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ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 1  |  Page : 23-27

Prevalence and comparison of cervical cytology abnormalities in postmenopausal and elderly women: A experience from tertiary care hospital


Department of Pathology, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, Tamil Nadu, India

Date of Web Publication17-Jan-2017

Correspondence Address:
P Arul
83, Ayyanar Kovil Street, Vinayagampet, Sorapet Post, Puducherry - 605 501
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.198432

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  Abstract 

Background: In developing countries, cervical cancer is the most common cancer cause of death among women. Aim: This study was undertaken to evaluate the cervical cytology smears in postmenopausal and elderly age group women, and also to assess the usefulness of cytological screening in elderly women. Materials and Methods: In this prospective study, a total of 600 Papanicolaou smears were evaluated and categorized according to Bethesda system for reporting cervical cytology 2014. Of these, 420 smears were obtained from postmenopausal women aged over 45-65 years and 180 were from elderly women aged over 65 years. Results: Overall, the prevalence of epithelial cell abnormality was 5.5%. Epithelial cell abnormalities found in elderly women were 10.5% and in postmenopausal women were 3.3%. Reactive cellular changes associated with inflammation were observed in 72.3% of postmenopausal women and 28.3% of the elderly female; whereas, atrophic changes were noted 61.1% in elderly female and 24.2% in postmenopausal women. Both these findings revealed statistically significant differences (P < 0.001). Conclusion: The present study showed that postmenopausal and elderly female from rural areas and low socio-economic groups significantly suffered from precancerous lesions of the cervix; even though, the rate seems to be low. Hence, our study concluded that postmenopausal and elderly female should undergo cervical cancer screening to avoid morbidity and mortality.

Keywords: Cervical intraepithelial lesions, cervical smear, elderly women, postmenopausal women


How to cite this article:
Akshatha C, Arul P, Shetty S. Prevalence and comparison of cervical cytology abnormalities in postmenopausal and elderly women: A experience from tertiary care hospital. J Med Soc 2017;31:23-7

How to cite this URL:
Akshatha C, Arul P, Shetty S. Prevalence and comparison of cervical cytology abnormalities in postmenopausal and elderly women: A experience from tertiary care hospital. J Med Soc [serial online] 2017 [cited 2022 May 19];31:23-7. Available from: https://www.jmedsoc.org/text.asp?2017/31/1/23/198432


  Introduction Top


Cervical cancer is the third most common cancer worldwide and a major fatal malignancy among women, causing about 275,000 deaths annually worldwide, mostly in developing countries. It can be a preventable disease if identified at its early (precancerous) stages and treated by ablation. [1] Since the initiation of Papanicolaou (Pap) method as cervical cancer screening tool, it decreased the cervical cancer rates in most developed countries. Mortality rate is higher in countries where screening and appropriate treatment facilities are not available. [2],[3],[4]

In developing countries, approximately 5% of women have been screened for cervical dysplasia compared with 85% in developed countries in the past 5 years. [5] Human papilloma virus (HPV), a sexually-transmitted oncogenic virus and it plays major role in the development of cervical cancer. [6] Disease burden caused by cervical cancer in women of vulnerable age groups can be decreased by vaccination for HPV before viral exposure, cervical cytology screening using Pap method and safe sexual practices. [7]

Due to under usage of Pap smear screening in elderly women, there is relatively higher incidence of invasive cancer. One of the most common cancers among women in India is cervical cancer. It occurs in about one in 53 Indian women compared with one in 100 women in more developed regions of the world during their lifetime. [5] The present study was aimed to evaluate the Pap smears of postmenopausal women of 45-64 years and over 65 years of age and also to assess the usefulness of cytological screening in elderly women.


  Materials And Methods Top


Study design

This prospective study was carried out in the Department of Pathology at our institution from September 2015 to March 2016 after obtaining approval from the Institutional Ethical Committee. Informed written consent was obtained from each patient.

Study population

Women with age more than 45 years presenting for cervical screening were included in the study. Women <45 years of age, women more than 45 years of age with a history of hysterectomy/invasive carcinoma at the time of clinical evaluation and previously treated for cervical or any other genital malignancy were excluded from the study. In total, 600 patients were enrolled and of these, 420 were postmenopausal women (45-64 years of age), and 180 were elderly women (>65 years of age). Detailed clinical history and demographic characteristics such as age, gravidity, parity, time of menopause, and smoking were recorded.

Specimen collection and cytological examination

Cervical scrape smears were obtained by Ayre's spatula, and specimen was fixed in 95% ethyl alcohol. Subsequently, smears were stained with Pap method. The slides were categorized into negative for intraepithelial lesion or malignancy (NILM) and epithelial cell abnormalities according to Bethesda system for reporting cervical cytology 2014. [8] Reactive cellular changes associated with inflammation and atrophy was considered NILM, atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells cannot exclude a high-grade squamous intraepithelial lesion (ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous cell carcinoma (SSC) or adenocarcinoma was considered epithelial cell abnormalities.

Statistical analysis

The difference between two groups of the women was assessed using Chi-square test and the value of P < 0.05 was considered statistically significant. Statistical analysis was performed using International Business Machines (IBM) Corporation Statistical Package for the Social Sciences Statistics for Windows (version 20.0, Armonk, New York: IBM Corporation, USA).


  Results Top


[Table 1] shows a comparison of demographic characteristics of both postmenopausal women and elderly female age group. Number of parity were equal in both groups (P = 0.04). Age and time of menopause were higher in elderly women. Prevalence of smoking was more in postmenopausal women (P = 0.4).
Table 1: Comparison of demographic characteristics of postmenopausal and elderly age group


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Overall, the prevalence of epithelial cell abnormality was 5.5%, and the prevalence of ASC-US [Figure 1]a, ASC-H [Figure 1]b, LSIL [Figure 1]c, and HSIL [Figure 1]d were 0.8%, 0.2%, 2.2%, and 2.3%, respectively. Koilocytic changes were observed in ASC-H, LSIL, and HSIL [Table 2].
Figure 1: Squamous epithelial cell abnormalities. (a) Atypical squamous cells of undetermined significance. (b) Atypical squamous cells cannot exclude a high-grade squamous intraepithelial lesion. (c) Low-grade squamous intraepithelial lesion. (d) High-grade squamous intraepithelial lesion

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Table 2: Prevalence and comparison of papanicolaou smear results of postmenopausal (n=420) and elderly age group (n=180)

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The prevalence of NILM in the postmenopausal women was higher than the elderly age group (96.7% vs. 89.4%). However, the prevalence of atrophy in the postmenopausal women was lower than the elderly age group (24.3% vs. 61.1%) (P < 0.001). In contrast, reactive cellular changes associated with inflammation detection rate were higher in the postmenopausal age group (P < 0.001) than an elderly female. The prevalence of epithelial cell abnormality was higher in the elderly age group (10.5% vs. 3.3%). HSIL was detected to be 5% in the elderly age group and 1.2% in the postmenopausal group. However, there was no statistically significant difference between the groups in means of any epithelial cell abnormalities [Table 2]. None of our patients were found to have either SSC or adenocarcinoma.


  Discussion Top


To date, there are very less published data from India concerning the pattern of epithelial cell abnormalities in Pap smear especially in postmenopausal and elderly age groups. In this study, we have applied the Bethesda system, which will obviously provide an idea about the overall picture of the epithelial cell abnormalities in the Pap smears.

In the present study, the prevalence of atrophic changes on cervical cytology was higher in the elderly female than the postmenopausal women (61.1% vs. 24.3%). It is known that proportion of atrophic changes in the cervix, increases with age. [9] Screening in older women can be uncomfortable, and a lack of estrogen can make obtaining an adequate cytology sample, and interpretation difficult. In this study, the duration of postmenopausal period was found to be higher in the elderly female group. This could be the reason for the high prevalence of atrophic changes in the elderly female enrolled in the current study.

In developed countries, Pap test was introduced in the 1940s which lead to a major decrease in rates of cervical cancer morbidity and mortality during the last half of the 20 th century. Persistent HPV infections leading to dysplasia generally take about 10 years to develop. Hence, expanded screening should focus on women aged 30 years and older, who are most at risk. [10] Because middle-aged or older women are at heightened risk for cervical cancer, anything less than universal screening for eligible middle-aged or older women constitutes an unacceptable risk for cervical cancer. [11]

Most organizations recommend cessation of regular screening for cervical cancer between the ages of 60 and 75 if the last two or three examinations in the past decade have negative results. The frequency of screening and the age at which screening can be stopped remains controversial. However, a woman of any age who has not had a Pap smear in the recent past should be screened with at least two Pap smears that are 1 year apart; because many elderly women have not undergone regular screening. [12] When it comes to cervical adenocarcinoma, incorporating HPV testing with cytology could detect women at high risk of cervical cancer, which is poorly identified by Pap tests. [13]

The prevalence of cervical cytological abnormalities varies between 1.5% and 6% in developing countries. [14] In India, studies have revealed the prevalence of cervical cytological abnormalities to be approximately 5% by Bal et al., [15] Gupta et al., [16] detected this value to be 3.2% and Banik et al., [17] detected this value to be 8.18% in the general population. In the present study, the prevalence of overall epithelial cell abnormality was found to be 5.5%. The studies mentioned above-included women of all ages, but our study includes only postmenopausal and elderly women. Furthermore, the higher prevalence of epithelial cell abnormality in our study in elderly women is could be due to this age difference.

Screening up to age 65 years greatly reduces the risk of cervical cancer in the following decade. However, protection becomes weak when time goes on and is substantially <15 years after the last screen. Currently, certain countries stop screening cervical cancer between the ages 60 and 69 years and it appear to be inappropriate. [18] Few authors reported that in perimenopausal and postmenopausal women, nuclear enlargement in the absence of significant hyperchromasia has been related to either endogenous or exogenous hormonal changes. [19],[20] A study done by Johnston and Logani [21] found that 73% of ASC-US specimens in patients aged 40 years were negative for HPV DNA. The HPV-DNA detection rate dropped from 60% in the group ages 10-19 years to approximately 18% in the group aged >50 years indicating causative agent itself reduces the risk as age advances.

There are no standard guidelines associated with cervical cancer screening in postmenopausal and elderly females in India. In our study, the prevalence of epithelial cell abnormality in elderly women was higher than postmenopausal women (10.5% vs. 3.3%). In contrast, a study done by Meyer et al., [22] observed that prevalence of epithelial cell abnormality in a group of women aged over 65 was 1.4%. According to this study, precancerous lesions and cervical cancer can be discovered after the age of 65, despite an adequate previous follow-up. In the present study, the rates of ASC-US, ASC-H, and LSIL were similar in the both groups, but HSIL was slightly higher in elderly group. The probable cause of higher prevalence of epithelial cell abnormality in the group of women over 65 years age in our study was due lower follow-up rates for cervical screening. Similarly, in the postmenopausal women as well as the elderly female, rates of cervical screening follow-up were found lower. Most studies have shown that women with abnormal Pap smears or no Pap smears in the past are at higher risk of developing cervical cancer than women who have been screened regularly. [23]

The present study was conducted in the rural areas in and around the hospital. Those living in the district, especially postmenopausal and elderly women were not aware of significance and purpose of doing Pap smear. Our study found that women more than 45 years of age groups significantly suffered from precancerous lesions of the cervix, even though the rate seems to be low. Hence, community health awareness programs should be initiated regarding Pap smear screening for women more than 45 years of age for the early detection of cytological abnormalities.

Our study has some limitations. One of the major limitation was small sample size. Still large scale work should be done with colposcopic biopsy examination with follow-up. Other limitation was possibility of false negative results which could be due to background blood, mucus and inflammatory cells causing obscuration of the abnormal cells. This could be reduced/eliminated by liquid-based cytology preparation.


  Conclusion Top


The present study showed that postmenopausal and elderly female from rural areas and low socio-economic groups significantly suffered from precancerous lesions of the cervix, even though the rate seems to be low. Hence, our study concluded that postmenopausal and elderly female should undergo cervical cancer screening to avoid morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Castañón A, Landy R, Cuzick J, Sasieni P. Cervical screening at age 50-64 years and the risk of cervical cancer at age 65 years and older: Population-based case control study. PLoS Med 2014;11:e1001585.  Back to cited text no. 18
    
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Johnston EI, Logani S. Cytologic diagnosis of atypical squamous cells of undetermined significance in perimenopausal and postmenopausal women: Lessons learned from human papillomavirus DNA testing. Cancer 2007;111:160-5.  Back to cited text no. 21
    
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    Figures

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    Tables

  [Table 1], [Table 2]


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