Introduction
Cervix cancer is a rising health issue and significant cause of mortality in Women across the globe. The incidence of cervical cancer increased in worldwide. Pap smear is the most important test which is used to assess the women health and early detection of cervical cancer. Cervical screening has been one of the most successful public health program practiced for the prevention of cervical screening. Cervical Cytology forms the basis for this screening. Therefore, this test is recommended by the gynecologists to all women who are sexually active. Pap smear test is a cytological screening test introduced by George Papinicolaou in 1940 in the diagnosis and prevention of cervical cancer.1
Though many studies have reported less prevalence of cervical cancer in women who are screened annually, it is recommended that, pap smear test can be repeated at least once in every year to check the health status of a women.2, 3 Pap smear test is not recommended for those women who are below the age of 21 years because of low incidence of cervical cancer and is also associated with high false positive.4, 5
The American College of Obstetricians and Gynecologists (ACOG) in 2009, recommended that pap smear test can be advised for the married women who are above theage of 21years.5 It also stated that women aged in between 21-29 should be screened for the same every three years. The organization noted that women ages between 30 to 65 years should undergo pap smear with HPV testing every 5 years, and screening should stop after age 65.6, 7
As mentioned earlier pap smear screening is important to assess the health and in the diagnosis of cervical cancer. There is limited data available on the health status of the women from rural population of Tamil Nadu, India. Hence, the present study was designed to understand the health status of the women of rural population of Siddipet and Siddipet district of the Telangana, India. The results of this study can help to design the necessary educational programs and counseling services, also to reduce the gaps and barriers to improve the quality of health services for women in the society.
Materials and Methods
Study design
The study was a cross-sectional study involving the screening of women from the rural population of siddipet district for the assessment of health status using pap smear test who have attended the outpatient department (OPD) of Obstetrics and Gynecology (OBGY) at Surabhi Multispecialty Hospital, Mittapally, Siddipet, Telangana, India. The study was conducted during the period of August 2019 to May 2021.
Inclusion criteria
Married women from the rural areas of Siddipet district and belongs to siddipet district of Telangana, India, attending OPD of Obstetrics and Gynecology Department at Surabhi Multispeciality Hospital, were included in this study.
Exclusion criteria
Women who have undergone pap smear test within a period one year, pregnant women, who were in menstruation, and those who are already diagnosed with cervical cancer were excluded from the study.
Demographic, educational, and socioeconomic factors, sexual behavior, use of contraceptives, pap smear testing and other related gynecological and obstetrics history was collected from the patients during their visit to the OPD. A total of 1500 patients were recruited for the study during the study period. All the participants were subjected to pap smear test after obtaining informed consent. The samples were sent to the central clinical lab for processing, evaluation, and diagnosis. For those smears found to be satisfactory for evaluation, cytological abnormalities were reported based on the Bethesda System.8 The slides were examined, and results were reported by the pathologist. Since 1988, the Bethesda System for Reporting Cervical Cytology has been the accepted reporting system in the United States. The 2014 revision is the most recent.8 The reporting format includes Specimen type, Specimen adequacy, General Categorization, Interpretation/Result, Epithelial Cell Abnormalities and other malignant neoplasms.7, 8
Ethics approval
The study protocol was approved by the Institutional Ethics Committee of Surabhi institute of Medical Sciences, Mundrai, Mittapally village, Telangana, India. Written and oral consent was obtained from the individuals who participated in the screening before registration and were ensured of the confidentiality of their report. Participation in the study is purely voluntary and did not have any financial burden for the participants.
Statistical analyses
Descriptive indices including mean and standard deviation for quantitative variables and number and percent for categorical variables were reported. Logistic regression was performed to investigate the associated factor with behavior. All analysis was performed in SPSS version 16.0.
Results
This cross-sectional study was conducted at Surabhi multispecialty Hospital, Telangana, India. Study includes participation of 1500 women who are willing to take part in the study. Demographic data like age, marital status, education, occupation, and parity of all the study subjects was noted and tabulated in Table 1. There are total of 1500 participants in this study. Based on their age the participants were categorized into five groups. Group 1 consists of participants aged between 21 – 30 years, Group 2 consists of participants aged between 31 – 40 years, Group 3 consists of participants ranged between 41 – 50 years, Group 4 consists of 51 – 60 years and Group 5 consists of women aged above 60 years (Table 1). Highest number of participants (485 – 32.3%) were in the age group of 31 – 40 years, followed by 41 -50 years (443 – 29.5%) and least number of participants (79 – 5.3%) were in the age range of >60 years. All the participants who took part in the pap smear screening test were married (Table 1) and above the age of 21 years (Figure 1). The mean age of the study population is 38 ± 9 years and highest numbers of participants were in the age group of 31 – 40 years.
Of all the study participants 15.3% women were not having the formal basic education, 23.9% had primary school education, 33.5% of the women have completed secondary school education, 20.4% of the women have higher secondary education and 6.8% of the women were having degree and above educational qualification (Table 1, Figure 2).
Symptoms present in the women selected for the study include Urinary Tract Infection (UTI) in 9.5% of the population, bleeding vaginum in 24.3%, white discharge in 66.2%, and 9.2% women were asymptomatic. Among all the participants 3.1% of the women were nulliparous and remaining 96.9% of the women are primi or multiparous (Table 3, Figure 3). PAP smear findings were tabulated in (Table 3) and categorized as per the age group of the women. In group 1 there are total 342 women, of them 208 women presented with normal smear report, inflammatory smear was seen in 106 women, 5 women were presented with candidiasis, 1 presented with Ascus, 10 people showed bacterial vaginosis, 4 people showed Trichomonas Vaginalis and 8 samples were inadequate so no diagnosis was confirmed for those samples (Table 3, Figure 3) Group 2 includes a total 485 women, of them 255 pap smear reports were normal, 156 women presented with inflammatory reports, 7 women reported with candidiasis, 9 women were presented with Ascus, 14 women were presented with bacterial vaginosis, 5 atrophic smears were reported in this group, 12 women were presented with Trichomonas Vaginalis, 27 samples were inadequate (Table 3, Figure 4). Group 3 includes 443 women, of them 224 women were presented with normal smear report, 112 pap smear reports were inflammatory smear, 6 women were reported candidiasis, 8 were presented with Ascus, 7 were presented with bacterial vaginosis, 54 were presented with atrophic smear, 3 people were presented with Trichomonas Vaginalis, 29 samples were inadequate (Table 3, Figure 4). Group 4 includes 151 women, of them 54 were presented with normal smear report, 30 women were reported with inflammatory smear, 1 Ascus sample was reported, 3 samples were bacterial vaginosis, 50 atrophic smears and 13 samples were inadequate (Table 3, Figure 4). Group 5 includes 79 women, of them 16 samples were normal, 13 samples were inflammatory, 3 samples were reported Ascus, 1 women reported Bacterial Vaginosis, 39 samples were reported as atrophic smear, and 7 samples were inadequate (Table 3, Figure 4).
Figure 4
Depicts the details of consolidated pap smear analysis report of all the study participants
Table 1
Demographic, educational, occupational, and obstetrics history details of the study participants
Table 2
Symptoms of the patients presented with at OPD at the time of pap smear screening
|
Parameter |
N |
% |
|
Symptoms |
|
|
|
Not recorded |
0 |
0 |
|
No complaints |
137 |
9.2% |
|
Complaints present |
1363 |
90.8% |
|
White discharge |
901 |
66.2% |
|
Vaginal Bleeding |
332 |
24.3% |
|
UTI |
130 |
9.5% |
.
Table 3
Summary of the pap smear studied for all the participants
Discussion
The present study is a hospital-based study conducted in a tertiary care hospital situated in rural set up women from nearby villages visiting our hospital OPD, department of obstetrics and gynecology were recruited for the study. It is recommended that pap smear screening test should be started above the 21 years of age.8, 9, 10
The present study included 1500 Pap smears, of which the most common abnormality was inflammatory smear, which is followed by atrophic smear. Among all the study subject’s majority (64.5%) of the women were home makers and not working, remaining participants were either self-employed or working women. Percentage of abnormal smear reports was reported in group 2 (31-40 years) subjects followed by group 3 (41-50 years) women. In 22 patients, Atypical Squamous Cell of Undetermined Significance (ASCUS) was observed. Lack of health education on personal hygiene and knowledge on safe sexual practices in women from rural areas are one of the reasons for high rates inflammation and infection of cervix which can lead to cervical cancer in India.11, 12, 13
Study done by Gupta et al. in3 4703 women in the year 2013 reported an incidence of 0.52% ASCUS, but they had, Low-grade squamous intraepithelial cell lesion (LSIL) as the most common epithelial cell abnormality (1.36%) instead of ASCUS (3). Many hospital based studies showed that LSIL is the most prevalent epithelial cell abnormality. Studies reported by Sengul et al. and Nair et al. showed maximum cases of ASCUS among the various epithelial cell abnormalities which is in line with the present study reports.4, 8, 12, 13, 14, 15, 16, 17 The study conducted by Nene et al. in12 79,449 women and the study conducted by Misra et al.,18 in 4279 rural women population of India, reported the lowest and highest rate of epithelial cell abnormality in 0.92% and 18.8% of cases, respectively.12, 18 The present study reports showed less rate of cervical cancer prevalence in our study population compared to the studies conducted by Bhattacharyya AK et al. which is 2.6% (studied in 5032 women) and Satyanarayan et al., reported 2.6% (study conducted in 7603 women) in 2014.14, 19
Vision 2030 of the United Nations Global Join Program is to tackle the cervical cancer by ensuring reproductive health and reducing the gaps within and among countries.9, 19, 20, 21, 22 It recommends all the countries and their governments to strengthen their research capacity by all means to support decisions on countryadapted screening and treatment plans. As our tertiary care center is in the rural area of Tamil Nadu the rate of women’s referral for screening is very low because of social, lack of proper education and economical barrier for undergoing the Pap smear test.
The present study reports the hospital based pap smear test screening data in Surabhi Multispecialty Hospital, Siddipet, Telangana, India. The Indian government is also implementing a national program under NPCDCS since 2016.
Conclusion
More number of hospital based studies with large sample size is needed to be conducted in India and other developing countries for assessing the reproductive health and prevalence of cervical cancer in women. The study data from the teaching hospitals should be published so that researchers will come up with more effective strategies for the management of the disease and help in while planning national wide programs. It can be concluded that Pap smear is a sensitive and effective screening test which can be used for assessing the reproductive health status of the women and in the early detection of cervical cancer by doing screening at regular intervals.
