Effect of Endometriosis on Colposcopy Findings in Patients with HPV Infection: A Cross-Sectional Study

Effect of Endometriosis on Colposcopy Findings in Patients with HPV Infection: A Cross-Sectional Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 11 September 2025 V1 Latest version Share on Effect of Endometriosis on Colposcopy Findings in Patients with HPV Infection: A Cross-Sectional Study Authors : Shaghayegh Vandadi , Akram Ghahghaei-Nezamabadi [email protected] , Reihaneh Hosseini , Kasra Jafari 0009-0002-1029-1000 , and Amirhossein Hajialigol 0000-0001-7701-9840 Authors Info & Affiliations https://doi.org/10.22541/au.175758019.94953156/v1 455 views 122 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Endometriosis is a chronic gynecological condition characterized by ectopic endometrial tissue, which may influence host immune response and alter the clinical course of concurrent infections such as human papillomavirus (HPV). However, the impact of endometriosis on colposcopic findings in HPV-positive women remains understudied. Objective: To evaluate the effect of endometriosis on colposcopy findings and HPV genotype distribution among HPV-infected women. Methods: In this cross-sectional study conducted at Arash Women Hospital (2024–2025), 801 HPV-positive women were enrolled and stratified into two groups: 400 women with confirmed endometriosis and 401 controls without endometriosis. Data on demographics, reproductive history, HPV genotyping (high-risk vs. low-risk), and colposcopic findings (normal, aceto-white changes, coarse mosaicism) were collected and analyzed. Statistical comparisons were made using chi-square and t-tests. Results: Women with endometriosis were more likely to exhibit abnormal colposcopic findings, including aceto-white changes (38.5%) and coarse mosaicism (31.0%), compared to controls (10.0% and 7.8%, respectively; p < 0.0001). Normal colposcopic patterns were significantly more common in the control group (82.2% vs. 30.5%). Additionally, high-risk HPV genotypes were more prevalent in the endometriosis group (73.2% vs. 40.5%; p < 0.0001), despite no significant differences in age or BMI between groups. Conclusions: Endometriosis in HPV-positive women is associated with a higher prevalence of high-risk HPV genotypes and a greater frequency of abnormal colposcopic findings. These results support the need for personalized colposcopic surveillance and risk-based HPV screening protocols in this population. Effect of Endometriosis on Colposcopy Findings in Patients with HPV Infection: A Cross-Sectional Study Shaghayegh Vandadi 1 , Akram Ghahghaei Nezamabadi 1 , Reyhane Hosseini 1 , Kasra Jafari 1 , Amirhossein Hajialigol 2 Depatrtment of Obstetrics and Gynecology, Arash Women’s Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. MD/hMBA cahndidate, Alborz Office of Universal Scientific Education and Research Network (USERN), Alborz University of Medical Sciences, Karaj, Iran Corresponding Author: Akram Ghahghaei Nezamabadi Postal code: 77883196Postal address: 3th floor, St. 162 AVE – Baghdarnia St.- Bagheri EXP- Resulat HWY- Tehran- IranEmail: [email protected] : 00989122553368 Background\RL: Endometriosis is a chronic gynecological condition characterized by ectopic endometrial tissue, which may influence host immune response and alter the clinical course of concurrent infections such as human papillomavirus (HPV). However, the impact of endometriosis on colposcopic findings in HPV-positive women remains understudied\RL. Objective\RL: To evaluate the effect of endometriosis on colposcopy findings and HPV genotype distribution among HPV-infected women\RL. Methods\RL: In this cross-sectional study conducted at Arash Women Hospital (2024–2025), 801 HPV-positive women were enrolled and stratified into two groups: 400 women with confirmed endometriosis and 401 controls without endometriosis. Data on demographics, reproductive history, HPV genotyping (high-risk vs. low-risk), and colposcopic findings (normal, aceto-white changes, coarse mosaicism) were collected and analyzed. Statistical comparisons were made using chi-square and t-tests\RL. Results\RL: Women with endometriosis were more likely to exhibit abnormal colposcopic findings, including aceto-white changes (38.5%) and coarse mosaicism (31.0%), compared to controls (10.0% and 7.8%, respectively; p < 0.0001). Normal colposcopic patterns were significantly more common in the control group (82.2% vs. 30.5%). Additionally, high-risk HPV genotypes were more prevalent in the endometriosis group (73.2% vs. 40.5%; p < 0.0001), despite no significant differences in age or BMI between groups\RL. Conclusions\RL: Endometriosis in HPV-positive women is associated with a higher prevalence of high-risk HPV genotypes and a greater frequency of abnormal colposcopic findings. These results support the need for personalized colposcopic surveillance and risk-based HPV screening protocols in this population\RL. Keywords\RL: Endometriosis; Human Papillomavirus; Colposcopy; High-Risk HPV; Cervical Screening Introduction Endometriosis is a chronic, estrogen-dependent condition in which endometrial-like tissue exists outside the uterine cavity, often resulting in pain, infertility, and inflammatory changes in the pelvic environment(1, 2). Despite being a prevalent gynecological disorder, its systemic effects, including potential interactions with infectious agents such as human papillomavirus (HPV), are not yet fully understood(3). Given the immunomodulatory nature of endometriosis and the viral persistence mechanisms of HPV, investigating the potential interplay between these two conditions is essential for improving diagnostic and surveillance strategies\RL. HPV infection, particularly with high-risk genotypes, is a well-established cause of cervical neoplasia and remains a significant global health burden. Colposcopy serves as a cornerstone in the clinical evaluation of HPV-infected women, offering visual cues to guide the detection and management of precancerous cervical lesions(4). However, factors that may influence colposcopic patterns—such as coexisting gynecological conditions like endometriosis—have not been extensively investigated, despite their possible impact on local immune responses and epithelial integrity(5)\RL. Emerging research has suggested a possible association between endometriosis and altered HPV infection dynamics, including differences in genotype distribution and infection persistence(5, 6). These findings raise questions about whether endometriosis may modify the cervical microenvironment in ways that affect colposcopic appearance. Understanding such changes is crucial, as misinterpretation of colposcopic features could lead to under- or over-treatment in affected patients\RL. furthermore, the chronic inflammation and altered hormonal milieu seen in endometriosis may exacerbate epithelial changes in the cervix, mimicking or masking lesions typically associated with HPV(7, 8). This biological complexity necessitates a deeper exploration into how endometriosis might influence the detection and interpretation of cervical abnormalities under colposcopic examination. The presence of coexisting endometriosis could have clinical implications for the surveillance and risk stratification of HPV-positive women(9)\RL. to date, few studies have specifically addressed the relationship between endometriosis and colposcopic findings in HPV-infected populations. Most literature has focused on either condition in isolation, leaving a gap in knowledge regarding their potential interaction. With HPV vaccination efforts underway globally, and an increasing emphasis on precision medicine in gynecology, identifying patient subgroups with unique risk profiles remains a priority(10)\RL. This study aims to fill this gap by examining the effect of endometriosis on colposcopic patterns in a cohort of HPV-positive women. By comparing the demographic, clinical, and colposcopic characteristics of women with and without endometriosis, we hope to provide insight into whether this gynecological comorbidity influences cervical assessment outcomes. The findings could inform tailored screening protocols and contribute to a more nuanced understanding of HPV-related disease in women with complex gynecological histories. II. Methods 1\RL. Study Design and Participants This study employed a cross-sectional design to explore the impact of endometriosis on colposcopic findings among HPV-infected women. The research was conducted at Arash Women Hospital, a tertiary referral center affiliated with Tehran University of Medical Sciences, over a one-year period from 2024 to 2025\RL.A total of 801 women with laboratory-confirmed HPV infection were enrolled. Participants were recruited consecutively from outpatient gynecology and colposcopy clinics. Eligible women were aged between 21 and 50 years and had undergone HPV testing using polymerase chain reaction (PCR)-based methods. Based on clinical, imaging (e.g., transvaginal ultrasound, MRI), and surgical (laparoscopy or laparotomy) criteria, women were divided into two groups\RL: endometriosis group (n = 400): patients diagnosed with endometriosis and control group (n = 401): hpv-positive women without endometriosis Exclusion criteria included prior hysterectomy, current pregnancy, immunosuppression (e.g., HIV infection, chronic corticosteroid use), known cervical dysplasia or cancer, and history of HPV vaccination\RL. The sample size for this study was calculated based on a previously reported HPV prevalence of around 40% in women with endometriosis, using a standard formula with a 95% confidence level and 6% margin of error. This approach, similar to the one used in the study by Moslehi et al., resulted in a required sample size of around 270 participants(5). However, to improve the reliability and strength of the findings, especially in subgroup analyses, we increased our sample size to approximately 800 participants\RL. 2\RL. Data Collection After obtaining informed consent, data were gathered through clinical examination, structured interviews, and electronic medical records. The following variables were recorded\RL: Demographic and reproductive information: Age, body mass index (BMI), gravidity, parity, number of abortions, and method of contraceptionHPV-related data: Type of HPV infection was classified as either high-risk (e.g., types 16, 18, 31, 33, etc.) or low-risk (e.g., types 6, 11), based on PCR genotyping results\RL. Colposcopic examination: All women underwent standardized colposcopic evaluation using an optical colposcope. The examination was performed by certified gynecologists who were blinded to the endometriosis status of each patient. Colposcopic findings were classified into the following categories\RL: Normal, Aceto-white (ACW) changes, Coarse mosaicism. To ensure consistency, acetic acid (3–5%) was applied to the cervix during colposcopy, and findings were documented based on International Federation for Cervical Pathology and Colposcopy (IFCPC) guidelines\RL. 3\RL. Statistical Analysis All data were analyzed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were tested for normality using the Kolmogorov–Smirnov test\RL. descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables (e.g., age, BMI) were presented as mean ± standard deviation (SD) and compared using independent t-tests\RL. categorical variables (e.g., colposcopic findings, HPV type) were expressed as frequencies and percentages, and comparisons between groups were performed using the chi-square test or Fisher’s exact test when appropriate\RL. a p-value < 0.05 was considered statistically significant\RL. no imputation was applied for missing data, as complete case analysis was performed. Additionally, subgroup analyses were conducted to assess the prevalence of abnormal colposcopy findings within each HPV type category across groups\RL. III. Results 1\RL. Demographic and Reproductive Characteristics A total of 801 women with confirmed HPV infection participated in this study, with 400 diagnosed with endometriosis and 401 serving as HPV-positive controls without endometriosis. The two groups were broadly similar in terms of age and body mass index (BMI). The mean age of women with endometriosis was 32.6 years (±4.8), slightly higher but not significantly different from the control group, whose mean age was 32.3 years (±5.1) (p = 0.432). Similarly, the average BMI was comparable between groups—25.5 kg/m² in the endometriosis group and 25.2 kg/m² in the control group (p = 0.222)\RL. Although the differences did not reach statistical significance, women in the endometriosis group had slightly higher reproductive activity. On average, they reported more pregnancies, more deliveries, and more instances of abortion than their counterparts in the control group. These trends may reflect reproductive challenges or increased gynecological care-seeking behavior among women with endometriosis, both of which could influence HPV exposure or detection\RL. This demographic consistency between groups strengthens the internal validity of our findings, as it reduces the likelihood that age or BMI confounded the observed differences in HPV characteristics and colposcopic outcomes (Table1)\RL. There was no statistically significant difference in the baseline demographic characteristics between the endometriosis and control groups. These similarities indicate that both groups were demographically comparable, minimizing the potential for confounding effects from age or body composition in interpreting the study outcomes. 2\RL. HPV Typing Patterns A notable and statistically significant difference emerged in the distribution of HPV genotypes between the two groups (p < 0.0001). In the endometriosis group, nearly three-quarters of women (73.2%) tested positive for high-risk HPV types, which are known to be associated with the development of cervical dysplasia and cancer. Only 26.8% of women in this group carried low-risk HPV types, which are less likely to lead to malignant transformation (Figure 1)\RL. In contrast, women in the control group were more likely to harbor low-risk HPV (59.5%), with fewer individuals testing positive for high-risk genotypes (40.5%). This reversed trend is striking and may point to important biological or immunological differences in HPV persistence or acquisition in the context of endometriosis\RL. The higher prevalence of oncogenic HPV types among women with endometriosis raises the possibility that this condition may alter susceptibility to or clearance of high-risk viral infections. Such an association underscores the need for more vigilant HPV monitoring in this patient population, particularly as they may be at increased risk for cervical neoplastic changes (Table2)\RL. 3\RL. Colposcopic Findings Colpocopic evaluation revealed clear and clinically meaningful differences between the two groups. Women with endometriosis demonstrated a substantially higher frequency of abnormal colposcopic findings. Specifically, 38.5% of these patients exhibited aceto-white (ACW) changes, and 31.0% had coarse mosaic patterns, both of which are considered suspicious for cervical intraepithelial neoplasia and often warrant biopsy (Figure 1)\RL. In contrast, the majority of control patients (82.2%) had normal colposcopic findings, with only 10.0% and 7.8% showing ACW changes and coarse mosaicism, respectively. This significant disparity (p < 0.0001) suggests that endometriosis may influence cervical epithelial response or immune surveillance, making abnormal colposcopic features more likely\RL. The increased rate of abnormal findings in the endometriosis group could stem from several mechanisms. Chronic pelvic inflammation, altered hormonal signaling, and immune dysregulation associated with endometriosis may contribute to epithelial changes that mimic or facilitate dysplastic progression. Moreover, the elevated presence of high-risk HPV types in this group adds further weight to the need for careful colposcopic evaluation and follow-up (Table1)\RL. These results not only demonstrate a higher prevalence of suspicious cervical lesions in women with endometriosis but also reinforce the importance of integrating their gynecologic history into cervical cancer screening protocols. Enhanced surveillance in this population could aid in early detection and reduce the risk of progression to more severe pathology. IV. Discussion This study explored the relationship between endometriosis and colposcopic findings in women with HPV infection, revealing that patients with endometriosis exhibit a significantly higher prevalence of abnormal cervical changes and are more likely to harbor high-risk HPV genotypes. These results support the hypothesis that endometriosis, through its chronic inflammatory and immunologic alterations, may predispose to more pronounced cervical pathology in the presence of HPV. Notably, the differences in colposcopic patterns and HPV typing were observed despite similar age and BMI profiles across groups, strengthening the argument that endometriosis itself plays a key role in modulating cervical outcomes\RL. one of the most important findings was the substantially increased frequency of abnormal colposcopic patterns—particularly aceto-white changes and coarse mosaicism—in the endometriosis group. These findings align with the pathophysiological characteristics of endometriosis, which include chronic inflammation, angiogenesis, and local immune dysregulation. Such changes may influence the cervical epithelium’s response to HPV infection, rendering it more susceptible to visible morphological transformation. From a clinical standpoint, this observation suggests that HPV-positive patients with endometriosis may require more frequent or targeted colposcopic surveillance to ensure early detection of pre-malignant lesions\RL. Our data also indicated a significantly higher prevalence of high-risk HPV types among women with endometriosis (73.2% vs. 40.5%). This is a compelling finding, as high-risk HPV types—particularly types 16 and 18—are strongly associated with cervical intraepithelial neoplasia and cancer. These results resonate with recent studies, including a 2023 investigation by Hong et al., which reported that women with endometriosis had a higher overall HPV infection rate and were more likely to carry high-risk genotypes compared to controls without endometriosis (6). The authors suggested that hormonal treatments and impaired immune clearance in endometriosis patients could contribute to these outcomes\RL. Similarly, a 2023 study by Moslehi et al., published in Biomed Research International, found that the presence of deep endometriosis was associated with persistent high-risk HPV infections, even in the absence of advanced cervical pathology. This supports the notion that endometriosis may alter host-virus dynamics, making HPV clearance more difficult and facilitating lesion development. Our study adds to this evidence by linking these HPV patterns to visible colposcopic abnormalities, further bridging the gap between viral persistence and clinical manifestation\RL.(5)In a recent study by Kaur et al., extensive colposcopy-directed biopsy was shown to significantly improve detection of premalignant and malignant cervical lesions. The authors reported increased diagnostic sensitivity when sampling multiple quadrants—even in the absence of visibly abnormal colposcopic findings. This reinforces our view that deeper assessment may be warranted in women with endometriosis, given their propensity for atypical colposcopic presentations(11). An important strength of our study is its relatively large sample size and structured comparison across two well-defined patient populations. Unlike prior studies that focused solely on HPV prevalence or colposcopic outcomes, our work integrated both aspects to provide a more holistic understanding of how endometriosis may influence the course of HPV-related cervical disease. The use of standardized colposcopy performed by blinded evaluators also limits potential bias in visual interpretation, enhancing the reliability of our observations\RL. however, several limitations should be acknowledged. First, the cross-sectional design of our study precludes any inference of causality or temporal relationships. It remains unclear whether endometriosis directly promotes HPV persistence or whether the two conditions share underlying risk factors. Second, while we accounted for age and BMI, other confounding factors—such as hormonal therapy use, sexual behavior, and smoking—were not controlled for and may have influenced the results. Longitudinal cohort studies are needed to confirm our findings and explore the long-term impact of endometriosis on HPV outcomes and cervical cancer risk\RL.Clinically, our findings emphasize the need for heightened awareness among gynecologists and colposcopists regarding the potential for atypical cervical presentations in HPV-positive women with endometriosis. Standardized screening protocols may need to be adapted for this population, with consideration for more frequent follow-up or earlier biopsy thresholds. Furthermore, HPV vaccination strategies and preventive education should be emphasized in women with endometriosis, who may be more vulnerable to high-risk HPV acquisition and persistence\RL. Conclusion In conclusion, our study provides strong evidence that endometriosis is associated with a higher prevalence of high-risk HPV infections and abnormal colposcopic findings in HPV-positive women. These findings underscore the importance of integrating gynecologic comorbidities into HPV surveillance and cervical cancer prevention strategies. Future studies should aim to unravel the biological mechanisms behind this association and explore whether intervention on endometriosis itself can alter the trajectory of HPV-related cervical disease. VI. Declarations Conflict of interest: The authors declare that they have no conflict of interest. Ethical approval: Ethics approval and consent to participate: Ethical approval was obtained from the Tehran University of Medical Sciences Ethics Committee (IR.TUMS.IKHC.REC.1403.192). Informed consent was obtained from all participants. Consent for publication: Not applicable\RL. Availability of data and materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request\RL. Author contributions: AHH, MJ, and SAM: Conceptualization, methodology and data curation, SA, SYT, SHK, and AS: Investigation, AHH, MJ, NSH, and SHK: Formal analysis, supervision, visualization, original draft preparation. SAM,MN and AKV: Review and editing. Financial disclosure: The authors declare that this study has received no financial support. Informed consent: Informed consent was obtained from all individual participants included in the study. Competing interests: The authors declare that they have no competing interests\RL. Funding: This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\RL. Acknowledgements: The authors would like to thank the staff of Arash Women Hospital and the participants for their cooperation and contribution to this study. Abbreviations\RL: ACW: Aceto-White Changes BMI: \RL Body Mass Index CIN: \RL Cervical Intraepithelial Neoplasia GI: \RL Gastrointestinal HSIL: \RL High-Grade Squamous Intraepithelial Lesion HPV: \RL Human Papillomavirus HR-HPV: \RL High-Risk Human Papillomavirus IFCPC: \RL International Federation for Cervical Pathology and Colposcopy LR-HPV: \RL Low-Risk Human Papillomavirus LSIL: \RL Low-Grade Squamous Intraepithelial Lesion MRI: \RL Magnetic Resonance Imaging PCR: \RL Polymerase Chain Reaction SD: \RL Standard Deviation TUMS: Tehran University of Medical Sciences References 1. Saunders PTK, Horne AW. Endometriosis: Etiology, pathobiology, and therapeutic prospects. Cell. 2021;184(11):2807-24.2. Cousins FL, McKinnon BD, Mortlock S, Fitzgerald HC, Zhang C, Montgomery GW, et al. New concepts on the etiology of endometriosis. Journal of Obstetrics and Gynaecology Research. 2023;49(4):1090-105.3. Jensen JE, Becker GL, Jackson JB, Rysavy MB. Human Papillomavirus and Associated Cancers: A Review. Viruses. 2024;16(5).4. Qi SY, Yang MM, Li CY, Yu K, Deng SL. The HPV viral regulatory mechanism of TLRs and the related treatments for HPV-associated cancers. Front Immunol. 2024;15:1407649.5. Moslehi Z, Derakhshan R, Chaichian S, Mehdizadeh Kashi A, Sabet B, Rokhgireh S. Correlation of High-Risk Human Papilloma Virus with Deep Endometriosis: A Cross-Sectional Study. Biomed Res Int. 2023;2023:6793898.6. Hong YS, Park J, Kim H. Association of endometriosis with genital human papillomavirus infection in US women: a national population-based study. Sci Rep. 2023;13(1):8020.7. Fernandes JV, TA DEMF, JC DEA, Cobucci RN, MG DEC, Andrade VS, et al. Link between chronic inflammation and human papillomavirus-induced carcinogenesis (Review). Oncol Lett. 2015;9(3):1015-26.8. Adilbayeva A, Kunz J. Pathogenesis of Endometriosis and Endometriosis-Associated Cancers. International Journal of Molecular Sciences. 2024;25(14):7624.9. Garvey M. Endometriosis: Future Biological Perspectives for Diagnosis and Treatment. International Journal of Molecular Sciences. 2024;25(22):12242.10. Heidarpour M, Derakhshan M, Derakhshan-Horeh M, Kheirollahi M, Dashti S. Prevalence of high-risk human papillomavirus infection in women with ovarian endometriosis: HPV in women with ovarian endometriosis. Journal of Obstetrics and Gynaecology Research. 2016;43.11. Kaur G, Shivani, Zutshi V, Yadav AK. Role of Multiple Cervical Biopsies on Colposcopy for the Detection of Premalignant and Malignant Lesions of the Cervix. Journal of Colposcopy and Lower Genital Tract Pathology. 2024;2(3). Age (years), mean ± SD 32.6 ± 4.8 32.3 ± 5.1 0.432 BMI (kg/m²), mean ± SD 25.5 ± 4.0 25.2 ± 4.0 0.222 Pregnancies, mean ± SD 1.55 ± 1.28 1.49 ± 1.25 — Abortions, mean ± SD 0.35 ± 0.54 0.40 ± 0.55 — Deliveries, mean ± SD 1.20 ± 1.36 1.10 ± 1.31 — Table 1. Demographic and Reproductive Characteristics of Study Participants High-Risk 293 (73.2%) 162 (40.5%) < 0.0001 Low-Risk 107 (26.8%) 239 (59.5%) Table 2. Distribution of HPV Typing Among Study Groups,Statistically significant difference in HPV risk types between groups ( χ² , p < 0.0001). Normal 122 (30.5%) 329 (82.2%) < 0.0001 Aceto-white (ACW) 154 (38.5%) 40 (10.0%) Coarse Mosaicism 124 (31.0%) 31 (7.8%) Table 3. Colposcopic Findings by Group, Endometriosis group had significantly more abnormal colposcopic patterns (χ², p < 0.0001). Information & Authors Information Version history V1 Version 1 11 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords basic science carcinoma of the cervix: diagnosis colposcopy endometriosis: diagnosis endometriosis: drug treatment Authors Affiliations Shaghayegh Vandadi Tehran University of Medical Sciences School of Medicine View all articles by this author Akram Ghahghaei-Nezamabadi [email protected] Tehran University of Medical Sciences School of Medicine View all articles by this author Reihaneh Hosseini Tehran University of Medical Sciences School of Medicine View all articles by this author Kasra Jafari 0009-0002-1029-1000 Tehran University of Medical Sciences School of Medicine View all articles by this author Amirhossein Hajialigol 0000-0001-7701-9840 Universal Scientific Education and Research Network View all articles by this author Metrics & Citations Metrics Article Usage 455 views 122 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Shaghayegh Vandadi, Akram Ghahghaei-Nezamabadi, Reihaneh Hosseini, et al. 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