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Clinical Infection & Immunity

Original Article

Volume 2, Number 1, March 2017, pages 5-7

Study of Cervical Pap Smears in 558 Cases

Cervical cancer is the fifth most common cancer in humans and the fourth most common cancer in women worldwide. It is the most common cancer death in women in the developing countries [1]. Screening of cervical cancer in effective, feasible and affordable way for early detection and management is a public health priority. Five screening methods, namely naked eye visual inspection of the cervix with application of diluted acetic acid (VIA), examination with Lugol’s iodine (VILI) or with a magnifying device (VIAM), the pap smear and human papilloma virus (HPV) testing with high-risk probe of the hybrid capture-2 assay (HC2), are used to detect the cervical cancer in precancerous stage [2].

Cytology is a simple and inexpensive diagnostic method and is therefore useful especially in areas with limited resources. Even though the pap smear test alone does not have a high sensitivity and specificity, it is the most commonly used test in most screening programs. The diagnostic utility of cervicovaginal cytology (pap test) as a first line of investigation has assumed importance in screening of cervical cancer. It is a simple, safe, cost effective and reliable technique. Its accuracy and cost effectiveness can be compromised by inadequate samples [3]. Usually pap smear screening test is recommended starting around 21 years of age until the age of 65 years. It can be repeated at 3 years interval. In case of abnormal pap smear report, depending on the type of abnormality, the test may need to be repeated in 6 - 12 months. More sensitive and specific investigations like colposcopy-guided cervical biopsy are needed to diagnose and prevent further progression to cervical cancer [4].

The aim of the study was to study and analyze the pap smear reports and to help plan the treatment of patients accordingly.

The study was carried out in the Department of Pathology of Jahurul Islam Medical College from the pap smears coming from the Gynecology OPD from February 9, 2015 to February 11, 2016. A total of 558 pap smears were taken from women aged 20 - 70 years presenting with different gynecological complaints and as a routine test. Smears were reported as per the Bethesda System [5].

Women aged 20 - 69 years were included.

Women below 20 years and above 69 years, in menstruation, and diagnosed of carcinoma of the cervix were excluded.

Pap smears were taken by using Ayres spatula. The broad end of spatula was placed on the cervix and rotated through 360° and the collected material was spread over a glass slide. The oblong relabeled narrow end of spatula was used to take smear from posterior vaginal fornix and spread over a second glass slide. All the slides were labeled and immediately transferred to 95% ehyl alcohol (transport medium) and sent to pathology department for cytological study.

Evaluation was done by cytology using Bethesda classification [5]: 1) within normal limits; 2) infection (specify organism); 3) reactive/reparative changes; 4) atypical squamous cells of undetermined significance (ASCUS); 5) atypical glandular cells of undetermined significance (AGUS); 6) low grade squamous intraepithelial invasion (LSIL); 7) high grade squamous intraepithelial invasion (HSIL); and 8) invasive carcinoma.

Data were analyzed by SPSS and descriptive statistics were presented as frequencies and percentages.

In our study, we analyzed 558 pap smears taken from women coming from Gynecology OPD of Jahurul Islam Medical College Hospital, Bajitpur, Kishoregonj, aged 20 - 70 years presenting with different gynecological complaints and as a routine screening test. Among them, 405 (72.5%) patients were aged 20 - 39 years, 112 (20.1%) patients were aged 40 - 49 years, 29 (5.1%) women were aged 50 - 59 years and 12 (2.1%) patients were aged 60 - 70 years (Table 1).

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Table 1. Distribution of Patients According to Age (n = 558)

Among the 558 women undergoing pap smear tests, 392 (70.2%) women presented with chronic white discharge with itching. One hundred twenty-two (21.9%) women underwent pap smear test as part of routine gynecological examination. Sixteen (2.9%) women presented with pelvic inflammatory disease. Eight (1.4%) women presented with post hysterectomy chronic white discharge. Twelve (2.1%) women had abnormal uterine bleeding and eight (1.4%) women presented with intermenstrual spotting (Table 2).

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Table 2. Reasons for Performing Pap Smears (n = 558)

Among the 558 pap smear reports analyzed, 26 (4.6%) smears were unsatisfactory for evaluation. Among the 532 satisfactory smear reports, 492 (92.5%) showed inflammatory changes, 16 (3.0%) smears were reported as LSIL, HSIL was seen in four (0.8%) smears, ASCUS was seen in 10 (1.8%) smears, and four (0.7%) smears were suggestive of squamous cell carcinoma (Table 3).

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Table 3. Pap Smear Findings (n = 532)

Conventional cervical cytology is the most widely used cervical cancer screening test in the world. Cervical cytology screening program in several developed countries has been associated with impressive reductions in cervical cancer burden. The WHO recommends that in developing countries, women aged 18 - 69 years should be screened for cervical cancer every 3 years [6]. In our study, the youngest age screened was 20 years and oldest age was 69 years, and maximum number of women was in 30 - 39 years age group (50.1%). In the study conducted by Bamanikar et al [7], maximum number of women was in 31 - 40 years age group (32.68%). In the study conducted by Patel et al [8], maximum number of women aged 15 - 30 years was studied. The rate of unsatisfactory smear was 4.6% in the present study, which was higher than that in the study conducted by Bhatla et al [9] (1.36%). The unsatisfactory rate is an important quality assurance indicator in cervical cytology as it identifies women who are being inadequately screened. High rate of unsatisfactory smears could be due to sampling errors. Hence regular training and feedback are essential.

Inflammatory smear reports were 492 (92.4%) in our study, whereas in the study conducted by Bamanikar et al [7], 71.96% of reports were inflammatory smears. Smears showing ASCUS were 10 (1.8%) in our study which is different from the study by Patel et al [8] showing ASCUS in 41 (4.1%) of the smears. Smears showing LSIL were 16 (3%) in our study. In the study conducted by Patel et al [8] reports showing LSIL were 41 (0.1%). In our study, HSIL reports were four (0.7%), whereas in the study conducted by Bamanikar et al [7], two (0.3%) reports gave HSIL which is consistent with the present study. Smears showing atypical cells suggestive of squamous cell carcinoma were four (0.7%) in our study. In the study conducted by Patel et al [8], reports showing squamous cell carcinoma were in 0.7% of smears.

It is seen that reports in our study like many other studies have shown the importance of pap smear test in screening cervical cancer and guiding the clinician about their treatment strategy. By increasing health awareness and performing pap smear screening programs, the incidence of cervical carcinoma can be decreased [10].

Pap smear tests are inexpensive and affordable by the patients. This procedure does not need experts and specialists for collection of smear. Early detection of possibility of malignancy helps in prompt treatment at early stage and prolongation of life expectancy of many women and reduces the mortality and morbidity of cancer cervix. Till today, pap smear test is the most useful screening procedure for cervical cancer.

Conflicts of Interest

None of the authors have any conflicts of interest.

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Clinical Infection and Immunity is published by Elmer Press Inc.