Cervical Ectropion and Intra-Uterine Contraceptive Device (IUCD): a five-year retrospective study of family planning clients of a tertiary health institution in Lagos Nigeria

Background Cervical ectropion (also known as cervical erosion) is a common finding on routine pelvic examination during the fertile years. The decision to treat or not remains controversial. According to studies in support of routine treatment of cervical erosion, there is a possible relationship between squamous metaplasia and squamous cell carcinoma of the cervix. To determine the prevalence of cervical ectropion and associated risk factors among clients with intra-uterine contraceptive devices (IUCDs) attending a family planning clinic of a tertiary health institution in Lagos, Nigeria. Methods A 5-year retrospective study was conducted by assessing existing clinic records from years 2007–2011. Clients with IUCDs undergo routine pelvic examination during check-up visits. A total of 628 clients’ records were seen within the stated time frame. This study was approved by the ethical committee of the Lagos State University Teaching Hospital (LASUTH) and the collected data were analyzed using SPSS version 19.0. Results The mean age of the IUCD users was 34.7 ± 6.52 years, while 517 (82.3%) had secondary education. On routine pelvic examination, seventy-nine clients (12.6%) had cervical ectropion. Thirty-nine (6.2%) clients had presented with a history of abnormal vaginal bleeding while 12.1% had vaginal discharge. Treatments offered to cases of cervical ectropion include cervical painting with gentian violet (89.9%) and antibiotics prescription (58.2%). On bivariate analysis, previous hormonal contraceptive use (P = 0.041) and vaginal discharge (P < 0.001) were significantly associated with developing cervical ectropion. Clients with ectropion were significantly more likely to receive prescriptions for antibiotics (P < 0.001). Conclusion Less than one fifth of the clients had cervical erosion. However, routine pelvic examination could aid the detection and control of latent reproductive health problems such as cervical ectropion which may require further investigations for example, pap smears, to exclude potentially lethal conditions and to determine appropriate treatment modality.


Background
Cervical ectropion which is also called cervical ectopy or erosion occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu [1]. The prevalence of cervical ectropion ranges from 17% to 50% [1][2][3][4][5]. A prevalence study in China among female users of family planning services reported that 43.2% of the women had cervical ectropion [6]. Another study on women using oral contraceptive pills (OCPs) and IUCDs in Benghazi, Libya also observed that cervical ectropion was the commonest gynecological disorder among the women (54.9%) [7]. Ectropion is considered to be a common physiological condition in adolescents and pregnant women [1,8,9].
Cervical ectropion has been associated with both the combined oral contraceptive pill and chlamydia trachomatis [1,8,10,11]. In a study among women attending a sexually transmitted diseases clinic in USA, cervical ectropion was positively associated with oral contraception and Chlamydia trachomatis infection [8]. Inflammation and trauma have also been implicated in the etiology of cervical ectropion [8,12]. This is important considering the fact that IUCD usage could be linked to inflammation and trauma of the cervix. In view of the fact that vaginal discharge is a common symptom of IUCD users, [9] changing the method of contraception is a common practice for women who are unable to accept the increase in physiological discharge associated with cervical ectropion [13].
Reproductive tract infection is one of the major complications caused by prolonged usage of IUCDs [14]. A Turkish study showed that 14.7% of women using IUCDs had cervical ectropion. Cervical ectropion and vaginal discharge were also found to be significantly higher among IUCD users compared with women on OCPs [15].
Furthermore, ectropion has been found in 5% to 25% of women presenting with postcoital bleeding [16]. Differentiating between cervical ectropion and cervical intraepithelial neoplasia macroscopically is difficult [17]. In addition, available literature concerning treatment for cervical ectropion can be described as controversial [12,13]. Some arguments advanced in support of routine treatment include the relationship between squamous metaplasia and induction of squamous cell carcinoma of the cervix [18]. Pre-cancerous lesions often develop at the squamouscolumnar junction, hence theoretically, treating cervical ectropion may prove to be protective against the incidence of cervical cancer [18]. Proponents of routine treatment have also argued that some sexually transmitted microorganisms such as Chlamydia trachomatis and Neisseria gonorrhea preferentially infect glandular epithelium [10,15,19]. Thus ectropion would, by exposing this epithelium, aid an infective process [10,15,19]. Several treatment modalities have been used for cases of ectropion including use of antibiotics, microwave tissue coagulation, laser coagulation, infrared light, an interferon-alpha suppository, electrocautery or cryotherapy [2,12,13,20,21].
Based on the fore-going, the aim of this study was to determine the prevalence of cervical ectropion and associated risk factors among clients with IUCDs of a family planning clinic in a tertiary health institution in Lagos Nigeria.

Methods
A retrospective study was conducted by assessing existing clinic records between years 2007-2011. Clients  with no control over exposure or outcome. It was also hospital-based and may not be readily generalizable to the Nigerian population. However, it provides useful information considering the paucity of research works on cervical ectropion in Nigeria, in addition to highlighting the need for future studies using stronger study designs.
Treatments offered to cases of cervical ectropion include cervical painting with gentian violet paint (89.9%) and antibiotics (58.2%). Forty two clients who had cervical ectropion received both cervical painting with gentian violet and antibiotics (Table 6).
There was no statistically significant association between age group of clients and presence of cervical erosion (P>0.05, Table 7). On bivariate analysis, previous hormonal contraceptive use (P = 0.041) and vaginal discharge (P < 0.001) were significantly associated with developing cervical ectropion (Tables 8 and 9). Clients with ectropion were more likely to receive prescriptions for antibiotics (P < 0.001).
Multiple logistic regression analysis was employed to predict the probability that a client would have cervical ectropion. The predictor variables were client's age, parity, history of previous use of hormonal contraceptives, presence of abnormal vaginal bleeding and presence of vaginal discharge. A test of the full model versus a model with intercept only was statistically significant, χ2 = 33.337, d.f. = 5, p < 0.001. Table 10 shows the Multiple logistic regression coefficient, Wald test, odds ratio and 95% confidence interval of odds ratio for each of the predictors. Employing a P < 0.05 criterion of statistical significance, only presence of vaginal discharge had a statistically significant partial effect on the presence of cervical ectropion. The odds ratio for presence of vaginal discharge indicates that when holding all other variables constant, a client with vaginal discharge is 2.56 times more likely to have cervical ectropion than is a client without vaginal discharge. Although previous use of hormonal contraceptive was statistically significantly associated with cervical ectropion on bivariate analysis, this significant association was lost after multivariate analysis.

Discussion
The prevalence of cervical ectropion among women using IUCDs varies widely in the literature. In China the prevalence in this group of women was 43.2% compared to the 12.6% observed in this study [6]. The prevalence was higher (26%) among IUCD users in a family planning clinic at Edinburgh [1]. In a study to assess the effects of IUCD and oral contraceptives on vaginal flora and epithelium conducted in Turkey however, the prevalence of   [15]. Notwithstanding the fact that previous studies observed higher prevalence of ectropion among IUCD users, the 12.6% prevalence rate observed in this study indicates that ectropion is a fairly common occurrence in this group of women. A possible explanation for the occurrence of cervical ectopy in IUCD users is the constant friction between the hanging string and the cervical os. This study observed that women were significantly more likely to have developed an abnormal vaginal discharge if they had cervical ectropion compared with those without ectropion. A previous research has demonstrated an association between use of the IUCD and cervical inflammation and ectropion, either of which could potentially lead to abnormal discharge [4]. Vaginal samples for Trichomonas vaginalis and other sexually transmitted diseases were not obtained as part of this study. Therefore, it was not possible to differentiate vaginal discharge due to pelvic infection from that which may have been solely due to the ectropion. However, it is known that prolonged use of IUCD is associated with increased risk of pelvic infection [15].
Studies have suggested that cervical ectropion is common among those taking estrogen-containing contraceptives [1,11,22]. The observation from this study that women who had a previous history of hormonal contraceptive use were more likely to develop ectropion (P < 0.05) however disappeared when other factors were taken into consideration (P = 0.072). This finding is supported by a study which observed that cervical ectropion was more common among IUCD users than hormonal contraceptive users [15]. This suggests therefore that previous use of hormonal contraceptives does not confer additional risk of ectropion to IUCD users.
The tendency towards treating cervical ectropion is strong as has been demonstrated in this study. Most of the clients with ectropion in this study received some form of treatment. Several treatment modalities are currently used in the clinical management of cervical ectropion [13]. However the two modalities used in this study comprise of the use of antibiotics and painting of the cervix with gentian violet. The 12.6% prevalence of ectropion means that a substantial number of women were exposed to antibiotics. A contrary argument on the current treatment modality is that inappropriate use of antibiotics increases the risk of antimicrobial resistance and places an unnecessary financial burden on patients [23,24]. Moreover, in the context of cervical erosion being a non-infective and physiological condition, it may resolve spontaneously without medical intervention.

Conclusions
The study findings indicate that cervical ectropion may be a common occurrence among women using IUCD. Reproductive health clinics offer screening opportunities for various groups of women in the society. Therefore,  routine pelvic examination should be emphasized for all family planning clients as it could aid the detection and control of latent reproductive health problems such as cervical ectopy which may require further investigations such as microscopy, culture and sensitivity as well as pap smears to exclude potentially lethal conditions and to determine appropriate treatment modality.