Abstracts

discussion for screening overdue patients in the early antenatal

Category – Colposcopy and Cervical Pathology
period.
2306
Is a short interpregnancy interval to blame? A pilot
study of cervical screening uptake in antenatal 349
populations served by two university teaching Evidence for clinical utility of extended HPV
hospitals genotyping in screening, triage, persistence
Miti, C1; Fulcher, J2; Kessler, L2; Nijjar, S1; tracking and follow up after abnormal results and
Woodman, J3; Iskander, KS1 colposcopy, and test of cure
1
Northwick Park Hospital, London, UK; 2University of Warwick, Andrews, J
Warwick, UK; 3Walsgrave Hospital, Coventry, UK
BD, Sparks, USA
Objective This study set out to assess the prevalence of antenatal
Objectives Guideline originators have not yet included an analysis
patients on schedule with their cervical screening invitations and
of the body of science published recently about the clinical value
to test the hypothesis that a short interpregnancy interval is
of extended HPV genotyping (xGT) in screening, triage, risk
associated with a long interval between cervical screens.
discrimination, persistence tracking, follow up of women with
Design Quantitative observational study–cross-sectional survey
abnormal results, and follow up after treatment of high-grade
being inexpensive, easy to conduct, and able to assess the
cervical intraepithelial neoplasia (CIN).
prevalence of cervical cytology uptake in patients embarking on
Design This systematic review has been registered with
pregnancies.
PROSPERO and conducted according to Cochrane standards.
Methods One hundred and six patients were recruited over a 4-
Methods PubMed, Cochrane Database of Systematic Reviews, and
month period between October 2018 and January 2019 from
Health Technology Assessment database were searched from 2001
Walsgrave Hospital, Coventry, and Northwick Park Hospital, London.
through 2018 for relevant studies. Hand-searching of retrieved
Verbally consenting antenatal inpatients or those attending
article reference lists supplemented the search. Eligible studies
antenatal outpatient clinics completed a 14-point anonymous
included prospective studies of women and retrospective studies
questionnaire. Initial data entry into Excel was imported into
of residual specimens from women that were tested using HPV
IBM SPSS Statistics 25 for statistical analysis.
genotyping tests in screening or following an abnormal screening
Results 65% of the cohort were aged between 25 and 34, while
result, or colposcopy, or treatment for high-grade cervical
13% were under screening age. 85% had never been recalled, and
intraepithelial neoplasia. The reference standards were CIN2 or
pooled colposcopy and retest rates were 10.4%.
CIN3 or CIN2+ or CIN3+ or invasive cervical cancer. Cochrane
The point prevalence of cervical screening attendance was 69%,
risk of bias assessment was performed. GRADE methodology was
mean parity was 2 (range 0–8), the average IPI was 34 and
used to establish quality and strength of evidence.
52 months as the shortest and longest, respectively, while the
Results Thirty-one original research articles met inclusion and
mean duration since last screen was 25 months (SD 15.89)
exclusion criteria. Reporting xGT results provides profound
Using a linear regression model, statistical significance was just
discrimination of both current and future CIN3+ risks, due to the
reached for the relationship between the duration since last
differential risks of same genotype persistence versus new
cervical screen and the number of previous pregnancies which was
genotype infection. Within subjects with persistent same genotype,
predictive of the former (P = 0.051, 95% CI 0.009 to 4.648,
xGT can discriminate risk by more than ten-fold. Extended
r2 = 0.066, regression equation y = 20.98 + 2.32x).
genotyping could be used as follow-up type-specific persistence
Multiple regression analysis did not identify statistically significant
versus clearance, to support risk-based clinical decisions. Similar
factors confounding the duration since the last smear when
management for similar risk discrimination is benchmarked.
adjusted for other variables.
Conclusion Based on quality-evaluated studies that met inclusion
Conclusion Attendance for routine cervical screening in women of
criteria, xGT appears very promising as follow up of persistence
childbearing age is interrupted by pregnancy episodes. We have
versus clearance, to discriminate risk and support risk-based
shown that the duration since the last smear may be significantly
clinical action steps by the principle of equal management for
affected by gravidity which is an independent risk factor and
equal risk. The role of same genotype persistence is critical to test-
predictor for nonconcordance to the cervical screening programme
of-cure assessments. Models for different management paradigms
With Public Health England set to roll out HPV Primary Screening
are described. The information in this report is intended to help
in 2019, and our findings support a unique opportunity to educate
guideline panels, policymakers, clinicians, and women make
women on the benefits of cervical screening and to work with GPs
informed decisions about the selection of healthcare services, and
in adopting rigorous methods of postnatal screening by ensuring
is intended as a reference and not as a substitute for clinical
compliance at the 6- to 8-week postnatal check.
judgement.
Moreover, with HPV primary screening detecting cervical lesions
Note: The author/presenter is a former associate professor of Ob/
earlier and more accurately, although pregnant patients were
Gyn, Editor-in-Chief of a peer-reviewed journal; Cochrane
excluded from the landmark trial, this pilot study opens the
reviewer; Senior Scientist in an Evidence-based Practice Center;
and current member of GRADE.

ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG 7
Abstracts

685 CI = 1.6–4.6; P < 0.001) and antepartum haemorrhage (OR = 9.0,

A 10-year retrospective review of the maternal and 95% CI = 0.5–3.9; P = 0.011) were significantly associated with
neonatal outcomes in patients with history- birthweight <2.5 kg.
indicated, ultrasound-indicated and rescue cervical Conclusion History-indicated and ultrasound-indicated cerclages
have better outcomes than rescue cerclages. This analysis identifies
cerclages
women at risk of cervical dysfunction, in whom serial cervical
Premikha, M1; Lim, KMX2; Gosavi, A2; length measurements can be performed, promoting ultrasound-
Velaisamy, J3; Biswas, A2 indicated cerclages instead of rescue cerclages. Twin pregnancies,
1
Yong Loo Lin School of Medicine, National University of Singapore, T2DM, and Indian ethnicity are associated with cerclage failure,
Singapore, Singapore; 2Department of Obstetrics & Gynaecology, allowing us to counsel women about local cerclage success rates.
National University Hospital Singapore, Singapore, Singapore; 3Faculty
of Science, Statistics, National University of Singapore, Singapore,
Singapore
2513
Objective To assess the differences in cervical cerclage success Biopsy rate for borderline and low-grade smears
rates, and maternal and neonatal outcomes in patients with referred to colposcopy in North Glasgow
history-indicated, ultrasound-indicated, and rescue cerclages, and
Wong, S1; Vella, S1; Laing, M2
identify factors associated with these differences. 1
Design This is the largest South-East Asian retrospective study of Glasgow Royal Infirmary, Glasgow, UK; 2Stobhill Ambulatory Care
Hospital, Glasgow, UK
patients who underwent cervical cerclages between January 2008
and October 2017 at National University Hospital Singapore.
Objective HPV triage is not currently undertaken in Scotland;
Methods Patients’ data – demographics, past medical history,
however, the Hr-HPV primary test will be implemented in
obstetric history, clinical presentation, delivery details, and
Scotland in 2020. Within the planning model, there is an
neonatal outcomes – were extracted from the electronic health
anticipation of a rise in colposcopy visits in the first 3 years of
records and analysed using R commander. One hundred and
implementation before the number will start to reduce. As high-
sixty-three cerclages were inserted, of which 14 patients were lost
grade smear has a very clear guidance of biopsy rate, we are now
to follow up and excluded.
studying our biopsy rate for borderline and low-grade smear to
Results The 149 cerclages were split into three groups – history-
optimise our practice and to ensure we will be able to meet the
indicated (n = 83), ultrasound-indicated (n = 39), and rescue
initial raised in numbers.
(n = 27) cerclages – for analysis. Cerclage success was defined as
Design This was a retrospective study of all low-grade and
pregnancies that continued beyond 24 weeks. Patients with rescue
borderline smears referred to colposcopy in North Glasgow in
cerclages had the lowest success rate of 55.56%, while patients
2017.
with history-indicated and ultrasound-indicated cerclages had
Methods Data including smear result, colposcopy outcome,
similar success rates of 91.57% and 92.31%, respectively. On
histology result, and other related factors have been obtained from
logistic regression, rescue cerclage (OR = 74.9, 95% CI = 1.0–7.6;
a central database in Scotland (NCCIAS & SCCRS). Duration will
P < 0.001), twin pregnancies (OR = 72.4, 95% CI = 2.0–6.6;
include all new colposcopy visits taken place in North Glasgow
P < 0.001), larger cervical dilation at presentation (OR = 1.6, 95%
within 2017 with borderline changes (squamous) and low-grade
CI = 0.1–0.8; P = 0.007), pre-existing type 2 diabetes mellitus
smears. Further details of the colposcopy visit will be verified in
(T2DM) (OR = 18.6, 95% CI = 2.9–3.0; P = 0.020), and Indian
case notes.
ethnicity (OR = 7.5, 95% CI = 0.2–3.8; P = 0.030) were
Results A total of 248 cases with borderline smears were seen
significantly associated with cerclage failure.
within 2017, 177 biopsies were performed, and 97% were
For maternal outcomes, patients with rescue cerclages had the
adequate. One hundred and eighteen of the biopsies confirmed
highest proportion of patients with one or more maternal
normal result, 30 with CIN 1, 18 with CIN 2, 3 with CIN 3, and 1
complications (48.15%), and highest rates of preterm premature
with CGIN. A total of 578 cases with low-grade smears were seen,
rupture of membranes (33.33%) and preterm labour (33.33%).
and 430 biopsies were performed with 97% adequacy. Two
On logistic regression, larger cervical dilation (OR = 1.4, 95%
hundred and twenty-four biopsies were normal, 99 with CIN1, 69
CI = 0.1–0.6; P = 0.020) and per-vaginal bleeding at presentation
with CIN2, 20 with CIN3, one with CGIN, and one with
(OR = 7.4, 95% CI = 0.2–3.8; P = 0.028) were significantly
squamous cell carcinoma.
associated with occurrence of maternal complications.
Conclusion The total biopsy rate was 73% at a cost of £25 000 to
For neonatal outcomes, patients with rescue cerclages had the
the trust, which is higher than the total biopsy rate in Scotland
lowest neonatal survival rate of 73.33%, while patients with
(67%). Further staff education on reducing unnecessary biopsy is
history-indicated and ultrasound-indicated cerclages had similar
required, and interval re-audit of biopsy rate and consideration of
survival rates of 98.70% and 100%, respectively. Also, babies from
the usage of adjunctive colposcopy technology such as DYSIS may
patients with rescue cerclages had the lowest mean birthweight
result in reduction together with cost saving and a less painful
(2.21 kg) and highest proportion of neonatal complications, that
colposcopy visit.
is respiratory distress syndrome (35.71%), intraventricular
haemorrhage (21.43%), and hypoxic-ischaemic encephalopathy
(7.14%). On logistic regression, preterm labour (OR = 22.0, 95%

8 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG

350
Vaginal microbiome molecular assay for diagnosis
of vaginitis, vaginosis and risk of acquisition and
persistence of HPV
Andrews, J
BD, Sparks, USA
Objective The vaginal microbiome plays a significant role in the
maintenance of health and occurrence of disease in the female
lower genital tract. Human papillomavirus (HPV) causes cervical
intraepithelial neoplasia (CIN) and cervical and vaginal cancer.
This secondary research study provides an analysis of the current
state of the evidence regarding role of vaginal microbiome in
vaginitis, in bacterial vaginosis, and in acquisition and persistence
of HPV.
Design Systematic review.
Methods We searched the Database of Abstracts of Reviews of
Effects, Cochrane Database of Systematic Reviews, PubMed, and
the Health Technology Assessment database from January 2001
through January 2018 for relevant controlled trials and
observational studies. We supplemented by hand-searching of
retrieved article reference lists. Eligible studies included
prospective studies of women and retrospective studies of residual
specimens from women who were tested using molecular assays of
healthy and pathogenic bacteria of the vagina and human
papillomavirus DNA assays.
Results A PRISMA flow diagram is presented for this systematic
review. The complete analysis of results of the systematic review,
with tables, is presented. Past cross-sectional studies relying on
Nugent’s score have been superceded by molecular next-
generation sequencing. Molecular assessment of the vaginal
microbiome assists with diagnosis of vaginitis and bacterial
vaginosis. Dysbiosis of the vaginal microbiome, bacterial vaginosis,
and vaginitis is associated with increased risk of acquisition of
HPV infection. Dysbiosis of the vaginal microbiome and bacterial
vaginosis is associated with increased risk of persistence of the
same HPV genotype. Persistence of HPV is associated with
increased risk of high-grade CIN.
Conclusion The vaginal microbiome plays a substantial role in the
persistence or clearance of HPV, and in the progression or
regression of CIN. The challenge to date has been that most
studies were observational, limiting conclusions to associations,
rather than causation. Future research should target longitudinal
risk assessment.
Note: The author/presenter is a former associate professor of Ob/
Gyn, Editor-in-Chief of a peer-reviewed journal; Cochrane
reviewer; Senior Scientist in an Evidence-based Practice Center;
and current member of GRADE.
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Abstracts
494
Prevalence and management of CIN by colposcopy
among VIA-positive cases in a tertiary-level
hospital of Bangladesh
Biswas, R1; Parvin, Z1; Biswas, R2
1
Faridpur Medical College, Dhaka, Bangladesh; 2International Centre
for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
Background Cervical cancer is the second most common cancer
among women in Bangladesh where CIN is the forerunner. Visual
inspection of cervix with acetic acid (VIA) is adopted as national
cervical cancer screening programme in this country. All positive
VIA cases are evaluated by colposcopy.
Objective This study was conducted to evaluate the prevalence of
CIN among the VIA-positive cases and to audit the performance
of a tertiary-level hospital in the colposcopic management of CIN
to prevent invasive cancer.
Methods This population-based retrospective study was
conducted in Faridpur Medical College Hospital of Bangladesh.
Study period was 06 (six) years from 2013 to 2018. All VIA-
positive cases were evaluated by colposcopy. A total of 2102 VIA-
positive cases were evaluated and were documented in
‘Colposcopy register’ supplied by the Government. International
Federation of Cervical Pathology and Colposcopy (IFCPC) 2011
nomenclature was used for diagnosis. Modified Reid Colposcopic
Index (RCI) was followed for management. ‘See and treat’
protocol was mostly followed. Histopathological correlations were
done. Data were screened, grouped, and analysed by SPSS version
23. Frequency and percentage were determined for comparative
purpose.
Results In this study, prevalence of CIN in VIA-positive cases is
26.1%. Among them, 65.5% were low-grade squamous
intraepithelial lesion (CIN-I) and 32.5% were high-grade
squamous intraepithelial lesion (CIN-II and III). Colposcopically
diagnosed 64.1% cases of low-grade squamous intraepithelial
lesion (LSIL) and 74.2% of high-grade squamous intraepithelial
lesion (HSIL) cases received treatment and histopathological
confirmation. Demographically, most of the patients were between
30 and 45 years (66.7%), had their primary or secondary
education (56.5%), and belonged to middle-class family (60.6%).
Important finding is that 27.4% of the CIN cases are below
30 years.
Conclusion From this study, we got information about the
demography and prevalence of CIN among VIA-positive cases at
the same time management of CIN to prevent invasive cervical
cancer. In developing countries like Bangladesh, adequate coverage
of the total female population by cervical cytology is not feasible
at present. Also, women are not complaint for follow-up visits. In
such situation, VIA is suitable for primary screening and all VIA-
positive cases should have secondary screening by colposcopy and
biopsy. Colposcopy is the gold standard for diagnosis of CIN, and
colposcopy-based management can reduce the incidence of
carcinoma cervix. We should extend our screening programme
and that should be population-based.
9
Abstracts
947
Primary HPV testing with cytology versus cytology
alone in cervical screening – a prospective
randomised controlled trial (RCT) with 2 rounds of
screening in a Chinese population
Chan, KKL1; Ngu, SF1; Chu, MY1; Tse, KY1;
Wei, N1; Liu, SS1; Lau, L1; Cheung, AN2;
Ngan, HYS1
1
Department of O&G, University of Hong Kong, Hong Kong, Hong
Kong; 2Department of Pathology, University of Hong Kong, Hong
Kong, Hong Kong
Objective To evaluate the effectiveness of primary human
papillomavirus (HPV) testing combined with cytology in cervical
cancer screening in a Chinese population.
Design Prospective randomised controlled trial with 2 screening
rounds about 3 years apart in a Chinese population, comparing
high-risk HPV testing combined with liquid-based cytology (LBC)
versus LBC alone.
Methods Women aged 30–60 attending health clinics for routine
cervical screening were recruited and randomised with 1:1 ratio
into an intervention group (HPV testing with LBC) and a control
group (LBC alone). Digene HC 2 High-risk HPV DNA test was
used for HPV testing. Women in the intervention group would be
referred to colposcopy and biopsy immediately if they were found
to have high-risk HPV regardless of the cytology result. Women
in the control group would be managed according to standard
cervical screening protocol. Women were scheduled for second
round of screening with LBC alone 36 months after the baseline
round. The primary outcome was the detection rate of high-grade
cervical intraepithelial neoplasia (CIN). Results were analysed by
intention to treat.
Results Over a 4-year period, a total of 15955 women were
recruited into the study and were randomised into intervention
group (n = 7979) and control group (n = 7976). Majority of the
women had been attending regular screening prior to entry to the
study. At baseline screen, high-grade cytology was found in 0.13%
of all women. The detection of CIN3+ lesions was significantly
higher in the intervention group compared to the control (0.62%
versus 0.2%, OR 3.06, 95% CI 1.78–5.58). At the subsequent
round of screening, however, CIN3+ detection was significantly
lower in the intervention group (0.07% versus 0.24%, OR 0.27, CI
0.08–0.76). Over 2 rounds of screening, the total detection of
CIN3+ was higher in the intervention group (0.67% versus 0.39%,
OR 1.71, CI 1.1–2.69). The no. of colposcopies done was four-
fold (10.6% versus 2.4%) higher in the intervention arm.
Conclusion Our results confirmed that the addition of a HPV test
to cytology in primary cervical screening led to earlier detection of
clinically significant pre-invasive lesions resulting in a fall in the
incidence of high-grade lesions in the subsequent rounds. Triage
for HPV-positive women is necessary to reduce colposcopy
referrals. (ClinicalTrials.gov NCT01058460)
10 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
582
A comparative analysis of estrogen receptor alpha
and beta expression in normal cervix and cervical
cancer: a case–control pilot study
Priyadarshini, V; Singh, A
UCMS & GTB hospital, New Delhi, India
Introduction Estrogen receptors (ER) were categorised into two
subgroups (alpha and beta) after the discovery of estrogen
receptor beta in the mid-nineties. Studies show that ER alpha and
beta have their own unique cell-specific expression patterns and
actions and may also have mutual antagonistic roles if present in
the same tissue.
Aim and objectives The aim of the research was to study and
compare the expression of ER alpha and beta in ectocervix of
healthy women and cervical cancer patients.
Design Case–control study.
Methods One gram of cervical tissue was taken from 30 cervical
cancer patients (cases) and 20 healthy women (controls) and
subjected to immunohistochemical analysis. The expression
pattern of ER alpha and beta was studied in terms of number of
women expressing the receptor and their respective
immunoreactivity scores and compared between healthy and
cancerous cervix.
Results Ectocervical cells of normal and cancerous cervix
expressed both ER alpha and beta in their nuclei and only ER
beta in their cytoplasm. 90% of controls expressed ER alpha in
the ectocervix compared to only 6.67% of cases (P = 0.000) while
there was comparable expression of ER beta between the 2 groups
(80% versus 90%). The mean immunoreactivity scores for ER
alpha expression was also lower in cervical cancer patients
(0.167  0.75) compared to healthy women (2.60  2.01)
(P = 0.000). The mean score of ER beta was higher in cases
(5.4  4.21) than controls (4.65  3.28), and the difference was
not significant.
Conclusion ER alpha and beta have different expression patterns
in ectocervical cells. ER alpha is significantly downexpressed, while
ER beta expression is retained or slightly increased in cervical
cancer cells when compared to normal cervix.
2171
The low risk of CIN2+ in triage-negative HPV-
positive women 5 years after primary screening
Stanczuk, G1; Currie, H2; Forson, W2; Palmer, T3;
Cuschieri, K4
1
Western Isles Hospital, Stornoway, UK; 2Dumfries and Galloway
Royal Infirmary, Dumfries, UK; 3NHS Highlands, Inverness, UK;
4
Scottish HPV Reference Laboratory, Edinburgh, UK
Objective The optimal triage of screen-positive women is one
of the most important considerations when introducing primary
human papillomavirus (HPV) testing. Performing liquid-based
cytology (LBC) on HPV-positive (HPV+) women and/or limited
genotyping has been recommended as a triage strategy in
several settings including the UK. Additionally p16/ki-67 dual-

stained cytology is a credible triage approach. We previously
reported an evaluation of triage strategies in a cross-sectional
study where disease was ascertained at the time of the positive
triage. The aim of this study was to evaluate the cumulative
incidence rate (CIR) of high-grade cervical intraepithelial
neoplasia (CIN2+) within 5 years of primary triage strategies of
HPV+ women.
Design Population-based longitudinal study.
Methods The study population (n = 385) was nested in the
Papillomavirus Dumfries and Galloway (PaVDaG) study and
comprised of HPV+ women, who all had HPV 16/18 typing, LBC,
and p16/ki-67 dual-stained cytology at the first screening round.
The aim of PaVDaG study was to evaluate effectiveness of HPV
testing using LBC and self-collected vaginal and urine samples in
a Scottish population-based screening cohort. All participants
were re-called for the second screening round, which was based
on LBC only as per current screening practice in Scotland. We
used the second round screening results to describe CIR of CIN2+
within 5 years of primary HPV+ testing stratified by the various
triage strategies with proportions reflected within 95% confidence
intervals.
Results The length of follow up was up to 5.5 years. Overall
compliance to screening was 90%. During the first and second
round of screening, 66 and 8 CIN2+ lesions were detected,
respectively. The HPV+ women with an LBC-negative triage had
5-year CIR of CIN2+ of 9.4% (6.5–13.3%) compared with 7.2%
(4.6–11.1%) in women who were p16/ki-67dual-stained cytology-
negative and 10.6% (7.5–15.0%) in women who were HPV 16/18-
negative. Regarding combination approaches, HPV 16/18-negative/
LBC-negative women had 5-year CIR of CIN2+ of 3.9% (2.0–
7.6%). Furthermore, women who were ‘triple’ triage-negative
(HPV16/18, LBC, and p16/ki-67 dual-stained) had the lowest CIR
of CIN2+ of 2.4% (0.9–6.0%).
Conclusion Full analysis will be presented however; our initial
data indicate that multistep triage options may offer the greatest
longitudinal protection for concurrent and subsequent disease
compared to individual approaches. Cost-utility analyses that
incorporate the additional improvement in sensitivity/detection
gained alongside additional cost and implications for colposcopy
are thus warranted.
1283
A comparison of awareness and attitudes on
human papillomavirus (HPV) vaccination in
Singapore: now versus 6 years before
Kwek, M; Ang, J; Kho, L
KK Women’s and Children’s Hospital, Singapore, Singapore
Objective There have been nationwide education campaigns on
HPV vaccination and the inclusion of HPV vaccine in the
National Childhood and Adult Immunisation Schedule over the
years. The bivalent and quadrivalent vaccines were made claimable
via Medisave since 2017. We assess changes in the awareness and
attitudes in our population and evaluate the effectiveness of these
campaigns.
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Abstracts
Design We conducted a comparison between two cross-sectional
surveys done in 2013 and 2019.
Methods A total of 639 women aged 21 years and above
attending the general gynaecology clinic in KK Women’s and
Children’s Hospital in March to July 2013 and January 2019 were
recruited by simple random sampling. Three hundred and
nineteen women were surveyed in 2013, whereas 320 were
surveyed in 2019. Participants were made to answer a
questionnaire made available in English, Chinese, and Malay.
Analyses were carried out using SPSS version 21.0.
Results There is no significant difference in the awareness of
cervical cancer 88.4% (2019) versus 88% (2013) (P = 0.576).
However, there is a significant increase in understanding of risk
factors and association of HPV infection with cervical cancer from
33.7% to 69.4% (P ≤ 0.001). Women are more aware of HPV
infection and vaccination from 43.7% (2013) to 56.3% (2019)
(P = 0.002) and from 38.6% to 50.3% (P = 0.004), respectively.
This has resulted in a nonsignificant increase in acceptance of
HPV vaccination from 44% to 49.5% (P = 0.470). Among
participants who declined HPV vaccination, 91.6% attributed to
namely two reasons – cost and lack of knowledge. Major sources
of information were from the internet and healthcare
professionals.
Conclusion Our study demonstrates that awareness of the HPV
vaccine is directly related to the acceptability of the vaccine.
Despite nationwide efforts to increase the public’s awareness of
cervical cancer and HPV vaccination, the level of awareness and
the acceptability of the HPV vaccine in Singapore is still below the
reported level among developed countries. Also, uptake is low due
to cost. In order to improve our HPV acceptance rates, our study
suggests that more intensive campaigns may need to be
undertaken, including schools and in healthcare institutions. In
addition, subsidies to reduce costs of the nanovalent vaccine and a
school-based vaccination programme could also improve the
uptake rate.
2072
Developing trends in referrals to colposcopy unit
at GSTT
Majeed, G
Guys and St Thomas NHS Foundation Trust, London, UK
Background Guys and St Thomas NHS foundation Trust has the
largest colposcopy unit in London and third largest in England.
As young women who had HPV immunisation reach screening
age, there are changing trends in colposcopy referrals for both
direct and clinical indications.
Objective To look at the trends of change in referrals and
underlying pathology.
Aim Plan and deliver high-quality colposcopy service efficiently.
Methods Referrals to colposcopy unit both direct and clinical
indications were identified using colposcopy database Viewpoint,
colposcopy scorecard, and Cyres over four years (2014–2018).
Histology with subsequent treatment was reviewed.
11
Abstracts
Results Total referrals increased from (2015) n = 2852 to
n = 2950 in 2018. However, abnormal cytology reduced from
n = 1657 (2015) to n = 1537 in 2018, and at the same time,
clinical indications including others increased from n = 1195 in
(2015) to n = 1413 in 2018. CINIII reduced from n = 172 (2015)
to n = 121 (2018), and LLETZ procedures reduced from n = 479
(2015) to n = 266 (2018). There were 38 cancers, and over four-
year period, only one was detected via clinical indication. Number
of cancers was n = 8 in 2018 and n = 11 in 2017.
Conclusion Colposcopy referrals have increased over the last four
years. Main increase is in the clinical indications, and only 1
cancer was detected. Prevalence of precancer is decreasing which
may be due to primary prevention by HPV immunisation as these
vaccinated young women are screened. Excisional treatment has
almost halved as more young women with CINII are managed
conservatively, n = 197 in 2015 versus n = 81 in 2018.
Recommendations GSTT colposcopy Unit is holding educational
meetings for GPs advising about appropriate referrals for women
with clinical indication especially through electronic referral
system. VTS trainees are exposed to colposcopy clinics during
their training to identify changes in cervix and pathology. An
audit of clinical indications is being undertaken via Pan London
Colposcopy group. With introduction of primary HPV screening,
three trainees are currently under training to meet the challenges.
Each gynae oncologists conduct one clinic a month, and a unit
lead will conduct a clinic per week.
2410
CGIN – 10 years’ experience
Montgomery, A; Ahmadhi, M; Wood, M;
Carter, P
St. George’s Hospital, London, UK
Objective Cervical glandular intraepithelial neoplasia is a rare but
important smear finding due to the high levels of pre-invasive
(20–28%) and invasive disease (40–43%). It also carries high
levels of concomitant cervical intraepithelial neoplasia. Therefore,
it is important that it is investigated and managed appropriately
to ensure cases of invasive disease are not missed.
Design Ten years worth of CGIN cases was therefore examined,
and investigations and managements were compared to the latest
BSCCP document outlining the standards expected from March
2016.
Methods Cases of CGIN on smear were examined from the 1
January 2007 to the 31 December 2016. The standards examined
to see whether they were being met where:
 93% cases of abnormal glandular cells originating from cervix must
be seen within 2 weeks of referral (93%).
 93% cases of abnormal glandular cells of nonendocervical type must
be seen in the gynaecology clinic within 2 weeks of referral.
 Endometrial biopsy or assessment is a good practice point.
 Primary excision for those under 40 years of age should be at least
1 cm above the squamocolumnar junction.
 Primary excision for those over 40 years of age should include 20–
25 mm of the endocervical canal.
12 ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Results Only 48% of patients with abnormal glandular cells
originating from the cervix were seen within 2 weeks. Nine of
these patients had cancer. In contrast, 100% of patients with
abnormal glandular cells of nonendocervical type were seen in
gynaecology clinic. Thirteen out of 128 cases had an endometrial
biopsy, 5 of which showed malignancy (4 of endometrial type and
one from the Fallopian tube). Eleven of these cases also had either
an ultrasound of hysteroscopy. Ninety-five patients were less than
or equal to 40 years of age. The average depth of excision was
11 mm with a range of (4–30 mm). In those less than 1 cm
excised, there were 12 patients and 4 needed repeat excision. Two
of these patients had cancer but were known from the initial
excision. Thirty-two patients were over 40 years of age. The
average depth of excision was 15 mm (range 4–25 mm). twenty-
six patients had specimens less than 20 mm in depth. Of those, 5
had adenocarcinoma. All had repeat excisions, 4 of which showed
no residual disease.
Conclusion These data were all largely representative of the pre-
2016 guideline, and so a prospective audit is needed to analyse
adherence to the current guideline and standards.
2211
Outcomes of referrals with glandular neoplasia
Chiu, S1,2; Lyons, D2
1
Chelsea and Westminster Hospital NHS Foundation Trust, London,
UK; 2Imperial College Healthcare NHS Trust, London, UK
Objective To determine the outcomes of all referrals with
cytology glandular neoplasia over an eighteen-year period.
Design Abnormal cervical cytology – glandular neoplasia are
uncommon, accounting for 0.05–0.1% of all samples and are
associated with high prevalence of pre-invasive and invasive
disease, representing 20–28% and 40–43%, respectively. NHSCSP
20 guidelines suggest all reports indicative of glandular neoplasia
should have a written descriptive report indicating the likely
source of abnormal glandular cells wherever possible. Reliable
diagnosis requires cylindrical-shaped excisional cervical biopsy in
order to ascertain and treat pathology. In women with suspected
CGIN or early invasive adenocarcinoma, the extent of the cervical
excision can be individualised:
1. Younger women <36y.o desirous of fertility with SCJ visible –
cylindrical-shaped cervical excisional biopsy including the whole
TZ and at least 1 cm of endocervix above SCJ.
2. Older women or where SCJ is not visible – cylindrical biopsy
should be taken that includes all of the visible TZ and 20–25 mm
of endocervical canal.
3. Consider extra-cervical lesions of female reproductive tract.
Methods Retrospective detailed analysis of all women referred to
colposcopy with glandular neoplasia between 2000 and 2017 at
Imperial College Healthcare Trust. This comprised of 2 audits:
2000–2009 – 129 referrals
2010–2017 – 99 referrals.
Data were collected from the colposcopy database and regional
reporting database.

Results The total number of referrals received over 18 years was
24 000, and glandular neoplasia accounted for 0.95%. The
majority of patients had the site or origin delineated, the last
10 years being 100% identified. Pre-invasive disease accounted for
52.6%, of which HGCGIN accounted 26.3%, HGCIN 16.2%, and
mixed 10.1%. Invasive disease represented 21% with 18.4% being
adenocarcinoma (cervical and noncervical), and the remaining
2.6% was SCC. LGCIN/benign was identified in 26.4%. Overall,
pre-invasive and invasive disease in this population accounted for
73.6%. In 2000–2009, 12.4% had nonendocervical disease, whereas
4% were identified between 2010 and 2017. HGCGIN was also
found to be increased in the last 8 years. This would have been
expected as nonendocervical disease was investigated using the
rapid access pathway. Patients <36 y.o. only had cervical disease
and were associated with an increased prevalence of HGCGIN in
comparison with those >36 y.o, representing 48% and 27.4%,
respectively.
Conclusion Results are in keeping with literature, identifying a
high incidence of pre-invasive and invasive disease in referrals
suggestive of glandular neoplasia. These patients therefore require
a rigorous investigative protocol to identify and treat pathology.
2395
Endometriosis presenting as a vaginal polyp: a case
report
Safioleas, P1; Mehr, M1; Liakou, C2
1
Queen Elizabeth Hospital, Kings Lynn, UK; 2Norfolk Norwich
University Hospital, Norwich, UK
Background A 33-year-old woman with a vaginal wall polyp was
referred to gynaecology outpatient for evaluation and
management. Her past medical and surgical history were
unremarkable, she had a normal vaginal delivery four months ago,
and at the time of referral, she was on progesterone-only pill and
therefore amenorrhoeic. The patient reported mild post-coital
ª 2019 The Authors. BJOG An International Journal of Obstetrics and Gynaecology ª 2019 RCOG
Abstracts
bleeding, but no dyspareunia. She was up-to-date with negative
smear test. On clinical examination, multiple, smooth, polypoid
masses were seen arising around the vaginal fornices; cervix was
healthy. A biopsy was taken, and the histology report revealed
endometriosis within the vaginal wall.
Discussion Endometriosis is characterised by the presence of
histologically functioning endometrial glands and stroma outside
the uterine cavity.
The prevalence of endometriosis in the general population is
difficult to estimate as some women are asymptomatic while those
with symptoms can have varied and nonspecific presentations.
However, endometriosis has been reported in up to 50% of
women with infertility and up to 70% of women with pelvic pain.
Abdominopelvic pain, dysmenorrhoea, dyspareunia, heavy
menstrual bleeding, and infertility are the commonest presenting
symptoms of women affected by endometriosis.
Endometriotic lesions predominantly locate in the pelvis, but
extra-pelvic locations have been described such as central nervous
system, lungs, urinary and gastrointestinal tract, and surgical scars.
The vagina, vulva, and perineum can also be affected usually
secondary to surgical or obstetric trauma. Endometriosis of the
vagina following an uncomplicated vaginal delivery is a fairly rare
phenomenon.
This case report highlights the widespread locations in which
endometrial tissue can be found and therefore the wide range of
symptomatology.
Conclusion Endometriosis should always be considered in women
of reproductive age. The diagnosis might be challenging and
requires a high degree of clinical suspicion and histological
confirmation. The clinical doctor should bear in mind that
endometriosis can be multifocal; thus, a thorough investigation is
required in every case.
13