|Year : 2019 | Volume
| Issue : 2 | Page : 145-149
Study of cervical papanicolaou smear in intrauterine contraceptive device users in a tertiary care hospital
Nirvana Rasaily Halder, Babai Halder, Yalavarthi Sushma
Department of Pathology, Mamata Medical College, Khammam, Telangana, India
|Date of Submission||16-Jul-2018|
|Date of Acceptance||16-Jan-2019|
|Date of Web Publication||25-Mar-2019|
Department of Pathology, Mamata Medical College, Khammam, Telangana
Source of Support: None, Conflict of Interest: None
Background: The use of intrauterine contraceptive device (IUCD) generally has been known to be safe and effective but tends to have some side effects. Reproductive tract infection is one of the major complications caused by prolonged usage of an IUCD. Cervical smears have shown an increase in inflammation, inflammatory epithelial changes, or metaplastic cells among the IUCD users as compared to nonusers. There is also a predisposition to higher rate of infections such as Actinomyces, atypical squamous cells of undetermined significance, and low-grade squamous intraepithelial lesion. Aims and Objectives: The aim of this study was to study changes in cervical cytology in IUCD users and to assess the risk of epithelial cell abnormalities among IUCD users compared to nonusers. Materials and Methods: A 2-year cross-sectional study was carried out to screen Papanicolaou (Pap) smears in women of the reproductive age group who were categorized as IUCD and non-IUCD users. Results and Observations: A total of 1100 (550 + 550) Pap smears from IUCD and non-IUCD users were analyzed. Among IUCD users, 544 cases (98.90%) were adequate for reporting including 533 cases (97.98%) showing negative for intraepithelial lesion or malignancy (NILM) and 11 cases (2.02%) showing epithelial cell abnormality (ECA). In non-IUCD users, 541 cases (98.36%) were adequate for reporting. Among these, 538 cases (99.44%) showed NILM and 3 cases (0.56%) showed ECA. Conclusion: In IUCD users, the prevalence of infections and ECA is higher than non-IUCD users.
Keywords: Intrauterine contraceptive devices, negative for intraepithelial lesion or malignancy, Papanicolaou smear
|How to cite this article:|
Halder NR, Halder B, Sushma Y. Study of cervical papanicolaou smear in intrauterine contraceptive device users in a tertiary care hospital. Med J DY Patil Vidyapeeth 2019;12:145-9
|How to cite this URL:|
Halder NR, Halder B, Sushma Y. Study of cervical papanicolaou smear in intrauterine contraceptive device users in a tertiary care hospital. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2020 Feb 28];12:145-9. Available from: http://www.mjdrdypv.org/text.asp?2019/12/2/145/254763
| Introduction|| |
The use of intrauterine contraceptive device (IUCD) generally has been known to be safe and effective, reliable, reversible, economic, and safe method for regulation of population but tends to have some side effects., At present, copper-T380A (Cu-T) is the most widely used IUCD in India. Reproductive tract infection is one of the major complications caused by prolonged usage of an IUCD., Several studies have demonstrated a higher prevalence of bacterial vaginosis (BV) and pelvic inflammatory disease among IUCD users in different countries.,,,
Cervical smears have shown an increase in inflammation, inflammatory epithelial changes, or metaplastic cells among the IUCD users as compared to nonusers. There is also an increased incidence of inflammation with prolonged use of Cu-T. There is also a predisposition to higher rate of infections such as Actinomyces, atypical squamous cells of undetermined significance (ASCUS), and low-grade squamous intraepithelial lesion (LSIL).
IUCD use has been shown to reduce the risk of endometrial cancer, but little is known about its association with cervical cancer. In the present study, we aimed to observe the changes in cervical cytology in IUCD users and to assess the risk of epithelial cell abnormalities among IUCD users compared to nonusers.
| Materials and Methods|| |
This hospital-based cross-sectional study design was conducted in the department of pathology, in collaboration with the department of obstetrics and gynecology, for a period of 2 years. A total of 550 women who were in the age group of 18–45 years with more than 6 months of using the IUCD were the study population, and 550 women of similar age range but nonusers of any hormonal or IUCD contraceptive method were taken as controls. Women who were using IUCD for <6 months were not included in the current study.
Relevant history, presenting complaints, and examination findings including per-speculum findings were noted before doing the procedure.
After taking informed consent from the patient, they were instructed to avoid conjugal relation 2–3 days before sample collection and not to use any vaginal douche for 24 h before subjecting to a Papanicolaou (Pap) smear examination. The cervix was made completely visible after the introduction of a cervical speculum. The cervix was sampled using an Ayre's spatula. The material was spread evenly and thinly on two clean glass slides and wet-fixed by immersing it in 95% ethanol for a minimum of 15 min. The smears were stained with Pap stain followed by mounting with distyrene plasticizer xylene and coverslip of suitable size and reported according to The Bethesda Classification 2014.
| Results and Observations|| |
A total of 550 Pap smear More Detailss of IUCD users were screened and compared the result with the result of 550 Pap smears which were taken from female non-IUCD users of the reproductive age group. The data were complied, tabulated, and analyzed statistically.
Among 550 Pap smears of IUCD users, 544 cases (98.90%) were adequate and 6 cases (1.10%) were inadequate for reporting. On the other hand, among 550 Pap smears studied in non-IUCD users, 541 cases (98.36%) were adequate and 9 cases (1.64%) were inadequate for reporting.
In IUCD users, 533 cases (97.98%) showed negative for intraepithelial lesion or malignancy (NILM) and 11 cases (2.02%) had epithelial cell abnormality (ECA). Among ECA, 4 cases (33.36%) of ASCUS, 4 cases (33.36%) of LSIL, 2 cases (18.19%) of high-grade squamous intraepithelial lesion (HSIL), and 1 case (9.09%) of squamous cell carcinoma (SCC) of the cervix were observed. Among NILM cases, 28 cases (5.26%) showed normal findings while 402 cases (75.42%) were reactive cellular changes associated with inflammation, 69 cases (12.94%) showed BV, 22 cases (4.13%) were infection with Candida species, 9 cases (1.69%) of Trichomonas vaginalis, and 3 cases (0.56%) of Actinomyces. Different types of Pap smear findings in non-IUCD users were also compared [Table 1], [Table 2] and [Figure 1], [Figure 2].
|Table 1: General categorization of Papanicolaou smears in intrauterine contraceptive device and nonintrauterine contraceptive device users (according to The Bethesda System 2014)|
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|Table 2: Different types of Papanicolaou smear diagnoses in intrauterine contraceptive device users and nonintrauterine contraceptive device users|
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|Figure 1: (a) Reactive cellular changes associated with inflammation (Conventional Pap, ×40), (b) shift in vaginal flora (bacterial vaginosis) (Conventional Pap, ×40), (c) fungal organism morphologically consistent with Candida species (Conventional Pap, ×100), (d) pear-shaped organism (Trichomonas vaginalis) (Conventional Pap, ×40), and (e) Actinomyces (Conventional Pap, ×100). Arrows in the pictures (b-e) representing respective organisms|
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|Figure 2: (a) Atypical squamous cell of undetermined significance, (b) low-grade squamous intraepithelial lesion, (c) high-grade squamous intraepithelial lesion, and (d) squamous cell carcinoma of the cervix (Conventional Pap, ×40)|
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The present study showed that both infections and ECA were more commonly encountered in IUCD users as compared with non-IUCD users; P values were 0.0314 and <0.0001, respectively, which are statistically significant (P < 0.05).
Age distribution of the IUCD users in the study group showed that the maximum number of patients belonged to the age group of 21–30 years (268 cases, 49.26%), followed by 31–40 years (216 cases, 39.71%), >40 years (47 cases, 8.64%), and the least number of cases was in the group <20 years (13 cases, 2.39%). The youngest patient among the IUCD users was 19 years old and the eldest was 45 years old with a mean age of 31.45 years and median age of 30 years. Among non-IUCD users, the maximum number of patients belonged to the age group of 31–40 years (319 cases, 58.97%), followed by 21–30 years (198 cases, 36.60%), >40 years (13 cases, 2.40%), and the least number of cases was in the group <20 years (11 cases, 2.03%). The youngest age of the non-IUCD users screened was 19 years and the eldest was 44 years with a mean age of 31.47 years and median age of 32 years [Table 3].
|Table 3: Age distribution in intrauterine contraceptive device and nonintrauterine contraceptive device users|
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The parity in the IUCD users ranges from P1+0 to P6+0. Maximum patients were in the P2+0 group (228 cases, 41.91%), followed by P1+0 (112 cases, 20.59%), P3+0 (108 cases, 19.85%), P4+0 (83 cases, 15.26%), P5+0 (2 cases, 0.37%), and P6+0 (11 cases, 2.02%). Among 533 NILM cases in IUCD users, majority of the cases were in P2+0 group (230 cases, 24.53%). On the other hand, in non-IUCD users, maximum patients were in P2+0 group (199 cases, 36.78%) which was followed by P3+0 (151 cases, 27.91%), P1+0 (118 cases, 21.81%), P4+0 (62 cases, 11.46%), P5+0 group (9 case, 1.67%), and P6+0 group (2 cases, 0.37%) [Table 4].
|Table 4: Parity-wise distribution in intrauterine contraceptive device and nonintrauterine contraceptive device users|
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| Discussion|| |
The Pap smear is a screening test that can be carried out readily during gynecological examination. It should be conducted once a year in women of the reproductive age. Although the Pap smear was developed for cervical cancer screening, it is obvious that it sheds light on nonneoplastic pathologies, as well.
In our study, 98.90% of cases were adequate and 1.10% were inadequate for reporting. This finding was comparable with the study conducted by Rahime et al. which showed that 93% Pap smears of IUCD users were adequate for reporting while 7% were inadequate.
In our study, 97.98% of the IUCD users were diagnosed cytologically as NILM and only 2.02% were diagnosed as ECA. Similar findings were seen in the studies conducted by Nayak et al. which showed that 98.6% of cases were NILM and 1.4% of cases were ECA.
In the present study, among ECA detected in IUCD users, ASCUS and LSIL comprised most 33.36% each, followed by HSIL (18.19%) and SCC of the cervix (9.09%), which was similar to a study done by Nayak et al. which revealed that 57.14% of ECA were of ASCUS. However, a study by Lekovic et al. showed that 5.9% of cases had ECA, and among these, 98% were of ASCUS.
Observation of high ASCUS and LSIL rate in the study group might reflect reactive cellular alterations that are derived from inflammation and vaginal flora alterations.
The copper in the device progressively diminishes, leaving a minimal amount of the metal on the device at the end of 3 years. However, it may be possible that constant release of the copper from the device in the first 3 years of insertion in some way initiates cellular changes in the cervical epithelium that promotes the occurrence of dysplasia at a later date.
Among NILM group in IUCD users, we found that 5.26% showed normal findings, 75.42% showed benign reactive changes associated with inflammation, 12.94% of BV, 4.13% of Candida species, 1.69% of T. vaginalis, and only 0.56% of Actinomyces. Findings of the present study were comparable with a study done by Rahime et al. which showed 9.3% normal findings, 71% benign reactive changes associated with inflammation, 7% BV, 7.3% Candida species, 1.4% T. vaginalis, and 4% Actinomyces.
In the present study, we found that the incidence of BV in IUCD users was 12.94%, which was similar to that of a study by Shobeiri and Nazari which showed that 12% of NILM cases had BV.
We found from the present study that 4.13% of NILM cases in IUCD users showed fungal organism morphologically consistent with Candida species, which was similar to that of a study by Haltas et al. which showed that 2.81% of NILM cases were infected by Candida species. In the study by Demirezen et al., the incidence of Candida was quite high (14%).
In the study by Nasir et al., T. vaginalis was reported as the most important cause of specific infection (33.33%). However, in the present study, the incidence of T. vaginalis in IUCD users was 1.69%, which was similar to that of a study by Rahime et al. which showed that 1.4% of NILM cases had T. vaginalis.
In our study, we got only 0.56% Actinomyces cases in IUCD users, though in IUCD users, Actinomyces infection is quite common.
In the present study, parity-wise distribution of the overall IUCD users showed that the maximum number of patients belonged to the P2+0 group (41.91%), followed by P1+0 group (20.59%), P3+0 group (19.85%), and least number of cases in >P4+0 group (17.65%). A study conducted by Anant et al. also showed a similar result.
| Conclusion|| |
From the present study, we concluded that in IUCD users, the prevalence of infections and ECA is higher than non-IUCD users. Therefore, women in the reproductive age group who are taking IUCD as a contraceptive method should undergo PAP screening with follow-up whenever required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Speroff L, Glass RH, Kase NG. The Intrauterine Device. Clinical Gynaecologic Endocrinology and Infertility. 6th
ed. USA: Lippincott Williams and Wilkins; 1999. p. 975-96.
Mishell DR Jr., Israel R, Freid N. A study of the copper T intrauterine contraceptive device (T Cu 200) in nulliparous women. Am J Obstect Gynecol 1973;116:1092-7.
Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: An international perspective. Lancet 1992;339:785-8.
Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003;8:150-5.
Burkman RT. Intrauterine devices and pelvic inflammatory disease: Evolving perspectives on the data. Obstet Gynecol Surv 1996;51:S35-41.
Avonts D, Sercu M, Heyerick P, Vandermeeren I, Meheus A, Piot P. Incidence of uncomplicated genital infections in women using oral contraception or an intrauterine device: A prospective study. Sex Transm Dis 1990;17:23-9.
Calzolari E, Masciangelo R, Milite V, Verteramo R. Bacterial vaginosis and contraceptive methods. Int J Gynaecol Obstet 2000;70:341-6.
Agarwal K, Sharma U, Acharya V. Microbial and cytopathological study of intrauterine contraceptive device users. Indian J Med Sci 2004;58:394-9.
] [Full text]
Kazerooni T, Mosalaee A. Does contraceptive method change the Pap smear finding? Contraception 2002;66:243-6.
Castellsagué X, Díaz M, Vaccarella S, de Sanjosé S, Muñoz N, Herrero R, et al.
Intrauterine device use, cervical infection with human papillomavirus, and risk of cervical cancer: A pooled analysis of 26 epidemiological studies. Lancet Oncol 2011;12:1023-31.
Rahime BF, Servet G, Ayşe NU, Jale K. Evaluation of nonneoplastic findings on vaginal smears with comparison of intrauterine devices and oral contraceptive pill effects. Turk J Med Sci 2013;43:299-303.
Nayak SR, Chaitanya LL, Radhika P. Clinicocytological study in copper-T users. J Obstet Gynecol India 2007;57:231-3.
Lekovic J, Melissa KF, Pangasa M, Chan M, Varrey A, Taylor J, et al
. A comparison of human papilloma virus infection and cervical cytology in women with copper and levonorgestrel containing intrauterine devices. Hum Reprod 2013;28:i247-8.
Shobeiri F, Nazari M. Vaginitis in intrauterine contraceptive device users. Health 2014;6:1218-23.
Haltas H, Bayrak R, Yenidunya S. To determine of the prevalence of bacterial vaginosis, Candida
sp, mixed infections (Bacterial vaginosis + Candida
sp), Trichomonas vaginalis, Actinomyces
sp in Turkish women from Ankara, Turkey. Ginekol Pol 2012;83:744-8.
Demirezen S, Dirlik OO, Beksaç MS. The association of Candida
infection with intrauterine contraceptive device. Cent Eur J Public Health 2005;13:32-4.
Nasir JA, Najma J, Tahir F, Asghar MN, Iqbal J. Trichomonas vaginalis
in vaginal smears of women using intrauterine contraceptive device. Pak J Med Res 2005;44:114-6.
Anant MP, Angsuwathana S, Thamkhantho M, Paytay K, Chiravacharadej G. The comparative study of different contraceptive methods between copper T 380A and norplant 6 Siriraj experience. Siriraj Med J 2007;59:287-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]