Introduction

Worldwide, cervical is the second cancer to breast cancer.^1,2 It has been observed that the determination of risk factors for cervical cancer is crucial to understand the disease process and the treatment modality. These factors include age at sexual debut, parity, multiple sexual partners, use of contraceptives and smoking. In India, approximately 122,844 women are diagnosed with cancer cervix and 67,477 die from the disease with the peak age of incidence being 55-59 years.³

Moreover, poor socioeconomic status, repeated sexually transmitted infections and child marriages are associated with cervical cancer.

 For secondary prevention of cervical cancer lesions, screen and treat approach is to be implemented. The three most commonly and widely accepted screening modalities are cervical cytology, visual inspection with acetic acid/ lugol’s Iodine, and Human Papilloma Virus testing.⁴ The mainstay of screening is to prevent the progression of precancerous lesions into invasive form of cancer.

Therefore, the method of screening has to be widely acceptable, easy to perform?, prompt diagnostic investigations, good specificity and sensitivity so that immediate appropriate treatment can be initiated with good posttreatment follow-up.^{5, 6}

Out of all the available screening modalities a conventional Pap smear is commonly practiced method since its inception in the 1960s especially in countries with minimum resources. It is the safest, simplest and is inexpensive to diagnose benign and malignant lesions of cervix. In addition, implementation of the screening programs has shown reductions in cervical cancer incidence and mortality.^{7, 8} However, a section of the female population is reluctant to undergo the test due to illiteracy, misconceptions, assumptions about the process and disbelief of being diagnosed with cervical cancer.^9,10,11,12

This study evaluated the cytological abnormalities, in patients who underwent pap smear test routinely in the OPD of the hospital.

Material and Methods

It was a prospective study to evaluate the pap smears received in the pathology lab from January 2019 to July 2019 of patients attending the Outpatient department at the Ajmal Khan Tibbiya College and Hospital, catering to the subjects living in the densely located areas called Shah-Jamal, Bhujpura, Jeevangarh and Jamalpur in Aligarh. The symptoms and pap smears of all patients were analyzed, especially the ones who had undergone the test in this six-month period.

The patients were instructed to maintain abstinence, vigorous washing with antiseptics/ or use of douche before the pap test.  Following Per-Speculum visualization of the cervix, two samples were collected. The first sample was obtained by using Ayre’s wooden spatula, from the Squamo-columnar Junction. The material obtained was smeared on the frosted slide, and a thin film is prepared. The glass slide is then dipped for fixation in 95% ethyl alcohol. Another sample was collected from the endocervical canal using the cytobrush. The cytobrush was similarly rotated 360˚once to collect the cells from the endocervix. The collected sample was then smeared on another slide without fixation.

Both the slides one with fixative and another air-dried were sent to the cytopathology lab. The diagnosis of the pap smears was done following the new Bethesda system(2001). 

Results

Table 1: Distribution of inflammatory lesions according to age.

 Table 2: Subject -wise distribution of the cytological abnormalities.

 Table 3: Distribution of epithelial cell abnormalities according to age.

Table 4: SES distribution of the population.

 202 cervical pap smears were sent to the cytopathologist during the 6-month study period. Out of these 112 (55.4%) paps smears had epithelial cell abnormalities, infective and inflammatory smears, whereas 76 (37.6%) were normal. 14 (6.9%) smears were inadequate or unsatisfactory for evaluation and 89 (44%) cases showed reparative changes and epithelial abnormality was found in 23 (11%) cases.

8 patients had non-specific inflammation with no specific etiology. Candidiasis was the most common infection reported. 12 patients had trichomoniasis, who also clinically complained of a foul-smelling vaginal discharge and 18 cases of Gardenella vaginalis were reported. In 6 cases, HPV infection was seen without any feature of dysplasia. 8 cases had senile vaginitis.

Epithelial cell abnormalities were seen in 23cases, 7 cases as HSIL (High-grade Squamous Intraepithelial Lesion), 8 cases as LSIL (Low-grade Squamous Intraepithelial Lesion) and 3 cases as SCC (Squamous cell carcinoma) (table 2).

54 patients were in the age group of 21-30 years, 21 in the second decade, 3 in fourth decade and 6 cases in fifth decade and 5 in their 70’s respectively (table 1).

The majority of the patients i.e., 78 (38.6%) were in the lower socioeconomic group followed by 54 (26%) in the upper middle class and 36 cases (17.8%) in the upper lower group was found.

Discussion

Age-wise Distribution

89 patients had inflammatory lesions in the cytological examination. The most common etiology was of candidiasis infection 37 in the age group of 21-30 years. The second and third common etiologies were T. vaginalis and G. vaginalis infections at 18 and 12 respectively and were also seen in the 21-30 years age group. 5 patients were positive for HPV infection seen in the similar age group. 8 patients with atrophic vaginitis were seen in the post-menopausal age group which is an obvious finding. A study conducted on patients with leucorrhea in Jamnagar, Gujarat India had 16.6% cases of candidiasis infection in non-pregnant females in the age group of 20-30 years and 22.5% in pregnant patients presenting with leucorrhea.¹³

Our study is consistent with the findings as 18.1% of patients presented with candidiasis infection. The increased number of inflammatory changes seen in the second and third decade is a common finding as during this period the female is sexually active and prone to develop infections. HPV infection as seen in 5 patients is a self-limiting infection and hence a repeat pap smear was advised in the patients.

Cytological diagnosis of Pap smears

The cytological abnormalities in the pap smear showed 89 patients with inflammatory smears. The study revealed 11.3% had epithelial abnormalities. Similar findings were seen in the study by Daniel et al wherein the prevalence of precancerous lesions was found to be 10.2% in women.¹⁴ These findings could be attributed to the fact that women irrespective of their STI status are exposed to the same risk factors for the development of cervical cancers as is the case in our study. However, our study didn’t evaluate sexually transmitted infections in any of the patients. As observed in the present study, 8 patients had LSILs and 7 patients had HSIL. There is a strong association between LSILs and HPV infection and hence holds a diagnostic significance since these low‐grade lesions on the squamous cells of a host are a manifestation of virion production in HPV infections. Further, these lesions were more likely to persist and may progress, and hence viewed as high grade or high risk. Although the present study did not assess HPV infection, if done it would have been helpful in correlating the with decisions on the course of management.¹⁵

Evidence as per the genomic studies has shown that high‐grade lesions reveal abnormalities that are very similar as found in cervical cancer.¹⁶ Therefore, the women who had High grade cervical lesions in the present study are of importance since the detection and eradication of HSILs is related to the prevention of cervical cancer.

Age wise distribution of epithelial cell abnormalities

As seen in this study women in the age group of 21-30years 4 had LSIL whereas in 30s and 50s there were 3 and 1 women respectively, HSIL was seen in the 4^th and the 5^th decade. Cases aged between 30-50years had higher odds to develop cervical precancerous lesions than compared to those aged 21-30 years. These findings are similar to the study conducted in Jimma, Ethiopia, that found older age (40-59) years to be at greater risk for invasive cervical cancer.¹⁷

SES distribution of the population

38.6% of the population was in the lower socioeconomic group followed by 26% in the upper middle class and 17.8% in the upper lower group was found. This showed that majority of the study population belonged to the densely populated areas. In these circumstances the women’s tendencies and abilities to prioritize their health is gets compromised immensely. In addition, regular checkups and visits to health care institutions by women are not a routine in developing countries. Identify women in the lower SES and targeting them to evaluate for epithelial cell abnormalities, has been done in a number of studies. However, in this study we didn’t correlate the socioeconomic status to the abnormal pap smear findings.

Conclusion

The Papanicolaou (Pap) test is widely known as a screening tool and as a simple method to detect cervical lesions in the initial precancerous stage. We are aware of the fact that cervical cancer is one of the leading malignancies in Indian women. Community sensitization about the risk factors, and educating women through social health activists and workers along-with screening of women of reproductive age on a regular basis for cervical cancer should be encouraged for its prevention and management. Its incidence is greater among women of poor socioeconomic status and lack of knowledge, as seen in this study. Further, the screening levels are low in the general population. In order to increase this, it is necessary to carry out specific health education sessions for women as well as their partners to facilitate care seeking.

Acknowledgement

We acknowledge the contribution Dr. Uroos Abdi, the cytopathologist in providing the smear reports in time and lead her helping throughout the work process. We are also grateful to the Head of the Department Prof. Syeda Aamena Naaz for encouraging us to publish the findings.

Conflict of Interest

There was no conflict of interest among the authors.

Funding sources

This research received no particular grant from any funding agency.

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