Background: The use of the long acting hormonal contraceptive Depot Medroxv-Progesterone
Acetate (DVIPA) has been increasing in the last decade The hormonal effects of this
contraceptive agent on human cervical epithelium have been underreported in the literature
especially for the women infected with the Human Immune-deficiency Virus (HTV) Of concern
is the increased nsk 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 DMPA, HIV' and cervical cytology is unclear.
Objective: This study set out to determine the hormonal effects of DMPA on cervical smears
among HTV positive women by determining cervical changes and lesions of HIV positive
women on DMPA. These were compared with cervical changes seen in HTV positive women
who were not on hormonal contraception. The relative nsk of abnormal cytology associated with
the DMPA use for at least 6 months in HIV positive women was estimated.
Design: This was a case control study where cases were selected from among HTV positive
women using DMPA while controls were selected from HTV positive women who were not
using any method of contraception
Setting: The study was earned out at the research training and care programme/Comprehensive
Care Centre (CCC) clinics at Lumumba Health Centre and Kisumu District hospital sites where
HTV positive women receive treatment and follow up Cytomorphological changes and
cytohormonal changes were interpreted at the University of Nairobi (UON) laboratory
Materials and Methods: HIV positive women who sought services from CCC’s clinics were
recruited dunng 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.
x
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 DMPA users and non users. P=0.023 OR 2 4(1.1-
5.1). 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 (31.3%.).
Generally there was no statistically significant difference of abnormal cytology in DMPA users
and non users P=0 080. OR 2 7 (0 9-8.2) when compared to normal cytology. The prevalence of
High grade squamous intraepithelial lesion (HGS1L) was 6.3% in DMPA users and 3 2% nonusers.
P=0 680. Low grade intraepithelial lesion with HPV effect (LGSIL and HPV) was 6.3% in
DMPA users and 111% m 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=9.365,
OR4 2 (95% Cl 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 Iactobacilli 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 cerv ical intraepithelial neoplasia in
patients using DMPA
Recommendations
1 Further evaluation of abnormal cytology in HIV positive women on DMPA 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