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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 112-115

The reasons for colposcopy and histopathological outcomes in referral patients to Ayatollah Mosavi Hospital of Zanjan (2012–2017)


1 Department of Obstetrics and Gynecology, Zanjan University of Medical Sciences, Zanjan, Iran
2 Department of Pathology, Zanjan University of Medical Sciences, Zanjan, Iran
3 Endometriosis Research Center, Tehran University of Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
4 Department of Mosavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran

Date of Web Publication8-May-2019

Correspondence Address:
Hamideh Gholami
Department of Obstetrics and Gynecology, Mosavi Hospital, Zanjan University of Medical Sciences, Zanjan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_64_18

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  Abstract 


Objectives: The present study aimed at assessing the prevalence of cervical cancer and premalignant lesions of the cervix in patient referred to colposcopy unit in Zanjan, and to determine what extent colposcopy is conducted based on the scientific indications. Materials and Methods: In this registry-based cross-sectional study, all women who were referred to the Colposcopy unit of Zanjan Ayatollah-Mousavi Hospital to undergo colposcopy during 2012–2017 were studied. The required data were collected from the registered medical records in the Pathology Department of the hospital. The Bethesda System Terminology was used for classifying premalignant cervical lesions. Results: In the present study, the most common abnormal clinical signs were abnormal vaginal bleeding, whereas atypical squamous cells of undetermined significance (39.5%) remained the most common abnormal Pap smear test result. The clinical appearance of the cervix in 104 patients (62.3%) showed cervical erosion. The results of colposcopy showed some signs of inflammation in all patients. Out of these patients, 5.4% were reported with acute inflammation, and 39.5% with chronic inflammation. Conclusions: It can be concluded that the patients' referral for a colposcopy must be based on the scientific indications and unnecessary colposcopy should be avoided.

Keywords: Cervical cancer, colposcopy, pre-cancerous lesions


How to cite this article:
Molaei B, Jalilvand A, Hashemi N, Razavi S, Gholami H. The reasons for colposcopy and histopathological outcomes in referral patients to Ayatollah Mosavi Hospital of Zanjan (2012–2017). Adv Hum Biol 2019;9:112-5

How to cite this URL:
Molaei B, Jalilvand A, Hashemi N, Razavi S, Gholami H. The reasons for colposcopy and histopathological outcomes in referral patients to Ayatollah Mosavi Hospital of Zanjan (2012–2017). Adv Hum Biol [serial online] 2019 [cited 2019 Dec 7];9:112-5. Available from: http://www.aihbonline.com/text.asp?2019/9/2/112/257818




  Introduction Top


Cervical cancer is one of the most common malignancies of the female genital tract. Worldwide, this cancer is the third-most common cancer in women. Cervical cancer remains a sixth-most common cause of cancer death due to cancer.[1] However, the prevalence of cervical cancer and the mortality rate associated with it varies in different areas. This is probably because of variations in the screening programmes of cervical cancer and the management of premalignant cases.[2] Approximately, 85% of the cervical cancers occur in developing countries while 87% of the mortality of the disease also occurs in these countries, which reflects the primary and secondary prevention procedures in these areas.[2],[3]

Cervical cancer is the fifth most common cause of cancer in Iran.[4] According to the results of the study conducted in 2012, the prevalence of cervical cancer in Iran is estimated at an annual number of 947 new cases (134 cases with an age range of 15–39, 599 cases ranging from 40 to 64, and 214 cases over the age of 65). Cervical cancer is now ranked the 12th most frequent cancer deaths among women aged at 15–44 years in Iran.[5] Over the past 30 years, however, due to the progress of screening programmes and early detection of the disease and subsequently, optimal disease management, mortality and morbidity rate of cervical cancer have decreased by around 70%.[5]

Nowadays, it is a major challenge for public health that pre-malignant lesions of cervix are neither diagnosed, nor prevented and treated. Whenever in the screening stage, there appear abnormal cytology changes, the results must be confirmed using high-sensitivity tests. Colposcopy is an exact diagnostic procedure to closely examine the cervix, vagina, vulva and anus with a high magnification of the cervix.[6] The principal goal of colposcopy is the detection of pre-cancerous and cancerous lesions in their early stages, which have great potential for better treatment. This approach is used for further investigation of patients with suspicious pre-cancerous and cancerous lesions during routine cervical screening (abnormal cytology ± positive human papillomavirus [HPV] test), abnormal cervical appearance and abnormal vaginal bleeding (especially post-coital bleeding) and any sign suggestive of cervical cancer.[5] It is not economically cost-effective to do colposcopy unnecessarily. Moreover, it causes unnecessary stress in low-risk patients, and sometimes, it leads to additional intervention in young people which, in turn, has a negative effect on their future reproduction. Therefore, the patients' referral for colposcopy should be done with great care and hence that, on the one hand, suspicious cases can be detected precisely and on the other hand, the practice of unnecessary colposcopy can be avoided.[7]

Attempts have been made to study the screening with  Pap smear More Details or performing colposcopy in different countries. Nevertheless, the present study aims to investigate the reasons of referral for colposcopy performance and its subsequent results. In a sense, it attempts to determine to what the extent colposcopy is conducted based on scientific indications.


  Materials and Methods Top


The present registry-based cross-sectional study was conducted on all of the women who were referred to the Colposcopy Unit of Zanjan Ayatollah-Mousavi Hospital to undergo a colposcopy from 2012 to 2017.

The study is approved by the ethics committee of Mousavi Hospital with the code of A-11-230-8, and then the required data were collected from the registered medical records in the Pathology Department of the hospital.

Inclusion criteria were all medical records in the colposcopy unit during 2012–2017 belonging to patients referenced for a colposcopy for various reasons from different areas of Zanjan province. The exclusion criteria were incomplete medical records that did not have a phone number to follow-up and complete the information.

In this study, 189 records were found based on medical records from 2012 to 2017 by census method.

The required data, including age, gravidity, parity, menopause, the patient's complaint of vaginal discharge or vaginal bleeding, the result of previous Pap smear, the reason for colposcopy, observations during colposcopy procedure and the pathology report of a colposcopy were obtained from the patients' records and collected in a research-made checklist.

The Bethesda System Terminology was used for classifying premalignant cervical lesions. Based on this classification, cervical lesions are divided into several categories as the following: atypical squamous cells of undetermined significance (ASCUS); atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H); low-grade squamous intraepithelial lesion (LSIL); high-grade squamous intraepithelial lesion (HSIL). In this terminology, terms such as cervical intraepithelial neoplasia 1 (CIN1), CIN2 and also CIN3 are defined in the pathology specimen obtained from the cervical biopsy which reflects the depth of cervical involvement. In CIN1, the lesion is in bottom 1/3 of the cervix, in CIN2 2/3 of the cervix is affected and in CIN3, abnormal cells cover the full thickness of the surface layer of the cervix. The results of colposcopy included the following: Inflammation (acute cervicitis, chronic cervicitis and acute on chronic cervicitis), low-grade dysplasia (CIN 1 and koilocytosis) and high-grade dysplasia (CIN 2 and CIN 3). Regarding experiencing pregnancy, the participants were divided into five groups: nulliparous (no pregnancies), gravid 1 (one pregnancy), gravid 2 (two pregnancies), gravid 3 (three pregnancies) and gravid 4 and more (four pregnancies or more). According to varieties of delivery, the participants were recorded into three groups, including those who had a vaginal delivery and those who had caesarean sections and individuals who had experienced both methods. According to the patient's age, the participants were put in one of the three age groups: under 40 years of age, 40–50 years of age and over 50 years of age. Data were analysed through descriptive statistics, including frequency and percentage through the SPSS (version 23) (SPSS Inc., Illinois, USA). A value of P < 0.05 was considered as statistically significant.


  Results Top


In the present study, 189 records were assessed and of these 189 cases, 22 cases were excluded from the data analysis due to incomplete medical records and 167 cases remained. The mean age of the patients was 38.8 ± 9.9 years. Nearly, 60% of the patients were under 40 years of age. Of the total number of patients, 118 patients (70.7%) have had a vaginal delivery and 29 patients (17.4%) had caesarean sections. Only, 20 patients (12%) had experienced both methods [Table 1].
Table 1: Baseline characteristics of participants (n=167)

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Of the total number of patients, 80 patients had undergone colposcopy due to abnormal clinical symptoms, and 79 patients for an abnormal Pap smear report. The most common abnormal clinical signs, nevertheless, were abnormal vaginal bleeding while ASC-US remained the most common abnormal Pap smear test result. Meanwhile, 38 patients (22.8%) complained of having an abnormal vaginal discharge. Furthermore, 56 patients (33%) reported abnormal uterine bleeding, the most common of which was post-coital bleeding (29 patients). The most common abnormal findings in referral cases were the unusual appearance of the cervix (52 patients) (due to the existence of erosion in the cervix) and abnormal vaginal bleeding (56 patients). The patients' Pap smear results are presented in [Table 2]. The most common reason for referring to a colposcopy was ASCUS (39.5%). The prevalence of ASCH, LSIL, HSIL and AGUS were 3%, 2.4%, 1.8% and 6%, respectively.
Table 2: The results of Pap smear test (n=167)

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The clinical appearance of the cervix in 104 patients (62.3%) showed cervical erosion, whereas 18 other patients (10.7%) had abnormal vascular pattern [Table 3].
Table 3: The appearance of the cervix of the participants (n=167)

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When the cervix was exposed to acetic acid, the acetowhite changes appeared in 20 (12%) of the patients. Out of 167 assessed Pap smear cases, 23 cases were reported mild inflammation (13.7%), 21 cases with moderate inflammation (12.5%) and 39 cases with severe inflammation (23.35%). However, the results of a colposcopy showed some signs of inflammation in all patients. Out of these patients, 5.4% were reported with acute inflammation, 39.5% with chronic inflammation and 55% with acute on chronic inflammation. Among the examined cases, 56 patients (33.4%) were diagnosed with low-grade dysplasia, whereas two patients (1.2%) were reported with the frequency of high-grade dysplasia. Of those patients with Pap smear ASCUS (66 cases), only 12 patients (18%) had CIN1, with no report of CIN2 and CIN3 [Table 4].
Table 4: The results of colposcopy (n=167)

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Among five patients with Pap smear ASCH, only one of them (20%) had CIN1 with no report of CIN2 and CIN3. Among four cases with Pap smear LSIL, two cases (50%) had CIN1 and not found cases with CIN2 and CIN3 in these cases. Among three patients with Pap smear HSIL, one case (33%) was reported with CIN1, and one (33%) with CIN2 with not found cases with CIN3. It should be noted here that among the population under study, only one case of AGUS Pap smear was reported for whom CIN was not reported. Of the 20 cases with white epithelium during colposcopy, five cases (25%) had CIN1 and not found cases with CIN2 and CIN3 in these cases.


  Discussion Top


In this research, 83 patients (49%) had inflammation during the primary Pap smear test and during biopsy accompanying a colposcopy; the results showed some signs of inflammation in all patients so that 39.5% had chronic cervicitis. CIN1 was reported in 14.3% of these cases with no report of CIN2 and CIN3.

In 2014, Sharma et al.[4] conducted a survey to understand whether persistent inflammation in Pap smear is symptomatic of pre-cancerous changes or do these women need to do colposcopy? To this end, the women were screened with Pap smear and those with positive results of inflammation in Pap smear were at first received treatment for cervicitis and then repeated cytology was performed. Patients with persistent inflammatory Pap smear underwent a colposcopy-directed biopsy in 20.7% of whom CIN1 was reported which is in line with this study even though we did not treat cervical inflammation cases before performing colposcopy. Nevertheless, since in our study, all of the reported cases of CIN are CIN1, it seems that, in case, the patient has no other signs in physical examination or medical history to the benefit of cervical cancer, solely inflammatory Pap smear report is not an indication for a colposcopy.

In 2015, Zhao et al.[8] conducted a study to determine the prevalence of CIN in Chinese population. Nearly, 95.9% of the biopsied samples were diagnosed with normal/CIN1, 2.0% were CIN2 and 2.1% were CIN3. Likewise, in the study carried out by Perksanusak et al.[9] in 2015 in Thailand, the prevalence of CIN2 and CIN3 was 3.3%. In Catherine O'Connor's study, the incidence rates of CIN1, CIN2 and CIN3 were 1.5%, 1.2% and 0.8%, respectively.[10] In this study, the prevalence of CIN1 was 13.1%, and that of CIN2 and CIN3 was reported as 0.6%. The difference between the results of this study and those of other studies may be due to the greater number of CIN1 report from the Zanjan laboratories, and the lower number of CIN2 and CIN3 because of firm religious beliefs as well as proper control of sexual relationships. Furthermore, in 2012, a study was carried out by Mohit in Tehran[11] the reasons for colposcopy referral was as the following: atypical shape of cervix (47%), bleeding after intercourse (30%), abnormal Pap smear (17.1%), vulvar Condyloma (4.3%) and previous record of CIN in 2.6% of them. Among these patients, 9.2% had CIN, and 0.5% had invasive cervical cancer. Our results are in agreement with this study. Patients' referral for colposcopy must be based on scientific indications and unnecessary colposcopy should be avoided.

In the present study, of those patients with Pap smear ASCUS, only 18% of the patients had CIN1, whereas 50% of the patients diagnosed with Pap smear LSIL, had CIN1. Not a single case of CIN2 and CIN3 was reported in these cases, while in the study by Fallani et al., 15% of the patients with ASCUS, and 20.8% of the patients who had a cytologic diagnosis of LSIL had CIN2 and CIN3 in pathology.[12] This diversity could be due to the difference between the two populations. It could also be due to the increased number of reports on ASCUS and LSIL in diagnostic cytology of Papanicolaou test or Pap smear in Zanjan. These results, on the one hand, implies that in the triage of women with ASCUS cytology, it has not been cost-effective to perform colposcopy for all of the patients and it is necessary to perform an HPV triage test for patients and those HPV positive or persistent ASCUS cytology cases undergo colposcopy.

Since this study was a retrospective study, it was conducted based on existing records that 22 cases of which were excluded from study because of incompleteness and limited access. Obviously, this could affect the validity of the study findings. To yield more precise statistics and figures, it is highly recommended that the prospective studies be carried out on the exact incidence rates of CIN2 and CIN3 in different region of the country to help good-health planning be achieved.


  Conclusions Top


It can be concluded that patients' referral for colposcopy must be based on scientific indications and unnecessary colposcopy should be avoided

Acknowledgements

This study was supported by the Zanjan University of Medical Sciences. The authors would like to gratefully acknowledge the staffs on Colposcopy Department of the clinic of Ayatollah-Mousavi Hospital for their contribution to the study. Special thanks are also of the pathology unit personnel for their collaboration and support.

Financial support and sponsorship

This study was supported by Zanjan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pour Javad M. Efficiency of pap-smear and colposcopic method in screening cervical cancer. Med J Mashhad Univ Med Sci 2001;44:73-8.  Back to cited text no. 1
    
2.
Jeronimo J, Castle PE, Temin S, Denny L, Gupta V, Kim JJ, et al. Secondary prevention of cervical cancer: ASCO resource-stratified clinical practice guideline. J Glob Oncol 2017;3:635-57.  Back to cited text no. 2
    
3.
Ferlay J, Soerjomataram I, Eevik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.2, Cancer Incidence and Mortality Worldwider: IARC Cancer Base No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globocan.iarc.fr. [Last accessed on 2019 Jan 10].  Back to cited text no. 3
    
4.
Sharma S, Saini M, Saini A, Bhalla AA. Colposcopic evaluation of patients with abnormal cervical cytology and its histopathological correlation. Int J Gynecol Obstet 2014;18:1-8.  Back to cited text no. 4
    
5.
Zamani M, Torabian S. Evaluation the colposcopic and histologic findings in oncology ward of Fatemieh hospital, Hamadan, Iran. Iran J Obstet Gynecol Infertil 2013;16:1-6.  Back to cited text no. 5
    
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Giuntoli R 2nd, Bristow R. Cervical cancer. In: Danforth's Obstetrics and Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.  Back to cited text no. 6
    
7.
Ashmita D, Shakuntala P. Comparison and correlation of PAP smear, colposcopy and histopathology in symptomatic women and suspicious looking cervix in a tertiary hospital care centre. Int J Health Sci Res 2013;3:50-9.  Back to cited text no. 7
    
8.
Zhao YQ, Chang IJ, Zhao FH, Hu SY, Smith JS, Zhang X, et al. Distribution of cervical intraepithelial neoplasia on the cervix in Chinese women: Pooled analysis of 19 population based screening studies. BMC Cancer 2015;15:485.  Back to cited text no. 8
    
9.
Perksanusak T, Sananpanichkul P, Chirdchim W, Bhamarapravatana K, Suwannarurk K. Colposcopy requirement of papanicolaou smear after atypical squamous cells of undetermined significance (ASC-US) by follow-up protocol in an urban gynaecology clinic, a retrospective study in Thailand. Asian Pac J Cancer Prev 2015;16:4977-80.  Back to cited text no. 9
    
10.
O'Connor C, Myles H, O'Connor MB, Clancy J, Ryan A, Traynor M, et al. An audit of colposcopy referrals from a GU/STD clinic. BMC Res Notes 2008;1:24.  Back to cited text no. 10
    
11.
Mohit M. Evaluation of the Colposcopic Referral Reasons & Pathologic Results in Admitted Patients to Booali Hospital between 2004-2010. Tehran: Islamic Azad University of Tehran; 2011.  Back to cited text no. 11
    
12.
Fallani MG, Penna C, Fambrini M, Marchionni M. Cervical cytologic reports of ASCUS and LSIL. Cyto-histological correlation and implication for management. Minerva Ginecol 2002;54:263-9.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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