/multifocal biopsy was performed in 17/44 (38.64%), LLETZ in 2/44 (4.55%), cervical electroconization in 20/44 (45.45%), APC of the cervix in 37/44 (84.09%), LV of the cervix in 0, DEC of the cervix in 3/44 (6.82%), polypectomy of the cervix in 2/44 (4.55%), and endocervical curettage in 28/44 (63.64%) patients. Surgeries on the body of the uterus included aspirate from the uterine cavity (pipelle biopsy) in 3/44 (6.82%), office hysteroscopy (0), insertion and removal of the IUD (0. In group 2, vaginal vault biopsy was performed in 2/44 (4.55%) cases.

In group 3, in 28/30 (93.33%) patients, the genital tract was treated with solutions cavitated using LFUS. Therapeutic and diagnostic procedures of the cervix: point/multifocal biopsy in 14/30 (46.67%), LLETZ – in 3/30 (10%), cervical electroconization in 11/30 (36.67%), APC of the cervix in 27/30 (90%), cervical LV in 1/30 (3.33%), cervical DEC in 1/30 (3.33%), cervical polypectomy in 0, and endocervical curettage in 20/30 (66.67%). Operations on the body of the uterus included aspiration from the uterine cavity (pipelle biopsy) in 11/30 (36.67%) patients; office hysteroscopy, 0; insertion and removal of the IUD, 0. In group 3, vaginal vault biopsy was performed in 1/30 (3.33%) patients.

Discussion

The use of LFUS-generated solutions was lowest in group 3, i.e., in 28/30 (93.3%) patients, compared to patients in groups 1 and 2 (Table 2). Several studies have described a therapeutic approach to gynecological diseases using LFUS, which is widely used in Russia and other countries with impressive results [8–13]. In the cervical pathology office, this technique is often used before surgery to prevent postoperative infection and inflammation, especially in women with a history of cervicitis and vaginitis. These findings suggest that inflammatory diseases of the female reproductive system are more prevalent in women of reproductive age, making the use of LFUS particularly beneficial in this patient population. In older women, the use of local estrogens in addition to LFUS may be necessary to accelerate tissue repair [13]. We did not find significant differences in the frequency of cervical biopsy (spot or multifocal), cervical electroconization, and therapeutic and diagnostic endocervical curettage, as well as in the incidence of manipulations such as pipelle biopsy (aspiration from the uterine cavity), insertion and removal of the IUD, and biopsy of the vaginal vault. This indicates a high frequency of diagnostic procedures (e.g., cervical biopsy) to confirm the diagnosis and determine the extent of surgical treatment in patients of different age groups. It should also be noted that a high percentage of cervical curettages were performed immediately after electroconization or LLETZ, as described in the 2020 clinical guidelines, regardless of patient age [14]. LLETZ was performed much less frequently (group 1, 8.62%; group 2, 4.55%; and group 3, 10%) than cervical electroconization (group 1, 27.93%; group 2, 45.45%; group 3, 36.67%) in all age groups. This trend is determined only by the choice of surgeon performing the operation, taking into account the diagnosis, additional examination data, and patient age. The literature data indicate comparable effectiveness for both procedures [15].

Cervical electroconization was performed least frequently in women in group 1, in favor of LLETZ. This may be due to the desire of physitioans to perform manipulations in the operating room to preserve the length of cervical canal for the subsequent implementation of reproductive function, prevention of isthmic cervical insufficiency, and pretrm birth [16].

Cervical APC was most often performed in women group 3 – 90% compared to group 1 – 69%. It should be noted that, basically, the use of this type of energy was required for hemostasis, and taking into account the fact that patients in group 3 more often underwent operations with the removal of a large volume of tissue, these figures are logical and understandable. Another reason for the low percentage of cervical APC use in group 1 was the choice in favor of cervical LV (in group 1 – 20%; group 3 – 3.33%). According to the literature, laser vaporization of the cervix is increasingly common in young patients [17].

In group 2, hemostasis was most often performed using cervical DEC (6.82%) compared to group 1 (1.72%) and group 3 (3.33%). In the case of capillary bleeding, hemostasis can be performed with an argon plasma torch, penetrating 3 mm into the tissue depth; argon effectively stops bleeding and does not cause additional damage to the underlying stroma and surrounding tissues. Jet bleeding should be stopped using a ball electrode in the appropriate mode (DEC) because in this case, an impact to a depth of more than 3 mm is required [18]. It can be assumed that patients in group 1 developed capillary bleeding more often after manipulation than those in group 2 (jet). In general, the authors demonstrated the active use of a variety of diagnostic and treatment methods in patients at the cervical and endometrial pathology office. Patients with cervical pathology are treated more often than those with endometrial pathology, which is explained by the growth of CIN I in the Ural region [19] and the good work of the administrative resources of the metropolis in routing patients with precancerous cervical pathology.

According to the results of pipelle biopsy, uterine pathology (mainly endometrial hyperplasia) was found only in 17/290 (5.86%) women in the first group, in 2/44 (4.55%) women in the second group, and in none of the women in the third group.

This indicates that patients with endometrial pathology are most often referred to the hospital for hysteroscopy not only for diagnosis but also for therapeutic purposes. Due to the frequent detection of occlusion of the cervical canal in postmenopausal women over 60 years of age, they do not undergo a pipelle biopsy.

Polypectomy in outpatient settings was performed significantly more often in group 2 (4.55%) than in groups 1 (1.1%) and 3 (0%). We can conclude that a polyp in the lower third of the cervical canal (a polyp of the upper 2/3 of the cervical canal is removed during hysteroscopy) is more often found in women aged 45–59 years than in younger people (up to 44 years) or women over 60 years of age [18].

Conclusion

In the cervical and endometrial pathology office, 78.6% of the patients were young women aged 18–44 years, mainly with cervical diseases. The standard of diagnosis of cervical pathology is observed regardless of age: first biopsy, then excision, or cervical electroconization. In the cervical pathology office, in 93.3–100% of cases, in patients of all ages, prior to surgical treatment, the tissue was treated with a solution cavitated by LFUS. Cervical electroconization was most commonly used (45.5%) to treat precancerous cervical conditions in women aged 45–59 years. Ablative procedures (cervical APC and LV) are most frequently used for hemostasis and less commonly for treating CIN I.