Role of endocervical curettage in detecting CIN2 + in postmenopausal women with persistent high-risk HPV and type 3 transformation zone

Abstract

Background

This study aimed to evaluate the effectiveness of endocervical curettage (ECC) in detecting cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in HPV-positive postmenopausal women with a type 3 transformation zone (TZ3) and to identify additional predictive factors.

Methods

A retrospective observational study was conducted including 137 HPV-positive postmenopausal women who underwent colposcopy, ECC, and subsequent LEEP. Variables analyzed included age group, HPV genotype (16/18 vs. non-16/18), transformation zone type, cytology results, and ECC findings. Univariate and multivariable logistic regression analyses were performed to identify predictors of CIN2 + confirmed by LEEP histology.

Results

CIN2 + prevalence was 27.7% (38/137); ≥CIN3 occurred in 26/137 (19.0%). In multivariable analysis, high-grade cytology (adjusted OR [aOR] 4.65; 95% CI 1.92–11.30; p < 0.001), TZ3 (aOR 3.05; 1.05–8.85; p = 0.040) and hrHPV non-16/18 (aOR 2.52; 1.08–5.90; p = 0.032) were independently associated with CIN2+, while age ≥ 51 years was not (aOR 1.28; 0.57–2.85; p = 0.55). Absolute risks of CIN2 + were 36.8% with non-16/18 vs. 16.4% with HPV16/18. ECC (cut-off CIN2+) yielded sensitivity 73.7%, specificity 77.8%, PPV 56.0% and NPV 88.5%.

Conclusion

In postmenopausal women with persistent hrHPV, high-grade cytology and TZ3 are the main drivers of CIN2+ risk. ECC is most useful as a rule-out test (high NPV), whereas expedited diagnostic-therapeutic LEEP may be considered when ASC-H/HSIL coexists with TZ3 in women without fertility desire. The association between non-16/18 genotypes and CIN2+ observed here warrants confirmation in larger multicentre cohorts.

Background

Cervical cancer represents a significant public health problem and is currently the fourth most common malignancy among women worldwide. According to the most recent estimates (GLOBOCAN 2022), approximately 660,000 new cases and 350,000 deaths attributable to this disease were recorded in 2022 [1]. Global disparities in access to prevention and treatment are associated with greater impact and mortality from cervical carcinoma in contexts with limited resources, where anti-HPV vaccination, screening and treatments are less widespread and the most marked unfavorable social determinants [2]. The hr-HPV, moreover, is etiologically implicated also in neoplasms of oropharynx, anus, vulva and penises [3, 4].

The persistent infection from human papillomavirus (HPV) high -risk oncogenic constitutes a necessary, but not sufficient factor, for the progression towards high -grade cervical intraepithelial lesions (CIN2+) and, in a minority of cases, towards invasive carcinoma [5]. Cohort studies have shown that, between women with normal cytology and persistent infection from HPV16, the cumulative risk to 12 years to develop CIN3 + is equal to 26.7%, while it is lower for other oncogenic genotypes such as HPV18 (19.1%), HPV31 (14.3%) and HPV33 (14.9%); for other types of high -risk HPVs, the absolute risk stands at around 6.0% [6, 7]. In addition, among women with an untreated CIN3, about 30% develop invasive cervical carcinoma within 30 years of follow-up [8]. These data indicate that although viral persistence is a decisive key to neoplastic progression, most HPV infections and a significant share of CIN3 lesions do not necessarily evolve into invasive cancer [9].

In countries with organized screening programs, the incidence of cervical cancer tends to decrease after a peak observed between 35 and 39 years old [10, 11]. Although in programs based exclusively on cytology the decline may be more content, more consecutive screening cycles with negative results are associated with a significant reduction in the risk of invasive carcinoma [12]. Furthermore, in the screening systems that use the HPV test as a primary method, the residual risk of developing carcinoma after several negative tests is extremely low [13].

In postmenopausal women who have not regularly participated in screening, the risk of invasive cancer can be increased (50–64 years, with rates respectively equal to 16.5 and 14.8 cases per 100,000 women) [14, 15] also due to the greater difficulty of detecting dysplastic alterations. The cervical atrophy secondary to the estrogen deficiency, in fact, determines the internal migration of the squamocolumnar junction (type 3 transformation), reducing the effectiveness of cytology and colposcopy and increasing the risk of hidden carcinoma, estimated between 10.4% and 17% [16]. In this context, endocervical curettage (ECC) has emerged as a useful technique to sample the endocervical canal and identify high-grade lesions not visible at standard colposcopy [17, 18]. However, the systematic use of ECC is not uniform internationally: in some health systems (Norway) ECC is part of protocols that, in the absence of visible lesions, also include blind four-quadrant biopsies to increase diagnostic sensitivity [19–21], while in other contexts its routine adoption remains debated.

The aim of this study is to evaluate the effectiveness of ECC in detecting CIN2 + lesions in HPV- positive postmenopausal women using LEEP histology as the reference standard.

Additionally, it examines the association between high-risk HPV infection and the presence of.

CIN2 + lesions, with the goal of identifying subgroups of patients who may benefit most from the.

routine use of ECC.

Methods

Anonymized data from a dedicated database were analyzed for 196 postmenopausal patients referred for colposcopy due to persistent HPV infection at the secondary care center of the University Hospital of Catania and the Humanitas Center in Catania between 2019 and 2022.

A retrospective observational study was conducted. All patients were postmenopausal and a type 3 transformation zone (TZ3). To be enrolled, patients had to meet the following inclusion criteria: age ≥ 45 years, positive and persistent HPV test for high oncogenic risk genotypes, colposcopy with identification of the transformation zone evaluated according to international colposcopic criteria, performance of endocervical curettage (ECC), performance of excisional treatment (LEEP) with histological confirmation.

Exclusion criteria were: previous history of cervical conization, pregnant women, incomplete clinical or histological data.

Persistent infection was defined as the detection of the same HPV genotype at ≥ 2 consecutive visits spaced ≥ 6 or ≥ 12 months apart. Incidental or transient HPV infection was defined as the detection of a new HPV genotype. Cervical cytology was interpreted according to the Bethesda System, while histological diagnoses of excised specimens were made using the World Health Organization (WHO) classification.

Both included centers used the same technique for cervical canal study and the same molecular technique for HPV DNA detection and genotyping.

The identified genotypes were divided into HPV 16/18 and non-16/18 HPV genotypes (HPV 31, 33, 35, 45, 39, 51, 52, 58, 59, 66 and 68).

A positive ECC was defined as a CIN2 + finding (CIN2, CIN3, or carcinoma in situ). Findings ≤ CIN1 were classified as negative ECC.

Only 137 patients met the inclusion criteria and their clinical data were collected: age, HPV genotype, Transformation Zone Type, ECC and histological examination of the cone. The data were analyzed anonymously.

This study conforms to the principles of the Declaration of Helsinki, as revised in 2013. The research was conducted through a retrospective review of medical records. In accordance with current legislation on observational studies (March 20, 2008), the study protocol was submitted to the Catania 1 Ethics Committee of the Catania University Hospital. The committee did not request any modifications to the protocol and deemed informed consent unnecessary, as the study involved only retrospective analysis of anonymized clinical data.

Endocervical curettage (ECC)

For ECC, a sharp Kevorkian curette without a basket was inserted into the endocervical canal. Gentle pressure was applied to the tip, and the curette was moved back and forth along the length of the endocervix while being simultaneously rotated in a circular motion to sample the entire circumference of the canal. Sampling of lesions extending beyond the external cervical orifice was deliberately avoided to minimize contamination with ectocervical tissue. A rapid rotational movement was applied while withdrawing the curette from the canal, ensuring that all tissue and cellular material were captured within the curette chamber.

ECC: excluded from the model to avoid incorporation bias; its diagnostic performance is calculated separately using sensitivity, specificity, PPV, and NPV.

Cytological evaluation

Using the Bethesda System, cytological assessment yielded the following classifications: NILM (Negative for Intraepithelial Lesion or Malignancy, indicating a normal result), ASC-US (Atypical Squamous Cells of Undetermined Significance), ASC-H (Atypical Squamous Cells—cannot exclude High-Grade Squamous Intraepithelial Lesion), LSIL (Low-Grade Squamous Intraepithelial Lesion), HSIL (High-Grade Squamous Intraepithelial Lesion), AGC (Atypical Glandular Cells), and others.

Cytological findings were categorized as normal, inadequate sampling, or abnormal. NILM cases and those indicating infection were classified within the normal range. For analysis, cytology recoded as: low grade = ASC-US + LSIL; high grade = ASC-H + HSIL.

HPV DNA testing and genotyping

Exocervical cytology samples were collected and placed into ThinPrep solution. The samples were sent to the laboratory for DNA extraction and viral DNA genotyping, performed via genetic amplification followed by hybridization with genotype-specific probes capable of identifying most genital-region HPV genotypes. These included high-risk HPV genotypes (16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, and 82), low-risk genotypes (6, 11, 40, 43, 44, 54, and 70), and genotypes of undetermined risk (69, 71, and 74). The commercial assay used was the MAG NucliSENS easyMAG system (bioMérieux SA, Marcy-l’Étoile, France). HPV genotypes were further categorized into HPV 16/18 and non-16/18 high-risk HPV (hrHPV). For complete genotyping, the Inno-LiPA HPV genotyping kit was used, capable of identifying 32 genotypes, clinically validated for primary screening according to the Meijer criteria [22].

Colposcopy

Colposcopy was performed using a Zeiss OPM1F colposcope (Carl Zeiss, Jena, Germany) with the application of acetic acid and Lugol’s iodine solution. Any colposcopic abnormalities were classified according to the terminology proposed by the International Federation for Cervical Pathology and.

Colposcopy (IFCPC), which grades findings by severity into three levels: abnormal transformation zone (ATZ) grade 1 (ATZ1), grade 2 (ATZ2), or invasive cancer. The visibility of the squamocolumnar junction and the transformation zone was also assessed. The transformation zone was classified as type 1, 2, or 3: type 1 when the squamocolumnar junction was fully visible; type 2 when fully visible but extending into the endocervical canal; and type 3 when not visible and located deep within the canal, making it impossible to determine its endpoint. This classification is relevant for determining the type of excision required.

LEEP Procedure

LEEP was performed under local anesthesia in an outpatient setting by experienced personnel under colposcopic guidance. For type 3 transformation zones, a Fisher loop was used, with the loop size adjusted to the volume of the cervix. A single cone was excised, measuring between 15 and 20 mm in length, to ensure complete removal of the transformation zone. Histological examination of the cervical cone was performed, and margin status was evaluated. Cone margins were considered positive if the distance between CIN2 + lesions and the resection surface was less than 1 mm. Oriented specimens, formalin-fixed, 2–3 mm serial sections, EE staining and p16 immunohistochemistry according to local standards.

Statistical Analysis

Descriptive statistics were used to summarize the characteristics of the study population. Continuous variables were expressed as mean ± standard deviation or as median and interquartile range, as appropriate. Categorical variables were presented as frequencies and percentages.

To verify any differences between women with a CIN2 + outcome on LEEP and those with a ≤ CIN1 outcome, Pearson’s χ² test was used, or, when the expected number in at least one cell was < 5, Fisher’s exact test. Comparisons were made for: age (≥ 51 vs. 45–50 years), cytology (low grade = ASC-US/LSIL; high grade = ASC-H/HSIL), viral genotype (HPV 16/18 vs. other-HPVs non-16/18), and transformation zone type (TZ3 vs. TZ1-2). The association between clinical covariates and the endpoint (CIN2 + on LEEP) was explored with univariate logistic regression. Odds ratios (ORs), their 95% confidence intervals, and p-values (Wald test) were calculated.

To avoid incorporation bias, the variable “positive ECC” (defined as a finding ≥ CIN2 on ECC) was not included in the primary model, as it shares the same histological criterion as the outcome.

For ECC, with a diagnostic cutoff of CIN2+, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were calculated, with 95% CIs obtained using the Wald approximation.

Variables with a p-value < 0.10 in the univariate analysis were included in a multivariate logistic regression model to identify independent predictors of CIN2+. Statistical significance was set at p < 0.05. Statistical analyses were performed using the SPSS software package for Windows (version 30.0, SPSS Inc., Chicago, IL, USA).

Results

Of the 196 patients enrolled, 38 were excluded due to non-diagnostic ECC samples caused by insufficient material. An additional 11 cases were excluded due to uncertain interpretation of the LEEP cone histology and 10 cases due to inconclusive ECC histology. Thus, the final study cohort consisted of 137 patients, aged between 45 and 72 years. The characteristics of the study population are shown in Table 1.

Table 1.

Clinical and virological characteristics of the cohort according to histological outcome on LEEP (≤ CIN1 vs. CIN2+)

Variable	Total (n)	CIN2+ (%) (n = 38)	p
Age
45–50 years old	50	12 (24,0)	0,46
≥ 51 years old	87	26 (29,9)
Cytology
Low-grade (ASC-US/LSIL)	60	7 (11,7)	< 0,001
High-grade (ASC-H/HSIL)	77	31 (40,3)
HPV genotype
16/18	61	10 (16,4)	0,009
hr-HPV non-16/18	76	28 (36,8)
Transformation Zone
TZ1–2	42	5 (11,9)	0,006
TZ3	95	33 (34,7)
ECC*
Negative (≤ CIN1)	87	10 (11,5)	< 0,001
Positive (CIN2+)	50	28 (56,0)

*ECC reported for descriptive purposes only; not used as a covariate in models to avoid incorporation bias

The overall prevalence of CIN2 + at baseline histology (LEEP) was 27.7% (38/137). Within these, lesions ≥ CIN3 were 26/137 (19.0%).

In patients with high-grade cytology (ASC-H/HSIL), the risk of CIN2 + was 40.3% (31/77) compared to 11.7% (7/60) in those with low-grade cytology (ASC-US/LSIL).

Consistently, logistic analysis confirmed a strong association both in univariate analysis (OR ≈ 5.10; 95% CI 2.05–12.7; p < 0.001) and, especially, in the multivariate model, where high-grade cytology remained the most robust independent predictor (aOR ≈ 4.65; 95% CI 1.92–11.30; p < 0.001) (Table 2).

Table 2.

Univariate logistic regression (outcome = CIN2 + on LEEP)

Independent variable	OR	CI 95%	p
Age ≥ 51 anni vs. 45–50	1,35	0,61–2,99	0,46
High-grade cytology (ASC-H/HSIL) vs. Low-grade (ASC-US/LSIL)	5,10	2,05–12,7	< 0,001
Genotype hr-HPV non-16/18 vs. 16/18	2,98	1,31–6,78	0,009
Transformation zone TZ3 vs. TZ1–2	3,58	1,28 − 10,0	0,015

Compared to HPV 16/18 infections, non-16/18 hr-HPV infections show approximately threefold increased odds of CIN2+ (OR 2.98; 95% CI 1.31–6.78; p = 0.009). In absolute terms, the observed risk increases from 16.4% (10/61) for 16/18 to 36.8% (28/76) for other types (RR ≈ 2.24; Δ risk + 20.4 points). The result is statistically robust and clinically relevant.

Restricting the endpoint to ≥ CIN3, a trend toward higher odds is observed with non-16/18 hr-HPV (OR 2.57; 95% CI 1.00–6.64; p = 0.050). Here too, the absolute risks are higher with the other types (25.0% vs. 11.5%; RR ≈ 2.17; Δ + 13.5 points), but the confidence interval reaches unity, so the evidence is borderline and should be interpreted with caution (Table 3).

Table 3.

Distribution of HPV genotypes by histological outcome

Outcome	n	HPV 16/18 (%)	hr-HPV non-16/18(%)	Absolute Difference	RR (non-16/18 vs. 16/18)	OR	CI 95%	p
CIN2+	61	10 (16,4)	28 (36,8)	+ 20,4 pp	2,24	2,98	1,31–6,78	0,009
≥CIN3	76	7 (11,5)	19 (25,0)	+ 13,5 pp	2,17	2,57	1,00–6,64	0,050

For the corresponding crude ORs (comparison other hr-HPV vs. 16/18). After multivariate adjustment, hr-HPV genotypes other than 16/18 showed an almost three-fold increased probability of CIN2 + compared to 16/18 (OR = 2.98; 95% CI 1.31–6.78). It is important to note that the odds ratio does not coincide with the risk ratio: the observed risk of CIN2 + increased from 16.4–36.8%, corresponding to an increase of approximately 2.2-fold and an absolute increase of 20%

RR risk ratio (point estimate)

Table 4Shows the distribution of genotypes in CIN3 + cases

Table 4.

Distribution of genotypes in CIN3 + cases

Histologies after LEEP	HPV 16/18	HPV non-16/18
CIN3 (n = 21)	5	16
AIS (n = 1)	1	0
IA1 (n = 1)	1	0
IA2 (n = 1)	0	1
Invasive Ca (n = 2)	0	2
Total (n = 26)	7	19

Transformation zone type had an independent impact: transformation zone type 3 (TZ3) was associated with an increased risk of CIN2+ (univariate OR 3.58; 95% CI 1.28–10.0; p = 0.015), confirmed in the multivariate analysis (aOR ≈ 3.05; 95% CI 1.05–8.85; p = 0.040). Conversely, age ≥ 51 years did not show a significant association (24.0% of CIN2 + in 45–50 years vs. 29.9% in ≥ 51 years; p = 0.46; multivariate aOR ≈ 1.28; 95% CI 0.57–2.85; p = 0.55), suggesting that the effect of age is mediated by cytology, genotype and TZ.

Diagnostic performance of ECC (defining CIN2 + positive on curettage) was: sensitivity 73.7% (28/38), specificity 77.8% (77/99), PPV 56.0% (28/50), and NPV 88.5% (77/87), with overall accuracy 76.6%. These values indicate that a negative ECC substantially reduces the probability of significant lesion (particularly useful as a “rule-out” test in low-moderate risk settings), whereas a positive ECC has only moderate confirmatory value (Table 5).

Table 5.

Diagnostic performance of ECC (cut-off = CIN2+)

Index	Value	CI 95%
Sensitivity	73,7%	59,7–87,6%
Specificity	77,8%	69,6–86,0%
PPV	56,0%	42,3–69,7%
NPV	88,5%	81,8–95,2%
Accuracy	76,6%	—

These numbers show that ECC, with a negative predictive value close to 90%, is particularly useful for excluding CIN2 + in patients with TZ3, while the more modest PPV reflects the presence of focal lesions not always sampled by the endocervical smear.

In the clinical multivariate model (without ECC to avoid incorporation bias), the covariates that remained independently associated with CIN2 + were: high-grade cytology (aOR ≈ 4.65), TZ3 (aOR ≈ 3.05), and non-16/18 genotypes (aOR ≈ 2.52; 95% CI 1.08–5.90; p = 0.032) (Table 6).

Table 6.

Multivariate logistic regression (clinical model; outcome = CIN2 + on LEEP)

Independent Variable	aOR	CI 95%	p
Age ≥ 51 vs. 45–50	1,28	0,57–2,85	0,55
High-grade cytology vs. low-grade	4,65	1,92–11,30	< 0,001
Genotype hr-HPV non-16/18 vs. 16/18	2,52	1,08–5,90	0,032
Transformation Zone TZ3 vs. TZ1–2	3,05	1,05–8,85	0,040

Discussion

The overall detection rate of CIN2 + in our cohort was 27.7%, a result comparable to previous studies examining postmenopausal women with persistent HPV infection. Some authors have reported a prevalence of CIN2 + of 19% among women with persistent HPV infection, negative cytology and TZ3 [23], similar estimates can be found in the literature: in a retrospective study of patients with negative cytology but positivity for HR-HPV, the immediate risk of CIN2 + was 11.32% (non-16/18) [24]. In a large prospective Danish cohort, 9.7% of hrHPV-positive persistent women with negative cytology developed CIN3 + over the follow-up period (up to 11.5 years) [25].

Other cohorts have shown rates ranging from 20 to 40% depending on HPV genotyping and cytological status [26].

Our data clearly confirm the prognostic advantage of high-grade cytology in postmenopausal women with persistent HPV infection. In the presence of an ASC-H/HSIL finding, the risk of a CIN2 or higher lesion at conization is fivefold higher compared to low-grade abnormalities, even after adjusting for age, viral genotype, and transformation zone type. The magnitude of the association is very close to that described by Hammer et al. in the Kaiser Permanente cohort study, where an HSIL pattern conferred a hazard ratio of around 4 for CIN3 + in HPV-based primary screening [13]. This finding is particularly relevant in postmenopausal women, when atrophy and endocervical migration of the squamocolumnar junction reduce colposcopy performance and tend to “hide” more proximal lesions.

Transformation zone type 3 (TZ3) emerged as the second independent determinant (aOR ≈ 3.0). The mere presence of a type 3 transformation zone tripled the odds of identifying CIN2 + on LEEP, consistent with the experience of Chu et al., who emphasized that the depth of the squamocolumnar junction makes complementary procedures such as ECC or randomized biopsies indispensable [19]. Our result reinforces the idea that, in TZ3 women, traditional colposcopy risks underestimating the disease and that an excisional approach may be justified, especially if the cytology is high-grade and the patient no longer has the desire to reproduce.

More unexpected is the effect of viral genotypes: infections with hr-HPVs other than 16/18 showed double the odds for CIN2 + compared to genotypes 16/18 and showed a similar trend for ≥ CIN3.

The literature attributes the highest oncogenicity for invasive cervical neoplasms to HPV16/18 genotypes [27–29]. However, in cohorts of older women, less linear trends in genotype-specific risk emerge [30–35]. It has also been suggested that HPV16-related lesions tend to present larger/more visible colposcopic areas and are therefore intercepted and treated earlier, while those caused by other hr-HPVs may escape detection for longer—especially in the presence of TZ3—and then emerge at LEEP [36, 37]. In parallel, the adoption of HPV-based screening advances diagnosis and reduces invasive cases (stage shift) [12]. In this context, our results—although obtained on a limited sample—are consistent with this interpretation and invite us not to neglect extended typing in postmenopausal follow-up [29, 38].

From an operational standpoint, we evaluated ECC as a diagnostic test (cut-off = CIN2+) but excluded it from the predictive model to avoid incorporation bias (predictor and outcome would share the same histological endpoint), which is why we evaluated its performance separately. ECC confirmed its usefulness as a rule-out test: with a sensitivity of 74% and a negative predictive value close to 90%, a negative curettage makes the presence of occult CIN2 + unlikely, in line with the meta-analysis by Hu et al. [20] and can support conservative approaches when cytology is low-grade or the colposcopic picture is uninformative [39]. Conversely, in the presence of high-grade cytology and TZ3, the marginal utility of ECC decreases and immediate excision tends to be the most efficient strategy.

Finally, chronological age was not found to be an independent predictor once other factors were controlled, confirming the observations of Kjær et al. that age-related risk disappears when viral persistence and screening history are considered [7]. This suggests that invasive decisions should not be based on age as such, but rather on a composite risk profile that integrates cytology, genotype, and colposcopic morphology.

Clinical implications

The results reinforce the idea that, in postmenopausal women with persistent hr-HPV, high-grade cytology (ASC-H/HSIL) associated with a type 3 transformation zone constitutes a risk profile that justifies an immediate excisional approach, without intermediate diagnostic steps. This is consistent with the “Risk-Based Management” risk thresholds introduced by the 2019 ASCCP guidelines and the most recent Canadian recommendations proposing direct LEEP in the presence of HSIL and TZ3 in menopausal patients [40]. On the other hand, ECC remains valuable as a “rule-out” test: a negative result, thanks to a negative predictive value close to 90%, can avoid unnecessary treatment when cytology is low-grade or colposcopic findings are equivocal. Finally, the unexpected association between non-16/18 genotypes and the risk of CIN2 + calls for going beyond the simple 16/18-versus-other distinction in follow-up protocols, and for considering extended typing even in postmenopausal surveillance settings.

Strengths and limitations

A substantial strength is the use of a unified histological gold standard (LEEP) for all participants, which reduces the risk of endpoint misclassification. Reclassification of cytology into two levels (low vs. high grade) follows current clinical practice and improved the statistical power of the model.

The main limitations include the retrospective design and the moderate number of patients (n = 137), which leads to relatively wide confidence intervals, especially for the TZ3 variable. The exclusion of ECC from the multivariate model—necessary to avoid incorporation bias—prevents estimating its independent effect. Furthermore, the “non-16/18 genotypes” were analyzed as a single group; differences between viral types (e.g., HPV 31 vs. 33) may have been attenuated. Moreover, potential confounding factors, including age, smoking status, and immunosuppression, were not consistently documented due to the retrospective nature of the study.

Future directions

Prospective, multicenter studies enrolling a larger number of postmenopausal patients will be useful, allowing for: a fine stratification of single hr-HPV genotypes to verify whether the signal observed in “minor” types is confirmed; validation of a simplified decision-making algorithm (“HSIL/ASC-H + TZ3 → Immediate LEEP”) with long-term clinical endpoints, including reduced diagnostic time and impact on quality of life; the integration of viral or host biomarkers (e.g., E6/E7 mRNA, gene methylation) that could refine risk stratification beyond traditional morphological and virological parameters.

Authors’ contributions

MTB designed the study; AP, MCS and GV collected the data; MTB and AGC drifted the manuscript; MF compiled the statistical data. All authors were involved in editing the manuscript. All authors read and approved the final manuscript.

Funding

No funding was involved in the preparation of this research.

Availability of data and materials.

The datasets used and/or analyzed during the current study are already discussed in the “Results” section.

Data availability

The datasets used and/or analyzed during the current study are already discussed in the “Results” section.

Declarations

Ethics approval and consent to participate

This study conforms to the principles of the Declaration of Helsinki, as revised in 2013. The research was conducted through a retrospective review of medical records. In accordance with current legislation on observational studies (March 20, 2008), the study protocol was submitted to the Catania 1 Ethics Committee of the Catania University Hospital. The committee did not request any modifications to the protocol and deemed informed consent unnecessary, as the study involved only retrospective analysis of anonymized clinical data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.