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COMMENTARY
Year : 2019  |  Volume : 12  |  Issue : 2  |  Page : 150-151  

Intrauterine contraceptive device and the cervicovaginal smear – Exploring the enigma


Department of Pathology, K S Hegde Medical Academy of Nitte University, Mangalore, Karnataka, India

Date of Web Publication25-Mar-2019

Correspondence Address:
H L Kishan Prasad
Department of Pathology, K S Hegde Medical Academy, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_211_18

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How to cite this article:
Kishan Prasad H L. Intrauterine contraceptive device and the cervicovaginal smear – Exploring the enigma. Med J DY Patil Vidyapeeth 2019;12:150-1

How to cite this URL:
Kishan Prasad H L. Intrauterine contraceptive device and the cervicovaginal smear – Exploring the enigma. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jun 16];12:150-1. Available from: http://www.mjdrdypv.org/text.asp?2019/12/2/150/254766



The intrauterine contraceptive device (IUCD) is the most frequently used family planning method across the world. Among these, the copper IUCD is used by more than 150 million women across the world. The Copper T-380A is the best and safe contraceptive with a meager failure rate of less than 1/100 women in the first year of use. It prevents pregnancy by the creation of a sterile inflammatory response in the endometrium. Few hormone-releasing intrauterine systems release progesterone into the uterus. The common problem with these methods is menstrual bleeding and dysmenorrhea.[1]

An IUCD has the “body” which rests in the uterine cavity, a “neck” which occupies the endocervical canal, and a “tail” that may be seen or felt at the external OS. This tail thread is made up of monofilaments and synthetic material. When correctly fitted, the IUCD establishes a guided to and fro channel between the uterine cavity and the vagina, helping in the descent of normal and abnormal uterine contents to the posterior fornix and the ascent of microorganisms from the vagina into the uterine cavity. Many of the clinicopathologic sequelae of IUCD usage are the direct effects of this foreign body on the endometrial and endocervical lining epithelium. It is observed that significant of females will be asymptomatic even when their smears showed abnormality. There is an increased frequency of Gardnerella vaginalis, Trichomonas vaginalis, and Candida when compared with the general population.[1],[2],[3],[4]

Efficacy of IUCD is shown in various studies, but it also has some unwanted effects.[2],[3] IUCD, with its tail extending to the vagina, leads to foreign-body giant cell reaction, forms the surface for bacterial colonization, and also alters the flora of the female genital system.[3],[4],[5] Besides, due to local irritation and pressure effect, it might cause the dense inflammatory response and reactive cytological changes. These changes may be observed in cervicovaginal smears as metaplasia, cytoplasmic giant vacuoles, multinucleated giant cells, papillary proliferation, cells with scanty cytoplasm, irregular chromatin, and large nucleus (termed as IUCD cells) that mimic high-grade squamous intraepithelial lesion.[2],[6] Furthermore, atypical glandular and atypical squamous cells also may be detected.[4],[5],[6] The other findings in cervicovaginal smears are amorphous calcified bodies. These calcified bodies which are also termed as psammoma-like bodies will be seen as fragmented, small concentric calcified bodies surrounded by macrophages.[4]

It is also observed that there is the presence of bacterial vaginosis (BV) at the time of IUCD insertion. The current standard of care treatment does not require screening for BV before IUCD insertion. Hence, screening and treatment before IUCD insertion must be offered to all users who are symptomatic to prevent complications. Larger samples of women with BV at the time of IUCD insertion need to be studied to make substantial observations regarding new information and trends in the clinical outcomes and whether there might be the possible role for BV screening before IUCD insertion.[4]

The role of IUCD in pelvic inflammatory disease (PID) is now debated, and IUCD users are at least four times more prone to PID than nonusers.[4]

The changes that are worrisome in cervical smear are the epithelial atypia which can mimic neoplastic lesions, particularly when information regarding IUCD usage is not furnished. Irritated endocervical and endometrial cells can manifest with morphological changes in the  Pap smear More Details. Some of these will resemble cells shed from carcinoma in situ. However, Gupta et al. observed this cytologic atypia would revert to normal within 1–13 months after removal of the IUCD. There is much controversy regarding the role of IUCD in causing neoplastic transformation of the cervical epithelium; current opinion is that the development of malignant or premalignant cervical lesions cannot be attributed to the IUCD itself. It is more probable that the IUCD wearer who develops cervical cancer, feeling protected from unwanted pregnancy, exposes herself to risk factors well-established in the genesis of cervical cancer.[3],[4],[5],[6]

Some studies shown that the benign and atypical endometrial cells in cervicovaginal smears of 80% of the women who had menorrhagia or intermenstrual bleeding and its possibly due to endometritis or chronic endometrial irritation. In few studies, the nuclear DNA values of atypical glandular cell clusters from the uterine fluid of IUCD users were measured and interpreted to show a polyploid pattern.[4],[5],[6]

Hence, it is essential to note that the history of IUCD insertion is essential and it will cause significant alterations in cervicovaginal smears. Due to this, cervical screening will be done more vigilant to detect the lesions early and start the treatment at the earliest.



 
  References Top

1.
Bagchi S, Sah S, Agrawal T. Effect of intrauterine copper device on cervical cytology and its comparison with other contraceptive methods. Int J Reprod Contracept Obstet Gynecol 2016;5:2795-8.  Back to cited text no. 1
    
2.
Agarwal K, Sharma U, Acharya V. Microbial and cytopathological study of intrauterine contraceptive device users. Indian J Med Sci 2004;58:394-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Akinajo OR, Bello FA, Bello OO, Olayemi OO. Screening for bacterial vaginosis before intrauterine device insertion at a family planning clinic in South-West Nigeria. Niger Postgrad Med J 2017;24:75-80.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Erhan SS, Keser SH, Sensu S, Sargan A, Vurgun E. Effect of intrauterine device on cervicovaginal smears and its association with calcified bodies: A retrospective study. Int J Clin Exp Pathol 2016;9:9372-9.  Back to cited text no. 4
    
5.
Cortessis VK, Barrett M, Brown Wade N, Enebish T, Perrigo JL, Tobin J, et al. Intrauterine device use and cervical cancer risk: A systematic review and meta-analysis. Obstet Gynecol 2017;130:1226-36.  Back to cited text no. 5
    
6.
Lopez-del Burgo C, Osorio A, De Irala J. Intrauterine device and cervical cancer: We need more evidence. Lancet Oncol 2011;12:1185-6.  Back to cited text no. 6
    




 

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