Unsatisfactory Colposcopy in Late Postmenopausal Women: The Effectiveness of Conjugated Topic Estrogen

Unsatisfactory Colposcopy in Late Postmenopausal Women: The Effectiveness of Conjugated Topic Estrogen | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Unsatisfactory Colposcopy in Late Postmenopausal Women: The Effectiveness of Conjugated Topic Estrogen Tatiane Andreia Schwingel, Leila Caroline Souza Reis, Paula Vieira de Mello, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4986862/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Menopause’s hypoestrogenic state which is characterized by atrophy can lead to incorrect interpretation of the cytological smears, as well as it can turn colposcopy challenging because of non-visualization of squamocolumnar junction. This study aims to determine the effect of estrogen therapy on the topography of the colposcopic transformation zone in hypoestrogenic patients and its effect on the differentiation of abnormal Papanicolaou smears secondary to atrophy and true intraepithelial lesions to improve the management of cervical disease after menopause. Methods This was a retrospective evaluation of postmenopausal women aged 50 years or older who were treated between January 2010 and February 2019 at a public hospital in southern Brazil and who had abnormal cervical cytologies and negative initial colposcopies and who were subjected to topical conjugated estrogen therapy and follow-up evaluations. Results Ninety-eight patients aged 57 years and 9.5 years after menopause were included. After 3 months of conjugated-topic estrogen therapy, the rate of satisfactory colposcopy ranged from 20.4–32.7%. Of the 78 (79.6%) subjects with a type 3 transformation zone in the entry colposcopy, 66 (67.3%) remained in the same topography. Additionally, of the 98 patients, 67 (68%) had negative cervical cytology results after treatment. Persistence of high-grade intraepithelial lesions was observed in 33.3% of the patients, 16.7% of whom were diagnosed with microcarcinoma. Conclusion The use of conjugated topical estrogen improved the accuracy of cytology smears in late postmenopausal women. However, it did not show a good response in the topography of the transformation zone and, consequently, a satisfactory colposcopy rate. atrophy postmenopause Papanicolaou test unsatisfactory colposcopy vaginal estrogen therapy Figures Figure 1 Background Among women in the preconized screening age group for cervical cancer, one-third were over 50 years of age. Compared to young women, those aged 65 and older represent 20% of cervical cancers and have a higher rate of mortality. Moreover, vaginal atrophy and, in some cases, physical mobility issues make screening, diagnosis and treatment more difficult in individuals over 10 years postmenopause. [ 1 , 2 ] Low estrogen levels cause cellular glycogenization in the cervical epithelium, causing Papanicolaou (Pap) smears to mimic dyskaryosis and cervical intraepithelial neoplasia (CIN) [ 1 ]. Reactive inflammation and coexisting infection may also cause this problem [ 3 ]. The result of these changes is the poor positive predictive value of atypical Pap smears in postmenopausal age groups [ 4 – 6 ]. Studies have shown that the longer the duration of the postmenopausal period is, the greater the rate of atrophic changes in cytology tests [ 7 ]. The hypoestrogenic state of climacteric women challenge the performance of colposcopy due to the inaccessibility of the Transformation Zone (TZ), which can be located inside the cervical canal (type 3 TZ), resulting in unsatisfactory colposcopy [ 8 ]. This is due to the effect of decreasing estrogen levels on cervical collagen [ 1 ]. Additionally, acetowhite changes secondary to the thinning of the epithelium and the lack of intracellular glycogen, which may result in iodine negativity, can mimic CIN [ 1 ]. The location of the TZ inside the cervical canal can also result in incomplete excision of preneoplastic lesions, with increased failure rates of treatment for women older than 50 years [ 9 ]. It is noteworthy that there are few Latin American reports on the relationship between genital atrophy in women over 50 years of age and the effect of vaginal estrogen cream on the improvement of cytology tests and colposcopy [ 10 ]. The present study aimed to assess the effect of conjugated topical estrogen on cervical cytology and the topography of the TZ in late menopausal women. Methods This cross-sectional retrospective study was performed by analyzing the electronic medical records of postmenopausal women who had undergone colposcopy at the outpatient public practice of Hospital de Clínicas do Paraná in southern Brazil between January 2010 and February 2020. Institutional ethics committee approval was granted. Cervical cytology (Papanicolaou smear) was performed via conventional method. Colposcopy was performed by applying 5% acetic acid to the surface of the uterine cervix and evaluating the TZ and any possible lesions. Colposcopy was considered satisfactory when the entire SCJ could be visualized. The TZ was then classified as TZ 1, 2 or 3 according to its topography. The exam was considered positive when any abnormal findings were observed. Eligible patients were those over 50 years of age who were experiencing at least a 12-month period of amenorrhea and who were referred for abnormal Papanicolaou smears. Those with abnormal cytology, negative colposcopic examination results and clinical signs of hypoestrogenism received 0.625 mg/gram conjugated estrogen cream in 0.5 g doses for 21 days, with a 7-day pause, for 3 consecutive months. At the end of treatment, repeat cytology and colposcopy were performed. The collected data included the position of the squamocolumnar junction (SCJ) and TZ, the presence of minor and major colposcopic findings, and the biopsy result, when needed. For subjects with negative colposcopic findings, follow-up was performed at 12 months, and estrogen treatment was maintained two times a week until the test was repeated. In cases of high-grade lesion diagnosis, appropriate management was conducted based on the biopsy results according to national guidelines for cervical neoplasia. Subjects with invasive cancer, previous hysterectomy, endometrial disease, incomplete data on their records, and who presented with positive colposcopies at entry were excluded from the study. Results During the ten-year period of this retrospective study, the medical records of 223 postmenopausal women were analyzed. The mean age of the subjects was 57 years, and the mean time of menopause was 9.4 years. At the starting point, 74 of those women had visible SCJs on colposcopic examination, and 149 had unsatisfactory colposcopies due to nonvisible SCJs. Seventy-six subjects presented abnormal findings in the initial examination and received specific management, while 147 had negative colposcopies. There were 49 patients lost to follow-up, for a final sample of 98 women. (Figure 1) After 3 months of estrogen cream treatment, control colposcopy revealed visible SCJs in 32 patients (32.6%) (TZ 1 and 2), compared to visible SCJs in 20 (20.4%) patients at the starting point. Of the 78 (79.6%) women with TZ 3 in the initial colposcopy, 66 (67.3%) had their SCJs remaining on the same topography (Table 1). Table 1 - Cytological findings and colposcopic examination. The initial abnormal cytology tests revealed 35 patients (35.7%) with atypical squamous cells of undetermined significance (ASCUS), 18 (18.4%) with low grade squamous intraepithelial lesion (LSIL), 6 (6.1%) with atypical glandular cells (AGC), 33 (33.7%) with atypical squamous cells – cannot exclude a high grade intraepithelial lesion (ASC-H), and 6 (6.1%) with high grade squamous intraepithelial lesion (HSIL). (Table 2) Table 2 - Initial cytology and after estrogen supplementation. After estrogen therapy, 27 (77.1%) of the 35 patients with initial ASCUS were negative, 3 had the same result, and 5 had high-grade cytology. All 77.1% of the patients remained negative at the 12-month follow-up. (Table 3) Of those 17 tests corresponding to the LSIL, 10 (55.6%) were negative after estrogen therapy, 5 (29.4%) persisted, and 2 (11.7%) presented higher-grade results. One patient with initial LSIL underwent cold knife conization without repeat cytology due to abnormal findings suggesting a high-grade lesion in the control colposcopy. After 12 months, 77.8% of the patients were negative. Among the 6 women in the AGC cytology group, all had negative results 3 months after estrogen therapy, but 1 (16.7%) returned an AGC result after 12 months. Among the 33 women in the ASC-H subgroup, 23 (69.7%) were negative after estrogen cream treatment, 7 (21.2%) had ASCUS, and 3 (9%) had AGC. At the 12-month follow-up, 90.9% of the patients were negative. Of the 6 patients with initial HSIL, 2 (33.3%) underwent conization because of major findings in their control colposcopies, and cytology was not performed. One patient (16.7%) became negative, 1 with ASCUS and 1 with LSIL. One patient had a repeat cytology result of ASC-H, was subjected to conization, and was diagnosed with stage 1a1 microinvasive carcinoma. After 12 months, one more patient became negative, and 1 persisted with HSIL. Discussion The topography of the TZ is influenced by age, hormonal status and parity [ 11 ]. Hypoestrogenism leads to cervix stenosis, and there is greater difficulty in viewing the SCJ with advancing age [ 12 ]. The decrease in hormone receptor cells in the TZ of women in a state of hypoestrogenism explains the greater consistency of the cervix and the cranial location of the TZ [ 12 ]. In this study, the use of estrogen therapy led to clinical improvement of atrophic signs during colposcopy, as previously reported by Roberts et al. in a classic study on colposcopy and hormone deficiency [ 13 ]. However, it was found that the use of estrogen modified the rate of satisfactory colposcopy to a nonsignificant extent, from 20.4–32.7%, differing from other studies in which this evaluation was performed. In 2015, Richards and Dalrymple reported a significant difference in the percentage of satisfactory colposcopies, ranging from 32–64%, after the use of vaginal estrogen cream [ 14 ]. However, there was no description of the time women were menopausal or of their average age, only the indication that they had one year of amenorrhea [ 14 ]. Another large Italian study of local synthetic estrogen with low potency for 3 months reported an improvement in the percentage of patients with satisfactory colposcopies from 17.2–73% in women aged 54.9 ± 5 years and menopausal time between 4 and a half to six years [ 15 ]. According to the study by Prendville et al., 64% of colposcopies were adequate for the control examination using an oral estrogen regimen; however, the age range of these subjects was 20 to 47 years, and none were menopausal [ 16 ]. In addition, Saunders et al. compared placebo and estrogen and reported that 71% of women aged 21 to 62 years in the treated group had satisfactory colposcopies [ 17 ]. The subjects in our study had a mean menopausal time of 9.4 years. All the previously mentioned articles included women who had a shorter menopause time or who were still of reproductive age. An increase in SCJ eversion after estrogen administration was not detected in the present study because the subjects were mostly in a late menopausal period and consequently lacked endogenous hormonal activity. With the deep and cranial SCJ in the cervical canal, the reach of estrogen cream to the receptors may have become difficult. It was observed in the present research that cytology had a different evolution from colposcopy findings. Of the subjects with an initial cytological diagnosis of ASC-US, 77.1% had a negative control test and remained negative during the follow-up. In a similar study, only 5.1% of ASC-US patients received surgical treatment, a number very similar to that in the present study [ 15 ]. The finding of ASC-US in Pap smears includes a broad spectrum of cellular changes, such as an increased nucleus/cytoplasm ratio, perinuclear halos in intermediate cells, increased numbers of basal and parabasal cells, and pseudokeratosis, which are similar characteristics to atrophy changes [ 15 , 18 , 19 ]. It is clear that in postmenopausal women, there is a greater incidence of false positives, leading to unnecessary invasive exams and emotional stress from "indeterminate" diagnoses [ 19 ]. The correct diagnosis of this category is a challenge in this hormonal period of life. It is known that neither the ASC-H nor the ASC-US/LSIL ratio has the same positive predictive value for high-grade intraepithelial lesions, as is the case for menacme lesions [ 1 , 14 , 20 ]. When performing cytomorphological analysis of cytology smears from women over 60 years old, Backes et al. classified 95% of the samples as atrophic and 10% as LSILs [ 21 ]. In the present study, 55.6% of patients with initial LSIL were normal in the first control cytology, but 10% needed excisional treatment in the second control because they showed persistent abnormalities, revealing high-grade lesions in the histopathological study. Selvaggi et al. reported that atrophic vaginitis can mimic the granulomatous background of squamocellular carcinoma or squamous cell carcinoma (SCMC), as well as LSIL, which can be a diagnosis of a true high-grade lesion [ 22 ]. Therefore, the use of estrogen improves both false-positive and false-negative results and better defines true lesions. Saad et al. reviewed cytological tests and compared them with histology to identify possible causes of inadequate interpretation of ASC-H and HSIL and false positives in postmenopausal women. They reported a greater frequency of ASC-H cytology results in women over 55 years of age and showed that estrogen deficiency leads to the mimicking of high-grade lesions. These older women have less reliable diagnoses than women of reproductive age. [ 4 ] In the sample studied, a relatively high percentage of initial ASC-H cytological tests (33.7%) were observed. After the administration of estrogen cream, approximately 69.7% of the patients had negative results in the control cytology, and none of them presented with high-grade lesions or cancer by the end of the 12-month follow-up period. Ratree et al., when investigating women with ASC-H, reported a 30.8% rate of high-grade lesions and a 4.5% rate of invasive disease [ 23 ]. Parabasal cells and reactive and inflammatory changes can easily mimic the changes found in high-grade lesions, which are characterized by coarse chromatin, an irregular nuclear membrane and hyperchromasia of the cell nucleus [ 24 ]. In the present study, a low and true incidence of HSILs was observed. Only one subject had negative control cytology results after the use of estrogen cream. In 1982, Paterson reported that estrogen absorption occurs mainly in the first months of treatment, when the epithelium is still thinner, promoting better absorption [ 25 ]. After this period, the epithelium becomes thicker and more mature, and the upper third of the epithelium is composed of superficial cells that are poor in receptors and do not react to estrogen cream [ 26 , 27 ]. In the present study, the same phenomenon was observed. Estrogen therapy has a positive effect during the first three months of therapy, and this effect remains stable until the months of follow-up. Conclusions It can be concluded that the use of estrogen did not improve the position of the SCJ/TZ, presumably due to the age and prolonged menopausal time of the study subjects, and that topical estrogen improved cytological changes, leading to decreased false-positive cytology tests. Thus, estrogen cream therapy should be recommended prior to obtaining new cytology data and performing colposcopy to monitor cytological changes. Further research should be performed to further comprehend the dosage and duration of estrogen therapy, considering the individual duration of menopause. Abbreviations Pap Papanicolaou CIN Cervical intraepithelial neoplasia TZ Transformation Zone SCJ Squamocolumnar junction ASCUS atypical squamous cells of undetermined significance LSIL low grade squamous intraepithelial lesion AGC atypical glandular cells ASC H–atypical squamous cells–cannot exclude a high grade intraepithelial lesion HSIL high grade squamous intraepithelial lesion Declarations Ethics approval and consent to participate This study was approved by the Hospital de Clinicas do Paraná Ethics Committee in Human Research and is registered with the identifier number 02993918.9.0000.0096. Consent to participate was no applicable for this study’s design. Consent for publication Not applicable, does not contain individual person’s details, images or videos. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors have no relevant financial or nonfinancial interests to disclose. Funding The authors declare that no funds, grants, or other support was received during the preparation of this manuscript. Authors’ contributions All the authors contributed to the study conception and design. Material preparation and analysis were performed by Tatiane Andreia Schwingel and Leila Caroline Souza Reis. The first draft of the manuscript was written by Paula Vieira de Mello, who also participated in the data analysis, and all the authors commented on previous versions of the manuscript. Professor Rita Maira Zanine was responsible for data collection supervision and data analysis and participated in all the colposcopies performed. All the authors have read and approved the final manuscript. Acknowlegments Not applicable. References Freeman-Wang T, Walker P. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4986862","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":349819775,"identity":"3dadfaba-7e45-4e3c-a21b-c9144fca2a0b","order_by":0,"name":"Tatiane Andreia Schwingel","email":"","orcid":"","institution":"Universidade Federal do Paraná","correspondingAuthor":false,"prefix":"","firstName":"Tatiane","middleName":"Andreia","lastName":"Schwingel","suffix":""},{"id":349819777,"identity":"16345b47-613c-4905-8573-7650ca6cb226","order_by":1,"name":"Leila Caroline Souza Reis","email":"","orcid":"","institution":"Universidade Federal do Paraná","correspondingAuthor":false,"prefix":"","firstName":"Leila","middleName":"Caroline Souza","lastName":"Reis","suffix":""},{"id":349819780,"identity":"0a50be67-41ca-49e8-af1f-0e4bf3506964","order_by":2,"name":"Paula Vieira de Mello","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYHACxgNgip25geEDkGZjJ0IPRAszYwPjDJAWZlK0MPOAGQSUm7OfMTjwg+FwND8zY+Njm1/b5PmYGRg/fMzBrcWyJ8fgYA/D4dyZzYzNxrl9tw3bmBmYJWduw63F4ECOwQEehrTcDYcZ26Rze24zArWwMfPi03L+jcHBP0At+0FaLHtu2xPWciPH4DAPg03uBmagFoYftxMJarGc8azgsIyBTe6Mw4zNhr0Nt5PbmBmb8frFnD9548M3FRK5/e3NBx/8+HPbdj6Q8eEjPochkcCE0AYmG3CrR1IMBX/wKh4Fo2AUjIIRCgAW3lA3yoqgJAAAAABJRU5ErkJggg==","orcid":"","institution":"Universidade Federal do Paraná","correspondingAuthor":true,"prefix":"","firstName":"Paula","middleName":"Vieira","lastName":"de Mello","suffix":""},{"id":349819783,"identity":"e8d2da9a-098e-40fd-a258-c0bcf46aa340","order_by":3,"name":"Rita Maira Zanine","email":"","orcid":"","institution":"Universidade Federal do Paraná","correspondingAuthor":false,"prefix":"","firstName":"Rita","middleName":"Maira","lastName":"Zanine","suffix":""}],"badges":[],"createdAt":"2024-08-27 21:27:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4986862/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4986862/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67101765,"identity":"1db635ab-3afc-4a9c-ad31-565dca900ab8","added_by":"auto","created_at":"2024-10-21 08:18:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":284278,"visible":true,"origin":"","legend":"\u003cp\u003eSample selection flowchart.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4986862/v1/c931667136277ba4001275c7.jpg"},{"id":93092469,"identity":"3bd32fad-112f-4531-8bbd-5736085c0c35","added_by":"auto","created_at":"2025-10-09 02:51:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725721,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4986862/v1/6c14acc2-49fa-45c4-8244-418d08aa922a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unsatisfactory Colposcopy in Late Postmenopausal Women: The Effectiveness of Conjugated Topic Estrogen","fulltext":[{"header":"Background","content":"\u003cp\u003eAmong women in the preconized screening age group for cervical cancer, one-third were over 50 years of age. Compared to young women, those aged 65 and older represent 20% of cervical cancers and have a higher rate of mortality. Moreover, vaginal atrophy and, in some cases, physical mobility issues make screening, diagnosis and treatment more difficult in individuals over 10 years postmenopause. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLow estrogen levels cause cellular glycogenization in the cervical epithelium, causing Papanicolaou (Pap) smears to mimic dyskaryosis and cervical intraepithelial neoplasia (CIN) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Reactive inflammation and coexisting infection may also cause this problem [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The result of these changes is the poor positive predictive value of atypical Pap smears in postmenopausal age groups [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies have shown that the longer the duration of the postmenopausal period is, the greater the rate of atrophic changes in cytology tests [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe hypoestrogenic state of climacteric women challenge the performance of colposcopy due to the inaccessibility of the Transformation Zone (TZ), which can be located inside the cervical canal (type 3 TZ), resulting in unsatisfactory colposcopy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is due to the effect of decreasing estrogen levels on cervical collagen [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, acetowhite changes secondary to the thinning of the epithelium and the lack of intracellular glycogen, which may result in iodine negativity, can mimic CIN [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe location of the TZ inside the cervical canal can also result in incomplete excision of preneoplastic lesions, with increased failure rates of treatment for women older than 50 years [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is noteworthy that there are few Latin American reports on the relationship between genital atrophy in women over 50 years of age and the effect of vaginal estrogen cream on the improvement of cytology tests and colposcopy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study aimed to assess the effect of conjugated topical estrogen on cervical cytology and the topography of the TZ in late menopausal women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional retrospective study was performed by analyzing the electronic medical records of postmenopausal women who had undergone colposcopy at the outpatient public practice of Hospital de Cl\u0026iacute;nicas do Paran\u0026aacute; in southern Brazil between January 2010 and February 2020. Institutional ethics committee approval was granted.\u003c/p\u003e \u003cp\u003eCervical cytology (Papanicolaou smear) was performed via conventional method. Colposcopy was performed by applying 5% acetic acid to the surface of the uterine cervix and evaluating the TZ and any possible lesions. Colposcopy was considered satisfactory when the entire SCJ could be visualized. The TZ was then classified as TZ 1, 2 or 3 according to its topography. The exam was considered positive when any abnormal findings were observed.\u003c/p\u003e \u003cp\u003eEligible patients were those over 50 years of age who were experiencing at least a 12-month period of amenorrhea and who were referred for abnormal Papanicolaou smears. Those with abnormal cytology, negative colposcopic examination results and clinical signs of hypoestrogenism received 0.625 mg/gram conjugated estrogen cream in 0.5 g doses for 21 days, with a 7-day pause, for 3 consecutive months. At the end of treatment, repeat cytology and colposcopy were performed.\u003c/p\u003e \u003cp\u003eThe collected data included the position of the squamocolumnar junction (SCJ) and TZ, the presence of minor and major colposcopic findings, and the biopsy result, when needed. For subjects with negative colposcopic findings, follow-up was performed at 12 months, and estrogen treatment was maintained two times a week until the test was repeated.\u003c/p\u003e \u003cp\u003e In cases of high-grade lesion diagnosis, appropriate management was conducted based on the biopsy results according to national guidelines for cervical neoplasia.\u003c/p\u003e \u003cp\u003eSubjects with invasive cancer, previous hysterectomy, endometrial disease, incomplete data on their records, and who presented with positive colposcopies at entry were excluded from the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the ten-year period of this retrospective study, the medical records of 223 postmenopausal women were analyzed. The mean age of the subjects was 57 years, and the mean time of menopause was 9.4 years.\u003c/p\u003e\n\u003cp\u003eAt the starting point, 74 of those women had visible SCJs on colposcopic examination, and 149 had unsatisfactory colposcopies due to nonvisible SCJs. Seventy-six subjects presented abnormal findings in the initial examination and received specific management, while 147 had negative colposcopies. There were 49 patients lost to follow-up, for a final sample of 98 women. (Figure 1)\u003c/p\u003e\n\u003cp\u003eAfter 3 months of estrogen cream treatment, control colposcopy revealed visible SCJs in 32 patients (32.6%) (TZ 1 and 2), compared to visible SCJs in 20 (20.4%) patients at the starting point. Of the 78 (79.6%) women with TZ 3 in the initial colposcopy, 66 (67.3%) had their SCJs remaining on the same topography (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1\u003c/strong\u003e - Cytological findings and colposcopic examination.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eThe initial abnormal cytology tests revealed 35 patients (35.7%) with atypical squamous cells of undetermined significance (ASCUS), 18 (18.4%) with low grade squamous intraepithelial lesion (LSIL), 6 (6.1%) with atypical glandular cells (AGC), 33 (33.7%) with atypical squamous cells \u0026ndash; cannot exclude a high grade intraepithelial lesion (ASC-H), and 6 (6.1%) with high grade squamous intraepithelial lesion (HSIL). (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2 -\u003c/strong\u003e Initial cytology and after estrogen supplementation.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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/X9Hg1S+08T52OWCBh1Ht2NxWaKW0X7HPE3X/H1R2aj8dHl5Wc25PwQZGIoyryq+GGj42YK6qFm/rJoHIJELVsm7M1QR9is81Xrh5zBcETv46FYh3xd1i9QFP0ofVSxKv9iKoGNXuvpBUN3J+FkX0zF2e6jVd8ZxudbXNnXORK0BcXvaj2lsIVC6xPylvBLzzqzxuY3fntCgO1BXoKpYdYyqgLtxIJr/sKDu4KfhLrYb5TNdu/HYNYiuE+XZPN+KWkZn9ZibpPSJrTZKB1378UHQe1OeWDwwkzytZcV250/epMy86TPKQqKac/eP5Txonuj9cX5ZcKb5EpdpexqbP0eD9kP02tsVf66XW3yvh7IAr5YOT+8fl467bh80T9vXPjsNuu2z1/WQn5tcXTponuXnrd/2etH7x1WXj7RP+XHEPOT3WJ6GGkY593Gbk1Z3XZk+N+bnQY4nXye/HiZF2x6Xz2XMh6bj8LnVOB5Tvv4wx6y07lZG1O3HMLSNpg2y/1rHaaEhlpOx7PH74hCvp0njFz8fIN35TMtp1d2Ivr8ev06lu1I1BcfulGk3TWk6rR5aGnHOO5EmnUiT3uguQaP04Fr+jQj1+cffggAAPEy0ZDxA0xZZq4//PDykt7e3N1OtGMLdSn8PLY04551Ik06kSW8EGQ8QmX7ySNP+Hloacc47kSadSJPe6C4BAACNIMgAAACNIMgAAACNIMgAAACNIMgAAACNIMgAAACNIMgAAACNIMgAAACNuPNjXPpREQAAgHEpvOAXPwEAQCPoLgEAAI0gyAAAAI0gyAAAAI0gyAAAAI0YOsi4uLhI30LJv4ni+Ro35ejoqFheXq6mrm1sbKQBGIXyk/NznrdQFKenpzfpo2F/f79aMps4353i+aUsvUW6dBrl+hm5JWNpaanY3t6upu7P8fFxGoBhqeDQhaIvWGnQawqTW7phePLkSXF4eJjS5/z8vNjZ2UnB/izifHdSGmxtbd2kydnZ2VSU6/eNdOk08vVTrjyUsqDRV17/lAVPGms6zve0lIFImqdhfX29mnvN8+Ng8X3liU7z9vb27qyrdUTLvY7mn5ycpNeS75P2IX8/2qkuvyrv5PPaTNdcft3qWsvnzQLOdycff+Ryvc1Il07jXD8jt2SsrKwUZWHTNbpThLO2tqazkgZxU6uWOUosdzTNK3c0jbXs8+fPaZnmHRwcpCbbN2/epDsqtaBomSLLnPbny5cv1VRRfP36Nc1bXFy82U/vj/aNiL29rq6u0lh5w+bn59PYy9ru169fd9JHHj9+XHvtTTvOd6fLy8tUnkYLCwtp3GS397QjXTqNc/2M9eDnx48fi2/fvqUgINKJ0PzXr19Xc4ri5cuXxadPn9JrFVL//vtver26uprG3lF1fXieDkgnWyd9EPoMBSWmz9M80fzd3d30Wl68eHFnXSCvUNHp0aNH1avZx/nu5IoDd5EunQa9fsYKMvQhe3t7NxV5TgGCHxJ5/vx5Nfe6v+vHjx/ptQMUn0QFKH6PBrdwDOLZs2dprG1q0Hs9T9S/7O3qNRC1+e5tUL9//65ezT7Od6e2tur0Q7p0GvT6GSvIEHVjqDJX10RO8909kXdxqBXBlb26QRwVKTDRtN+TN1v1o24YdZn873//S68jdc3E/dGAdopBrbkgcUta26lrJC9I1IWirsZZw/nupC6A/CbOXQVtbuUhXTqNdf2UFe1QysTveNjDD8XE+Xo4zA9k5vL3R1qmB0rED5Zo+3E60mfEz/E6ZYa42Y5onVl8YA3NUR6JeadXnm0jX0u+jnztx+tqlnC+O+l86gFfUxrF6bYiXTqNev1MJMgQfaDmR9opzfPgHYpBiQcXXHGZ3q/tOsgQb1PzRdvMD1TraMh5Hz14G2gv8kNv+bUar8VZFI+F831bnnsYpNJoA9KlXkyTQa+fv/4vrGpuKQOA1Bzlpid9714PZc7iU+sAAKDe2M9kDMv9OLFvSw+T6WFQAADwcPz1lgzR72XolwNNLRu0YgAA8LDcS5ABAAAevr/eXQIAANqBIAMAADSCIAMAADSCIAMAADSCIAMAADSCIAMAADSCIAMAADSCIAMAADSCIAMAADSi4xc/3759W70CAAAYzbt37/hZcQAA0Ay6SwAAQCMIMgAAQCMIMgAAQCMIMgAAQCPGCjLm5uaK5eXlaurWxcVFWubh6OioWnJN03H59vZ2taSTltUt39jYKPb396up62lvT68BUR6Jee309LRacp1/64a4Ttvp2ntIaaPyysdSV3a1UTy/lJ3XYn3igXJhtOtn5CBDgcL6+np6nSf+0tJScXh4WOiLKxo+f/5cLbku9J8/f16cn5/fLJc8EBmGgxBv7+nTp2QIpGD306dPN/lib2+vePLkSbX0Nr94UJ5V3l1dXa3WaDddQ0pDp8/W1lbx8uXLaunsUcWhgtHHo9dtr1SVBjqvTpOzs7OeN31tovLC6aKh7eXCyNdPufJIygDjT1ko/ykzaBqsDB4UNfw5OTmp5tzqtaybfPumzy8zwc3runWAyPlP4zplgHGTp9BJ1+0YRca9qjv3Pp5u+eGhqzufKtNn9RxPUqxfMN71M1JLhu5uvn37VqysrBQvXrwoDg4OqiVFsbi4mFo4dMeYtyb8/PkzjScdEeruSvtABI5erq6u0lh5NKeWtPJiKd68eVPNQe79+/fprncW1Z37+fn5NPaytrm8vEwtd9HCwkIaq4xvu52dnZuugbbXLeNcPyMFGV+/fk2BhD5QAYMyauzuOD4+vmmazvuy8kw9Cc+ePUsVhAINMgS6UTCqfFlnd3e367I2i8+0yMePH9P4IagLNtvOFUfbqQ4rb8LT4LolPgOIwa+fkYIM9XPHvtm1tbVUSEe6I9QJUj93XatGHfXxuEAbtq9UB+xMQasGcsoPyl91LRXKmypINjc3qzkwX8cadM3r2hzkWp4F3K13amurTi+qW9SC999//1VzIINeP0MHGS6Q9fCmAwJV6ppXV/iolUGtF2qaU/dKt/VEDx25QFMkKY8fP649GK376NGjauou3ZFSgMAUYHz//v0mT+XcDcCdbW/xWp41vkOP5YIr1LY+0KeuEZXHkbtQuBY6tTlNxrp+ygp9KHrAUg/F5MqMmZb5YVDzwyEai5blH6sHbPS+On5/XK714zby7XlfAOXVuvxqgz681Ea6zjRYfi3PmrxcUL5oezmh8xnPsdIoTreR8nevOqytRr1+hg4yuiV2rPj14XrtIV/f63rot6M+yXGI/ES0h7YXHLhWl2/y/NEvCGm7PO1mvaCNx8J5v/3WgAfKzmuqUGO6zHq+n5SYJoNeP/wLKwAAaMTIP8YFAADQC0EGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoBEEGAABoRMcfpL19+7Z6BQAAMJp37951BhkAAACTQHcJAABoBEEGAABoBEEGAABoBEEGAABoxNBBxsXFRTE3N5fGuf39/bTMg52ent6Z1nobGxvVFNCso6OjlP+2t7erObeUD+vyLO7qlYazxOXX8vJyNQcx/1Mu33K9RZrcGuX6mVhLhgqhnZ2dQl9W0XBycpKCCeA+6WL48eNHsbW1Vc25pQrz7OzsJs9qHSqfes+fPy/W19erqdmk8722tlYcHh5Wc6D8rnzva0DXw6wHkpOgwOL9+/fF3t5eNQejXj8TCzJ+//5dLC0tVVNFsbq6Wrx586aaAu6HCs2PHz9WU3cdHBwUnz9/rqaK4vXr18X5+Xm6g8EtFS4qbBcXF6s5s0n5QPkB15TPld/j9aGKVddF2x0fH6cBt0a9fiYWZGxubqYMy50gZoG7++bn59NYXIleXl6mMa5bKL9//84NwwOkfB5vDGVhYSGN67rDgVFMLMhQAa3mNhm2zwaYFnmh23bqJomtPXjYYtANTMLEggxzH7eCDAINzBq1xuGauknUX6+uT7TD1dVV9QqYjIkHGba7u0uBjanlrpFYqLqJeGVlJY3bTt0k6p/3Nw/02tOYfeoayctod6HM+vM3mB4TCzL0NG58YO7Lly80PWOq6dsSetDNPnz4kOZRwF5zq6QHtWr4mwiYfW6hit8C1M3hq1evqilgAsoCYyhl5KsS5s5QBhMd8zXPTk5O0jzb29u7s64GzQMmTfkwz2tlRVktvbs85ll0UrrFtJs12veYDzjnneX5LJ/fSSpvNu6kiwbNa7NRrx/+hRUAADSisWcyAABAuxFkAACARhBkAACARhBkAACARhBkAACARhBkAACARhBkAACARhBkAACARhBkAACARhBkAACARhBkAACARnT8d8nbt2+rVwAAAKN59+5dZ5ABAAAwCXSXAACARhBkAACARhBkAACARhBkAACARowVZMzNzRXLy8vVVCct0zoeNjY2qiW38nUuLi6qJUDzTk9P7+S/ujzaZnn67O/vV0tmUyxvepVdbRLPL/n/FunSaZTrZ+Qg4+joqFhfX0+vVRBFChS0E2tra4W+vOJhcXHxTiGVr3N+fp6mgb9B+fbJkycp3zkPHh8fV0uh61jpc3h4eHN97uzspGt/FqmiUMHoc63Xba88lAZbW1s3aXJ2dlZsb29XS9uLdOk08vVTrjySMsD4UxY+f8oTkYZIy/J5OS3XesB9cR5Gvb29vY5rdFav2zJA0lf109hOTk465rWJjz/S9TBGtfAgkC6dxrl+RmrJ0B3Ot2/fipWVleLFixfFwcFBteR2meb38v379+Lp06fVFPD3KZ/u7u7eNP9pyFvl2uzXr1+p9TF6/PhxuqubNVdXV2kcj2d+fj6NvaxtLi8vi6WlpWrq2sLCQhq3uduadOk0zvUzUpDx9evX1FWiD1xdXU0nJG9C9Q706tN99OhR9Qq4H+/fv9ftSRrKO/fUPYDuHtI1mwdQuC23cRfp0mnQ62ekIOPTp0/Fy5cvq6kiPUehO8LI0Y2CEBfiCkyAaeI7FNnc3EzjNt/F9fP79+/q1ezjPHdqa6tOP6RLp0Gvn6GDDLVMnJ+fF8+fP79pnVB3ieZpmaIbtWx8+fKlekc9BSafP3+upoC/T/lUTaOop66RvCBRF8osPpztO9F4PPFGqI0UYKvcjtxV0OZWHtKl01jXz58hdXvwqzwBNw97+oGQ/OFPvU8Pk4keFtE6njZtB/gblD9jfpvVhxqb4utYY/E16+lZE8so0bnOy6i2yctgpVFeJrcR6dJp1Otn6CCjWyGjE6BlkabzIZcvV0EG/C26cJz39Bp3+al6D7P+bZx4LASUt4Gjh7YHXUa61ItpMuj1w7+wAgCARoz8Y1wAAAC9EGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGEGQAAIBGdPxB2tu3b6tXAAAAo3n37l1nkAEAADAJdJcAAIBGEGQAAIBGEGQAAIBGEGQAAIBGjBVkzM3NFcvLy9XUrYuLi7TMw9HRUbXkmqbj8u3t7WpJJy2rW673nZ6eVlNAvf39/Tt5LeaZPJ9ubGxUSyB52j2EdFJ55eOoK7vaJi+Ldc5xLaYLZcO1Ua6fkYMMZc719fX0Oq/sl5aWisPDw0JfXNHw+fPnasl1wfX8+fPi/Pz8ZrnkgQgwLgURnz59uslne3t7xZMnT6ql1wHsyclJWqb8+O3bN/Jh8ObNm5u086Br++XLl9Uas0UVhQpGH4tet73yUFns9FCZvbOzk66btlPe2Nraukmbs7OznjfDbTDy9VOuPJIywPhTZso/5YlIg5WFtaKGP2XhXc251WtZN/n2bdjtAM5/GtdRni4DkWoKOV3vYxQZ96ru3Kv86JUf2ohy9TZfRLOc9ydhnOtnpJYMRbq661tZWSlevHhRHBwcVEuKYnFxMbVw6I4xb+H4+fNnGq+urqYx8DddXV2lsfJoTnlVeXpzc7Oag9zu7m5qDZpFded+fn4+jb2s7dTKrJaqtpfPl5eXKR2ihYWFNG5rK884189IQcbXr19TIKEPVIbUCYnNzMfHxzdN0+q7icFGfvIGoSDG/UAegGGpmT+vJJ2flFfLyLw2AMF1d2Z5x5K6UB4KzvV1cO1rQF0l6hZAJ1eouDXo9TNSkKF+7tgvu7a2lu5yIvfnqp+vrlWjjvp4nOFjX0/sG/MADEP9qcpfeSUZ85TydNv76LvRc1W6Dh8Snj24blV2/lcQqbKXhz870drVadDrZ+ggQ8GCMqMeGHJAoJYGzasLJJ49e5ZaL9QEpe6VbuuJomhneLWGAJOgAOP79+9989T79++5k6uh61VdSa9fv67mzB7ficaC0RUH3bfXdGeqQPLXr1/VnHZS14jqqchdKG1t/Rrn+hk6yPjy5UvqKnEw4EEnQMvUrBqfwnVQohPnTByf8BdFzjzVjyaoZUIXRl3woAA50t26Wjtwl4IvXbezXMBq31VGffjwoZpze1xtpbI5b7nTDePjx4+rqXZypRlbdNRS/+rVq2qqfca6fsoAYSh6S93Tx3oq35vTU/p67SFf3+t6KHe0WtJJy+qW120XiPz0cz44P+X5UPkWdzkNH8q1xvm+Ky+rdU3g9tsUHnrVUW0S02TQ64d/YQUAAI0Y6cFPAACAfggyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIwgyAABAIzr+u+Tt27fVKwAAgNG8e/euM8gAAACYBLpLAABAIwgyAABAIwgyAABAIwgyAABAI4YOMi4uLoq5ubk0jvb394uNjY1q6npa63mw09PTO9Pb29tpAO6D8/Py8nI1BzlfyxrPOs53J6WHh1iGt53rKtLklq4b55VBr6FGWjKOjo6KnZ2dQl9c0XBycvIgCig8LApu19bWisPDw2oOcipMZH19PY1nGee7kyqKra2tm7L67OyMm76SAov3798Xe3t71RwoTZRfnFf0epAArJEg4/fv38XS0lI1VRSrq6vFmzdvqilgOnz8+DEVquhOhclDuXY533fpTv38/Dyli6liPTg4qKba6/j4OA24phbAb9++3ckru7u7aV7eq5FrJMjY3NxMmXfQ5hQAwN91eXl552ZQFhYW0rhfxYF2ubq6SuPFxcU0lvn5+TT2sm5GDjKUOd03o0HdI6Yd0R2QDNN3AwC4P644gH5iwNHLyEGGWircN6Ohru9KTZNapiCDQAMAplu/u1LABm3taqS7JKe+GwUlAIDpoK6RvFx2F8qgd6loB7dwxcDCAameueylkSBDT5zqoSL78uVLR98fAOD+uHKI3/zTDeGrV6+qKeCagk7V4R8+fKjmXD8krG8m9fVnSGXkq4ct0jja29v7s76+nl57HQ/lzqX5cnJykuZZuZN31tVweHhYLQWaU5f3Yl5FerCqY9C1Pos4353yslpphD+pLovposH1W5uNkh78CysAAGjEX3kmAwAAtA9BBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaARBBgAAaETHf5fMzc1VrwAAAEaj8II/SAMAAI2guwQAADSCIAMAADSgKP4fDcM9+vfM1wMAAAAASUVORK5CYII=\"\u003e\u003c/p\u003e\n\u003cp\u003eAfter estrogen therapy, 27 (77.1%) of the 35 patients with initial ASCUS were negative, 3 had the same result, and 5 had high-grade cytology. All 77.1% of the patients remained negative at the 12-month follow-up. (Table 3)\u003c/p\u003e\n\u003cp\u003eOf those 17 tests corresponding to the LSIL, 10 (55.6%) were negative after estrogen therapy, 5 (29.4%) persisted, and 2 (11.7%) presented higher-grade results. One patient with initial LSIL underwent cold knife conization without repeat cytology due to abnormal findings suggesting a high-grade lesion in the control colposcopy. After 12 months, 77.8% of the patients were negative.\u003c/p\u003e\n\u003cp\u003eAmong the 6 women in the AGC cytology group, all had negative results 3 months after estrogen therapy, but 1 (16.7%) returned an AGC result after 12 months.\u003c/p\u003e\n\u003cp\u003eAmong the 33 women in the ASC-H subgroup, 23 (69.7%) were negative after estrogen cream treatment, 7 (21.2%) had ASCUS, and 3 (9%) had AGC. At the 12-month follow-up, 90.9% of the patients were negative.\u003c/p\u003e\n\u003cp\u003eOf the 6 patients with initial HSIL, 2 (33.3%) underwent conization because of major findings in their control colposcopies, and cytology was not performed. One patient (16.7%) became negative, 1 with ASCUS and 1 with LSIL. One patient had a repeat cytology result of ASC-H, was subjected to conization, and was diagnosed with stage 1a1 microinvasive carcinoma. After 12 months, one more patient became negative, and 1 persisted with HSIL.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe topography of the TZ is influenced by age, hormonal status and parity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Hypoestrogenism leads to cervix stenosis, and there is greater difficulty in viewing the SCJ with advancing age [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The decrease in hormone receptor cells in the TZ of women in a state of hypoestrogenism explains the greater consistency of the cervix and the cranial location of the TZ [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the use of estrogen therapy led to clinical improvement of atrophic signs during colposcopy, as previously reported by Roberts et al. in a classic study on colposcopy and hormone deficiency [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, it was found that the use of estrogen modified the rate of satisfactory colposcopy to a nonsignificant extent, from 20.4\u0026ndash;32.7%, differing from other studies in which this evaluation was performed.\u003c/p\u003e \u003cp\u003eIn 2015, Richards and Dalrymple reported a significant difference in the percentage of satisfactory colposcopies, ranging from 32\u0026ndash;64%, after the use of vaginal estrogen cream [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there was no description of the time women were menopausal or of their average age, only the indication that they had one year of amenorrhea [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Another large Italian study of local synthetic estrogen with low potency for 3 months reported an improvement in the percentage of patients with satisfactory colposcopies from 17.2\u0026ndash;73% in women aged 54.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5 years and menopausal time between 4 and a half to six years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the study by Prendville et al., 64% of colposcopies were adequate for the control examination using an oral estrogen regimen; however, the age range of these subjects was 20 to 47 years, and none were menopausal [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, Saunders et al. compared placebo and estrogen and reported that 71% of women aged 21 to 62 years in the treated group had satisfactory colposcopies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe subjects in our study had a mean menopausal time of 9.4 years. All the previously mentioned articles included women who had a shorter menopause time or who were still of reproductive age.\u003c/p\u003e \u003cp\u003eAn increase in SCJ eversion after estrogen administration was not detected in the present study because the subjects were mostly in a late menopausal period and consequently lacked endogenous hormonal activity. With the deep and cranial SCJ in the cervical canal, the reach of estrogen cream to the receptors may have become difficult.\u003c/p\u003e \u003cp\u003eIt was observed in the present research that cytology had a different evolution from colposcopy findings. Of the subjects with an initial cytological diagnosis of ASC-US, 77.1% had a negative control test and remained negative during the follow-up. In a similar study, only 5.1% of ASC-US patients received surgical treatment, a number very similar to that in the present study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe finding of ASC-US in Pap smears includes a broad spectrum of cellular changes, such as an increased nucleus/cytoplasm ratio, perinuclear halos in intermediate cells, increased numbers of basal and parabasal cells, and pseudokeratosis, which are similar characteristics to atrophy changes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It is clear that in postmenopausal women, there is a greater incidence of false positives, leading to unnecessary invasive exams and emotional stress from \"indeterminate\" diagnoses [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The correct diagnosis of this category is a challenge in this hormonal period of life. It is known that neither the ASC-H nor the ASC-US/LSIL ratio has the same positive predictive value for high-grade intraepithelial lesions, as is the case for menacme lesions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen performing cytomorphological analysis of cytology smears from women over 60 years old, Backes et al. classified 95% of the samples as atrophic and 10% as LSILs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the present study, 55.6% of patients with initial LSIL were normal in the first control cytology, but 10% needed excisional treatment in the second control because they showed persistent abnormalities, revealing high-grade lesions in the histopathological study. Selvaggi et al. reported that atrophic vaginitis can mimic the granulomatous background of squamocellular carcinoma or squamous cell carcinoma (SCMC), as well as LSIL, which can be a diagnosis of a true high-grade lesion [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, the use of estrogen improves both false-positive and false-negative results and better defines true lesions.\u003c/p\u003e \u003cp\u003eSaad et al. reviewed cytological tests and compared them with histology to identify possible causes of inadequate interpretation of ASC-H and HSIL and false positives in postmenopausal women. They reported a greater frequency of ASC-H cytology results in women over 55 years of age and showed that estrogen deficiency leads to the mimicking of high-grade lesions. These older women have less reliable diagnoses than women of reproductive age. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn the sample studied, a relatively high percentage of initial ASC-H cytological tests (33.7%) were observed. After the administration of estrogen cream, approximately 69.7% of the patients had negative results in the control cytology, and none of them presented with high-grade lesions or cancer by the end of the 12-month follow-up period. Ratree et al., when investigating women with ASC-H, reported a 30.8% rate of high-grade lesions and a 4.5% rate of invasive disease [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParabasal cells and reactive and inflammatory changes can easily mimic the changes found in high-grade lesions, which are characterized by coarse chromatin, an irregular nuclear membrane and hyperchromasia of the cell nucleus [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the present study, a low and true incidence of HSILs was observed. Only one subject had negative control cytology results after the use of estrogen cream.\u003c/p\u003e \u003cp\u003eIn 1982, Paterson reported that estrogen absorption occurs mainly in the first months of treatment, when the epithelium is still thinner, promoting better absorption [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. After this period, the epithelium becomes thicker and more mature, and the upper third of the epithelium is composed of superficial cells that are poor in receptors and do not react to estrogen cream [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the present study, the same phenomenon was observed. Estrogen therapy has a positive effect during the first three months of therapy, and this effect remains stable until the months of follow-up.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIt can be concluded that the use of estrogen did not improve the position of the SCJ/TZ, presumably due to the age and prolonged menopausal time of the study subjects, and that topical estrogen improved cytological changes, leading to decreased false-positive cytology tests. Thus, estrogen cream therapy should be recommended prior to obtaining new cytology data and performing colposcopy to monitor cytological changes. Further research should be performed to further comprehend the dosage and duration of estrogen therapy, considering the individual duration of menopause.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePap\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePapanicolaou\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCervical intraepithelial neoplasia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTZ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransformation Zone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSquamocolumnar junction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASCUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eatypical squamous cells of undetermined significance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSIL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow grade squamous intraepithelial lesion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAGC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eatypical glandular cells\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eH\u0026ndash;atypical squamous cells\u0026ndash;cannot exclude a high grade intraepithelial lesion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSIL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehigh grade squamous intraepithelial lesion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the \u003cem\u003eHospital de Clinicas do Paran\u0026aacute;\u003c/em\u003e Ethics Committee in Human Research and is registered with the identifier number 02993918.9.0000.0096. Consent to participate was no applicable for this study\u0026rsquo;s design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, does not contain individual person\u0026rsquo;s details, images or videos.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or nonfinancial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors contributed to the study conception and design. Material preparation and analysis were performed by Tatiane Andreia Schwingel and Leila Caroline Souza Reis. The first draft of the manuscript was written by Paula Vieira de Mello, who also participated in the data analysis, and all the authors commented on previous versions of the manuscript. Professor Rita Maira Zanine was responsible for data collection supervision and data analysis and participated in all the colposcopies performed. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowlegments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFreeman-Wang T, Walker P. Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause. 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Effects of the climacteric and sequential mestranol and norethisterone on the cervix and genital tract. Br J Obstet Gynaecol. 1982;89:657\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1471-0528.1982.tb04722.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.1982.tb04722.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMustafa FE-ZA, Elhanbaly R. Distribution of estrogen receptor in the rabbit cervix during pregnancy with special reference to stromal elements: an immunohistochemical study. 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Am J Obstet Gynecol. 2003;189:1660\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0002-9378(03)00852-4\u003c/span\u003e\u003cspan address=\"10.1016/s0002-9378(03)00852-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"atrophy, postmenopause, Papanicolaou test, unsatisfactory colposcopy, vaginal estrogen therapy","lastPublishedDoi":"10.21203/rs.3.rs-4986862/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4986862/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMenopause\u0026rsquo;s hypoestrogenic state which is characterized by atrophy can lead to incorrect interpretation of the cytological smears, as well as it can turn colposcopy challenging because of non-visualization of squamocolumnar junction. This study aims to determine the effect of estrogen therapy on the topography of the colposcopic transformation zone in hypoestrogenic patients and its effect on the differentiation of abnormal Papanicolaou smears secondary to atrophy and true intraepithelial lesions to improve the management of cervical disease after menopause.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a retrospective evaluation of postmenopausal women aged 50 years or older who were treated between January 2010 and February 2019 at a public hospital in southern Brazil and who had abnormal cervical cytologies and negative initial colposcopies and who were subjected to topical conjugated estrogen therapy and follow-up evaluations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNinety-eight patients aged 57 years and 9.5 years after menopause were included. After 3 months of conjugated-topic estrogen therapy, the rate of satisfactory colposcopy ranged from 20.4\u0026ndash;32.7%. Of the 78 (79.6%) subjects with a type 3 transformation zone in the entry colposcopy, 66 (67.3%) remained in the same topography. Additionally, of the 98 patients, 67 (68%) had negative cervical cytology results after treatment. Persistence of high-grade intraepithelial lesions was observed in 33.3% of the patients, 16.7% of whom were diagnosed with microcarcinoma.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe use of conjugated topical estrogen improved the accuracy of cytology smears in late postmenopausal women. However, it did not show a good response in the topography of the transformation zone and, consequently, a satisfactory colposcopy rate.\u003c/p\u003e","manuscriptTitle":"Unsatisfactory Colposcopy in Late Postmenopausal Women: The Effectiveness of Conjugated Topic Estrogen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-21 08:17:59","doi":"10.21203/rs.3.rs-4986862/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2c69cec8-44ed-420a-9980-06df129d29c8","owner":[],"postedDate":"October 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-09T02:39:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-21 08:17:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4986862","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4986862","identity":"rs-4986862","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}