Introduction

Persistent high-risk HPV infection can easily cause cervical and vaginal epithelial lesions, and even lead to cancer. Cervical cancer is the most common malignant tumor of the female genital tract in China, with 70% of the new cervical cancer cases in China each year occur in women over 45 years old1. From 2012 to 2016, 50% of patients diagnosed with cervical cancer in the United States were over 50 years old2, and 72% of patients who died from cervical cancer were over 50 years old3. Therefore, although HPV vaccine is available, cervical cancer screening remains essential for women over the age of 50 years old.

For patients with high-risk HPV 16 or HPV 18 infections, or other HPV infections combined with cellular abnormalities, it is necessary to refer them for colposcopy examination to determine whether there are any lesions that are not visible with the naked eye. Colposcopy plays a crucial role in the further detection of early cervical cancer and precancerous lesions in people with abnormal screening4. Studies in Costa Rica and Canada have shown a second peak in HPV infection rates in women over 55 years of age, with an HPV infection rate of 10.8% in 55ā€“64 years and 13.6% in women over 65 years of age. The average menopausal age of women is mostly 50ā€“51 years old5. Although colposcopy can guide biopsy and provide a pathology as gold standard diagnosis for the of cervical cancer and precancerous lesions, the diagnosis of colposcopy is subjective and affected by the transformation zone type 3, making it difficult to detect lesions located within the cervical canal. for postmenopausal women, due to the decline in estrogen levels, cervical and vaginal epithelial atrophy, colposcopy findings are more atypical and difficult to judge. Another difficulty faced by colposcopy is that many women have a fear mentality before colposcopy. Moreover, there is some pain and discomfort during the process of colposcopy, which harm womenā€™s physical and mental health. For postmenopausal women, vaginal atrophy exacerbates the discomfort during the colposcopy6,7. Therefore, how to effectively alleviate vaginal atrophy is also beneficial for improving the physical and mental health of postmenopausal women.

In order to improve the sensitivity and satisfaction of colposcopy in postmenopausal women, and to evaluate the effect of estrogen vaginal topical preparations and compound seabuckthorn oil suppositories in local vaginal pretreatment before colposcopy more scientifically and systematically, we conducted the following study.

Materials and methods

Patients and procedure

This study was a prospective investigation conducted at the Medical Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynaecology Hospital of Fudan University. The study was approved by the Ethics Committee of the Obstetrics and Gynecology Hospital of Fudan University (approval number: 2023-22) and we confirm that the methods used in the study comply with the relevant guidelines and regulations. The inclusion criteria of the study were postmenopausal patients who attended the cervical disease clinic of our hospital between April 2023 and July 2024, had cytological indications of ASCUS, high-risk HPV positive, or cytological indications of LSIL or above, and voluntarily participated in this clinical study. The exclusion criteria were:1. Patients with visible lesions or suspected cervical cancer; 2. Patients with a history of previous cervical surgery; 3. Patients with suspected breast disease or endometrial lesions or a history of breast cancer or endometrial cancer; 4. Patients who were unwilling to participate in this clinical study. Full informed consent was given to all patients, and the following information was recorded for each participant enrolled in the study: age, cytology, high-risk HPV, colposcopy content and colposcopy diagnosis, colposcopy-guided biopsy and/or endocervical curettage (ECC) pathology, etc.

Pretreatment prior to colposcopy

In this study, the inclusion criteria for patients before colposcopy were: abnormal liquid-based cytologic test (BD Company, USA) and/or high-risk HPV positivity (Combas 4800, Roche). After being included in the study, the patients were randomly assigned to three groups: Group A was the control group, Group B was the compound sea-buckthorn seed suppository group (Shanxi Haitian Pharmaceutical Co., Ltd., National Medicine Standard No. 19991076), and Group C was the estrogen ointment group (Xinjiang Xinziyuan Biopharmaceutical Co., Ltd., National Medicine Standard No. H20051718). Symptoms of topical vaginal discomfort symptoms (including itching, irritation, redness, swelling, allergy, etc.) and other adverse reactions were recorded.

Colposcopy

Colposcopy (TR6000G, high-definition electronic colposcopy, Beijing Tongren) examination was performed by colposcopy physicians (senior attending physicians) of the Cervical Disease Diagnosis and Treatment Center of our hospital. The procedure is as follows: the patient takes the lithotomy position, and the examiner first observes whether there is any abnormality in the vulva, then carefully inserts the vaginal speculum to completely expose the cervix, carefully rolls the secretions in the cervix and vagina using gauze. A large-headed cotton swab was dipped in normal saline to smear the surface of the cervix and vagina, then smears the cervix and vagina with 3ā€“5% acetic acid, and the examiner observes for 1Ā min to identify any cervical or vaginal epithelial changes, such as white or punctate, mosaic-like changes. A 2% iodine solution is then applied to the vaginal wall, and the examiner observes to check any iodine-resistant epithelium. If abnormalities are found in the cervix and vagina during colposcopy, a colposcopy-guided biopsy is performed at the same time, and endocervical canal scraping is performed for 3-type squamous junction. Evaluation was conducted according to the 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) colposcopy terminology8: the adequacy of the colposcopy examination (with reasons recorded if deemed inadequate), the type of SCJ, the colposcopy acetic acid and iodine staining tests, the pathology report of the colposcopy diagnosis, treatment and biopsy. The colposcopy sensitivity of high-grade squamous intraepithelial lesions (HSIL) of the cervix was the proportion of patients with HSIL on biopsy who had a colposcopy impression of HSIL (The number of cervical HSIL obtained by biopsy is used as the denominator. The number of colposcopist impression of HSIL is used as the numerator. This ratio is the sensitivity of the colposcopy examination)9. The satisfaction of the colposcopist in performing the acetic acid test and iodine staining test was also recorded (yes or no).

Statistical analysis

Data was recorded in EXCEL tables, and the statistical software used was Stata 17.0. Measurement data were expressed as ā€œXā€‰Ā±ā€‰s " and analyzed by t-test. Counting data were expressed as percentage (%) and analyzed by X2 test. Comparison of adverse reactions was performed by Fisherā€™s exact test, with Pā€‰<ā€‰0.05 considered statistically significant.

Results

General parameters

A total of 377 cases were included in this study, with 9 patients (6 in group B and 3 in group C) dropping out of the study due to side effects from the pretreatment medication (only included in the statistics when side effects were counted). Therefore, 368 patients were finally included in the colposcopy, including 125 cases in group A, 121 cases in group B, and 122 cases in group C. There were no statistically significant differences in average age, menopausal time, body mass index (BMI), or proportion of vaginal delivery among the three groups. The cost of pretreatment with compound sea-buckthorn oil suppository was significantly lower than that of the estrogen ointment group. The proportion of patients with high-risk HPV infection before colposcopy was 94.3% (347/368), of which HPV16 and/or HPV18 infection accounted for 20.4% (75/368), and other types of infection accounted for 75.3% (277/368). The proportion of patients with abnormal cytology (ASCUS and above) was 47.6% (175/368). There were no significant differences in cytology and HPV types before colposcopy among the three groups. Pathological abnormalities in colposcopy biopsy were found in 196 cases (53.3%), including 42 cases of high-grade cervical squamous intraepithelial lesions, 1 case of cervical adenocarcinoma in situ, and 2 cases of cervical squamous cell carcinoma (TableĀ 1).

Table 1 Comparison of general information among groups.
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Colposcopy

After 2 weeks of pretreatment with medication, the integrity of vaginal epithelium, the adequacy ratio of colposcopy, and the satisfaction rate of acetic acid test and iodine staining test in groups B and C showed significant improvement compared to group A (Pā€‰<ā€‰0.001). There was no significant difference between groups B and C. The sensitivity of cervical HSIL under colposcopy was 25% (3/12) in group A, 86.7% (13/15) in group B, and 80% (12/15) in group C. The accuracy in groups B and C was significantly higher than that in group A, and there was no significant difference between groups B and C (TableĀ 2).

Table 2 Comparison of colposcopy examination results among different groups.
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Among the 125 patients in group A, 41 cases had inadequate colposcopy, and the most common cause of inadequate examination was atrophic vaginitis, 37 cases of cervical and vaginal bleeding after acetic acid application significantly impacted the examination. There were 2 cases of inadequate examination due to obvious stenosis of the upper vaginal segment, and 2 cases of cervical exposure due to adhesion of the abdominal wall of the uterus after previous abdominal surgery. Among the 121 patients in group B, 5 cases had inadequate colposcopy, of which 3 cases were attributed to vaginal stenosis affecting the examination, and 2 cases were due to cervical and vaginal bleeding after acetic acid application. Among the 122 patients in group C, 7 cases had inadequate colposcopy, of which 3 cases were due to vaginal stenosis affecting the examination, 3 cases were due to cervical and vaginal bleeding after acetic acid application, and 1 case was due to uterine abdominal wall adhesions after previous cesarean section affecting the cervical exposure.

Adverse reactions

9 patients did not adhere to medication due to discomfort after pretreatment, including 6 cases in group B and 3 cases in group C. Considering the adverse reactions and not adhering to medication, all adverse reactions were included in the statistical analysis. Among the 377 cases included in the study, 10 cases in group B had topical vaginal discomfort, no breast tenderness or other adverse reactions. In group C, there were 7 cases of breast tenderness, 5 cases of vaginal discomfort, 5 cases of dizziness and headache. There was no significant statistically difference in topical vaginal adverse reactions among the groups (TableĀ 3). The incidence of breast discomfort in the estrogen ointment group was 5.6%, and the incidence of dizziness and headache was 4%, while there was no such side effect in the compound sea-buckthorn oil suppository group, and the difference was statistically significant.

Table 3 Comparison of adverse reactions in group B and C.
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Discussion

Clinical dilemma of colposcopy in postmenopausal women

Colposcopy, as a bridge between cervical screening for cytological abnormalities and/or high-risk HPV infections and histopathology, plays a very important role in the early detection of cervical cancer and cervicovaginal intraepithelial lesions. Colposcopy can magnify 6ā€“30 times and detect abnormal cervicovaginal epithelium and blood vessels through acetic acid staining and iodine staining under strong light source, so as to achieve accurate biopsy of lesions under colposcopy guidance10. Nevertheless, there may also be possibility of missed diagnosis during the colposcopy process (especially in the parts of the cervical canal that are not visible). During the colposcopy process, low-grade lesions and metaplasia cannot be visually distinguished, and biopsy is mostly required. Biopsy can cause bleeding, pain, infection, and psychological trauma. Acetic acid induces a transient contraction of nuclear proteins in the nucleus, which typically has no obvious effect on normal mature squamous epithelium. For postmenopausal women, squamous epithelium atrophies, cytoplasm content decreases, and nuclear-cytoplasmic ratio increases. False positive ā€œacetic acid whiteā€ is easily formed after acetic acid test11. In the iodine staining test, iodine ions combine with glycogen in normal mature squamous epithelial cells to stain dark brown, while after menopause, as ovarian function and estrogen level decreases, the middle surface cells of the lamella squamous epithelium of the vagina and cervix fall off, the mucosa becomes thinner and atrophy, and the glycogen content in the atrophic squamous epithelium is significantly reduced, resulting in negative iodine staining test12. Therefore, iodine non-staining is often observed in postmenopausal patients, and there is no significant difference in the epithelial appearance between atrophic squamous epithelium and intraepithelial lesions, that is, colposcopy lacks the precise localization of lesions and is unable to identify potential lesion areas. Due to the low sensitivity of colposcopy in most postmenopausal women, mostly colposcopists have to perform random biopsies, which would easily cause additional damage and miss the true lesions13,14. It is very necessary to perform pretreatment prior to colposcopy to alleviate the atrophy of the squamous epithelium of the cervix and vagina, so as to increase the sensitivity of colposcopy.

Comparison of different pretreatment methods prior to colposcopy

Some studies have found that oral estrogen is helpful for colposcopy15. Considering the potential risks of oral estrogen such as nausea, vomiting, breast tenderness, endometrial hyperplasia and even thrombosis, this study chose topical intravaginal medication. The findings indicated that topical use of estrogen did improve the sensitivity and adequacy of colposcopy diagnosis, which aligns with literature reports15. Topical vaginal use of estrogen preparations can alleviate senile atrophy, reduce epithelial bleeding, promote cervical and vaginal epithelial proliferation and maturation, enhance iodine staining, facilitate the detection of intraepithelial lesions under colposcopy, and improve the sensitivity of colposcopic biopsy. Nonetheless, in this study, it was observed that a very few patients showed epithelial atrophy after 2 weeks of medication, due to improper placement of the medication. Therefore, clinicians should instruct patients on the proper location (to the deepest part of the vaginal vault) and time of vaginal suppositories (before sleep) and reduce the upright activities after medication.

The most common side effects of topical estrogen are local irritation and breast pain (5%)16. Although the amount of topical medication entering the blood is minimal, there are still adverse reactions for a limited number of hormone-sensitive patients. Therefore, screening for endometrial lesions and breast cancer is recommended before using estrogen to prevent potential medical disputes.

This study also unexpectedly found that the compound sea-buckthorn oil suppository was effective as a pretreatment before colposcopy in postmenopausal women. After one week of treatment, the effect of the compound sea-buckthorn oil suppository was better than that of the estrogen group, and the side effects of the compound sea-buckthorn oil suppository were less frequent, with only a small number of patients experiencing local irritation and discomfort, and no breast-related side effects observed. Therefore, it is not only suitable for patients with breast nodules or a history of breast cancer or endometrial cancer, but also for patients who are worried about hormone products. This is the first surprising finding reported in clinical practice, which is very suitable for pre-colposcopy use in postmenopausal women. From the perspective of macro-view traditional Chinese medicine, sea-buckthorn seed oil has the effects of antibacterial and anti-inflammatory, improving immune function, promoting erosion surface repair and wound healing17,18. From the ingredient point of perspective, the primary component of compound sea-buckthorn seed oil suppository is seabuckthorn seed oil. Other ingredients include fructus cnidii, frankincense, myrrh, matrine, calamine, and borneol, among which matrine, fructus cnidii, calamine, and borneol are often used as common ingredients in gynecological suppository. We speculate that sea-buckthorn oil contains phytosterols and vitamin E, and phytosterols have certain estrogen-like effects19, Phospholipid compounds such as phospholipids in seabuckthorn are biologically active ingredients that can promote cell metabolism. but the specific mechanism needs to be further investigated.

Extended application of vaginal pretreatment in postmenopausal women

Topical vaginal pretreatment is essential not only for postmenopausal colposcopy, but also for the treatment of intraepithelial lesions of the lower genital tract in postmenopausal patients. Preoperative pretreatment for postmenopausal cervical HSIL patients with loop electrosurgical excision procedure (LEEP) is beneficial to evaluate the scope of cervical surface lesions20. Preoperative vaginal laser pretreatment for postmenopausal patients with vaginal intraepithelial lesions not only helps to accurately evaluate the scope of vaginal lesions, but also can effectively reduce the incidence of postoperative adhesions and promotes wound healing21.

There are some limitations in this study, including the limited number of cases included and the single-center study. Double blindness was not used because of the different colors of different drug residues, and most colposcopists can distinguish the medication. In addition, the specific mechanism of action of the compound sea-buckthorn oil suppository was not involved, which needs further in-depth research in the future.

Conclusion

This study found that topical use of estrogen ointment or compound sea-buckthorn oil suppository prior to colposcopy in postmenopausal patients can improve cervical vaginal atrophy epithelium, make iodine staining clear, aid in the detection of potential intraepithelial lesions, improve the satisfaction and sensitivity of colposcopy. Additionally, the sea-buckthorn oil suppository has the advantages of lower medical cost, higher satisfaction with colposcopy, which can be promoted and applied in clinical practice.