SLE, Sex and STDs Save

Once in a while, I find an abstract at the American College of Rheumatology meeting that can potentially save lives and be implemented in practice now.  

In Abstract #0939, Dr. J Patricia Dhar and colleagues shared data from a pilot study examining a new method to monitor cervical health in African American women with Systemic Lupus Erythematosus (SLE) using a self-sampling brush to assess cervical cytology and human papilloma virus (HPV) infection. The authors studied 30 non-pregnant women with SLE ages 18-50 years (mean age 37 years) who were willing and able to obtain vaginal self-sampling.  40% of the study participants had lupus nephritis with more than 80% taking corticosteroids, hydroxychloroquine, and immunosuppressants.  The women were interviewed and surveys were administered that assessed sexual history, cervical health information, knowledge about HPV, and opinions about using the self-sampling brush. The vaginal samples obtained by the participants were processed and read by a cytopathologist.  

Despite the absence of quality indicators, the samples show preservation of morphology with 4 out of 30 samples exhibiting abnormal findings (3 with low grade squamous intra-epithelial lesions, and 1 atypical squamous cells of undetermined significance). Patients found that self-sampling was easy to do and were comfortable performing the procedure; many preferred self-sampling over traditional pap smears.   While additional studies are needed to evaluate sensitivity, specificity, positive and negative predictive values of vaginal self-sampling to detect cervical cancer compared to traditional pap smears, this pilot study is enlightening.   

The study impressed me not just for the novel approach to cervical cancer screening, but also for the data collected about these women. As rheumatologists, we often are too busy worrying about the rheumatic disease that we forget to address sexual health. We are doing a poor job discussing pregnancy desire and are negligent about addressing contraception and protection to prevent STDs in patients who are sexually active.  

The authors noted 70% of study patients had a history of sexually transmitted disease other than HPV, and 16% ever had been vaccinated for HPV.  The average number of lifetime sexual partners was 9.5, but only 26% of patients used condoms. Additionally, over 70% of the participants had prior history of cervical cancer, 63% with prior abnormal pap smears, 33% had prior genital warts, 23% had prior oral warts, and 13% had prior anal cancers. 

Most of the participants understood that HPV can cause cervical cancer, but they were unaware that HPV can cause oral/ genital cancer and warts. We know immunosuppression can accelerate the development of cervical cancer, ano-genital cancer, vulvar cancer, penile cancer, and oropharyngeal cancers in patients infected with HPV (2).  Patients with SLE are at much higher risk than the general population; hence, current guidelines recommend cervical cancer screening should be conducted in all SLE patients regardless of immunosuppressant use throughout a patient’s lifetime and not just until age 65 years (3). 

The study by Dhar et al. highlights the need to find an easier way to screen for cervical cancer, but also it prompts us to do a better job at educating patients on sexual health and providing protection against STDs. I am looking forward to see a larger study examining the efficacy of vaginal self-sampling to screen for cervical cancer, but what I plan to implement in my practice now is a discussion with my patients about sex and STDs.

References:

1. Dhar J et al. Pilot Study: A Novel Method for Cervical Health Monitoring in African American Women with Systemic Lupus Erythematosus (SLE) Using a Self- Sampling Brush to Assess Cervical HPV Infection and Cervical Cytology, Abst#0939 ACR Convergence 2022

2. Reusser N et al. J Clin Med. 2015 Feb; 4(2): 260–281. Published online 2015 Jan 29. doi: 10.3390/jcm4020260

3. Moscicki A, et al. Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection J Low Genit Tract Dis. 2019 Apr;23(2):87-101. doi: 10.1097/LGT.0000000000000468.