Colposcopic Evaluation of Cervix with Persistent Inflammatory Pap Smear

In women the most common invasive cancer is cervical cancer. The risk factor of cervical cancer is Risk factors can be genetic, but some lifestyle factors, such as alcohol intake. For colposcopy evaluation of cervix Inflammatory Pap smear is commonly use. Our aim of the study is to examine women with persistent inflammation on Pap smear need further evaluation with colposcopy. In this study was conducted in Department of Obstetrics and Gynecology, Institute of Child & Mother Health (ICMH) Dhaka, 2011 January to 2014 January where from total 1457 married non pregnant women only 140 case screened and examine who complained inflammatory cellular changes on pap smear. The patients age was ≥19 where age between 20-30 shows highest percentage of inflammatory cellular changes on pap smear and multipara was found 93% than primipara. During the study oral contraceptives are taken highest among other contraceptives. In the study Most of the cervices were broad 78.9% and almost all of the uteri exhibited free fornix. Where size of uterus was normal and Colposcope comment: Positive was 76 and negative was 64. After many analysis and examination , all women with persistent inflammation on Pap smear should be subjected to further evaluation.


I. Introduction
Cervical cancer is a cancer arising from the cervixes. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The risk factor of cervical cancer is Risk factors can be genetic, but some lifestyle factors, such as alcohol intake. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain, or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer . [1] The early stages of cervical cancer may be completely free of symptoms. Vaginal bleeding, contact bleeding (one most common form being bleeding after sexual intercourse), or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs, or elsewhere.Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy vaginal bleeding, bone fractures, and (rarely) leakage of urine or feces from the vagina. Bleeding after douching or after a pelvic exam is a common symptom of cervical cancer . [2] Figure-1: Cervical cancer [3] Inflammatory Pap smear is the most common colposcopic evaluation of cervix with persistent Inflammation Pap smear. The suggested treatment for generous cell changes on Pap spread screening is treatment of contamination took after by a rehash Pap spread in 4 to a half year time. In the event that the incendiary changes proceed with, the patient is to be subjected to colposcopy. [4] [5] However, this is scarcely taken after, particularly in asset poor nations, where appropriate cervical screening convention has not been set up yet. Henceforth, a great number of patients in the premalignant arrange (which may experience threatening change amid the slack time) are missed. So the patients with tenacious fiery Pap smears ought to be tentatively assessed utilizing colposcopy. There are not very many examinations in the writing where the frequency of premalignant and dangerous injuries was investigated in instances of incendiary Pap spread. Aggravation can darken couple of dangerous cells and may bring about high false negative rates which might be lessened by utilizing fluid based cytology . [6] However, it was accounted for that fluid based cytology was not savvy for creating nations and the ongoing investigations found no measurably critical distinction of exactness between customary Pap test and fluid based cytology. [7] Colposcopy of ladies with cytological analysis of incendiary epithelial changes might be a valuable method to distinguish generally unrecognized instances of CIN. In Bangladesh, every year 17,686 women are diagnosed with cervical cancer; of them 10,364 die of the disease.
Although services for carcinoma of cervix screening are available in Bangladesh. It is not practically feasible to subject all women with inflammatory pap smear to colposcopy in our country.

II. Objective
General Objective:  To explore whether women with persistent inflammation on Pap smear need further evaluation with colposcopy.

Specific Study: 
To minimize morbidity and mortality from the disease.  To examine oral contraceptives usage.

Study Population:
In this study, Patients with two consecutive reports of inflammatory cellular changes without atypia on Pap smears despite anti-inflammatory therapy were the study population.

Sample Size:
In this study total 1457 married non pregnant women (aged 20 years or more) complaining of different gynecological problems underwent Paps test during the study period for gynecological problems. 313 were reported as having 'inflammatory cellular changes. After giving anti-inflammatory treatment most of them were cured leaving 140 cases with repeat report of inflammatory cellular changes on pap smear and hence were included the study.

Method:
During study at the age of ≥ 19 year with the complaints of excessive vaginal discharge, post coital bleeding etc, they were advised to paps smear. If pap smear test exhibited inflammatory cellular changes without atypia, the patients received treatment of infection with doxycycline daily for 14 or metronidazole. If the inflammatory change persists the patients are subject to colposcopy. To perform colposcopy examination the cervix are cline with saline solution and applied acetic acid. After 60 sec cervix are visualized under low and high magnification. Aceto-white areas and atypical vasculature were determined. Visual inspection with acetic acid (VIA) positivity was considered if there were acetowhite areas in the transformation zone close to squamacolumnar junction. Iodine negative areas were determined at cervix by applying legal solution. A biopsy was performed from aceto-white, mosaic, Iodine-negative areas and from punctuations, atypical vasculatures, and erosions.

Statistical analysis:
In this study Data were processed and analyzed using distribution of respondents by their Parity computer software SPSS (Statistical Package for (n=140

IV. Result
In table 2 shows distribution of responds by their age where Age between 20-30 yearhave highest frequency among all. The following table is given below: The figure -2 shows that distribution of responds by their parity where multipara has highest percentage. The following figure-2 is given below:  Table-3 shows the distribution of subjects by their per speculum examination of cervixes and P/V findings of fornix where Most of the cervices were broad 78.9%. Almost all of the uteri exhibited free fornix. The following tables shows in details:

Table 3: Distribution of subjects by their per speculum examination of cervixes and P/V findings of fornix
In figure-4 shows size of uterus of patients, where Normal size got highest percentage among all . The following figure is given below:

V. Discussion
Forcervix cancer Pap smear test is a major screening test for early diagnosis and treatment. Inflammation on Pap smear is considered a relatively benign finding. However, due to the low sensitivity and high false negative rate of Pap smear, there is a possibility that an inflammatory Pap smear may miss cervical premalignant changes and in rare cases malignant changes as well.In the present study total of 1457 women under-went Pap test during the study period for gynecological problems like vaginal discharge, postcoital bleeding, intermenstrual bleeding and leucorrhoea. Of them 313 were reported as having 'inflammatory cellular changes .Ant inflammatory treatment given to these patients cured most of them leaving 140 cases with a repeat report of inflammation on Pap smear which also compares well with the other study . [8] [9] The prevalence of inflammatory Pap smear in many Indian studies is reported to vary between 70% and 80.5% . [10] However, in a recent study the reported prevalence was lower is quite consistent with the findings of the present study.Among the persistent inflammatory Pap smear cases, 76 were Colposcopically positive for CIN whereCIN-1is 48, CIN-2 20 and of the 140 women.Various studies have found the possibility of CIN with a report of persistent inflammatory smear to range from to 35%. [11] According to various studies, ASCUS (atypical squamous or glandular cells of undetermined significance) on Pap smear has a 10-20% chance of harboring CIN. [12] [13] This is the reason why we triage women with ASCUS on Pap smear with either repeat cytology, HPV DNA testing, or colposcopy . [14] Our study has shown a sizable proportion of women (about 20%) with persistent inflammation on Pap smear could be harboring CIN. Moreover, the incidence of CIN and invasive carcinoma in women with persistent inflammatory Paprepeating the Pap smear may lead to a delay in diagnosis of CIN in a high

VI. Recommendation
A large-scale study should be conducted to validate the findings of the present study so that outcomes can be more accurate

VII. Conclusion
On the basis of the examination and findings of the study, it can be concluded that patients with persistent Inflammatory Pap smear can harbor a high proportion .pap smear report of persistent inflammatory cellular changes should not be considered as a variant of normal, especially when it doctor not respond to adequate recommended therapy. Such patients must be referred to further evaluation by colposcopy.