Cervical biopsy strategy under colposcopy: evidence from a retrospective study

Cervical biopsy strategy under colposcopy: evidence from a retrospective study | 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 Cervical biopsy strategy under colposcopy: evidence from a retrospective study Xiaoqian Xie, Yanning Yang, Qiyue Hu, Yangzhi Li, Meiqing Xie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6950409/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 20 You are reading this latest preprint version Abstract Objective To study the factors affecting the detection of cervical precancer and cancer under colposcopy, and to provide evidence for optimizing colposcopy biopsy strategy. Methods This was a retrospective study that included 1007 female patients who underwent colposcopy and cervical biopsy. Factors related to the detection rate of cervical precancer and cancer were analyzed. The accuracy of colposcopy diagnosis and possible influencing factors were also analyzed. Then subgroup analysis was performed in different types of cervical transformation zones to compare the efficiency of different biopsy methods. Results Abnormal cytology and positive detection of high-risk human papillomavirus (HPV) were risk factors for precancer and cancer, while positive detection of non-high-risk HPV was a protection factor. The consistency rate between colposcopy diagnosis and pathology diagnosis was 55.5%. The accuracy of colposcopy was affected by the type of cervical transformation zone rather than the seniority of the examiners. For type I transformation zone, the detection rate of high-grade lesions using 4-quadrant random biopsy (31.4% vs 21.2%, P = 0.038) and multi-point targeted biopsy (28.4% vs 12.5%, P = 0.001) was higher than corresponding control group. For type II transformation zone, the detection rate of high-grade lesions was higher when taking multi-point biopsy at ≥ 3 sites (21.7% vs 12.2%, P = 0.021). For type III transformation zone, the detection rate of lesions was higher when performing endocervical curettage (53.3% vs 35.5%, P = 0.061), but there was no statistical significance. Conclusions This study provides a basis for biopsy strategy during colposcopy. Biopsy is recommended for patients with both high-risk HPV infection and abnormal cytology. Multi-point targeted biopsy of ≥ 3 sites is recommended in type I and type II transformation zone. ECC may increase the detection rate of lesions in type III transformation zone. colposcopy cytology human papillomavirus transformation zone biopsy Introduction Cervical cancer stands as the fourth most prevalent gynecological malignancy among females worldwide. There were an estimated 662,301 newly diagnosed cases of cervical cancer globally, accompanied by 348,874 related deaths in 2022 (1). Due to widespread screening and vaccination, the incidence of cervical cancer has decreased significantly over decades (2–5). The World Health Organization has set a global target to decrease the incidence of cervical cancer to 4 or fewer cases per 100,000 women-years by 2030 using three interventions (6). The first intervention involves vaccinating 90% of women aged 15 years with the HPV vaccine. The second intervention involves screening 70% of women between the ages of 35 and 45 years using a high-performance screening test. The third intervention involves detecting cervical lesions in 90% of affected women to enable diagnosis and treatment. High-grade squamous intraepithelial lesions (HSIL) of the cervix can progress to cervical cancer if not treated (7), which is also calls cervical precancer. Thus, the identification of HSIL is pivotal for cervical cancer prevention. Abnormal results of cervical cytology and HPV are usually served as the initial indicators of HSIL or cervical carcinoma. Colposcopy is recommended for women with abnormal cervical screening (7–10). Targeted biopsy under colposcopy is the main approach to detect cervical precancer. The key of colposcopy is to find the suspicious lesion site and take biopsy to make a definite diagnosis. Whether everyone should take random biopsy? How to biopsy can improve the detection of HSIL? This study intends to provide evidence for colposcopy cervical biopsy decision-making. Materials and methods A retrospective study was carried out to analyze the clinical data of patients who underwent colposcopy in Sun Yat-sen Memorial Hospital between June 2022 and November 2023. The study protocol received approval from the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University. Study population Patients who had indications for colposcopy such as without contraindication and agreed to undergo colposcopy were included. Patients after hysterectomy, or those who did not undergo cervical biopsy when performing colposcopy, or underwent direct surgical treatment after colposcopy evaluation, or whose pathological results were not clear because of lacking immunohistochemical pathological were excluded. Pregnant women were also excluded. Colposcopy process Colposcopy was operated by physicians who have the qualification of practicing doctors, who have engaged in obstetrics and gynecology clinical work for more than 3 years, and have at least 1 year of experience in colposcopy. The operation of colposcopy in this study was performed by three doctors with different seniority. Before the operation, the doctor would truthfully and detailly recorded the patient 's basic information such as results of liquid-based cytology test (LCT) and HPV to the colposcopy system. LCT classification was based on the Bethesda system (TBS) (11), including no intraepithelial lesions or malignant lesions (NILM), atypical squamous cell undetermined significance (ASC-US), atypical squamous cell high-grade lesions (ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma (SCC), atypical glandular cells (AGC) and adenocarcinoma in situ (AIS). Given that nearly all cervical cancers globally were caused by persistent infections with these 13 types of human papillomaviruses (HPV): 16, 18, 31, 33, 35, 39, 45, 51,52,56,58, 59, and 68(7), which were called high-risk HPV, while others were non-high-risk HPV. Before taking colposcopy examination, patients should avoid sexual activity, vaginal flushing, and medication for at least 48 hours. The examinee took the bladder lithotomy site. After examining the external genitalia and perianal area, insert a proper size speculum. Firstly, moistened the cervix and vaginal epithelium with physiological saline to remove mucus that affects observation, observed the full view of the vagina and cervix. Secondly, performed acetic acid test. Wet compressed the cervix, vagina, and fornix with 3%~5% acetic acid cotton balls for 60 seconds, then thoroughly examined the changes in the cervical and vaginal epithelium and determine the type of transformation zone (TZ) from low to high magnification. Acetic acid test can be repeated after 3–4 minutes if necessary. Compound iodine test: Apply the compound iodine solution to the cervix and vagina and observe staining. Make a colposcopy diagnosis. Under the guidance of colposcopy, biopsy was conducted on the region of the cervix exhibiting the most severe abnormalities. The number of biopsies was determined by the operator independently, and the maximum diameter of the tissue should not be less than 3 mm in order to provide sufficient specimens for routine pathological sectioning and necessary immunohistochemical staining (12). Whether to perform endocervical curettage (ECC) was determined by the examiners according to the cytology results, the type of HPV infection, and the type of transformation zone. If ECC was performed, the maximum diameter (excluding mucus) of the cervical canal scraping tissue (often broken) should not be less than 2 mm. If the cervix lesion was diffuse or there was no obvious specific lesion site, examiners would perform a 4-quadrant random biopsy of the cervix at 3/6/9/12 o’clock. Samples obtained from different sites of the cervix should be individually labeled and promptly immersed in a 4% neutral formaldehyde solution for fixation prior to submission for pathological examination. The types of cervical transformation zones were classified based on the visibility of the boundary between the squamous epithelium and the columnar epithelium (13). (13). Type I transformation zone (TZ1): Both the original squamocolumnar junction (OSCJ) and the new squamocolumnar junction (NSCJ) are completely visible. The transformation zones are entirely outside the external of the cervix and does not extend into the endocervical canal. Type II transformation zone (TZ2): The NSCJ partially extends into the endocervical canal, but the entire boundary of the TZ, including the part within the endocervical canal, can still be observed under colposcopy. Type III transformation zone (TZ3): The NSCJ has completely retracted into the endocervical canal. The upper boundary of the transformation zone cannot be observed under colposcopy, and even part of the lower boundary is difficult to identify. Colposcopy diagnosis was divided into benign, LSIL, HSIL and carcinoma. Colposcopy impression was described with the colposcopy terminology of the International Federation for Cervical Pathology and Colposcopy (IFCPC) (14, 15). Benign colposcopy impression included inflammation, metaplasia, and polyps. LSIL was characterized by delicate puncturing, thin acetowhite epithelium, and irregular, geographic borders. The characteristics of HSIL were defined by sharp borders, an inner border, ridge sign, dense acetowhite epithelium, a coarse mosaic pattern, and coarse puncturing. The characteristics of carcinoma were represented by atypical vessels, fragile vessels, irregular surface, exophytic lesions, necrosis, and ulceration. Pathology diagnosis The pathological sections were read by two experienced pathologists and the conclusions were given. Pathology diagnosis was divided into benign, LSIL, HSIL and carcinoma. According to the WHO classification of female genital tumors, cervical Intraepithelial Neoplasia Grade 1(CIN1) belongs to low-grade squamous intraepithelial lesion (LSIL), cervical Intraepithelial Neoplasia Grade 2(CIN2) and cervical Intraepithelial Neoplasia Grade 3(CIN3) belong to high grade squamous intraepithelial lesion (HSIL) (16). Squamous cell carcinoma (SCC) and adenocarcinoma (AC) are both carcinomas. Data collection The colposcopy data from June 2022 to November 2023 were derived from the colposcopy system. These data included patient basic information and colposcopy results. The pathological results of these populations were searched respectively by two doctors from the query system of pathology. The pathology diagnosis would be concluded and recorded after being checked one by one. Statistical analysis Measurement data were presented as mean ± standard deviation (X ± s), while count data were described using frequencies. The chi-square test was employed to compare the rates between two groups. All statistical tests were two - sided, and a P - value < 0.05 was considered indicative of statistical significance. Multivariate logistic regression analysis was conducted to evaluate the predictive ability of cytology and HPV testing for cervical precancerous lesions and cancer. Measurement data were showed in mean ± standard deviation ( X ± s ), while count data were described by frequency. The chi-square test was used to compare the rates between two groups. All statistical tests were two-sided, P < 0.05 for the difference was statistically significant. Multivariate logistic regression analysis was performed to analyze the predictive effect of cytology and HPV test on cervical precancer and cancer. Statistical analyses were performed using R (version 4.4.3). Results Ultimately, a total of 1007 patients were enrolled in the analysis. The mean age of the study population was 40.3 years. About 60% of patients had abnormal cytology. ASC-US and LSIL accounted for a higher proportion in abnormal cytology. 93.9% of the patients were infected with HPV. Among high-risk HPV infection, the proportion of HPV 52 infection was the highest (23.8%), followed by HPV 16 infection (22.6%) and HPV 58 infection (11.7%). The type of cervical transformation zone in 38.7% of patients was TZ1, 34.4% was TZ2, and 26.9% was TZ3. The cervical biopsy pathology of 34.3% of the patients indicated chronic inflammation or normal tissue, 49.3% indicated LSIL, 14.7% indicated HSIL, and 1.8% indicated carcinoma. In this study, 411 cases were operated by junior physician, 247 cases were completed by attending physician, and 349 cases were completed by senior physician. (Table 1 ) Table 1 Basic information of the study population Total (n = 1007) Age(years) 40.3 ± 11.7 Menopausal status Premenopausal 216 (21.5%) Postmenopausal 791 (78.6%) Cytology NILM 392 (38.9%) ASC-US 295 (29.3%) LSIL 229 (22.7%) AGC 6 (0.6%) ASC-H 52 (5.2%) HSIL 20 (2.0%) SCC 2 (0.2%) not perform 11 (1.1%) HPV status positive 946 (93.9%) negative 61 (6.1%) HPV type HPV16 positive 228 (22.6%) HPV18 positive 83 (8.2%) HPV31 positive 20 (2.0%) HPV33 positive 27 (2.7%) HPV35 positive 16 (1.6%) HPV39 positive 69 (6.9%) HPV45 positive 16 (1.6%) HPV51 positive 83 (8.2%) HPV52 positive 240 (23.8%) HPV56 positive 55 (5.5%) HPV58 positive 118 (11.7%) HPV59 positive 28 (2.8%) HPV68 positive 56 (5.6%) Non-high-risk HPV positive 251 (24.9%) Transformation zone type TZ1 390 (38.7%) TZ2 346 (34.4%) TZ3 271 (26.9%) Colposcopy diagnosis Benign 434 (43.1%) LSIL 479 (47.6%) HSIL 81 (8.0%) Carcinoma 13 (1.3%) Biopsy numbers 0 22 (2.2%) 1 111 (11.0%) 2 286 (28.4%) 3 297 (29.5%) 4 287 (28.5%) 5 4 (0.4%) 4-quadrant random biopsy Yes 212 (21.1%) No 795 (78.9%) Endocervical curettage yes 745 (74.0%) no 262 (26.0%) Pathology diagnosis Benign 345 (34.3%) LSIL 496 (49.3%) HSIL 148 (14.7%) Carcinoma 18 (1.8%) Colposcopy examiner Junior physician 411 (40.8%) Attending physician 247 (24.5%) Senior physician 349 (34.7%) Patients were divided into two groups based on the pathological results, one group was benign and LSIL, the other group was HSIL and carcinoma. We analyzed the possible factors associated with the detection of HSIL and carcinoma (Table 2 ). The detection rate of HSIL and carcinoma in non-menopausal population (19.0%, 150/791) was higher than that in postmenopausal population (11.1%, 24/216). The higher grade of cytology, the greater the chance of detection of HSIL and carcinoma. 7.7% (30/392) patients whose cervical cytology were NILM were found HSIL or worse. While the proportion was 17.3% (30/392) in patients with ASC-US, was 15.7% (36/229) in the patients with LSIL. Among the patients with cytology of AGC or ASC-H, 56.9% (33/58) of them had biopsy pathology suggesting HSIL and worse. In the population with cytology results of HSIL or SCC, 95.5% (21/22) of them were pathologically diagnosed HSIL and carcinoma. HPV infection was closely related to cervical precancer and cancer, especially HPV 16 and HPV 18 infection. Among the patients whose pathology suggest HSIL or cancer, 99.4% (173/174) of them were HPV positive, and 43.7% (76/174) were HPV 16 and/or HPV 18 positive. However, there was no significant difference in the positive rate of other high-risk HPV between groups. The detection rate of HSIL and carcinoma in patients with different types of transformation zone was also inconsistent. The proportion of HSIL and carcinoma detected in patients with TZ1 was 23.8% (93/390), was 17.6% (61/346) in patients with TZ2, and was 7.4% (20/271) in patients with TZ3. In addition, the impression of colposcopy was also related to the detection of HSIL and carcinoma. The consistency rate between colposcopy diagnosis and pathology was 55.5%. The Kappa value was 0.271, which meant fair correlation. In this study, the positive predictive value of colposcopy detecting HSIL and carcinoma was 66.0% (62/94). The more the number of biopsy sites, the higher the detection rate of HSIL or worse. The probability of HSIL and carcinoma detected by biopsy at ≤ 2 sites was 10.0% (42/419), and was 22.4% (132/588) by biopsy at ≥ 3 sites. Whether performing the 4-quadrant random biopsy of the cervix at 3/6/9/12 o 'clock did not affect the detection rate of HSIL and carcinoma, neither did ECC. Table 2 Factors associated with the detection of HSIL and carcinoma Benign and LSIL (n = 833) HSIL and Carcinoma (n = 174) Chi-square value P Menopausal status 7.319 0.007 premenopausal 641 150 postmenopausal 192 24 Cytology 184.324 < 0.001 NILM 362 30 ASC-US 244 51 LSIL 193 36 AGC/ASC-H 25 33 HSIL/SCC 1 21 not perform 8 3 HPV status 11.112 0.001 positive 773 173 negative 60 1 HPV16/HPV18 positive 216 76 20.020 < 0.001 Other high-risk HPV positive 520 108 0.008 0.930 Non-high-risk HPV positive 232 19 22.051 < 0.001 Transformation zone type 30.376 < 0.001 TZ1 297 93 TZ2 285 61 TZ3 251 20 Colposcopy diagnosis 193.608 <0.001 Benign 405 29 LSIL 395 83 HSIL 30 51 Carcinoma 2 11 Biopsy numbers 26.426 < 0.001 ≤ 2 377 42 ≥ 3 456 132 4-quadrant random biopsy 2.270 0.132 Yes 168 44 No 665 130 Endocervical curettage 0.807 0.369 yes 621 124 no 212 50 Due to the error between colposcopy impression and pathological diagnosis, we analyzed the possible factors of missed diagnosis and misdiagnosis of colposcopy (Table 3 ). Consistency rate and missed diagnosis rate were evaluated between different examiners and different TZ types. Consistency means that the colposcopy diagnosis is completely consistent with the pathology diagnosis, and missed diagnosis means that pathological results were more severe than the colposcopy evaluation. The results showed that the consistency rate and missed diagnosis rate of different examiners were similar. But they were significantly different in three types of transformation zones groups. The consistency rate of colposcopy and pathology was highest in the TZ2 group, which was 61.6%. While the consistency rates in TZ1 and TZ3 groups were 52.0% and 52.6%, respectively. The missed diagnosis rate of colposcopy in TZ2 group was the lowest, which was 22.3%. And that in TZ1 and TZ3 groups were 34.6% and 30.6% respectively. Table 3 Factors of missed diagnosis and misdiagnosis of colposcopy The consistency rate between colposcopy and pathology P Missed diagnosis rate of colposcopy P Colposcopy examiner 0.207 0.098 Junior physician (241/411)58.6% (118/411)28.7% Attending physician (128/247)51.8% (85/247)34.4% Senior Physician (190/349)54.4% (92/349)26.4% Transformation zone type 0.020 0.001 TZ1 (141/271)52.0% (135/390)34.6% TZ2 (213/346)61.6% (77/346)22.3% TZ3 (205/390)52.6% (83/271)30.6% We further analyzed the effects of different biopsy methods on the detection of lesions in different transformation zone subgroups. The results were shown in Table 4 . As can be seen that in TZ1 group, biopsy at ≥ 3 sites was helpful to detect lesions, and which was statistically significant. The proportion of LSIL and wore lesion detected by multi-point biopsy was 75.2%, which was significantly higher than that of biopsy at ≤ 2 sites (61.6%). The detected rate of HSIL and worse by multi-point biopsy was 28.4%, which was significantly higher than by biopsy at ≤ 2 sites (12.5%). Random biopsy at 4-quadrant of the cervix could significantly increase the detection rate of HSIL and carcinoma in the TZ1 group (31.4% vs 21.2%). ECC did not increase detected rate in TZ1 group. In the TZ2 group, it could also be seen that multi-point biopsy at ≥ 3 sites was helpful to detect lesions, and the difference was statistically significant. Neither 4-quadrant random biopsy nor ECC increased the detected rate of cervix lesions in the TZ2 group. In the TZ3 group, neither multi-point biopsy nor 4-quadrant random biopsy increased detected rate of cervix lesions. But in the TZ3 group, the proportion for ECC detecting LSIL and worse lesions was 53.3%, which was higher than non-ECC group (35.5%), but the difference was not statistically significant ( P = 0.061). Table 4 The detection rate of different biopsy methods in different TZ groups LSIL and worse P HSIL and worse P TZ1(n = 390) 4-quadrant random biopsy 0.559 0.038 Yes(n = 102) (75/102)73.5% (32/102)31.4% No(n = 288) (203/288)70.5% (61/288)21.2% Biopsy numbers 0.007 0.001 ≤ 2(n = 112) (69/112)61.6% (14/112)12.5% ≥ 3(n = 278) (209/278)75.2% (79/278)28.4% Endocervical curettage 0.142 0.134 Yes(n = 200) (136/200)68.0% (54/200)27.0% No(n = 190) (142/190)74.7% (39/190)20.5% TZ2(n = 346) 4-quadrant random biopsy 0.379 0.256 Yes(n = 63) (48/63)76.2% (8/63)12.7% No(n = 283) (200/283)70.7% (53/283)18.7% Biopsy numbers 0.001 0.021 ≤ 2(n = 148) (92/148)62.2% (18/148)12.2% ≥ 3(n = 198) (156/198)78.8% (43/198)21.7% Endocervical curettage 0.552 0.598 Yes(n = 305) (217/305)71.1% (52/305)17.0% No(n = 41) (31/41)75.6% (9/41)22.0% TZ3(n = 271) 4-quadrant random biopsy 0.319 0.744 Yes(n = 47) (21/47)44.7% (4/47)8.5% No(n = 224) (118/224)52.7% (16/224)7.1% Biopsy numbers 0.701 0.413 ≤ 2(n = 159) (80/159)50.3% (10/159)6.3% ≥ 3(n = 112) (59/112)52.7% (10/112)8.9% Endocervical curettage 0.061 0.834 Yes(n = 240) (128/240)53.3% (18/240)7.5% No(n = 31) (11/31)35.5% (2/31)6.5% In order to predict which patients were more likely to suffer HSIL and carcinoma, we performed a multivariate logistic regression analysis of cytology and HPV. The results were shown in Table 5 . The probability of detecting HSIL and carcinoma in patients with LCT as ASC-US and LSIL was more than three times that of NILM patients. Compared with patients with normal LCT, patients with ASC-H or AGC were 19 times likely to pathologically diagnose HSIL and carcinoma, while patients with LCT as HSIL or SCC were about 261 times. The probability of HSIL and carcinoma in HPV 16 and/or HPV 18 positive patients was almost 4 times higher than that in HPV 16 and HPV 18 negative patients. The risk of HSIL and worse in patients with other high-risk HPV infections is about doubled. Non-high-risk HPV infection was a protective factor. Table 5 Multiple regression analysis of objective factors related to HSIL and carcinoma OR 95% CI for OR P lower upper Cytology NILM - - - < 0.001 ASC-US 3.634 2.169 6.086 < 0.001 LSIL 3.837 2.183 6.743 < 0.001 ASC-H/AGC 19.479 9.896 38.344 < 0.001 HSIL/SCC 261.294 33.311 2049.595 < 0.001 missing 5.857 1.409 24.353 0.015 HPV16/HPV18 positive 3.972 2.410 6.544 < 0.001 Other high-risk HPV positive 1.782 1.090 2.912 0.021 Non-high-risk HPV positive 0.416 0.240 0.721 0.002 Discussion This retrospective study was designed to explore the factors impacting the detection of cervical precancer and carcinoma under colposcopy. It provides evidence for colposcopy doctors to improve the colposcopy biopsy strategy. The results of the study mainly revealed that HPV infection is closely related to cervical precancer and cancer, especially HPV16 and HPV18 infection. 99.4% of patients that pathologically diagnosed with HSIL or worse in this study were infected with HPV, 43.7% of them were infected with type 16 or type 18 or both. It is reported that HPV type 16 and 18 account for approximately 70% of all cervical cancer (17). In a study conducted by Castle and colleagues (18), among women who were twice tested positive for HPV16 at an interval of 9–21 months, the 3-year cumulative incidence of CIN2 or more severe lesions was 40%. For HPV18, the corresponding 3-year cumulative incidence of CIN2 or worse was 15%, while for other high-risk HPV, it was 9%. The tests of cytology are also of great predictive value for cervical precancer. A pooled analysis of 25830 participants founded that HSIL or worse was found in 4.1% women with cytology of ASC-US, in 15.4% with cytology of LSIL, in 65.3% with cytology of HSIL, in 96.7% with cytology of SCC, in 14.8% with cytology of AGC, in 0.4% with cytology of NILM. (19) The proportions are higher in this study, which may because of that the population included in this study is a high-risk group of cervical precancer. Overall, high-grade abnormal cytology and persistent HPV infection, especially HPV 16 and HPV 18 infections, are high risk factors for cervical precancer and cancer. The consistency rate between colposcopy diagnosis and cervical pathology diagnosis was 55.5% in this study, while the agreement of other studies was between 46.9–77.0% (20–24). The accuracy of colposcopy impress has always been non-ideal. Study conclusions are various for whether the operator 's experience is related to the accuracy of colposcopy diagnosis (23, 24). Our study findings indicated that the accuracy of colposcopy was not correlated with the doctor's experience or seniority. Instead, it was significantly associated with the type of cervical transformation zone. A retrospective study also reported that the accuracy rate of cervical biopsy is contingent upon the TZ and the patient's age, rather than the examiner's level of training (25). In our research, the misdiagnosis rate of TZ2 group was the minimum and the consistency rate was the maximum, while for TZ1 and TZ3 groups, the misdiagnosis rate was higher and the consistency rate was lower. In addition to the type of transformation zone, another factor affecting the detection rate of HSIL is the number of biopsy points. Like many other studies (26–28), the results of this study also show that colposcopy-directed biopsies of multiple sites are helpful to detect HSIL and worse lesions. The current Danish clinical guidelines recommend the collection of four cervical biopsies, even when no abnormalities are visualized by colposcopy, and regardless of the woman's risk profile (29). The indiscriminate 4-quadrant cervical biopsies and ECC may lead to excessive examination, increasing the patient 's pain and cost. Our study found that different biopsy methods had different detection efficiency in different types of transformation zone. In TZ1 and TZ2, targeted biopsy at ≥ 3 sites was helpful for the detection of cervical lesions. Performing 4-quadrant random biopsy has a higher detection rate of HSIL and carcinoma in TZ1, but not in TZ2 nor TZ3. The detection rate of HSIL and worse in TZ3 group was lowest. Neither performing multi-point biopsy nor 4-quadrant random biopsy increased the detection rate of cervical intraepithelial neoplasia in TZ3 group. Performing ECC can improve the detection rate of LSIL and worse lesions in TZ3, but the difference is not statistically significant. Because there is a certain false negative rate of colposcopy impression, it is necessary to comprehensively consider the patient 's cytology and HPV test results and colposcopy impression to decide whether to take biopsies. A pooled analysis of 17 population-based cervical cancer screening studies indicates that, for women who have a positive result in any cervical screening test yet a negative colposcopy outcome, it is essential to conduct random biopsies along with ECC for those who have cytological findings of ASC-US/LSIL and are positive for high-risk HPV, or for those with other high-grade cytological abnormalities (30). We also recommend biopsy in patients with both high-risk HPV infection and abnormal cytology, or with high grade cytology, or with HPV16/HPV18 infection. For TZ1 and TZ2, multi-point targeted biopsy of ≥ 3 sites is first recommended. If the lesion is diffuse or atypical, random biopsy can be performed. For TZ3, ECC may increase the detection rate of lesions. This study provides evidence for the strategy of cervical biopsy under colposcopy. Nevertheless, the study is not without its limitations. First of all, it is a retrospective study, in which researchers are unable to control exposure and interventions. Secondly, the sample size included in this study is not large, especially in subgroup analysis, which may lead to the test efficiency is too small to show significant statistical results. Finally, the biopsy also has a certain rate of missed diagnosis. This study did not compare biopsy pathology with final surgical pathology. In the future, it will be essential to further increase the sample size, collect surgical pathological results, further compare biopsy pathology with postoperative pathology, to analyze the accuracy of different biopsy methods under colposcopy. Conclusion In this paper, a retrospective study is conducted to find out the factors related to the detection of cervical precancer and cancer under colposcopy. High-risk HPV infection and abnormal cytology are predictive for precancerous lesions. There are some missed diagnosis and misdiagnosis of colposcopy, which is not related to the seniority of examiners, but related to the type of transformation zone. For TZ1 and TZ2, multi-point targeted biopsy has the potential to significantly enhance the detection rate of lesions. For TZ3, ECC is likely to improve the detection rate. This study provides a basis for biopsy strategy under colposcopy. However, it is still necessary to repeatedly compare the results of colposcopy with biopsy pathology and even surgical pathology, so as to improve the accuracy of colposcopy. Abbreviations AC Adenocarcinoma AIS Adenocarcinoma in situ AGC Atypical glandular cells ASC-H Atypical squamous cell high-grade lesions ASC-US Atypical squamous cell undetermined significance CIN1 Cervical intraepithelial neoplasia grade 1 CIN2 Cervical intraepithelial neoplasia grade 2 CIN3 Cervical intraepithelial neoplasia grade 3 ECC Endocervical curettage HPV Human papillomavirus HSIL High-grade squamous intraepithelial lesions IFCPC International Federation for Cervical Pathology and Colposcopy LCT Liquid - based Cytology Test LSIL Low-grade squamous intraepithelial lesions NILM No intraepithelial lesions or malignant lesions NSCJ New squamocolumnar junction OSCJ Original squamocolumnar junction SCC Squamous cell carcinoma TZ Transformation zone TZ1 Type I transformation zone TZ2 Type II transformation zone TZ3 Type III transformation zone Declarations Ethics approval and consent to participate This study was approved by the Review Committee of Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China (Ethical approval number: SYSKY-2024-093-01). We confirm that all methods were performed in accordance with relevant guidelines and regulations. This was a retrospective study and it did not involve human experimentation. An informed consent waiver was obtained for our study from the Institutional Review Board of Sun Yat-sen Memorial Hospital, Sun Yat-sen University. Consent for publication All the authors confirm that this work has not been published before and it is not under consideration for publication elsewhere. This submission has been approved by all co-authors and its publication has been approved by the responsible authority at the institution where the work was carried out. All the authors agree to publish this work in BMC Women's Health in English Competing interests The authors declare no competing interests. Funding This study has been supported by National Natural Science Foundation of China (Grant No. 82171670) and Chinese Preventive Medicine Association special research funding for prevention and treatment of female pelvic floor disorders (Grant No. 201819126). Author Contribution XQ Xie: Data analysis and manuscript writing. YN Yang: Data collection and manuscript revising. QY Hu: Data collection.MQ Xie and YZ Li: Manuscript editing and revising. All authors reviewed the manuscript. Acknowledgement We thank the three doctors for their colposcopy work and the patients for their participation. Data availability Data and related materials supporting the findings of this study are available upon request from the corresponding author. References Li Z, Liu P, Yin A, Zhang B, Xu J, Chen Z, et al. Global landscape of cervical cancer incidence and mortality in 2022 and predictions to 2030: The urgent need to address inequalities in cervical cancer. INT J CANCER. [Journal Article]. 2025 2025-7-15;157(2):288-97. Siegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. CA-CANCER J CLIN. [Journal Article]. 2025 2025-1-1;75(1):10-45. Lei J, Ploner A, Elfström KM, Wang J, Roth A, Fang F, et al. HPV Vaccination and the Risk of Invasive Cervical Cancer. NEW ENGL J MED. [Journal Article; Research Support, Non-U.S. Gov't]. 2020 2020-10-1;383(14):1340-8. Falcaro M, Castañon A, Ndlela B, Checchi M, Soldan K, Lopez-Bernal J, et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. LANCET. [Journal Article; Observational Study]. 2021 2021-12-4;398(10316):2084-92. Wongpratate M, Bumrungthai S. Cervical cancer in Thailand: 2023 update. Obstet Gynecol Sci. [Journal Article]. 2024 2024-5-1;67(3):261-9. World Health Organization. Regional implementation framework for elimination of cervical cancer as a public health problem: 2021–2030 [Internet] New Delhi (IN): World Health Organization; c2021. [cited 2023 Apr 21]. Available from: https://www.who.int/publications/i/item/9789290228875. Perkins RB, Wentzensen N, Guido RS, Schiffman M. Cervical Cancer Screening: A Review. JAMA: the journal of the American Medical Association. 2023 2023-1-1;330(6):547-58. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J LOW GENIT TRACT DI. 2020;24(2):102-31. Ngu SF, Cheung A, Jong KK, Law J, Lee AY, Lee J, et al. 2024 Hong Kong College of Obstetricians and Gynaecologists Guidelines for cervical cancer prevention and screening. HONG KONG MED J. [Journal Article; Practice Guideline]. 2024 2024-12-1;30(6):488-97. Redman C, Kesic V, Cruickshank ME, Gultekin M, Carcopino X, Castro SM, et al. European consensus statement on essential colposcopy. EUR J OBSTET GYN R B. [Journal Article; Review]. 2021 2021-1-1; 256:57-62. Nayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology: A Historical Perspective. ACTA CYTOL. [Journal Article; Review]. 2017 2017-1-20;61(4-5):359-72. Chen Fei, You Zhixue, Sui Long, Li Shuang, Liu Jun, Liu Aijun, et al. Chinese Expert Consensus on Colposcopy Application. Chinese Journal of Obstetrics and Gynecology. 2020; 55 (7): 443-9. Quaas J, Reich O, Küppers V. Explanation and Use of the Rio 2011 Colposcopy Nomenclature of the IFCPC (International Federation for Cervical Pathology and Colposcopy): Comments on the general colposcopic assessment of the uterine cervix: adequate/inadequate; squamocolumnar junction; transformation zone. GEBURTSH FRAUENHEILK. [Journal Article]. 2014 2014-12-1;74(12):1090-2. Bornstein J, Bentley J, Bösze P, Girardi F, Haefner H, Menton M, et al. 2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy. OBSTET GYNECOL. [Journal Article]. 2012 2012-7-1;120(1):166-72. Quaas J, Reich O, Frey TB, Küppers V. Explanation and Use of the Colposcopy Terminology of the IFCPC (International Federation for Cervical Pathology and Colposcopy) Rio 2011. GEBURTSH FRAUENHEILK. [Journal Article]. 2013 2013-9-1;73(9):904-7. WHO classification of Tumours Editorial Board. WHO classification of tumors. Female genital tumors [M]. 5th ed. Lyon: IARC Press, 2020:342-346. Crosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. LANCET. [Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't]. 2013 2013-9-7;382(9895):889-99. Castle PE, Rodríguez AC, Burk RD, Herrero R, Wacholder S, Alfaro M, et al. Short term persistence of human papillomavirus and risk of cervical precancer and cancer: population based cohort study. BMJ-BRIT MED J. [Journal Article; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural]. 2009 2009-7-28;339: b2569. Pan QJ, Hu SY, Zhang X, Ci PW, Zhang WH, Guo HQ, et al. Pooled analysis of the performance of liquid-based cytology in population-based cervical cancer screening studies in China. CANCER CYTOPATHOL. [Comparative Study; Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't]. 2013 2013-9-1;121(9):473-82. Fan A, Wang C, Zhang L, Yan Y, Han C, Xue F. Diagnostic value of the 2011 International Federation for Cervical Pathology and Colposcopy Terminology in predicting cervical lesions. Oncotarget. [Journal Article]. 2018 2018-2-6;9(10):9166-76. Tatiyachonwiphut M, Jaishuen A, Sangkarat S, Laiwejpithaya S, Wongtiraporn W, Inthasorn P, et al. Agreement between colposcopic diagnosis and cervical pathology: Siriraj hospital experience. Asian Pac J Cancer Prev. [Journal Article]. 2014 2014-1-20;15(1):423-6. Li Y, Zhang H, Zheng R, Xie F, Sui L. [Agreement between colposcopic diagnosis with 2011 international terminology of colposcopy and cervical pathology in cervical lesions]. Zhonghua Fu Chan Ke Za Zhi. [Evaluation Study; Journal Article]. 2015 2015-5-1;50(5):361-6. Baum ME, Rader JS, Gibb RK, McAlister RP, Powell MA, Mutch DG, et al. Colposcopic accuracy of obstetrics and gynecology residents. GYNECOL ONCOL. 2006;103(3):966-70. Li J, Wang W, Yang P, Chen J, Dai Q, Hua P, et al. Analysis of the agreement between colposcopic impression and histopathological diagnosis of cervical biopsy in a single tertiary center of Chengdu. ARCH GYNECOL OBSTET. [Journal Article]. 2021 2021-10-1;304(4):1033-41. Stuebs FA, Schulmeyer CE, Mehlhorn G, Gass P, Kehl S, Renner SK, et al. Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study. ARCH GYNECOL OBSTET. 2019 2019-1-1;299(2):525-32. Gage JC, Hanson VW, Abbey K, Dippery S, Gardner S, Kubota J, et al. Number of cervical biopsies and sensitivity of colposcopy. OBSTET GYNECOL. [Evaluation Study; Journal Article; Multicenter Study; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural; Research Support, U.S. Gov't, Non-P.H.S.]. 2006 2006-8-1;108(2):264-72. Pretorius RG, Belinson JL, Burchette RJ, Hu S, Zhang X, Qiao YL. Regardless of skill, performing more biopsies increases the sensitivity of colposcopy. J LOW GENIT TRACT DI. [Journal Article]. 2011 2011-7-1;15(3):180-8. Vallapapan A, Chandeying N, Srijaipracharoen S, Uthagethaworn K. The role of random cervical biopsies in addition to colposcopy-directed biopsies in detection of CIN2. J OBSTET GYNAECOL. [Journal Article]. 2019 2019-2-1;39(2):184-9. DSOG. Danish Society of Obstetrics and Gynaecology Guideline Cervical dysplasia, 2019. Available: https://www.dsog.dk/s/guideline_3844-1_1-202008260659.pdf Hu S, Zhang W, Li S, Li N, Huang M, Pan Q, et al. Pooled analysis on the necessity of random 4-quadrant cervical biopsies and endocervical curettage in women with positive screening but negative colposcopy. MEDICINE. 2017;96(17): e6689. Additional Declarations No competing interests reported. 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There were an estimated 662,301 newly diagnosed cases of cervical cancer globally, accompanied by 348,874 related deaths in 2022 (1). Due to widespread screening and vaccination, the incidence of cervical cancer has decreased significantly over decades (2\u0026ndash;5). The World Health Organization has set a global target to decrease the incidence of cervical cancer to 4 or fewer cases per 100,000 women-years by 2030 using three interventions (6). The first intervention involves vaccinating 90% of women aged 15 years with the HPV vaccine. The second intervention involves screening 70% of women between the ages of 35 and 45 years using a high-performance screening test. The third intervention involves detecting cervical lesions in 90% of affected women to enable diagnosis and treatment. High-grade squamous intraepithelial lesions (HSIL) of the cervix can progress to cervical cancer if not treated (7), which is also calls cervical precancer. Thus, the identification of HSIL is pivotal for cervical cancer prevention. Abnormal results of cervical cytology and HPV are usually served as the initial indicators of HSIL or cervical carcinoma. Colposcopy is recommended for women with abnormal cervical screening (7\u0026ndash;10). Targeted biopsy under colposcopy is the main approach to detect cervical precancer. The key of colposcopy is to find the suspicious lesion site and take biopsy to make a definite diagnosis. Whether everyone should take random biopsy? How to biopsy can improve the detection of HSIL? This study intends to provide evidence for colposcopy cervical biopsy decision-making.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA retrospective study was carried out to analyze the clinical data of patients who underwent colposcopy in Sun Yat-sen Memorial Hospital between June 2022 and November 2023. The study protocol received approval from the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University.\u003c/p\u003e\u003cp\u003eStudy population\u003c/p\u003e\u003cp\u003ePatients who had indications for colposcopy such as without contraindication and agreed to undergo colposcopy were included. Patients after hysterectomy, or those who did not undergo cervical biopsy when performing colposcopy, or underwent direct surgical treatment after colposcopy evaluation, or whose pathological results were not clear because of lacking immunohistochemical pathological were excluded. Pregnant women were also excluded.\u003c/p\u003e\u003cp\u003eColposcopy process\u003c/p\u003e\u003cp\u003eColposcopy was operated by physicians who have the qualification of practicing doctors, who have engaged in obstetrics and gynecology clinical work for more than 3 years, and have at least 1 year of experience in colposcopy. The operation of colposcopy in this study was performed by three doctors with different seniority.\u003c/p\u003e\u003cp\u003eBefore the operation, the doctor would truthfully and detailly recorded the patient 's basic information such as results of liquid-based cytology test (LCT) and HPV to the colposcopy system. LCT classification was based on the Bethesda system (TBS) (11), including no intraepithelial lesions or malignant lesions (NILM), atypical squamous cell undetermined significance (ASC-US), atypical squamous cell high-grade lesions (ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma (SCC), atypical glandular cells (AGC) and adenocarcinoma in situ (AIS). Given that nearly all cervical cancers globally were caused by persistent infections with these 13 types of human papillomaviruses (HPV): 16, 18, 31, 33, 35, 39, 45, 51,52,56,58, 59, and 68(7), which were called high-risk HPV, while others were non-high-risk HPV.\u003c/p\u003e\u003cp\u003eBefore taking colposcopy examination, patients should avoid sexual activity, vaginal flushing, and medication for at least 48 hours. The examinee took the bladder lithotomy site. After examining the external genitalia and perianal area, insert a proper size speculum. Firstly, moistened the cervix and vaginal epithelium with physiological saline to remove mucus that affects observation, observed the full view of the vagina and cervix. Secondly, performed acetic acid test. Wet compressed the cervix, vagina, and fornix with 3%~5% acetic acid cotton balls for 60 seconds, then thoroughly examined the changes in the cervical and vaginal epithelium and determine the type of transformation zone (TZ) from low to high magnification. Acetic acid test can be repeated after 3\u0026ndash;4 minutes if necessary. Compound iodine test: Apply the compound iodine solution to the cervix and vagina and observe staining. Make a colposcopy diagnosis. Under the guidance of colposcopy, biopsy was conducted on the region of the cervix exhibiting the most severe abnormalities. The number of biopsies was determined by the operator independently, and the maximum diameter of the tissue should not be less than 3 mm in order to provide sufficient specimens for routine pathological sectioning and necessary immunohistochemical staining (12). Whether to perform endocervical curettage (ECC) was determined by the examiners according to the cytology results, the type of HPV infection, and the type of transformation zone. If ECC was performed, the maximum diameter (excluding mucus) of the cervical canal scraping tissue (often broken) should not be less than 2 mm. If the cervix lesion was diffuse or there was no obvious specific lesion site, examiners would perform a 4-quadrant random biopsy of the cervix at 3/6/9/12 o\u0026rsquo;clock. Samples obtained from different sites of the cervix should be individually labeled and promptly immersed in a 4% neutral formaldehyde solution for fixation prior to submission for pathological examination.\u003c/p\u003e\u003cp\u003eThe types of cervical transformation zones were classified based on the visibility of the boundary between the squamous epithelium and the columnar epithelium (13). (13). Type I transformation zone (TZ1): Both the original squamocolumnar junction (OSCJ) and the new squamocolumnar junction (NSCJ) are completely visible. The transformation zones are entirely outside the external of the cervix and does not extend into the endocervical canal. Type II transformation zone (TZ2): The NSCJ partially extends into the endocervical canal, but the entire boundary of the TZ, including the part within the endocervical canal, can still be observed under colposcopy. Type III transformation zone (TZ3): The NSCJ has completely retracted into the endocervical canal. The upper boundary of the transformation zone cannot be observed under colposcopy, and even part of the lower boundary is difficult to identify.\u003c/p\u003e\u003cp\u003eColposcopy diagnosis was divided into benign, LSIL, HSIL and carcinoma. Colposcopy impression was described with the colposcopy terminology of the International Federation for Cervical Pathology and Colposcopy (IFCPC) (14, 15). Benign colposcopy impression included inflammation, metaplasia, and polyps. LSIL was characterized by delicate puncturing, thin acetowhite epithelium, and irregular, geographic borders. The characteristics of HSIL were defined by sharp borders, an inner border, ridge sign, dense acetowhite epithelium, a coarse mosaic pattern, and coarse puncturing. The characteristics of carcinoma were represented by atypical vessels, fragile vessels, irregular surface, exophytic lesions, necrosis, and ulceration.\u003c/p\u003e\u003cp\u003ePathology diagnosis\u003c/p\u003e\u003cp\u003eThe pathological sections were read by two experienced pathologists and the conclusions were given. Pathology diagnosis was divided into benign, LSIL, HSIL and carcinoma. According to the WHO classification of female genital tumors, cervical Intraepithelial Neoplasia Grade 1(CIN1) belongs to low-grade squamous intraepithelial lesion (LSIL), cervical Intraepithelial Neoplasia Grade 2(CIN2) and cervical Intraepithelial Neoplasia Grade 3(CIN3) belong to high grade squamous intraepithelial lesion (HSIL) (16). Squamous cell carcinoma (SCC) and adenocarcinoma (AC) are both carcinomas.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eThe colposcopy data from June 2022 to November 2023 were derived from the colposcopy system. These data included patient basic information and colposcopy results. The pathological results of these populations were searched respectively by two doctors from the query system of pathology. The pathology diagnosis would be concluded and recorded after being checked one by one.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eMeasurement data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (X\u0026thinsp;\u0026plusmn;\u0026thinsp;s), while count data were described using frequencies. The chi-square test was employed to compare the rates between two groups. All statistical tests were two - sided, and a P - value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered indicative of statistical significance. Multivariate logistic regression analysis was conducted to evaluate the predictive ability of cytology and HPV testing for cervical precancerous lesions and cancer.\u003c/p\u003e\u003cp\u003eMeasurement data were showed in mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cem\u003eX\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003es\u003c/em\u003e), while count data were described by frequency. The chi-square test was used to compare the rates between two groups. All statistical tests were two-sided, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for the difference was statistically significant. Multivariate logistic regression analysis was performed to analyze the predictive effect of cytology and HPV test on cervical precancer and cancer. Statistical analyses were performed using R (version 4.4.3).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eUltimately, a total of 1007 patients were enrolled in the analysis. The mean age of the study population was 40.3 years. About 60% of patients had abnormal cytology. ASC-US and LSIL accounted for a higher proportion in abnormal cytology. 93.9% of the patients were infected with HPV. Among high-risk HPV infection, the proportion of HPV 52 infection was the highest (23.8%), followed by HPV 16 infection (22.6%) and HPV 58 infection (11.7%). The type of cervical transformation zone in 38.7% of patients was TZ1, 34.4% was TZ2, and 26.9% was TZ3. The cervical biopsy pathology of 34.3% of the patients indicated chronic inflammation or normal tissue, 49.3% indicated LSIL, 14.7% indicated HSIL, and 1.8% indicated carcinoma. In this study, 411 cases were operated by junior physician, 247 cases were completed by attending physician, and 349 cases were completed by senior physician. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBasic information of the study population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;1007)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e40.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMenopausal status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePremenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(21.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostmenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e791\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(78.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCytology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNILM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(38.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASC-US\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(29.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(22.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAGC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASC-H\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(5.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003enot perform\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHPV status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e946\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(93.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(6.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHPV type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV16 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(22.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV18 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(8.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV31 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV33 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV35 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV39 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(6.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV45 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV51 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(8.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV52 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(23.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV56 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(5.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV58 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(11.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV59 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPV68 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(5.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-high-risk HPV positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e251\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(24.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransformation zone type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e390\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(38.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e346\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(34.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e271\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(26.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColposcopy diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBenign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e434\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(43.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e479\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(47.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(8.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiopsy numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(11.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e286\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(28.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e297\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(29.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(28.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4-quadrant random biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(21.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e795\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(78.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndocervical curettage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e745\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(74.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(26.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathology diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBenign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(34.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e496\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(49.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(14.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColposcopy examiner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(40.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttending physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(24.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(34.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePatients were divided into two groups based on the pathological results, one group was benign and LSIL, the other group was HSIL and carcinoma. We analyzed the possible factors associated with the detection of HSIL and carcinoma (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The detection rate of HSIL and carcinoma in non-menopausal population (19.0%, 150/791) was higher than that in postmenopausal population (11.1%, 24/216). The higher grade of cytology, the greater the chance of detection of HSIL and carcinoma. 7.7% (30/392) patients whose cervical cytology were NILM were found HSIL or worse. While the proportion was 17.3% (30/392) in patients with ASC-US, was 15.7% (36/229) in the patients with LSIL. Among the patients with cytology of AGC or ASC-H, 56.9% (33/58) of them had biopsy pathology suggesting HSIL and worse. In the population with cytology results of HSIL or SCC, 95.5% (21/22) of them were pathologically diagnosed HSIL and carcinoma. HPV infection was closely related to cervical precancer and cancer, especially HPV 16 and HPV 18 infection. Among the patients whose pathology suggest HSIL or cancer, 99.4% (173/174) of them were HPV positive, and 43.7% (76/174) were HPV 16 and/or HPV 18 positive. However, there was no significant difference in the positive rate of other high-risk HPV between groups. The detection rate of HSIL and carcinoma in patients with different types of transformation zone was also inconsistent. The proportion of HSIL and carcinoma detected in patients with TZ1 was 23.8% (93/390), was 17.6% (61/346) in patients with TZ2, and was 7.4% (20/271) in patients with TZ3. In addition, the impression of colposcopy was also related to the detection of HSIL and carcinoma. The consistency rate between colposcopy diagnosis and pathology was 55.5%. The Kappa value was 0.271, which meant fair correlation. In this study, the positive predictive value of colposcopy detecting HSIL and carcinoma was 66.0% (62/94). The more the number of biopsy sites, the higher the detection rate of HSIL or worse. The probability of HSIL and carcinoma detected by biopsy at \u0026le;\u0026thinsp;2 sites was 10.0% (42/419), and was 22.4% (132/588) by biopsy at \u0026ge;\u0026thinsp;3 sites. Whether performing the 4-quadrant random biopsy of the cervix at 3/6/9/12 o 'clock did not affect the detection rate of HSIL and carcinoma, neither did ECC.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with the detection of HSIL and carcinoma\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBenign and LSIL\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;833)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHSIL and Carcinoma\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;174)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChi-square value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMenopausal status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.319\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epremenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e641\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epostmenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eCytology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e184.324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNILM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASC-US\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e193\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAGC/ASC-H\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL/SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003enot perform\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eHPV status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e773\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHPV16/HPV18 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOther high-risk HPV positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e520\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.930\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNon-high-risk HPV positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTransformation zone type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.376\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e297\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e285\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTZ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e251\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eColposcopy diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e193.608\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBenign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e405\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e395\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBiopsy numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.426\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e456\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e4-quadrant random biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.270\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e665\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEndocervical curettage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.807\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.369\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e621\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDue to the error between colposcopy impression and pathological diagnosis, we analyzed the possible factors of missed diagnosis and misdiagnosis of colposcopy (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Consistency rate and missed diagnosis rate were evaluated between different examiners and different TZ types. Consistency means that the colposcopy diagnosis is completely consistent with the pathology diagnosis, and missed diagnosis means that pathological results were more severe than the colposcopy evaluation. The results showed that the consistency rate and missed diagnosis rate of different examiners were similar. But they were significantly different in three types of transformation zones groups. The consistency rate of colposcopy and pathology was highest in the TZ2 group, which was 61.6%. While the consistency rates in TZ1 and TZ3 groups were 52.0% and 52.6%, respectively. The missed diagnosis rate of colposcopy in TZ2 group was the lowest, which was 22.3%. And that in TZ1 and TZ3 groups were 34.6% and 30.6% respectively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors of missed diagnosis and misdiagnosis of colposcopy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe consistency rate between colposcopy and pathology\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMissed diagnosis rate of colposcopy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eColposcopy examiner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.098\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(241/411)58.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(118/411)28.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttending physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(128/247)51.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(85/247)34.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior Physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(190/349)54.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(92/349)26.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTransformation zone type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(141/271)52.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(135/390)34.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(213/346)61.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(77/346)22.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(205/390)52.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e(83/271)30.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe further analyzed the effects of different biopsy methods on the detection of lesions in different transformation zone subgroups. The results were shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. As can be seen that in TZ1 group, biopsy at \u0026ge;\u0026thinsp;3 sites was helpful to detect lesions, and which was statistically significant. The proportion of LSIL and wore lesion detected by multi-point biopsy was 75.2%, which was significantly higher than that of biopsy at \u0026le;\u0026thinsp;2 sites (61.6%). The detected rate of HSIL and worse by multi-point biopsy was 28.4%, which was significantly higher than by biopsy at \u0026le;\u0026thinsp;2 sites (12.5%). Random biopsy at 4-quadrant of the cervix could significantly increase the detection rate of HSIL and carcinoma in the TZ1 group (31.4% vs 21.2%). ECC did not increase detected rate in TZ1 group. In the TZ2 group, it could also be seen that multi-point biopsy at \u0026ge;\u0026thinsp;3 sites was helpful to detect lesions, and the difference was statistically significant. Neither 4-quadrant random biopsy nor ECC increased the detected rate of cervix lesions in the TZ2 group. In the TZ3 group, neither multi-point biopsy nor 4-quadrant random biopsy increased detected rate of cervix lesions. But in the TZ3 group, the proportion for ECC detecting LSIL and worse lesions was 53.3%, which was higher than non-ECC group (35.5%), but the difference was not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.061).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe detection rate of different biopsy methods in different TZ groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLSIL and worse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHSIL and worse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ1(n\u0026thinsp;=\u0026thinsp;390)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e4-quadrant random biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.559\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(75/102)73.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(32/102)31.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;288)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(203/288)70.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(61/288)21.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBiopsy numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(69/112)61.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(14/112)12.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3(n\u0026thinsp;=\u0026thinsp;278)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(209/278)75.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(79/278)28.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEndocervical curettage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.134\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(136/200)68.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(54/200)27.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;190)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(142/190)74.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(39/190)20.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ2(n\u0026thinsp;=\u0026thinsp;346)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e4-quadrant random biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.379\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(48/63)76.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(8/63)12.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;283)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(200/283)70.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(53/283)18.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBiopsy numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2(n\u0026thinsp;=\u0026thinsp;148)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(92/148)62.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(18/148)12.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3(n\u0026thinsp;=\u0026thinsp;198)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(156/198)78.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(43/198)21.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEndocervical curettage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.598\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;305)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(217/305)71.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(52/305)17.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(31/41)75.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(9/41)22.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTZ3(n\u0026thinsp;=\u0026thinsp;271)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e4-quadrant random biopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.744\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(21/47)44.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(4/47)8.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;224)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(118/224)52.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(16/224)7.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBiopsy numbers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.701\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.413\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2(n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(80/159)50.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(10/159)6.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(59/112)52.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(10/112)8.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEndocervical curettage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.834\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes(n\u0026thinsp;=\u0026thinsp;240)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(128/240)53.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(18/240)7.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(11/31)35.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e(2/31)6.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn order to predict which patients were more likely to suffer HSIL and carcinoma, we performed a multivariate logistic regression analysis of cytology and HPV. The results were shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The probability of detecting HSIL and carcinoma in patients with LCT as ASC-US and LSIL was more than three times that of NILM patients. Compared with patients with normal LCT, patients with ASC-H or AGC were 19 times likely to pathologically diagnose HSIL and carcinoma, while patients with LCT as HSIL or SCC were about 261 times. The probability of HSIL and carcinoma in HPV 16 and/or HPV 18 positive patients was almost 4 times higher than that in HPV 16 and HPV 18 negative patients. The risk of HSIL and worse in patients with other high-risk HPV infections is about doubled. Non-high-risk HPV infection was a protective factor.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultiple regression analysis of objective factors related to HSIL and carcinoma\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e95% CI for OR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003elower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eupper\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCytology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNILM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASC-US\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.634\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.086\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLSIL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.837\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.743\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASC-H/AGC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.479\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.896\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHSIL/SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e261.294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.311\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2049.595\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emissing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.857\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.409\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.353\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHPV16/HPV18 positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.972\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.410\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOther high-risk HPV positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.782\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.090\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.912\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNon-high-risk HPV positive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective study was designed to explore the factors impacting the detection of cervical precancer and carcinoma under colposcopy. It provides evidence for colposcopy doctors to improve the colposcopy biopsy strategy. The results of the study mainly revealed that HPV infection is closely related to cervical precancer and cancer, especially HPV16 and HPV18 infection. 99.4% of patients that pathologically diagnosed with HSIL or worse in this study were infected with HPV, 43.7% of them were infected with type 16 or type 18 or both. It is reported that HPV type 16 and 18 account for approximately 70% of all cervical cancer (17). In a study conducted by Castle and colleagues (18), among women who were twice tested positive for HPV16 at an interval of 9\u0026ndash;21 months, the 3-year cumulative incidence of CIN2 or more severe lesions was 40%. For HPV18, the corresponding 3-year cumulative incidence of CIN2 or worse was 15%, while for other high-risk HPV, it was 9%. The tests of cytology are also of great predictive value for cervical precancer. A pooled analysis of 25830 participants founded that HSIL or worse was found in 4.1% women with cytology of ASC-US, in 15.4% with cytology of LSIL, in 65.3% with cytology of HSIL, in 96.7% with cytology of SCC, in 14.8% with cytology of AGC, in 0.4% with cytology of NILM. (19) The proportions are higher in this study, which may because of that the population included in this study is a high-risk group of cervical precancer. Overall, high-grade abnormal cytology and persistent HPV infection, especially HPV 16 and HPV 18 infections, are high risk factors for cervical precancer and cancer.\u003c/p\u003e\u003cp\u003eThe consistency rate between colposcopy diagnosis and cervical pathology diagnosis was 55.5% in this study, while the agreement of other studies was between 46.9\u0026ndash;77.0% (20\u0026ndash;24). The accuracy of colposcopy impress has always been non-ideal. Study conclusions are various for whether the operator 's experience is related to the accuracy of colposcopy diagnosis (23, 24). Our study findings indicated that the accuracy of colposcopy was not correlated with the doctor's experience or seniority. Instead, it was significantly associated with the type of cervical transformation zone. A retrospective study also reported that the accuracy rate of cervical biopsy is contingent upon the TZ and the patient's age, rather than the examiner's level of training (25). In our research, the misdiagnosis rate of TZ2 group was the minimum and the consistency rate was the maximum, while for TZ1 and TZ3 groups, the misdiagnosis rate was higher and the consistency rate was lower.\u003c/p\u003e\u003cp\u003eIn addition to the type of transformation zone, another factor affecting the detection rate of HSIL is the number of biopsy points. Like many other studies (26\u0026ndash;28), the results of this study also show that colposcopy-directed biopsies of multiple sites are helpful to detect HSIL and worse lesions. The current Danish clinical guidelines recommend the collection of four cervical biopsies, even when no abnormalities are visualized by colposcopy, and regardless of the woman's risk profile (29). The indiscriminate 4-quadrant cervical biopsies and ECC may lead to excessive examination, increasing the patient 's pain and cost. Our study found that different biopsy methods had different detection efficiency in different types of transformation zone. In TZ1 and TZ2, targeted biopsy at \u0026ge;\u0026thinsp;3 sites was helpful for the detection of cervical lesions. Performing 4-quadrant random biopsy has a higher detection rate of HSIL and carcinoma in TZ1, but not in TZ2 nor TZ3. The detection rate of HSIL and worse in TZ3 group was lowest. Neither performing multi-point biopsy nor 4-quadrant random biopsy increased the detection rate of cervical intraepithelial neoplasia in TZ3 group. Performing ECC can improve the detection rate of LSIL and worse lesions in TZ3, but the difference is not statistically significant.\u003c/p\u003e\u003cp\u003eBecause there is a certain false negative rate of colposcopy impression, it is necessary to comprehensively consider the patient 's cytology and HPV test results and colposcopy impression to decide whether to take biopsies. A pooled analysis of 17 population-based cervical cancer screening studies indicates that, for women who have a positive result in any cervical screening test yet a negative colposcopy outcome, it is essential to conduct random biopsies along with ECC for those who have cytological findings of ASC-US/LSIL and are positive for high-risk HPV, or for those with other high-grade cytological abnormalities (30). We also recommend biopsy in patients with both high-risk HPV infection and abnormal cytology, or with high grade cytology, or with HPV16/HPV18 infection. For TZ1 and TZ2, multi-point targeted biopsy of \u0026ge;\u0026thinsp;3 sites is first recommended. If the lesion is diffuse or atypical, random biopsy can be performed. For TZ3, ECC may increase the detection rate of lesions.\u003c/p\u003e\u003cp\u003eThis study provides evidence for the strategy of cervical biopsy under colposcopy. Nevertheless, the study is not without its limitations. First of all, it is a retrospective study, in which researchers are unable to control exposure and interventions. Secondly, the sample size included in this study is not large, especially in subgroup analysis, which may lead to the test efficiency is too small to show significant statistical results. Finally, the biopsy also has a certain rate of missed diagnosis. This study did not compare biopsy pathology with final surgical pathology. In the future, it will be essential to further increase the sample size, collect surgical pathological results, further compare biopsy pathology with postoperative pathology, to analyze the accuracy of different biopsy methods under colposcopy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this paper, a retrospective study is conducted to find out the factors related to the detection of cervical precancer and cancer under colposcopy. High-risk HPV infection and abnormal cytology are predictive for precancerous lesions. There are some missed diagnosis and misdiagnosis of colposcopy, which is not related to the seniority of examiners, but related to the type of transformation zone. For TZ1 and TZ2, multi-point targeted biopsy has the potential to significantly enhance the detection rate of lesions. For TZ3, ECC is likely to improve the detection rate. This study provides a basis for biopsy strategy under colposcopy. However, it is still necessary to repeatedly compare the results of colposcopy with biopsy pathology and even surgical pathology, so as to improve the accuracy of colposcopy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eAIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eAdenocarcinoma in situ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eAGC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eAtypical glandular cells\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eASC-H\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eAtypical squamous cell high-grade lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eASC-US\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eAtypical squamous cell undetermined significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCIN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eCervical intraepithelial neoplasia grade 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCIN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eCervical intraepithelial neoplasia grade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCIN3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eCervical intraepithelial neoplasia grade 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eECC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eEndocervical curettage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eHPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eHuman papillomavirus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eHSIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eHigh-grade squamous intraepithelial lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eIFCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eInternational Federation for Cervical Pathology and Colposcopy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eLCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eLiquid - based Cytology Test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eLSIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eLow-grade squamous intraepithelial lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNILM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eNo intraepithelial lesions or malignant lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eNSCJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eNew squamocolumnar junction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eOSCJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eOriginal squamocolumnar junction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eTransformation zone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTZ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eType I transformation zone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTZ2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eType II transformation zone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTZ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 459px;\"\u003e\n \u003cp\u003eType III transformation zone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Review Committee of Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou City, Guangdong Province, China (Ethical approval number: SYSKY-2024-093-01). We confirm that all methods were performed in accordance with relevant guidelines and regulations. This was a retrospective study and it did not involve human experimentation. An informed consent waiver was obtained for our study from the Institutional Review Board of Sun Yat-sen Memorial Hospital, Sun Yat-sen University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors confirm that this work has not been published before and it is not under consideration for publication elsewhere. This submission has been approved by all co-authors and its publication has been approved by the responsible authority at the institution where the work was carried out. All the authors agree to publish this work in BMC Women\u0026apos;s Health in English\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been supported by National Natural Science Foundation of China (Grant No. 82171670) and Chinese Preventive Medicine Association special research funding for prevention and treatment of female pelvic floor disorders (Grant No. 201819126).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXQ Xie: Data analysis and manuscript writing. YN Yang: Data collection and manuscript revising. QY Hu: Data collection.MQ Xie and YZ Li: Manuscript editing and revising. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the three doctors for their colposcopy work and the patients for their participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData and related materials supporting the findings of this study are available upon request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLi Z, Liu P, Yin A, Zhang B, Xu J, Chen Z, et al. Global landscape of cervical cancer incidence and mortality in 2022 and predictions to 2030: The urgent need to address inequalities in cervical cancer. INT J CANCER. [Journal Article]. 2025 2025-7-15;157(2):288-97.\u003c/li\u003e\n\u003cli\u003eSiegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. CA-CANCER J CLIN. [Journal Article]. 2025 2025-1-1;75(1):10-45.\u003c/li\u003e\n\u003cli\u003eLei J, Ploner A, Elfstr\u0026ouml;m KM, Wang J, Roth A, Fang F, et al. HPV Vaccination and the Risk of Invasive Cervical Cancer. NEW ENGL J MED. [Journal Article; Research Support, Non-U.S. Gov\u0026apos;t]. 2020 2020-10-1;383(14):1340-8.\u003c/li\u003e\n\u003cli\u003eFalcaro M, Casta\u0026ntilde;on A, Ndlela B, Checchi M, Soldan K, Lopez-Bernal J, et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. LANCET. [Journal Article; Observational Study]. 2021 2021-12-4;398(10316):2084-92.\u003c/li\u003e\n\u003cli\u003eWongpratate M, Bumrungthai S. Cervical cancer in Thailand: 2023 update. Obstet Gynecol Sci. [Journal Article]. 2024 2024-5-1;67(3):261-9.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Regional implementation framework for elimination of cervical cancer as a public health problem: 2021\u0026ndash;2030 [Internet] New Delhi (IN): World Health Organization; c2021. [cited 2023 Apr 21]. Available from: https://www.who.int/publications/i/item/9789290228875.\u003c/li\u003e\n\u003cli\u003ePerkins RB, Wentzensen N, Guido RS, Schiffman M. Cervical Cancer Screening: A Review. JAMA: the journal of the American Medical Association. 2023 2023-1-1;330(6):547-58.\u003c/li\u003e\n\u003cli\u003ePerkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J LOW GENIT TRACT DI. 2020;24(2):102-31.\u003c/li\u003e\n\u003cli\u003eNgu SF, Cheung A, Jong KK, Law J, Lee AY, Lee J, et al. 2024 Hong Kong College of Obstetricians and Gynaecologists Guidelines for cervical cancer prevention and screening. HONG KONG MED J. [Journal Article; Practice Guideline]. 2024 2024-12-1;30(6):488-97.\u003c/li\u003e\n\u003cli\u003eRedman C, Kesic V, Cruickshank ME, Gultekin M, Carcopino X, Castro SM, et al. European consensus statement on essential colposcopy. EUR J OBSTET GYN R B. [Journal Article; Review]. 2021 2021-1-1; 256:57-62.\u003c/li\u003e\n\u003cli\u003eNayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology: A Historical Perspective. ACTA CYTOL. [Journal Article; Review]. 2017 2017-1-20;61(4-5):359-72.\u003c/li\u003e\n\u003cli\u003eChen Fei, You Zhixue, Sui Long, Li Shuang, Liu Jun, Liu Aijun, et al. Chinese Expert Consensus on Colposcopy Application. Chinese Journal of Obstetrics and Gynecology. 2020; 55 (7): 443-9.\u003c/li\u003e\n\u003cli\u003eQuaas J, Reich O, K\u0026uuml;ppers V. Explanation and Use of the Rio 2011 Colposcopy Nomenclature of the IFCPC (International Federation for Cervical Pathology and Colposcopy): Comments on the general colposcopic assessment of the uterine cervix: adequate/inadequate; squamocolumnar junction; transformation zone. GEBURTSH FRAUENHEILK. [Journal Article]. 2014 2014-12-1;74(12):1090-2.\u003c/li\u003e\n\u003cli\u003eBornstein J, Bentley J, B\u0026ouml;sze P, Girardi F, Haefner H, Menton M, et al. 2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy. OBSTET GYNECOL. [Journal Article]. 2012 2012-7-1;120(1):166-72.\u003c/li\u003e\n\u003cli\u003eQuaas J, Reich O, Frey TB, K\u0026uuml;ppers V. Explanation and Use of the Colposcopy Terminology of the IFCPC (International Federation for Cervical Pathology and Colposcopy) Rio 2011. GEBURTSH FRAUENHEILK. [Journal Article]. 2013 2013-9-1;73(9):904-7.\u003c/li\u003e\n\u003cli\u003eWHO classification of Tumours Editorial Board. WHO classification of tumors. Female genital tumors [M]. 5th ed. Lyon: IARC Press, 2020:342-346.\u003c/li\u003e\n\u003cli\u003eCrosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. LANCET. [Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov\u0026apos;t]. 2013 2013-9-7;382(9895):889-99.\u003c/li\u003e\n\u003cli\u003eCastle PE, Rodr\u0026iacute;guez AC, Burk RD, Herrero R, Wacholder S, Alfaro M, et al. Short term persistence of human papillomavirus and risk of cervical precancer and cancer: population based cohort study. BMJ-BRIT MED J. [Journal Article; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural]. 2009 2009-7-28;339: b2569.\u003c/li\u003e\n\u003cli\u003ePan QJ, Hu SY, Zhang X, Ci PW, Zhang WH, Guo HQ, et al. Pooled analysis of the performance of liquid-based cytology in population-based cervical cancer screening studies in China. CANCER CYTOPATHOL. [Comparative Study; Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov\u0026apos;t]. 2013 2013-9-1;121(9):473-82.\u003c/li\u003e\n\u003cli\u003eFan A, Wang C, Zhang L, Yan Y, Han C, Xue F. Diagnostic value of the 2011 International Federation for Cervical Pathology and Colposcopy Terminology in predicting cervical lesions. Oncotarget. [Journal Article]. 2018 2018-2-6;9(10):9166-76.\u003c/li\u003e\n\u003cli\u003eTatiyachonwiphut M, Jaishuen A, Sangkarat S, Laiwejpithaya S, Wongtiraporn W, Inthasorn P, et al. Agreement between colposcopic diagnosis and cervical pathology: Siriraj hospital experience. Asian Pac J Cancer Prev. [Journal Article]. 2014 2014-1-20;15(1):423-6.\u003c/li\u003e\n\u003cli\u003eLi Y, Zhang H, Zheng R, Xie F, Sui L. [Agreement between colposcopic diagnosis with 2011 international terminology of colposcopy and cervical pathology in cervical lesions]. Zhonghua Fu Chan Ke Za Zhi. [Evaluation Study; Journal Article]. 2015 2015-5-1;50(5):361-6.\u003c/li\u003e\n\u003cli\u003eBaum ME, Rader JS, Gibb RK, McAlister RP, Powell MA, Mutch DG, et al. Colposcopic accuracy of obstetrics and gynecology residents. GYNECOL ONCOL. 2006;103(3):966-70.\u003c/li\u003e\n\u003cli\u003eLi J, Wang W, Yang P, Chen J, Dai Q, Hua P, et al. Analysis of the agreement between colposcopic impression and histopathological diagnosis of cervical biopsy in a single tertiary center of Chengdu. ARCH GYNECOL OBSTET. [Journal Article]. 2021 2021-10-1;304(4):1033-41.\u003c/li\u003e\n\u003cli\u003eStuebs FA, Schulmeyer CE, Mehlhorn G, Gass P, Kehl S, Renner SK, et al. Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study. ARCH GYNECOL OBSTET. 2019 2019-1-1;299(2):525-32.\u003c/li\u003e\n\u003cli\u003eGage JC, Hanson VW, Abbey K, Dippery S, Gardner S, Kubota J, et al. Number of cervical biopsies and sensitivity of colposcopy. OBSTET GYNECOL. [Evaluation Study; Journal Article; Multicenter Study; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural; Research Support, U.S. Gov\u0026apos;t, Non-P.H.S.]. 2006 2006-8-1;108(2):264-72.\u003c/li\u003e\n\u003cli\u003ePretorius RG, Belinson JL, Burchette RJ, Hu S, Zhang X, Qiao YL. Regardless of skill, performing more biopsies increases the sensitivity of colposcopy. J LOW GENIT TRACT DI. [Journal Article]. 2011 2011-7-1;15(3):180-8.\u003c/li\u003e\n\u003cli\u003eVallapapan A, Chandeying N, Srijaipracharoen S, Uthagethaworn K. The role of random cervical biopsies in addition to colposcopy-directed biopsies in detection of CIN2. J OBSTET GYNAECOL. [Journal Article]. 2019 2019-2-1;39(2):184-9.\u003c/li\u003e\n\u003cli\u003eDSOG. Danish Society of Obstetrics and Gynaecology Guideline Cervical dysplasia, 2019. Available: https://www.dsog.dk/s/guideline_3844-1_1-202008260659.pdf\u003c/li\u003e\n\u003cli\u003eHu S, Zhang W, Li S, Li N, Huang M, Pan Q, et al. Pooled analysis on the necessity of random 4-quadrant cervical biopsies and endocervical curettage in women with positive screening but negative colposcopy. MEDICINE. 2017;96(17): e6689.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"colposcopy, cytology, human papillomavirus, transformation zone, biopsy","lastPublishedDoi":"10.21203/rs.3.rs-6950409/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6950409/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo study the factors affecting the detection of cervical precancer and cancer under colposcopy, and to provide evidence for optimizing colposcopy biopsy strategy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis was a retrospective study that included 1007 female patients who underwent colposcopy and cervical biopsy. Factors related to the detection rate of cervical precancer and cancer were analyzed. The accuracy of colposcopy diagnosis and possible influencing factors were also analyzed. Then subgroup analysis was performed in different types of cervical transformation zones to compare the efficiency of different biopsy methods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAbnormal cytology and positive detection of high-risk human papillomavirus (HPV) were risk factors for precancer and cancer, while positive detection of non-high-risk HPV was a protection factor. The consistency rate between colposcopy diagnosis and pathology diagnosis was 55.5%. The accuracy of colposcopy was affected by the type of cervical transformation zone rather than the seniority of the examiners. For type I transformation zone, the detection rate of high-grade lesions using 4-quadrant random biopsy (31.4% vs 21.2%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038) and multi-point targeted biopsy (28.4% vs 12.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) was higher than corresponding control group. For type II transformation zone, the detection rate of high-grade lesions was higher when taking multi-point biopsy at \u0026ge;\u0026thinsp;3 sites (21.7% vs 12.2%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). For type III transformation zone, the detection rate of lesions was higher when performing endocervical curettage (53.3% vs 35.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.061), but there was no statistical significance.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study provides a basis for biopsy strategy during colposcopy. Biopsy is recommended for patients with both high-risk HPV infection and abnormal cytology. Multi-point targeted biopsy of \u0026ge;\u0026thinsp;3 sites is recommended in type I and type II transformation zone. ECC may increase the detection rate of lesions in type III transformation zone.\u003c/p\u003e","manuscriptTitle":"Cervical biopsy strategy under colposcopy: evidence from a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 16:14:52","doi":"10.21203/rs.3.rs-6950409/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-30T07:48:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T11:40:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309390097496936978852659264433056523919","date":"2025-08-26T11:21:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106692729574799272086204045674568945423","date":"2025-08-23T14:50:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T15:14:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118946158390213978477268293565957671590","date":"2025-08-22T06:19:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T08:09:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256785960866905720668158277658791515586","date":"2025-08-21T07:53:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177423072531931989180824557348283636467","date":"2025-08-21T06:43:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53855120706946625642250881959095016721","date":"2025-08-20T19:59:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205412154208321282305240377203291360486","date":"2025-08-20T19:39:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T23:30:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272813645415169005766785955390239539435","date":"2025-07-27T12:14:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-26T22:42:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159453094304281748907209384866419777425","date":"2025-07-25T20:14:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-18T15:31:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-25T15:54:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-25T04:08:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-25T04:07:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-06-22T15:24:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"633b82be-0e4a-4ff7-a51c-be61f135110b","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T07:42:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 16:14:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6950409","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6950409","identity":"rs-6950409","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}