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METHODS: We developed a survey from focus group results to measure the unpleasantness of hydrorrhea (watery discharge) from cryosurgery, the pad protection required, and the odor associated with the hydrorrhea. The cryosurgical experiences were compared with normal menses for the use and frequency of pad protection, medications used, and any activity restrictions.
RESULTS: Cryosurgical experiences were unpleasant for 78.3% of the women because of the pain and cramping of the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. These experiences after cryosurgery caused 38.6% to restrict their activities and 67.1% to take medications, a significantly greater proportion than the 16.9% whose activities were restricted by normal menses and the 26.8% who took medications for normal menses (P=.004, P <.001, respectively). In addition to these experiences, obese, multigravid, and older women were more bothered by the duration of wearing pads than their counterparts (P=.0246, P=.0061, and P=.0159, respectively).
CONCLUSIONS: Our study showed that the cryosurgical healing process was not pleasant, and was least tolerable for obese, multigravid, and older women. As many as 50% of women undergoing cryosurgery will perceive the hydrorrhea, its odor, and the wearing of pads to be worse than normal menses, especially if their menses are usually light.
Women experience discomfort during treatment for cervical intraepithelial neoplasia (CIN). The discomfort from cryosurgery has been studied and is usually alleviated by the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and mucosal blocks before the procedure.1-4 Pain and cramping alleviation is cost-effective.5 The cryosurgical healing process includes malodorous hydrorrhea (watery discharge) that lasts 12 days on average, but can continue for an entire month.6 Specific populations of women who are potentially more bothered by the healing process include those who are obese, nulligravid, and younger. Each of these subsets can experience more dysmenorrhea than their clinical counterparts.7,8
Obese women, in general, do not present for cervical cancer screenings as often as those who are not obese, because of lower self-esteem.9 All women’s experiences and those specific to these 3 groups have not previously been described for cryosurgical healing. Women’s perspectives and experiences with the healing process might influence their compliance with future cervical cancer screenings and treatments.
The purpose of our study was to describe women’s experiences after cryosurgery, particularly in relationship with obesity, gravidity, and age. We postulated that women who were obese, nulligravid, and younger would experience a more unpleasant healing process after cryosurgery than those who were nonobese, multigravid, and older. The experience following cryosurgery was compared with the experience of normal menses, and factors for women’s future treatment decisions were ranked in order of importance.
Methods
Survey Instrument
We designed a survey in 1995 to measure a woman’s experiences with the healing process of cryosurgery. The survey was developed from the results of a focus group of 8 women who had previously experienced cryosurgery. Validity and clarity were established by test-retest comparisons in a second group of women with cryosurgical experience. The survey consisted of 2 fixed-response questions, 8 open-ended questions, 10 dichotomous (yes/no) questions, and 16 5-point Likert-scaled questions. All items gauged the study participants’ experiences following cryosurgery and included questions regarding: the unpleasantness of the healing process, the bother of the hydrorrhea produced from the procedure, the frequency of pad protection required postprocedure, and the intensity of the malodorous hydrorrhea. Women were asked to compare their subjective experiences of menses with their postprocedure experiences in the following categories: use and frequency of pad protection, medication usage, and activity restriction due to hydrorrhea volume. The subjects were also asked to rank which factors were important to them in making their decision for future treatment. The respective institutional review boards or human subjects committees at each of the clinical sites approved the study.
Sample Population
All women who participated in our study had undergone a cryosurgical procedure for histologically proven CIN grade 1, 2, or 3 disease. All demographic information needed for analysis was collected at the time of cryosurgery. The power of our study was designed to detect a difference in experiences from cryosurgery compared with normal menses. Specifically, the study has a 95% power to detect a 20% difference in the proportion of women taking medications to alleviate symptoms and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. Obesity and age subsets of the population were also powered to 80% to detect a 35% difference in the proportion of women taking medications and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. The gravidity subset was powered to 80% to detect a 45% difference in the same outcome measures at the P=.05 level of significance.
Study Methods
All women who underwent cryosurgery were mailed a questionnaire and cover letter with instructions to return the survey in an enclosed self-addressed, stamped envelope. If the survey was not returned within 3 weeks the research assistant at each clinical site invited the woman to complete it when she presented for the next scheduled follow-up visit.
Data Analysis
Obesity, gravidity, and age were modeled as both continuous and dichotomous variables. Dichotomous definitions included obesity as a body mass index (BMI) of 26 kg/m2 or greater,10 nulligravidity as no pregnancies, and young age as less than 26 years, as most CIN develops in college-aged or younger sexually active women.11
All survey responses were coded and entered into Statistica software (Statsoft, Tulsa, Okla) for descriptive frequency analyses, chi-square testing of dichotomous variables, Likert scale means testing by the t test for independent variables, and Pearson correlation coefficients. Casewise deletion was not used to eliminate partial responses in the analysis.
Results
Of the 85 women who participated in the study, 72 completed the survey for a response rate of 84.7%. The mean time from the cryosurgical procedure to completion of the survey was 11.4 days (standard deviation [SD]=14.4), with a range of 1 to 57 days paralleling the cessation time for hydrorrhea. All women answered 27% of the questions, and 28% of women answered all of the questions. There was no pattern of nonresponse. [Table 1] shows the characteristics of the women who participated in the survey.
The cryosurgical healing process was unpleasant for 78.3% (54/69) of the women because of the pain and cramping following the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Of all the women, 8.7% felt neutral toward the experience, and 13% considered the experience positive. Even though unpleasant, only 53.5% (38/71) reported that the hydrorrhea was bothersome to them, and of those, 47.4% (18/38) quantified the hydrorrhea as very or extremely bothersome. Of all the women, 61.1% (44/72) responded affirmatively to the dichotomous question that wearing pads was bothersome, and of those, 34.1% (15/44) quantified the degree of inconvenience as very or extremely bothersome. Of all the subjects, 51.4% (37/72) stated that there was a foul to very foul odor associated with the hydrorrhea. Detailed frequencies and the mean Likert score intensities are displayed in [Table 2].
[Table 3] shows the comparisons of the cryosurgical healing process to normal menses. Of all the women, 66.7% (48/72) used pads for their menses. Of these, 61.7% ranked the use of the pads after cryosurgery as the same or less aggravating than those for their menses, and 51.1% (24/47) felt the frequency of pad changes required was more or much more than with normal menses. Of all the women, 52.8% (38/72) ranked the volume of hydrorrhea after cryosurgery as more or much more than with their menses.
Women who experienced light menstrual volumes perceived significantly more hydrorrhea from cryosurgery, while women who experienced heavy menstrual flow experienced significantly less hydrorrhea from cryosurgery. Of all the women, 56.3% felt that their experience with cryosurgery restricted their activities more than their normal menses. The restrictions were described through open-ended questions for at least one of 5 reasons: (1) social embarrassment due to overflowing and malodorous hydrorrhea; (2) concern for impairment of the healing process if normal activities, such as lifting, were resumed; (3) the abdominal and pelvic discomfort that continued for days after the procedure; (4) the inability to sleep at night because of the overflow of hydrorrhea; and (5) the physician-imposed limitations of no vaginal intercourse.
Medications for menstrual cramps were taken by 26.8% of the women, while after cryosurgery 67.1% of women reported taking medication (chi-square=23.09; P <.0001). Only 16.9% of the women stated that they were restricted in their activities because of their menses, while 38.6% stated they were limited by the hydrorrhea from the cryosurgery (chi-square=8.27, P=.004).
[Table 4] has the mean of the experiences with the cryosurgical healing process from the 3 subsets of women. For all 3 population subsets-those with obesity, younger age, and nulligravidity-the cryosurgical healing process results in significantly more medications being taken and activities restricted significantly more than for menses (obese: P=.0246; nonobese: P=.0043; multigravid: P=.0061; young: P=.0014; old: P=.001), an association seen for the general population. Activity restrictions were greater for the healing process than for menses for each of these respective groups of women (obese: P=.0018; nonobese: P=.0037; multigravid: P=.0084; young: P=.0500; old: P=.0419).
Obese women whose BMI was greater than 26 kg/m2 were significantly more bothered by wearing pads after cryosurgery than those with a lesser BMI (t=2.33, P=.0246). Multigravid women were more likely to be bothered or aggravated by wearing pads than nulligravid women (t=2.88, P=.0061). Similarly, women older than 26 years were more likely to be bothered by pad use than younger women (t=2.14, P=.0383). In the group of women aged 26 years or younger we found that those aged 15 to 18 years were significantly less bothered about the hydrorrhea than those in the 19 to 22 years cohort (1.0 vs 3.4, t=3.35, P=.0122), considered the frequency of pad changes to be less aggravating than menses than the 19 to 22 years cohort (2.67 vs 4.0, t=3.65, P=.0020), but considered the hydrorrhea more malodorous than those aged 19 to 22 years (4.3 vs 3.2, t=2.33, P=.0325).
More women ranked the number of days experiencing pain and cramping during the cryosurgery procedure as the most important factor in their decision to undergo future treatment (42.9%). It was not significantly more important than the amount of hydrorrhea subsequent to the procedure (37.1%) or the cost of the procedure (20.0%). All 3 factors-pain and cramping, hydrorrhea, and cost-were considered equally important by 7.9% in their decision for future treatment, while 22.2% felt that only the pain and cramping and the volume of hydrorrhea were important to consider for future treatment.
Discussion
Physicians have traditionally focused on relieving the pain and cramping of the cryosurgical procedure itself1-5 and have paid less attention to the healing process. Among all aspects of the healing process, women care most about the pain and cramping but are also were bothered by the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Few women were extremely bothered by the healing process; most ranked it as moderately bothersome, requiring more medications, and limiting activities more than normal menses. A small number of women found the procedure to be a positive experience. No similar study has been done for loop electrosurgery or laser surgery.
Our study documents that 16.9% of women were restricted in their daily activities by their menses. This proportion of our study population is slightly higher than Sundell’s report of 10% of 24-year-old women who were restricted in their activities because of dysmenorrhea.7 Menses causes significantly fewer days of activity restriction than the cryosurgical experience. Andersch and Milsom13 report that 38.1% of women use medications for dysmenorrhea, somewhat higher than our 26.8%. Both of these are clinically and statistically less than the almost 70% medication use for the cryosurgical healing process.
The 3 subsets of the population we examined were obese, nulligravid, and young. Obese women were stratified in the analysis because they are screened less often for cervical cancer,9,14-21 experience more dysmenorrhea cyclically,7 and take more medications for dysmenorrhea than nonobese women.8 Unpleasant experiences from cryosurgery could exacerbate the pattern of nonscreening in the future. Our study showed that obese women were more bothered by pad use than nonobese women but were not more restricted in their activities after cryosurgery. Previous work has shown that obese women produce more hydrorrhea quantitatively postprocedure than nonobese women.6 Our work shows that the obese women are not bothered by the hydrorrhea itself but by the necessity of wearing pads for protection.
Young and nulligravid subsets of the population have been found to experience more dysmenorrhea than older and multigravid women.7 These subsets of women, if sexually active, are also at high risk for human papillomavirus infection and subsequent CIN development, possibly requiring treatment. Surprisingly, in our study the youngest teens (15-18 years) were only bothered by the malodorous hy-drorrhea more than their counterparts aged 19 to 22 years and were less bothered by the hydrorrhea itself and the frequency of pad changes. Our study showed that older and multigravid woman rank the inconvenience of pad use after the cryosurgical procedure as worse than their clinical counterparts, potentially because these women had more daily responsibilities that were interrupted by the necessary pad changes.
The importance of our study is twofold. First, cryosurgery is a valuable treatment modality for all grades of CIN with lesions that meet the specific requirements. To set the patient’s expectations about the healing process following cryosurgery, patient education and informed consent should include, in addition to the description of the procedure, its necessity, and the standard Papanicolaou test follow-up, the comparison of cryosurgery with the woman’s menses, covering the points established by our study: (1) the volume of hydrorrhea will be perceived inversely to the volume of menses; (2) more activity restrictions occur; and (3) more medications are needed to alleviate cramping. Additionally, obese, older, and multigravid women experienced more aggravation from the pad use than others, and the youngest teens were more bothered by the malodorous hydrorrhea. Second, many physicians will treat CIN 1 lesions without allowing the lesion to undergo natural regression.22 By being this aggressive, the physician must weigh the quicker time that would have occurred without treatment to lesion regression caused by the cryosurgery with the risks of a bad cryosurgery experience that may affect future screening practices.
Decisions to undergo future CIN treatment were most influenced by the pain and cramping and the hydrorrhea of cryosurgery. It is unknown whether or when women will return for yearly preventive screening after experiencing cryosurgery. Winkler23 reported that women who underwent bilateral tubal ligations who later developed cervical cancer had more than a 6-year time lapse before returning for cervical cancer screening, longer than the 4 years for those women without tubal ligations. Future work will explore the influence of the cryosurgical experience on compliance with future screenings and will include formal disutility measurements due to cryosurgical treatment.
Acknowledgments
Our work was supported in part by the Robert Wood Johnson Foundation (D.M.H).
1. DM, Walstatter BS, Lofton BJ. Anesthetic blocks for loop electrosurgical excision procedure. J Fam Pract 1994;39:249-56.
2. DM. Pain and cramping associated with cryosurgery. J Fam Pract 1994;39:551-57.
3. DM. Paracervical block diminishes cramping associated with cryosurgery. J Fam Pract 1997;44:71-75.
4. DM, Cobb JL. Cervical mucosal block effectively reduces the pain and cramping from cryosurgery. J Fam Pract 1998;47:285-89.
5. DM, Cobb JL. Is it cost-effective to use a mucosal or paracervical block to relieve the pain and cramping from cryosurgery? J Fam Pract 1999;48:285-90.
6. DM, Ferris DG, Mayeaux EJ, Daaleman TP, Johnson CA. The amount and duration of malodorous hydrorrhea produced by cryosurgery is not diminished by cervical eschar debridement. J Fam Pract 2000;49:xxx-xxx.
7. G, Milsom I, Andesch B. Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 1990;97:588-94.
8. SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol 1996;103:1134-42.
9. CH, Smith NJ, Wilbur DC, Grady KE. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 1993;20:45-57.
10. site www.nhlbi.gov accessed on September 26, 1999.
11. SL, Papillo JL. A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern. New England. Pediatrics. 1999;103:539-45.
12. Inc. STATISTICA for Windows. Tulsa, Okla: Statsoft, Inc; 1998.
13. B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol 1982;144:655-59.
14. LC, Bernstein AB, Kessler LG. Cervical cancer screening: who is not screened and why? Am J Public Health 1991;81:885-91.
15. RA, Shapiro MF, Freeman HE, Corey CR. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 1988;148:1177-81.
16. JA, Slymen DJ, Drew JA, Wright BL, Elder JP, Williams SJ. Breast and cervical cancer screening in older women: the San Diego Medicare Preventive Health Project. Prev Med 1992;21:395-404.
17. DG, Lave JR, Traven ND, Schulz R, Kuller LH. Mammography and Pap smear use by older rural women. Pub Health Rep 1996;111:244-50.
18. JC, Kopstein A. Who is being screened for cervical cancer? Am J Public Health 1981;71:73-75.
19. S, Ansell D, Lacey L, Chen EH, Ebie N, Dell J, Phillips CW. Patterns of breast and cervical cancer screening at three public health clinics in an inner-city urban area. Am J Public Health 1991;81:1651-53.
20. RM, Litzelman DK, Dittus RM, Tierney WM. Is obesity a barrier to physician screening for cervical cancer? Am J Med 1995;98:491-96.
21. KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med 1998;7:381-84.
22. K, Nasiell M, Vaclavinokova V, Roger V, Hjerpe A. Follow-up series of cytologically detected precancerous lesions of the uterine cervix. In: Bostrom H, et al, eds. Health control in detection of cancer. Stockholm, Sweden: Aolmquist & Wiksell; 1976;244-56.
23. HA, Anderson PS, Fields AL, Runowicz CD, DeVictoria C, Goldberg GL. Compliance with Papanicolaou smear screening following tubal ligation in women with cervical cancer. J Womens Health 1999;8:103-07.
METHODS: We developed a survey from focus group results to measure the unpleasantness of hydrorrhea (watery discharge) from cryosurgery, the pad protection required, and the odor associated with the hydrorrhea. The cryosurgical experiences were compared with normal menses for the use and frequency of pad protection, medications used, and any activity restrictions.
RESULTS: Cryosurgical experiences were unpleasant for 78.3% of the women because of the pain and cramping of the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. These experiences after cryosurgery caused 38.6% to restrict their activities and 67.1% to take medications, a significantly greater proportion than the 16.9% whose activities were restricted by normal menses and the 26.8% who took medications for normal menses (P=.004, P <.001, respectively). In addition to these experiences, obese, multigravid, and older women were more bothered by the duration of wearing pads than their counterparts (P=.0246, P=.0061, and P=.0159, respectively).
CONCLUSIONS: Our study showed that the cryosurgical healing process was not pleasant, and was least tolerable for obese, multigravid, and older women. As many as 50% of women undergoing cryosurgery will perceive the hydrorrhea, its odor, and the wearing of pads to be worse than normal menses, especially if their menses are usually light.
Women experience discomfort during treatment for cervical intraepithelial neoplasia (CIN). The discomfort from cryosurgery has been studied and is usually alleviated by the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and mucosal blocks before the procedure.1-4 Pain and cramping alleviation is cost-effective.5 The cryosurgical healing process includes malodorous hydrorrhea (watery discharge) that lasts 12 days on average, but can continue for an entire month.6 Specific populations of women who are potentially more bothered by the healing process include those who are obese, nulligravid, and younger. Each of these subsets can experience more dysmenorrhea than their clinical counterparts.7,8
Obese women, in general, do not present for cervical cancer screenings as often as those who are not obese, because of lower self-esteem.9 All women’s experiences and those specific to these 3 groups have not previously been described for cryosurgical healing. Women’s perspectives and experiences with the healing process might influence their compliance with future cervical cancer screenings and treatments.
The purpose of our study was to describe women’s experiences after cryosurgery, particularly in relationship with obesity, gravidity, and age. We postulated that women who were obese, nulligravid, and younger would experience a more unpleasant healing process after cryosurgery than those who were nonobese, multigravid, and older. The experience following cryosurgery was compared with the experience of normal menses, and factors for women’s future treatment decisions were ranked in order of importance.
Methods
Survey Instrument
We designed a survey in 1995 to measure a woman’s experiences with the healing process of cryosurgery. The survey was developed from the results of a focus group of 8 women who had previously experienced cryosurgery. Validity and clarity were established by test-retest comparisons in a second group of women with cryosurgical experience. The survey consisted of 2 fixed-response questions, 8 open-ended questions, 10 dichotomous (yes/no) questions, and 16 5-point Likert-scaled questions. All items gauged the study participants’ experiences following cryosurgery and included questions regarding: the unpleasantness of the healing process, the bother of the hydrorrhea produced from the procedure, the frequency of pad protection required postprocedure, and the intensity of the malodorous hydrorrhea. Women were asked to compare their subjective experiences of menses with their postprocedure experiences in the following categories: use and frequency of pad protection, medication usage, and activity restriction due to hydrorrhea volume. The subjects were also asked to rank which factors were important to them in making their decision for future treatment. The respective institutional review boards or human subjects committees at each of the clinical sites approved the study.
Sample Population
All women who participated in our study had undergone a cryosurgical procedure for histologically proven CIN grade 1, 2, or 3 disease. All demographic information needed for analysis was collected at the time of cryosurgery. The power of our study was designed to detect a difference in experiences from cryosurgery compared with normal menses. Specifically, the study has a 95% power to detect a 20% difference in the proportion of women taking medications to alleviate symptoms and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. Obesity and age subsets of the population were also powered to 80% to detect a 35% difference in the proportion of women taking medications and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. The gravidity subset was powered to 80% to detect a 45% difference in the same outcome measures at the P=.05 level of significance.
Study Methods
All women who underwent cryosurgery were mailed a questionnaire and cover letter with instructions to return the survey in an enclosed self-addressed, stamped envelope. If the survey was not returned within 3 weeks the research assistant at each clinical site invited the woman to complete it when she presented for the next scheduled follow-up visit.
Data Analysis
Obesity, gravidity, and age were modeled as both continuous and dichotomous variables. Dichotomous definitions included obesity as a body mass index (BMI) of 26 kg/m2 or greater,10 nulligravidity as no pregnancies, and young age as less than 26 years, as most CIN develops in college-aged or younger sexually active women.11
All survey responses were coded and entered into Statistica software (Statsoft, Tulsa, Okla) for descriptive frequency analyses, chi-square testing of dichotomous variables, Likert scale means testing by the t test for independent variables, and Pearson correlation coefficients. Casewise deletion was not used to eliminate partial responses in the analysis.
Results
Of the 85 women who participated in the study, 72 completed the survey for a response rate of 84.7%. The mean time from the cryosurgical procedure to completion of the survey was 11.4 days (standard deviation [SD]=14.4), with a range of 1 to 57 days paralleling the cessation time for hydrorrhea. All women answered 27% of the questions, and 28% of women answered all of the questions. There was no pattern of nonresponse. [Table 1] shows the characteristics of the women who participated in the survey.
The cryosurgical healing process was unpleasant for 78.3% (54/69) of the women because of the pain and cramping following the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Of all the women, 8.7% felt neutral toward the experience, and 13% considered the experience positive. Even though unpleasant, only 53.5% (38/71) reported that the hydrorrhea was bothersome to them, and of those, 47.4% (18/38) quantified the hydrorrhea as very or extremely bothersome. Of all the women, 61.1% (44/72) responded affirmatively to the dichotomous question that wearing pads was bothersome, and of those, 34.1% (15/44) quantified the degree of inconvenience as very or extremely bothersome. Of all the subjects, 51.4% (37/72) stated that there was a foul to very foul odor associated with the hydrorrhea. Detailed frequencies and the mean Likert score intensities are displayed in [Table 2].
[Table 3] shows the comparisons of the cryosurgical healing process to normal menses. Of all the women, 66.7% (48/72) used pads for their menses. Of these, 61.7% ranked the use of the pads after cryosurgery as the same or less aggravating than those for their menses, and 51.1% (24/47) felt the frequency of pad changes required was more or much more than with normal menses. Of all the women, 52.8% (38/72) ranked the volume of hydrorrhea after cryosurgery as more or much more than with their menses.
Women who experienced light menstrual volumes perceived significantly more hydrorrhea from cryosurgery, while women who experienced heavy menstrual flow experienced significantly less hydrorrhea from cryosurgery. Of all the women, 56.3% felt that their experience with cryosurgery restricted their activities more than their normal menses. The restrictions were described through open-ended questions for at least one of 5 reasons: (1) social embarrassment due to overflowing and malodorous hydrorrhea; (2) concern for impairment of the healing process if normal activities, such as lifting, were resumed; (3) the abdominal and pelvic discomfort that continued for days after the procedure; (4) the inability to sleep at night because of the overflow of hydrorrhea; and (5) the physician-imposed limitations of no vaginal intercourse.
Medications for menstrual cramps were taken by 26.8% of the women, while after cryosurgery 67.1% of women reported taking medication (chi-square=23.09; P <.0001). Only 16.9% of the women stated that they were restricted in their activities because of their menses, while 38.6% stated they were limited by the hydrorrhea from the cryosurgery (chi-square=8.27, P=.004).
[Table 4] has the mean of the experiences with the cryosurgical healing process from the 3 subsets of women. For all 3 population subsets-those with obesity, younger age, and nulligravidity-the cryosurgical healing process results in significantly more medications being taken and activities restricted significantly more than for menses (obese: P=.0246; nonobese: P=.0043; multigravid: P=.0061; young: P=.0014; old: P=.001), an association seen for the general population. Activity restrictions were greater for the healing process than for menses for each of these respective groups of women (obese: P=.0018; nonobese: P=.0037; multigravid: P=.0084; young: P=.0500; old: P=.0419).
Obese women whose BMI was greater than 26 kg/m2 were significantly more bothered by wearing pads after cryosurgery than those with a lesser BMI (t=2.33, P=.0246). Multigravid women were more likely to be bothered or aggravated by wearing pads than nulligravid women (t=2.88, P=.0061). Similarly, women older than 26 years were more likely to be bothered by pad use than younger women (t=2.14, P=.0383). In the group of women aged 26 years or younger we found that those aged 15 to 18 years were significantly less bothered about the hydrorrhea than those in the 19 to 22 years cohort (1.0 vs 3.4, t=3.35, P=.0122), considered the frequency of pad changes to be less aggravating than menses than the 19 to 22 years cohort (2.67 vs 4.0, t=3.65, P=.0020), but considered the hydrorrhea more malodorous than those aged 19 to 22 years (4.3 vs 3.2, t=2.33, P=.0325).
More women ranked the number of days experiencing pain and cramping during the cryosurgery procedure as the most important factor in their decision to undergo future treatment (42.9%). It was not significantly more important than the amount of hydrorrhea subsequent to the procedure (37.1%) or the cost of the procedure (20.0%). All 3 factors-pain and cramping, hydrorrhea, and cost-were considered equally important by 7.9% in their decision for future treatment, while 22.2% felt that only the pain and cramping and the volume of hydrorrhea were important to consider for future treatment.
Discussion
Physicians have traditionally focused on relieving the pain and cramping of the cryosurgical procedure itself1-5 and have paid less attention to the healing process. Among all aspects of the healing process, women care most about the pain and cramping but are also were bothered by the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Few women were extremely bothered by the healing process; most ranked it as moderately bothersome, requiring more medications, and limiting activities more than normal menses. A small number of women found the procedure to be a positive experience. No similar study has been done for loop electrosurgery or laser surgery.
Our study documents that 16.9% of women were restricted in their daily activities by their menses. This proportion of our study population is slightly higher than Sundell’s report of 10% of 24-year-old women who were restricted in their activities because of dysmenorrhea.7 Menses causes significantly fewer days of activity restriction than the cryosurgical experience. Andersch and Milsom13 report that 38.1% of women use medications for dysmenorrhea, somewhat higher than our 26.8%. Both of these are clinically and statistically less than the almost 70% medication use for the cryosurgical healing process.
The 3 subsets of the population we examined were obese, nulligravid, and young. Obese women were stratified in the analysis because they are screened less often for cervical cancer,9,14-21 experience more dysmenorrhea cyclically,7 and take more medications for dysmenorrhea than nonobese women.8 Unpleasant experiences from cryosurgery could exacerbate the pattern of nonscreening in the future. Our study showed that obese women were more bothered by pad use than nonobese women but were not more restricted in their activities after cryosurgery. Previous work has shown that obese women produce more hydrorrhea quantitatively postprocedure than nonobese women.6 Our work shows that the obese women are not bothered by the hydrorrhea itself but by the necessity of wearing pads for protection.
Young and nulligravid subsets of the population have been found to experience more dysmenorrhea than older and multigravid women.7 These subsets of women, if sexually active, are also at high risk for human papillomavirus infection and subsequent CIN development, possibly requiring treatment. Surprisingly, in our study the youngest teens (15-18 years) were only bothered by the malodorous hy-drorrhea more than their counterparts aged 19 to 22 years and were less bothered by the hydrorrhea itself and the frequency of pad changes. Our study showed that older and multigravid woman rank the inconvenience of pad use after the cryosurgical procedure as worse than their clinical counterparts, potentially because these women had more daily responsibilities that were interrupted by the necessary pad changes.
The importance of our study is twofold. First, cryosurgery is a valuable treatment modality for all grades of CIN with lesions that meet the specific requirements. To set the patient’s expectations about the healing process following cryosurgery, patient education and informed consent should include, in addition to the description of the procedure, its necessity, and the standard Papanicolaou test follow-up, the comparison of cryosurgery with the woman’s menses, covering the points established by our study: (1) the volume of hydrorrhea will be perceived inversely to the volume of menses; (2) more activity restrictions occur; and (3) more medications are needed to alleviate cramping. Additionally, obese, older, and multigravid women experienced more aggravation from the pad use than others, and the youngest teens were more bothered by the malodorous hydrorrhea. Second, many physicians will treat CIN 1 lesions without allowing the lesion to undergo natural regression.22 By being this aggressive, the physician must weigh the quicker time that would have occurred without treatment to lesion regression caused by the cryosurgery with the risks of a bad cryosurgery experience that may affect future screening practices.
Decisions to undergo future CIN treatment were most influenced by the pain and cramping and the hydrorrhea of cryosurgery. It is unknown whether or when women will return for yearly preventive screening after experiencing cryosurgery. Winkler23 reported that women who underwent bilateral tubal ligations who later developed cervical cancer had more than a 6-year time lapse before returning for cervical cancer screening, longer than the 4 years for those women without tubal ligations. Future work will explore the influence of the cryosurgical experience on compliance with future screenings and will include formal disutility measurements due to cryosurgical treatment.
Acknowledgments
Our work was supported in part by the Robert Wood Johnson Foundation (D.M.H).
METHODS: We developed a survey from focus group results to measure the unpleasantness of hydrorrhea (watery discharge) from cryosurgery, the pad protection required, and the odor associated with the hydrorrhea. The cryosurgical experiences were compared with normal menses for the use and frequency of pad protection, medications used, and any activity restrictions.
RESULTS: Cryosurgical experiences were unpleasant for 78.3% of the women because of the pain and cramping of the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. These experiences after cryosurgery caused 38.6% to restrict their activities and 67.1% to take medications, a significantly greater proportion than the 16.9% whose activities were restricted by normal menses and the 26.8% who took medications for normal menses (P=.004, P <.001, respectively). In addition to these experiences, obese, multigravid, and older women were more bothered by the duration of wearing pads than their counterparts (P=.0246, P=.0061, and P=.0159, respectively).
CONCLUSIONS: Our study showed that the cryosurgical healing process was not pleasant, and was least tolerable for obese, multigravid, and older women. As many as 50% of women undergoing cryosurgery will perceive the hydrorrhea, its odor, and the wearing of pads to be worse than normal menses, especially if their menses are usually light.
Women experience discomfort during treatment for cervical intraepithelial neoplasia (CIN). The discomfort from cryosurgery has been studied and is usually alleviated by the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and mucosal blocks before the procedure.1-4 Pain and cramping alleviation is cost-effective.5 The cryosurgical healing process includes malodorous hydrorrhea (watery discharge) that lasts 12 days on average, but can continue for an entire month.6 Specific populations of women who are potentially more bothered by the healing process include those who are obese, nulligravid, and younger. Each of these subsets can experience more dysmenorrhea than their clinical counterparts.7,8
Obese women, in general, do not present for cervical cancer screenings as often as those who are not obese, because of lower self-esteem.9 All women’s experiences and those specific to these 3 groups have not previously been described for cryosurgical healing. Women’s perspectives and experiences with the healing process might influence their compliance with future cervical cancer screenings and treatments.
The purpose of our study was to describe women’s experiences after cryosurgery, particularly in relationship with obesity, gravidity, and age. We postulated that women who were obese, nulligravid, and younger would experience a more unpleasant healing process after cryosurgery than those who were nonobese, multigravid, and older. The experience following cryosurgery was compared with the experience of normal menses, and factors for women’s future treatment decisions were ranked in order of importance.
Methods
Survey Instrument
We designed a survey in 1995 to measure a woman’s experiences with the healing process of cryosurgery. The survey was developed from the results of a focus group of 8 women who had previously experienced cryosurgery. Validity and clarity were established by test-retest comparisons in a second group of women with cryosurgical experience. The survey consisted of 2 fixed-response questions, 8 open-ended questions, 10 dichotomous (yes/no) questions, and 16 5-point Likert-scaled questions. All items gauged the study participants’ experiences following cryosurgery and included questions regarding: the unpleasantness of the healing process, the bother of the hydrorrhea produced from the procedure, the frequency of pad protection required postprocedure, and the intensity of the malodorous hydrorrhea. Women were asked to compare their subjective experiences of menses with their postprocedure experiences in the following categories: use and frequency of pad protection, medication usage, and activity restriction due to hydrorrhea volume. The subjects were also asked to rank which factors were important to them in making their decision for future treatment. The respective institutional review boards or human subjects committees at each of the clinical sites approved the study.
Sample Population
All women who participated in our study had undergone a cryosurgical procedure for histologically proven CIN grade 1, 2, or 3 disease. All demographic information needed for analysis was collected at the time of cryosurgery. The power of our study was designed to detect a difference in experiences from cryosurgery compared with normal menses. Specifically, the study has a 95% power to detect a 20% difference in the proportion of women taking medications to alleviate symptoms and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. Obesity and age subsets of the population were also powered to 80% to detect a 35% difference in the proportion of women taking medications and having activity restrictions from cryosurgery compared with normal menses at the P=.05 level of significance. The gravidity subset was powered to 80% to detect a 45% difference in the same outcome measures at the P=.05 level of significance.
Study Methods
All women who underwent cryosurgery were mailed a questionnaire and cover letter with instructions to return the survey in an enclosed self-addressed, stamped envelope. If the survey was not returned within 3 weeks the research assistant at each clinical site invited the woman to complete it when she presented for the next scheduled follow-up visit.
Data Analysis
Obesity, gravidity, and age were modeled as both continuous and dichotomous variables. Dichotomous definitions included obesity as a body mass index (BMI) of 26 kg/m2 or greater,10 nulligravidity as no pregnancies, and young age as less than 26 years, as most CIN develops in college-aged or younger sexually active women.11
All survey responses were coded and entered into Statistica software (Statsoft, Tulsa, Okla) for descriptive frequency analyses, chi-square testing of dichotomous variables, Likert scale means testing by the t test for independent variables, and Pearson correlation coefficients. Casewise deletion was not used to eliminate partial responses in the analysis.
Results
Of the 85 women who participated in the study, 72 completed the survey for a response rate of 84.7%. The mean time from the cryosurgical procedure to completion of the survey was 11.4 days (standard deviation [SD]=14.4), with a range of 1 to 57 days paralleling the cessation time for hydrorrhea. All women answered 27% of the questions, and 28% of women answered all of the questions. There was no pattern of nonresponse. [Table 1] shows the characteristics of the women who participated in the survey.
The cryosurgical healing process was unpleasant for 78.3% (54/69) of the women because of the pain and cramping following the procedure and the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Of all the women, 8.7% felt neutral toward the experience, and 13% considered the experience positive. Even though unpleasant, only 53.5% (38/71) reported that the hydrorrhea was bothersome to them, and of those, 47.4% (18/38) quantified the hydrorrhea as very or extremely bothersome. Of all the women, 61.1% (44/72) responded affirmatively to the dichotomous question that wearing pads was bothersome, and of those, 34.1% (15/44) quantified the degree of inconvenience as very or extremely bothersome. Of all the subjects, 51.4% (37/72) stated that there was a foul to very foul odor associated with the hydrorrhea. Detailed frequencies and the mean Likert score intensities are displayed in [Table 2].
[Table 3] shows the comparisons of the cryosurgical healing process to normal menses. Of all the women, 66.7% (48/72) used pads for their menses. Of these, 61.7% ranked the use of the pads after cryosurgery as the same or less aggravating than those for their menses, and 51.1% (24/47) felt the frequency of pad changes required was more or much more than with normal menses. Of all the women, 52.8% (38/72) ranked the volume of hydrorrhea after cryosurgery as more or much more than with their menses.
Women who experienced light menstrual volumes perceived significantly more hydrorrhea from cryosurgery, while women who experienced heavy menstrual flow experienced significantly less hydrorrhea from cryosurgery. Of all the women, 56.3% felt that their experience with cryosurgery restricted their activities more than their normal menses. The restrictions were described through open-ended questions for at least one of 5 reasons: (1) social embarrassment due to overflowing and malodorous hydrorrhea; (2) concern for impairment of the healing process if normal activities, such as lifting, were resumed; (3) the abdominal and pelvic discomfort that continued for days after the procedure; (4) the inability to sleep at night because of the overflow of hydrorrhea; and (5) the physician-imposed limitations of no vaginal intercourse.
Medications for menstrual cramps were taken by 26.8% of the women, while after cryosurgery 67.1% of women reported taking medication (chi-square=23.09; P <.0001). Only 16.9% of the women stated that they were restricted in their activities because of their menses, while 38.6% stated they were limited by the hydrorrhea from the cryosurgery (chi-square=8.27, P=.004).
[Table 4] has the mean of the experiences with the cryosurgical healing process from the 3 subsets of women. For all 3 population subsets-those with obesity, younger age, and nulligravidity-the cryosurgical healing process results in significantly more medications being taken and activities restricted significantly more than for menses (obese: P=.0246; nonobese: P=.0043; multigravid: P=.0061; young: P=.0014; old: P=.001), an association seen for the general population. Activity restrictions were greater for the healing process than for menses for each of these respective groups of women (obese: P=.0018; nonobese: P=.0037; multigravid: P=.0084; young: P=.0500; old: P=.0419).
Obese women whose BMI was greater than 26 kg/m2 were significantly more bothered by wearing pads after cryosurgery than those with a lesser BMI (t=2.33, P=.0246). Multigravid women were more likely to be bothered or aggravated by wearing pads than nulligravid women (t=2.88, P=.0061). Similarly, women older than 26 years were more likely to be bothered by pad use than younger women (t=2.14, P=.0383). In the group of women aged 26 years or younger we found that those aged 15 to 18 years were significantly less bothered about the hydrorrhea than those in the 19 to 22 years cohort (1.0 vs 3.4, t=3.35, P=.0122), considered the frequency of pad changes to be less aggravating than menses than the 19 to 22 years cohort (2.67 vs 4.0, t=3.65, P=.0020), but considered the hydrorrhea more malodorous than those aged 19 to 22 years (4.3 vs 3.2, t=2.33, P=.0325).
More women ranked the number of days experiencing pain and cramping during the cryosurgery procedure as the most important factor in their decision to undergo future treatment (42.9%). It was not significantly more important than the amount of hydrorrhea subsequent to the procedure (37.1%) or the cost of the procedure (20.0%). All 3 factors-pain and cramping, hydrorrhea, and cost-were considered equally important by 7.9% in their decision for future treatment, while 22.2% felt that only the pain and cramping and the volume of hydrorrhea were important to consider for future treatment.
Discussion
Physicians have traditionally focused on relieving the pain and cramping of the cryosurgical procedure itself1-5 and have paid less attention to the healing process. Among all aspects of the healing process, women care most about the pain and cramping but are also were bothered by the resulting hydrorrhea, odor, and necessity of wearing pads for protection. Few women were extremely bothered by the healing process; most ranked it as moderately bothersome, requiring more medications, and limiting activities more than normal menses. A small number of women found the procedure to be a positive experience. No similar study has been done for loop electrosurgery or laser surgery.
Our study documents that 16.9% of women were restricted in their daily activities by their menses. This proportion of our study population is slightly higher than Sundell’s report of 10% of 24-year-old women who were restricted in their activities because of dysmenorrhea.7 Menses causes significantly fewer days of activity restriction than the cryosurgical experience. Andersch and Milsom13 report that 38.1% of women use medications for dysmenorrhea, somewhat higher than our 26.8%. Both of these are clinically and statistically less than the almost 70% medication use for the cryosurgical healing process.
The 3 subsets of the population we examined were obese, nulligravid, and young. Obese women were stratified in the analysis because they are screened less often for cervical cancer,9,14-21 experience more dysmenorrhea cyclically,7 and take more medications for dysmenorrhea than nonobese women.8 Unpleasant experiences from cryosurgery could exacerbate the pattern of nonscreening in the future. Our study showed that obese women were more bothered by pad use than nonobese women but were not more restricted in their activities after cryosurgery. Previous work has shown that obese women produce more hydrorrhea quantitatively postprocedure than nonobese women.6 Our work shows that the obese women are not bothered by the hydrorrhea itself but by the necessity of wearing pads for protection.
Young and nulligravid subsets of the population have been found to experience more dysmenorrhea than older and multigravid women.7 These subsets of women, if sexually active, are also at high risk for human papillomavirus infection and subsequent CIN development, possibly requiring treatment. Surprisingly, in our study the youngest teens (15-18 years) were only bothered by the malodorous hy-drorrhea more than their counterparts aged 19 to 22 years and were less bothered by the hydrorrhea itself and the frequency of pad changes. Our study showed that older and multigravid woman rank the inconvenience of pad use after the cryosurgical procedure as worse than their clinical counterparts, potentially because these women had more daily responsibilities that were interrupted by the necessary pad changes.
The importance of our study is twofold. First, cryosurgery is a valuable treatment modality for all grades of CIN with lesions that meet the specific requirements. To set the patient’s expectations about the healing process following cryosurgery, patient education and informed consent should include, in addition to the description of the procedure, its necessity, and the standard Papanicolaou test follow-up, the comparison of cryosurgery with the woman’s menses, covering the points established by our study: (1) the volume of hydrorrhea will be perceived inversely to the volume of menses; (2) more activity restrictions occur; and (3) more medications are needed to alleviate cramping. Additionally, obese, older, and multigravid women experienced more aggravation from the pad use than others, and the youngest teens were more bothered by the malodorous hydrorrhea. Second, many physicians will treat CIN 1 lesions without allowing the lesion to undergo natural regression.22 By being this aggressive, the physician must weigh the quicker time that would have occurred without treatment to lesion regression caused by the cryosurgery with the risks of a bad cryosurgery experience that may affect future screening practices.
Decisions to undergo future CIN treatment were most influenced by the pain and cramping and the hydrorrhea of cryosurgery. It is unknown whether or when women will return for yearly preventive screening after experiencing cryosurgery. Winkler23 reported that women who underwent bilateral tubal ligations who later developed cervical cancer had more than a 6-year time lapse before returning for cervical cancer screening, longer than the 4 years for those women without tubal ligations. Future work will explore the influence of the cryosurgical experience on compliance with future screenings and will include formal disutility measurements due to cryosurgical treatment.
Acknowledgments
Our work was supported in part by the Robert Wood Johnson Foundation (D.M.H).
1. DM, Walstatter BS, Lofton BJ. Anesthetic blocks for loop electrosurgical excision procedure. J Fam Pract 1994;39:249-56.
2. DM. Pain and cramping associated with cryosurgery. J Fam Pract 1994;39:551-57.
3. DM. Paracervical block diminishes cramping associated with cryosurgery. J Fam Pract 1997;44:71-75.
4. DM, Cobb JL. Cervical mucosal block effectively reduces the pain and cramping from cryosurgery. J Fam Pract 1998;47:285-89.
5. DM, Cobb JL. Is it cost-effective to use a mucosal or paracervical block to relieve the pain and cramping from cryosurgery? J Fam Pract 1999;48:285-90.
6. DM, Ferris DG, Mayeaux EJ, Daaleman TP, Johnson CA. The amount and duration of malodorous hydrorrhea produced by cryosurgery is not diminished by cervical eschar debridement. J Fam Pract 2000;49:xxx-xxx.
7. G, Milsom I, Andesch B. Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 1990;97:588-94.
8. SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol 1996;103:1134-42.
9. CH, Smith NJ, Wilbur DC, Grady KE. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 1993;20:45-57.
10. site www.nhlbi.gov accessed on September 26, 1999.
11. SL, Papillo JL. A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern. New England. Pediatrics. 1999;103:539-45.
12. Inc. STATISTICA for Windows. Tulsa, Okla: Statsoft, Inc; 1998.
13. B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol 1982;144:655-59.
14. LC, Bernstein AB, Kessler LG. Cervical cancer screening: who is not screened and why? Am J Public Health 1991;81:885-91.
15. RA, Shapiro MF, Freeman HE, Corey CR. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 1988;148:1177-81.
16. JA, Slymen DJ, Drew JA, Wright BL, Elder JP, Williams SJ. Breast and cervical cancer screening in older women: the San Diego Medicare Preventive Health Project. Prev Med 1992;21:395-404.
17. DG, Lave JR, Traven ND, Schulz R, Kuller LH. Mammography and Pap smear use by older rural women. Pub Health Rep 1996;111:244-50.
18. JC, Kopstein A. Who is being screened for cervical cancer? Am J Public Health 1981;71:73-75.
19. S, Ansell D, Lacey L, Chen EH, Ebie N, Dell J, Phillips CW. Patterns of breast and cervical cancer screening at three public health clinics in an inner-city urban area. Am J Public Health 1991;81:1651-53.
20. RM, Litzelman DK, Dittus RM, Tierney WM. Is obesity a barrier to physician screening for cervical cancer? Am J Med 1995;98:491-96.
21. KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med 1998;7:381-84.
22. K, Nasiell M, Vaclavinokova V, Roger V, Hjerpe A. Follow-up series of cytologically detected precancerous lesions of the uterine cervix. In: Bostrom H, et al, eds. Health control in detection of cancer. Stockholm, Sweden: Aolmquist & Wiksell; 1976;244-56.
23. HA, Anderson PS, Fields AL, Runowicz CD, DeVictoria C, Goldberg GL. Compliance with Papanicolaou smear screening following tubal ligation in women with cervical cancer. J Womens Health 1999;8:103-07.
1. DM, Walstatter BS, Lofton BJ. Anesthetic blocks for loop electrosurgical excision procedure. J Fam Pract 1994;39:249-56.
2. DM. Pain and cramping associated with cryosurgery. J Fam Pract 1994;39:551-57.
3. DM. Paracervical block diminishes cramping associated with cryosurgery. J Fam Pract 1997;44:71-75.
4. DM, Cobb JL. Cervical mucosal block effectively reduces the pain and cramping from cryosurgery. J Fam Pract 1998;47:285-89.
5. DM, Cobb JL. Is it cost-effective to use a mucosal or paracervical block to relieve the pain and cramping from cryosurgery? J Fam Pract 1999;48:285-90.
6. DM, Ferris DG, Mayeaux EJ, Daaleman TP, Johnson CA. The amount and duration of malodorous hydrorrhea produced by cryosurgery is not diminished by cervical eschar debridement. J Fam Pract 2000;49:xxx-xxx.
7. G, Milsom I, Andesch B. Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 1990;97:588-94.
8. SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol 1996;103:1134-42.
9. CH, Smith NJ, Wilbur DC, Grady KE. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 1993;20:45-57.
10. site www.nhlbi.gov accessed on September 26, 1999.
11. SL, Papillo JL. A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern. New England. Pediatrics. 1999;103:539-45.
12. Inc. STATISTICA for Windows. Tulsa, Okla: Statsoft, Inc; 1998.
13. B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol 1982;144:655-59.
14. LC, Bernstein AB, Kessler LG. Cervical cancer screening: who is not screened and why? Am J Public Health 1991;81:885-91.
15. RA, Shapiro MF, Freeman HE, Corey CR. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 1988;148:1177-81.
16. JA, Slymen DJ, Drew JA, Wright BL, Elder JP, Williams SJ. Breast and cervical cancer screening in older women: the San Diego Medicare Preventive Health Project. Prev Med 1992;21:395-404.
17. DG, Lave JR, Traven ND, Schulz R, Kuller LH. Mammography and Pap smear use by older rural women. Pub Health Rep 1996;111:244-50.
18. JC, Kopstein A. Who is being screened for cervical cancer? Am J Public Health 1981;71:73-75.
19. S, Ansell D, Lacey L, Chen EH, Ebie N, Dell J, Phillips CW. Patterns of breast and cervical cancer screening at three public health clinics in an inner-city urban area. Am J Public Health 1991;81:1651-53.
20. RM, Litzelman DK, Dittus RM, Tierney WM. Is obesity a barrier to physician screening for cervical cancer? Am J Med 1995;98:491-96.
21. KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med 1998;7:381-84.
22. K, Nasiell M, Vaclavinokova V, Roger V, Hjerpe A. Follow-up series of cytologically detected precancerous lesions of the uterine cervix. In: Bostrom H, et al, eds. Health control in detection of cancer. Stockholm, Sweden: Aolmquist & Wiksell; 1976;244-56.
23. HA, Anderson PS, Fields AL, Runowicz CD, DeVictoria C, Goldberg GL. Compliance with Papanicolaou smear screening following tubal ligation in women with cervical cancer. J Womens Health 1999;8:103-07.