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| Name | Class |
|---|---|
| Unidade de Saúde Familiar de Garcia de Orta, Porto | UNKNOWN |
| Unidade de Saúde Familiar da Prelada, Porto | UNKNOWN |
| Unidade de Saúde Familiar de Cedofeita, Porto | UNKNOWN |
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This study aims to test the effectiveness and cost-effectiveness of two different strategies of home-delivered HPV self-sampling, in comparison to the standard of care strategy, to increase adherence to cervical cancer screening.
An experimental and population-based study will be implemented at three primary healthcare centers located in the Western Porto region: Cedofeita, Garcia de Orta, and Prelada. Eligible women will be randomized into a control group or an intervention group. The control group will correspond to the standard of care (invitation to screening in a clinical setting). The intervention group will be randomized into two subgroups: 1) a "directly mailed" group that will receive a self-sampling kit at their home addresses by post; 2) an "opt-in" group that will receive an invitation at home asking if they want to receive a self-sampling kit, with a pre-paid envelope to return the answer to this question. Women who answer "yes" will receive the self-sampling kit at their home addresses by post.
Self-sampling samples will be subjected to HPV genotyping. In parallel, high-risk HPV positive women will be called in by their family doctors to undergo screening in a clinical setting so that they can continue their clinical follow-up in the conventional pathway.
The goal of this randomized clinical trial is to test the effectiveness and cost-effectiveness of two different strategies of home-delivered HPV self-sampling to increase the adherence to cervical cancer screening in women who are overdue for cervical cancer screening, in comparison to the standard of care strategy.
The main questions this study aims to answer are:
Eligible women will be randomized (1:1) into a control group and an intervention group:
Control group: corresponds to the standard of care, which is an invitation to cervical cancer screening in a clinical setting, through a written letter, printed and sent by the primary healthcare unit where the women are registered.
Intervention group: Women allocated to this group will be randomized (1:1) into two subgroups, described briefly as follows:
In Interventions 1 and 2, when HR-HPV is detected in the self-sampling test, this sample will be subjected to HPV-DNA methylation testing. If increased HPV DNA methylation is detected and the woman has yet not attended the conventional screening invitation by her family doctor, she will be informed by her family doctor that a new test has indicated an increased risk for cervical cancer and the need to attend a medical appointment will be reinforced.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control group | Active Comparator | An invitation to attend a cervical cancer screening in a clinical setting will be sent by post to the woman's address. |
|
| Intervention 1 (directly mailed group) | Experimental | The HPV self-sampling test will be sent by post directly to the woman's address. |
|
| Intervention 2 (opt-in group) | Experimental | The HPV self-sampling test will be sent by post directly to the woman's address after a opt-in procedure. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Directly mailed self-sampling kit to collect a vaginal sample | Device | The HPV self-sampling test will be sent by post directly to the woman's address. If the woman does not return the sample within 20 days, she will be sent a SMS reminder. The returned samples will be analysed. If high-risk HPV is present, women will be invited to be screened for cervical cancer in a clinical setting by their family doctors. Self-samples in which high-risk HPV is present will also be subjected to HPV DNA methylation test. If an abnormal HPV DNA methylation is detected and the woman has not attended the screening in a clinical setting yet, she will be informed by her family doctor that a new test has indicated the need to attend a medical appointment. |
| Measure | Description | Time Frame |
|---|---|---|
| Adherence to conventional screening in control group | Number of women in control group who adhered to conventional screening divided by the number of women assigned to control group | 45 and 90 days after the conventional screening appointment date |
| Adherence to HPV self-sampling in intervention 1 (directly mailed) group | Number of women who returned the self-sample in intervention 1 group divided by the number of women assigned to intervention 1 group | 45 and 90 days after the day the self-sampling kit is sent |
| Adherence to HPV self-sampling in intervention 2 (opt-in) group | Number of women who returned the self-sample in intervention 2 group divided by the number of women assigned to intervention 2 group | 45 and 90 days after the day the self-sampling kit is sent |
| Adherence proportion to HPV self-sampling in intervention 1 (directly mailed) group VS Adherence proportion to conventional screening in control group | The quotient of (Number of women in intervention 1 group who returned the self-sample divided by the women assigned to intervention 1 group) dividided by (Number of women in control group who adhered to conventional screening divided by the number of women assigned to control group). | 45 and 90 days after the day the self-sampling kit is sent or 45 and 90 days after the conventional screening appointment date, as appropriate |
| Adherence proportion to HPV self-sampling in intervention 2 (opt-in) group VS Adherence proportion to conventional screening in control group | The quotient of (Number of women in intervention 2 group who returned the self-sample divided by the women assigned to intervention 2 group) dividided by (Number of women in control group who adhered to conventional screening divided by the number of women assigned to control group). |
| Measure | Description | Time Frame |
|---|---|---|
| Adherence to first follow-up step in control group | Quotient of the number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group | 45 and 90 days after the colposcopy appointment date |
| Adherence to first follow-up step in intervention 1 (directly mailed) group |
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Inclusion Criteria:
Exclusion Criteria:
Women
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Maria Margarida MN Teixeira, Master | Contact | 00351933099685 | margaridat93@gmail.com |
| Name | Affiliation | Role |
|---|---|---|
| Maria Margarida MN Teixeira, MD | Instituto de Saude Publica da Universidade do Porto | Principal Investigator |
| Nuno Lunet, PhD | Instituto de Saude Publica da Universidade do Porto | Study Chair |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Unidade de Saúde Familiar Cedofeita | Recruiting | Porto | 4050-109 | Portugal |
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| Instituto Portugues de Oncologia, Francisco Gentil, Porto |
| OTHER |
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|
| Mailed self-sampling kit to collect a vaginal sample after opt-in prodecure | Device | Women will initially receive an invitation letter in their home addresses to receive the self-sampling kit, as well as a pre-paid envelope to return the answer to this invitation. If the woman does not return the answer within 10 days, she will be sent a SMS reminder. Only those who respond affirmatively to the question will receive the self-sampling kit. The steps that follow will be the same as in intervention 1. |
|
|
| Standard of care - screening in a clinical setting | Diagnostic Test | Corresponds to the standard of care. An invitation to attend the conventional cervical cancer screening (clinician-collected cervical sample for HPV test and reflex cytology) will be sent by post to the woman's address. |
|
| 45 and 90 days after the day the self-sampling kit is sent or 45 and 90 days after the conventional screening appointment date, as appropriate |
Quotient of the number of women in intervention 1 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 1 group |
| 45 and 90 days after the clinician-sampling appointment date |
| Adherence to first follow-up step in intervention 2 (opt-in) group | Quotient of the number of women in intervention 2 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 2 group | 45 and 90 days after the clinician-sampling appointment date |
| Adherence to first follow-up step in control group among women referred for follow-up | Quotient of the number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group who were referred for follow-up (colposcopy) after an abnormal result in conventional screening | 45 and 90 days after the colposcopy appointment date |
| Adherence to first follow-up step in intervention 1 (directly mailed) group among women referred for folow-up | Quotient of the number of women in intervention 1 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 1 group who were referred for follow-up (clinician-sampling) after an abnormal result in self-sampling | 45 and 90 days after the clinician-sampling appointment date |
| Adherence to first follow-up step in intervention 2 (opt-in) group among women referred for folow-up | Quotient of the number of women in intervention 2 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 2 group who were referred for follow-up (clinician-sampling) after an abnormal result in self-sampling | 45 and 90 days after the clinician-sampling appointment date |
| Adherence to colposcopy in control group | Quotient of the number of women in control group who adhered to colposcopy divided by the number of women assigned to control group | 45 and 90 days after the colposcopy appointment date |
| Adherence to colposcopy in intervention 1 (directly mailed) group | Quotient of the number of women in intervention 1 group who adhered to colposcopy divided by the number of women assigned to intervention 1 group | 45 and 90 days after the colposcopy appointment date |
| Adherence to colposcopy in intervention 2 (opt-in) group | Quotient of the number of women in intervention 2 group who adhered to colposcopy divided by the number of women assigned to intervention 2 group | 45 and 90 days after the colposcopy appointment date |
| Adherence to colposcopy in control group among women referred for colposcopy | Quotient of the number of women in control group who adhered to colposcopy divided by the number of women assigned to control group who were referred for colposcopy after an abnormal result in conventional screening | 45 and 90 days after the colposcopy appointment date |
| Adherence to colposcopy in intervention 1 (directly mailed) group among women referred for colposcopy | Quotient of the number of women in intervention 1 group who adhered to colposcopy divided by the number of women assigned to intervention 1 group who were referred for colposcopy after abnormal results in both self-sampling and clinician-sampling | 45 and 90 days after the colposcopy appointment date |
| Adherence to colposcopy in intervention 2 (opn-in) group among women referred for colposcopy | Quotient of the number of women in intervention 2 group who adhered to colposcopy divided by the number of women assigned to intervention 2 group who were referred for colposcopy after abnormal results in both self-sampling and clinician-sampling | 45 and 90 days after the colposcopy appointment date |
| Timelapse (in days) between the shipment of self-sampling kit and the return of the sample, in intervention 1 (directly mailed) group | Adherence will be assessed using Kaplan-Meier survival analysis. | Follow-up will end at 90 days |
| Timelapse (in days) between the invitation to receive a self-sampling kit and the return of the opt-in answer, in intervention 2 (opt-in) group | Adherence will be assessed using Kaplan-Meier survival analysis. | Follow-up will end at 90 days |
| Timelapse (in days) between the shipment of self-sampling kit and the return of the sample, in intervention 2 (opt-in) group | Adherence will be assessed using Kaplan-Meier survival analysis. | Follow-up will end at 90 days |
| Adherence proportion to first follow-up step in intervention 1 (directly mailed) group VS Adherence proportion to first follow-up step in control group | The quotient of (Number of women in intervention 1 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 1 group) divided by (Number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group) | 45 and 90 days after the first follow-up step (clinician-sampling appointment date or colposcopy appointment date, as appropriate) |
| Adherence proportion to first follow-up step in intervention 2 (opt-in) group VS Adherence proportion to first follow-up step in control group | The quotient of (Number of women in intervention 2 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 2 group) divided by (Number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group) | 45 and 90 days after the first follow-up step (clinician-sampling appointment date or colposcopy appointment date, as appropriate) |
| Adherence proportion to first follow-up step in intervention 1 (directly mailed) group among women referred for follow-up VS Adherence proportion to first follow-up step in control group among women referred for follow-up | The quotient of (Number of women in intervention 1 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 1 group who were referred for follow-up (clinician-sampling) after an abnormal result in self-sampling) divided by (Number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group who were referred for follow-up (colposcopy) after an abnormal result in conventional screening) | 45 and 90 days after the first follow-up step (clinician-sampling appointment date or colposcopy appointment date, as appropriate) |
| Adherence proportion to first follow-up step in intervention 2 (opt-in) group among women referred for follow-up VS Adherence proportion to first follow-up step in control group among women referred for follow-up | The quotient of (Number of women in intervention 2 group who adhered to first follow-up step (in this case, clinician-sampling) divided by the number of women assigned to intervention 2 group who were referred for follow-up (clinician-sampling) after an abnormal result in self-sampling) divided by (Number of women in control group who adhered to first follow-up step (in this case, colposcopy) divided by the number of women assigned to control group who were referred for follow-up (colposcopy) after an abnormal result in conventional screening) | 45 and 90 days after the first follow-up step (clinician-sampling appointment date or colposcopy appointment date, as appropriate) |
| Adherence proportion to colposcopy in intervention 1 (directly mailed) group VS Adherence proportion to colposcopy in control group | The quotient of (Number of women in intervention 1 group who adhered to colposcopy divided by the number of women assigned to intervention 1 group) divided by (Number of women in control group who adhered to colposcopy divided by the number of women assigned to control group) | 45 and 90 days after the colposcopy appointment date |
| Adherence proportion to colposcopy in intervention 2 (opt-in) group VS Adherence proportion to colposcopy in control group | The quotient of (Number of women in intervention 2 group who adhered to colposcopy divided by the number of women assigned to intervention 2 group) divided by (Number of women in control group who adhered to colposcopy divided by the number of women assigned to control group) | 45 and 90 days after the colposcopy appointment date |
| Adherence proportion to colposcopy in intervention 1 (directly mailed) group among women referred for colposcopy VS Adherence proportion to colposcopy in control group among women referred for colposcopy | The quotient of (Number of women in intervention 1 group who adhered to colposcopy divided by the number of women assigned to intervention 1 group who were referred for colposcopy after an abnormal result in both self-sampling and clinician-sampling) divided by (Number of women in control group who adhered to colposcopy divided by the number of women assigned to control group who were referred for colposcopy after an abnormal result in conventional screening) | 45 and 90 days after the colposcopy appointment date |
| Adherence proportion to colposcopy in intervention 2 (opt-in) group among women referred for colposcopy VS Adherence proportion to colposcopy in control group among women referred for colposcopy | The quotient of (Number of women in intervention 2 group who adhered to colposcopy divided by the number of women assigned to intervention 2 group who were referred for colposcopy after an abnormal result in both self-sampling and clinician-sampling) divided by (Number of women in control group who adhered to colposcopy divided by the number of women assigned to control group who were referred for colposcopy after an abnormal result in conventional screening) | 45 and 90 days after the colposcopy appointment date |
| Proportion of HR-HPV positivity in control group | The quotient of the number of women in control group who tested positive for HR-HPV in conventional screening divided by the number of women assigned to control group | 45 and 90 days after the conventional screening appointment date |
| Proportion of HR-HPV positivity in intervention 1 (directly mailed) group | The quotient of the number of women in intervention 1 group who tested positive for HR-HPV in self-sampling divided by the number of women assigned to intervention 1 group | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV positivity in intervention 2 (opt-in) group | The quotient of the number of women in intervention 2 group who tested positive for HR-HPV in self-sampling divided by the number of women assigned to intervention 2 group | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV positivity in control group among women who adhered to conventional screening | The quotient of the number of women in control group who tested positive for HR-HPV in conventional screening divided by the number of women assigned to control group who adhered to conventional screening | 45 and 90 days after the conventional screening appointment date |
| Proportion of HR-HPV positivity in intervention 1 (directly mailed) group among women who returned the self-sample | The quotient of the number of women in intervention 1 group who tested positive for HR-HPV in self-sampling divided by the number of women assigned to intervention 1 group who returned the self-sample | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV positivity in intervention 2 (opt-in) group among women who returned the self-sample | The quotient of the number of women in intervention 2 group who tested positive for HR-HPV in self-sampling divided by the number of women assigned to intervention 2 group who returned the self-sample | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV 16/18 positivity in control group | The quotient of the number of women in control group who tested positive for HR-HPV 16/18 in conventional screening divided by the number of women assigned to control group | 45 and 90 days after the conventional screening appointment date |
| Proportion of HR-HPV 16/18 positivity in intervention 1 (directly mailed) group | The quotient of the number of women in intervention 1 group who tested positive for HR-HPV 16/18 in self-sampling divided by the number of women assigned to intervention 1 group | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV 16/18 positivity in intervention 2 (opt-in) group | The quotient of the number of women in intervention 2 group who tested positive for HR-HPV 16/18 in self-sampling divided by the number of women assigned to intervention 2 group | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV 16/18 positivity in control group among women who adhered to conventional screening | The quotient of the number of women in control group who tested positive for HR-HPV 16/18 in conventional screening divided by the number of women assigned to control group who adhered to conventional screening | 45 and 90 days after the conventional screening appointment date |
| Proportion of HR-HPV 16/18 positivity in intervention 1 (directly mailed) group among women who returned the self-sample | The quotient of the number of women in intervention 1 group who tested positive for HR-HPV 16/18 in self-sampling divided by the number of women assigned to intervention 1 group who returned the self-sample | 45 and 90 days after the day the self-sampling kit is sent |
| Proportion of HR-HPV 16/18 positivity in intervention 2 (opt-in) group among women who returned the self-sample | The quotient of the number of women in intervention 2 group who tested positive for HR-HPV 16/18 in self-sampling divided by the number of women assigned to intervention 2 group who returned the self-sample | 45 and 90 days after the day the self-sampling kit is sent |
| Positive predictive value of self-sampling for the detection of HR-HPV, using clinician-sampling results as gold standard | The quotient of the number of cases in which both self-sampling and clinician-sampling tested positive for HR-HPV divided by the number of cases in which self-sampling tested positive for HR-HPV, regardless of the clinician-sampling HR-HPV test result) | 90 days after clinicial-sampling appointment date |
| Sensitivity of HR-HPV testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL | 90 days after the colposcopy appointment date |
| Specificity of HR-HPV testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL | 90 days after the colposcopy appointment date |
| Positive likelihood ratio of HR-HPV testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV positive result, abnormal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Negative likelihood ratio of HR-HPV testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV positive result, normal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Accuracy of HR-HPV testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (The sum of the number of self-samples with HR-HPV positive result, abnormal methylation result and ≥HSIL with the number of self-samples with HR-HPV positive result, normal methylation result and ≤LSIL) divided by the total number of self-samples with HR-HPV positive result, regardless of the methylation and biopsy results. | 90 days after the colposcopy appointment date |
| Sensitivity of HR-HPV non 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV non 16/18 positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL | 90 days after the colposcopy appointment date |
| Specificity of HR-HPV non 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV non 16/18 positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL | 90 days after the colposcopy appointment date |
| Positive likelihood ratio of HR-HPV non 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV non 16/18 positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV non 16/18 positive result, abnormal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Negative likelihood ratio of HR-HPV non 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV non 16/18 positive result, normal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV non 16/18 positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Accuracy of HR-HPV non 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (The sum of the number of self-samples with HR-HPV non 16/18 positive result, abnormal methylation result and ≥HSIL with the number of self-samples with HR-HPV non 16/18 positive result, normal methylation result and ≤LSIL) divided by the total number of self-samples with HR-HPV non 16/18 positive result, regardless of the methylation and biopsy results. | 90 days after the colposcopy appointment date |
| Sensitivity of HR-HPV 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV 16/18 positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL | 90 days after the colposcopy appointment date |
| Specificity of HR-HPV 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of the number of self-samples with HR-HPV 16/18 positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL | 90 days after the colposcopy appointment date |
| Positive likelihood ratio of HR-HPV 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV 16/18 positive result, abnormal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV 16/18 positive result, abnormal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Negative likelihood ratio of HR-HPV 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (Number of self-samples with HR-HPV 16/18 positive result, normal methylation result and ≥HSIL divided by the total number of self-samples with ≥HSIL) divided by (The quotient of the number of self-samples with HR-HPV 16/18 positive result, normal methylation result and ≤LSIL divided by the total number of self-samples with ≤LSIL) | 90 days after the colposcopy appointment date |
| Accuracy of HR-HPV 16/18 testing and methylation analysis in self-samples, using biopsy results as gold standard | The quotient of (The sum of the number of self-samples with HR-HPV 16/18 positive result, abnormal methylation result and ≥HSIL with the number of self-samples with HR-HPV positive result, normal methylation result and ≤LSIL) divided by the total number of self-samples with HR-HPV 16/18 positive result, regardless of the methylation and biopsy results. | 90 days after the colposcopy appointment date |
| Unidade de Saúde Familiar Prelada | Recruiting | Porto | 4250-113 | Portugal |
|
| ID | Term |
|---|---|
| D030361 | Papillomavirus Infections |
| D002583 | Uterine Cervical Neoplasms |
| D016353 | Self-Examination |
| ID | Term |
|---|---|
| D015229 | Sexually Transmitted Diseases, Viral |
| D012749 | Sexually Transmitted Diseases |
| D003141 | Communicable Diseases |
| D007239 | Infections |
| D004266 | DNA Virus Infections |
| D014777 | Virus Diseases |
| D014412 | Tumor Virus Infections |
| D000091662 | Genital Diseases |
| D000091642 | Urogenital Diseases |
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D014594 | Uterine Neoplasms |
| D005833 | Genital Neoplasms, Female |
| D014565 | Urogenital Neoplasms |
| D009371 | Neoplasms by Site |
| D009369 | Neoplasms |
| D002577 | Uterine Cervical Diseases |
| D014591 | Uterine Diseases |
| D005831 | Genital Diseases, Female |
| D052776 | Female Urogenital Diseases |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D015438 | Health Behavior |
| D001519 | Behavior |
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