PROFILE OF CERVICAL SMEAR CYTOLOGY IN WOMEN ATTENDING HEALTH CENTER IN RURAL AREA OF WESTERN MAHARASHTRA

Background: Cervical cancer caused by infection with a sexually transmitted agent human papillomavirus (HPV), can be readily prevented by identifying and treating women with HPVinduced precancerous lesions of the cervix. Objective: To study the profile of cervical smear cytology in rural women in western Maharashtra. Methods: The study was designed to look at the previous reports of the Pap smear present at the health center Pravaranagar in rural area of Western Maharashtra. The reports of 186 smears were analyzed. Results: Maximum numbers of the women (70.43%) were less than 40 years of age. Majority of the women were from lower socio-economic status. There were 29.03 % Pap smears, negative for intraepithelial lesion. Intraepithelial neoplasia of various grade and invasive cervical carcinoma were diagnosed in some cases. Other infections were also detected on Pap smear like bacterial vaginosis, candidial infection and trichomonas vaginalis infestation. Conclusion: An Awareness and education program needs to be implemented to target women about cervical cancer and Pap smear screening. The goal of any screening programme should be to pick up majority of the precursor lesions and not frank cancers; it is desirable to initiate Pap smear screening in women from lower socio-economic status before the 40 years of age.


Introduction
Cervical cancer caused by infection with a sexually transmitted agent human papillomavirus (HPV), can be readily prevented by identifying and treating women with HPVinduced precancerous lesions of the cervix. 1 Cervical cancer has a long premalignant phase. If it is detected and treated in this phase, advanced disease can be prevented. Unfortunately, more than 80% of cases are diagnosed at an advanced clinical stage when five-year survival is less than 40%. 2 In 1941 Papanicolaou described cervical mass screening for early detection of cancer cervix and early pre-cancerous lesions. Uterine cervical cancer is a favorable site for an effective control program. The long latent period of intraepithelial neoplasia and availability of easy and sensitive screening test like the pap smear make the cervix a useful site to screen for cancer. 3 Nationwide, the disease accounts for an estimated 24 % of India's cancer cases among women, compared with 20 percent for breast cancer. 4 India's National Cancer Control Program emphasizes the importance of early detection and treatment. Poor and rural women are at heightened risk for cervical cancer. Routine clinical screening of all women attending the rural hospitals irrespective of their complaint could detect cancers in the early stages. The absence of a preventive attitude towards one's health was noticeable among these women. In fact, they believed that in the absence of symptoms, there is no need for a Pap smear. 5 Present study is an attempt to study the profile of cervical smear cytology in women attending health center, Pravaranagar.

Material and Method
Routine cytological evaluation of cervical smear is carried out in women attending Outpatient Department (OPD) at health center, Pravaranagar. Their detailed clinical history particularly obstetric and menstrual history along with clinical examination findings and relevant investigations were recorded. Pap smears of these women were collected. The study was designed to look at the previous reports of the Pap smear. The study group comprised of 186 cervico-vaginal smears from women who attended the health center, which included cervical smear screening. All smears were taken by trained female health worker. There were no exclusion criteria in this study, so all the smears were included in the study. The samples were collected using Ayer's spatula. The smears were then fixed in alcohol and stained using the Papanicolaou's technique. All the smears were reported by pathologists at Rural Medical College using the Bethesda System. Reports of 186 smears were analyzed. All the known abnormalities were identified and stated in this reports. Analysis of data was done in the form of age wise distribution of women, chief complaint and percentage distribution of each diagnosis. The smears were categorized into different groups as prevalence of normal smears, non specific infections, and specific infections, other reactive changes and epithelial abnormalities. Modified Prasad's classification adjusted with current price index was used to determine socio-economic status (SES). 6

Results
Maximum numbers of the women (70.43%) were less than 40 years of age. They were ranging in age from 18 to 64 years with a mean of 35.3 years and standard deviation (S.D.) of 8.6 years. Age wise distribution of these women is presented in Table 1. 100 Of the 186 women, the majority were married before 19 years of age (68.5%) and 67.4% delivered their first child within 1-2 years. Pelvic pain (lower backache, pain in abdomen) was the most common presenting complaint (72.04%) of the women screened. Abnormal per vaginal discharge was the second most common presenting complaint (45.69 %). Urinary symptoms were present in 9.67% of women. Inter-menstrual bleeding was present in 4.3 % of women. It is evident from Table 2 that, Majority of the women were from lower (social class IV+V) socio-economic status (52.16%). The cervical Pap smears examination of all the women with vaginal discharge showed the presence of cervical infections ( Table 3). The sexually transmitted diseases (STD) namely Trichomonas vaginalis and Candida albicans were also diagnosed in the cytology smears.

Discussion
The cervix is both a sentinel for potentially serious upper genital tract infections and a target for viral and other carcinogens. Infection constitutes one of the most common clinical complaints in gynecologic practice and frequently vexes both patient and clinician. Present work has been undertaken mainly to study profile of precancerous and cancerous lesions as well as inflammatory lesions in female patients living in rural area. In present study much credit for early detection of precancerous lesion belongs to the effectiveness of the Papanicolaou cytologic test. In present study low grade squamous intraepithelial lesion was present in 2.69% and high grade squamous intraepithelial lesion in 1.07% and invasive squamous cell carcinoma 0.54% of women. In hospital based study by Misra et al(2009) in North India the frequency was found to be, low grade squamous intraepithelial lesion 5.5%, high grade squamous intraepithelial lesion 1.6% and carcinoma 0.6%. 10 12 Teresita et al (2001) observed that the sensitivity of the Pap smear for Candida species was 31%, for bacterial vaginosis 57%, and 51% for trichomonas vaginalis. He concluded that the sensitivity of Pap smears for Candida species bacterial vaginosis, and Trichomonas vaginalis is inadequate for screening. Pap smears that are positive for Trichomonas vaginalis could be used to complement the diagnosis. 13 It is fortunate that the uterine cervix is an accessible site with early symptomatology. The negative aspect is the ignorance of the rural women, the traditional reluctance of women to seek medical aid, especially for gynecologic complaints, added to the readily available, indigenous medical quackery. The women in rural areas have to work very hard and they live in very poor conditions. The health beliefs of individuals are strong determinants in their choice of action. Women require more information about cervical cancer and need of Pap smear screening.

Conclusion
An Awareness and education program needs to be implemented to target rural women about cervical cancer and Pap smear screening. Since the goal of any screening programme should be to pick up majority of the precursor lesions and not frank cancers, it is desirable to initiate Pap smear screening in women from lower socioeconomic status before the 40 years of age.