Introduction Women with inflammatory bowel diseases (IBD) may have increased rates of pre-malignant lesions in the uterine cervix compared to age and sex matched controls (1.2). European guidelines recommend regular gynaecological screening for women with IBD, especially if they are on immunomodulators (3). However protocols in the UK are lacking and cervical screening is often underutilised by gastroenterologists. We describe 3 cases of cervical neoplasia in patients who had none of the usual risk factors other than prior use of Infliximab (IFX) and azathioprine.
Methods Three patients on maintenance treatment with IFX for IBD have recently presented unexpectedly with high grade cervical dysplasia or cancer to the gynaecologists. We have summarised their clinical history and reviewed their risk factors for development of cervical neoplasia.
Results Case 1: 31-year-old lady with extensive small bowel Crohns disease on azathioprine received IFX for 11 months and developed adenocarcinoma of the cervix 8 months after stopping IFX. She required a radical hysterectomy. Case 2: 30-year-old lady with ileocolonic Crohn’s disease on azathioprine received IFX for 3 years and developed high grade cervical intra-epithelial neoplasia 2 months after stopping IFX. She required a large loop excision of the transformation zone (LLETZ). Case 3: 32-year-old lady with colonic and perianal Crohn’s disease on azathioprine received IFX for 1 year and then developed high grade cervical intra-epithelial neoplasia 1 month later. She also required a LLETZ procedure. All three patients had also previously been steroid dependent. They were all in longstanding monogamous relationships, were non-smokers and had one or no pregnancies.
Conclusion It is suggested in the literature that women with IBD have an increased risk of cervical neoplasia. It is possible that immunosupressants and biological therapies prevent clearing of the Human Papilloma Virus that predisposes to cervical dysplasia. These three cases remind us that women with none of the classical risk factors other having used a combination of biologic and immunomodulator therapies should have enhanced screening for cervical neoplasia prior to and during treatment with those drugs.
Disclosure of Interest None Declared.
Singh H, Demers AA, Nugent Z, Mahmud SM, Kliewer EV, Bernstein CN. Risk of cervical abnormalities in women with inflammatory bowel disease: a population-based nested case-control study. Gastroenterology. 2009; 136(2):451–8.
Kane S, Khatibi B, Reddy D. Higher incidence of abnormal Pap smears in women with inflammatory bowel disease. Am J Gastroenterol. 2008; 103(3):631–6.
Rahier JF, S. Ben-Horin et al. European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohn’s Colitis 2009; 3(2):47–91.