Comparative analyses of PAP smear data in pre and postmenopause Indian women

PAP smear is one of the best screening tools available for early detection of cervical cancer. Hence, we conducted a retrospective study at the Department of Pathology, Sree Balaji Medical College and Hospital over a period of one year by collecting PAP smear data. A total of 978 smears were collected out of which 59% were premenopausal and 41% were post menopausal women. Data shows that the prevalence of pre malignant and malignant lesions were more among the women of post menopausal age group than the pre menopausal age group.


Background:
Carcinoma cervix worldwide accounts for 15% of all cancers diagnosed in women [1]. Globally, cervical cancer is one of the most common cancers in women, with an estimate of 440,000 new cases annually. Eighty percent of these cases occurred in developing and under developed countries [2]. According to National Cancer Registry Program of India, it is evaluated that in India, roughly 100,000 ladies create cervical cancer growth every year. Cervical cancer is a preventable disease in the vast majority of women. Fortunately, the natural history of cervical cancer is such that it is possible to detect it early during a pre invasive curable stage by screening and early intervention thereby preventing progression ©Biomedical Informatics (2020) 453 into life threatening illness [3]. PAP smear is one of the best screening tools available for preventing cervical cancer. The most widely used system for describing PAP smear is The Bethesda System, 2001 [4]. PAP smear cervical cytology with sensitivity of 72% and specificity of 94% is suitable for population based screening programme [5]. Death rate from cervical cancer steadily increases with age. The mortality rate of cervical cancer will be reduced if screening is done between the ages of 40-45 years [6].

Materials and Methods:
This was a retrospective study of all cervical PAP smear cases reported at the Department of Pathology, Sree Balaji Medical College and Hospital, Chennai, India for a period of 1 year from October 2015 to September 2016. Smears were taken via specialist doctors using changed Ayres wooden spatula, which was inserted and rotated 360 o over cervix. Both ectocervix and endocervix were sampled. Samples were received in coplin jar (2 smears) dipped in isopropyl alcohol from the Dept of Obstetrics and Gynaecology, Sree Balaji Medical College & Hospital. Two smears were prepared, one stained with Haematoxylin and Eosin and other with PAP stains. All the smears were evaluated and subsequently examined and reported as per guidelines of the Bethesda system. Ethical Clearance on the use of data from human subjects: This study was conducted under the supervision of the research ethical committee at Sree Balaji Medical College and Hospital, Tamilnadu, India

Results:
A total of 978 cases were reported in the above-mentioned period and all the cases were analysed. The age of the patients ranged from 24 yrs to 79 yrs., of which 578 women (59%) were in pre menopausal age group and 400 women (41%) were in postmenopausal age group.

Premenopausal age group:
Among 978 women, 578 cases of women fell under the pre menopausal age Group. This group showed 43.5% (252) normal PAP smears. The inflammatory smear 50.5% (292) does not have any underlying pathology was seen in the investigated cases. Sexually Transmitted Diseases (STDs) caused by Trichomonas vaginalis, Candida albicans and Bacterial vaginosis were also diagnosed in the cytology smears.Bacterial vaginosis was seen in 6 women (1.0%), Trichomoniasis was found in 3 women (0.5%), candidiasis was found in 15 women (2.6%). LSIL was diagnosed in 6 (1.0%) women, HSIL was seen in 2 women (0.3%), and squamous cell carcinoma was found in 2 (0.3%) women (Figure 1).

Discussion:
Cancer of the cervix has been the most important cancer among women in the past two decades. In India the peak age for cervical cancer incidence is 55-59 years. Current data from the National Cancer Registry Program (NCRP) indicates that the most common sites of cancer among women are the breasts and the cervix found Eighty percent of all the epithelial abnormalities were found in the age group > 40 years of age. The average age of patients for all the epithelial abnormalities was 49 years. Mishra et al. [12] also has pointed that in out of 36484 women studied, 12681 women were above 40 yrs of age in which 10.1% had SIL and 1.3% had Ca cervix.
The inflammatory smear was found to be more common in premenopausal age group women than postmenopausal age group women in this study. The STDs namely Trichomonas vaginalis, Candida albicans and bacterial vaginosis were also diagnosed in the cytology smears, and was more among the pre menopausal women. Out of 578 premenopausal women studied, 24 women reported inflammatory smear with infections (4.2%) like bacterial vaginosis (0.6%), Trichomoniasis (0.5%) and Candidiasis (2.6%). In post menopausal age group 164 women (41%) had inflammatory smear without any underlying pathology, STDs like candidiasis was seen in 9 (2.2%) cases and bacterial vaginosis was seen in 7 (1.8%) cases. This is in concordance with Ranabhat et al.

Conclusion:
Squamous intraepithelial lesions are more common in the postmenopausal age group compared to the premenopausal age group. Screening by PAP smear is essential in both the groups for early detection and management of epithelial abnormalities. We recommend at least a single life-time PAP screening cytology of the uterine cervix of all the women aged 40 to 50 years as there is a rapid increase cervical cancer mainly among in postmenopausal age group women. We propose that larger studies are required to estimate the pattern of cervical cytological abnormalities along with detection of common HPV strains in cervical cancer in Indian population. This knowledge would be useful for prevention of HPV infection with adequate intervention.