Indian J Gynecol Oncolog DOI 10.1007/s40944-015-0029-x
ORIGINAL PAPER
Prevalence of Cervical Precancerous Lesions Among Women Attending El shatby University Hospital Using Visual Inspection with Acetic Acid VIA Mahmoud Hanafy Malis1 • Ahmed Mohammed Samy El-Agwany1
Received: 30 September 2015 / Revised: 12 November 2015 / Accepted: 13 November 2015 Ó Association of Gynecologic Oncologists of India 2015
Abstract Objective To detect the prevalence rate of cervical precancerous lesions among women attending El-Shatby Maternity University Hospital using visual inspection with acetic acid and to reveal some epidemiological data among the studied population. Methods A cross-sectional study of 300 women attending El shatby University Hospital was conducted. An interview questionnaire was used to collect data from participants followed by VIA test. Pap smears were done on all with only 82 participants were compliant to follow-up. Results The prevalence of acetowhite areas with VIA test among studied women was 37.3 %. The study showed that positivity of acetowhite areas with VIA test was more among women who had longer duration of marriage, younger age at first marriage, high parity, prolonged use of progesterone-only injections, and abnormal cervix on speculum examination. The specificity, sensitivity, and positive predictive value of VIA test compared to Pap smear were 87.5, 82.4, and 77.77 %, respectively. Conclusion The findings of this study showed that the prevalence of acetowhite areas among studied women was 37.3 % with accepted sensitivity and specificity compared to Pap smear. It indicates that VIA is useful for cervical cancer screening in primary healthcare settings.
Introduction
Keywords Cancer cervix VIA Screening test Acetowhite Shatby hospital
An epidemiological cross-sectional study was carried out at Gynecology Outpatient Clinics at El shatby Maternity University Hospital. A sample of 300 women was included. Subjects of the study should have been ever married for at least 3 years and above the age of 20 years. An interview questionnaire was used to obtain information about personal and socio-demographic data, marital history, reproductive profile, pattern of use of hormonal contraception, and the presence of past gynecological history. Speculum
& Ahmed Mohammed Samy El-Agwany
[email protected] 1
Department of Obstetrics and Gynecology, Faculty of Medicine, El-shatby Maternity University Hospital, Alexandria University, Alexandria, Egypt
Cervical cancer is considered the second most common female cancer [1], and it is the fifth fatal female cancer worldwide [2]. More than 85 % of diagnosed cervical cancer cases occur in developing countries where cancer cervix is responsible for 13 % of all female cancers in these parts of the world [1]. According to World Health Organization (WHO), there are approximately half million cases found worldwide [3]. Data from Egyptian studies provide varying estimates on the prevalence of preinvasive cervical lesions ranging from 1 to 8 % with an age range from 20 to 60 years [4]. VIA is an attractive alternative method for screening of cancer cervix as it is easy to be performed, has low cost, requires simple training of medical personnel, and has sensitivity and specificity rates that can be compared to Pap smear in detecting early stages of cancer cervix [5]. The aim of this study was to detect the prevalence rate of cervical precancerous lesions among women attending El shatby University Hospital using visual inspection with acetic acid and to reveal some epidemiological data among the studied population.
Methodology
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examination at lithotomy position and VIA test were carried out to all women in this study. Only 82 women had conventional Pap smear as histopathology of others was not available due to poor compliance of patients. Negative and positive smear according to atypia and dysplastic cells on smear based on Bethesda system. Visual inspection with acetic acid (VIA) was done with the naked eye (also called cervicoscopy or direct visual inspection [DVI]). A vaginal speculum examination was performed during which we applied dilute (3–5 %) acetic acid (vinegar) to the cervix. Abnormal tissue temporarily appears white when exposed to vinegar. Sensitivity and specificity were calculated in relation to results of VIA and Pap smear.
2.
3.
Results I. Distribution of Studied Cases According to 1.
Personal and socio-demographic characteristics: Table 1 shows that the age of studied women ranged from 20 to 58 years with a mean of 36.96 ± 8.5 years. About half of the studied women were middle aged with age ranging from 30 to 40 years. Minority of cases (5 %) of studied women aged 50 years or more. The majority of studied women were from Alexandria (86.3 %), with only (13.7 %) from outside Alexandria. About half of the studied women (51.6 %) had received high education (secondary school and
Table 1 Distribution of the studied cases according to their socio-demographic data (n = 300)
Socio-demographic character
4.
university). A minority of studied women can read and write (6.7 %); the rest of studied women were divided nearly equally between being illiterate and had primary or preparatory education. More than two-thirds of the studied women were nonworking women. Marital history: Table 2 shows that age at first marriage of studied women ranged from 12 to 43 years with mean of 21.55 ± 4.67 years. The duration of marriage of studied women ranged from 3 to 36 years with a mean of 14.63 ± 8.62 years. The majority of studied women had not previously been married to another husband, and only 9 % of studied women had previous another marriage. Reproductive profile: Table 3 shows that age of menarche of studied women ranged from 11 to 15 years with a mean of 12.46 ± 0.91 years. More than 85 % of studied cases had their first pregnancy before age of 25 years, the minimum age of first pregnancy was 14 years, and the maximum age of first pregnancy was 37 years with a mean of 21.64 ± 4.09 years. Number of pregnancies for studied women ranged from 0 to 8 times with a mean of 3.3 ± 1.69. The number of deliveries among studied women ranged from 0 to 7 deliveries with a mean of 2.65 ± 1.28 deliveries. Nearly 40 % of the studied women had history of previous abortion. Pattern of use of hormonal contraception: Table 4 shows that more than half of studied women never used hormonal contraception before. Among the Number of cases (n = 300)
Percentage
20–
72
24.0
30–
131
43.7
40–
82
27.3
[50
15
5.0
Age (years)
Min–max
20.0–58.0
Mean ± SD
36.96 ± 8.50
Place of residence Alexandria
259
86.3
Outside Alexandria
41
13.7
Illiterate
42
14.0
Read and write
20
6.7
Primary school Preparatory school
33 50
11.0 16.7
Level of education
Secondary school
84
28.0
University
71
23.6
Nonworking
208
69.3
Working
92
30.7
Working status
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Indian J Gynecol Oncolog Table 2 Distribution of the studied cases according to marital history (n = 300) Marital history
Number of cases (n = 300)
Percentage
Age at first marriage Min–max
12.0–43.0
Mean ± SD
21.55 ± 4.67
Duration of marriage Min–max
3.0–36.0
Mean ± SD
14.63 ± 8.62
6.
History of previous marriage No 273 Yes
91.0
27
9.0
Table 3 Distribution of the studied cases according to their reproductive profile (n = 300) No.
1. 11.0–15.0
Mean ± SD
12.46 ± 0.91
Age at first pregnancy (279) \20
90
32.3
20–
150
53.8
25–
33
11.8
30–
3
1.1
C35
3
1.1
Min–max
14.0–37.0
Mean ± SD
21.64 ± 4.09
Gravidity Min–max
0.0–8.0
Mean ± SD
3.30 ± 1.69
Parity Min–max Mean ± SD
0.0–7.0 2.65 ± 1.28
Abortion No history of abortion
179
59.7
History of abortion
121
40.3
5.
II. Relation Between Results of VIA Examination and Different Variables of the Studied Sample
%
Age of menarche Min–max
remaining (15.7%) studied women who reported having past gynecological history, more than half of them had history of fibroid, 29.8 % of them had history of polycystic ovary, and the rest had history of cervical erosion and bleeding per vagina. By speculum examination, 76 % of studied women were free, 13 % had vaginal discharge, and the minority had cervical erosion, ectropion, or bleeding on touch. Prevalence of acetowhite areas with VIA examination and results of Pap smear: Table 6 shows that about 62 % of studied women had negative results of VIA examination. The prevalence of acetowhite areas with VIA test among studied women was 37.3 %. Table 6 also shows that 36.1 % of the studied women who had done Pap smear were Pap positive.
43.3 % of studied women who used hormonal contraception, half of them used combined estrogen and progesterone pills and about one-third of them reported mixed use of hormonal contraception. The duration of use of hormonal contraception ranged from 1 to 144 months with a mean of 32.41 ± 33.61 months. Gynecological past history and results of speculum examination: Table 5 shows that about 84 % of studied women had no past gynecological history. The
Relation between VIA examination and marital history and reproductive profile: Table 7 shows that among studied women, those with positive VIA results had a significantly younger age at first marriage than those with negative VIA results where the mean of age at first marriage for women with positive VIA examination was 20.50 ± 4.18 years as compared to a mean of 22.18 ± 4.84 years for women with negative VIA examination. Studied women who had positive VIA examination had a significantly longer duration of marriage with a mean of 18.13 ± 9.29 years and a median of 17 years than women who had negative VIA examination where the mean was 12.54 ± 7.46 years and the median was 12 years. Table 7 shows that among studied women, the women who had their first pregnancy at a very young age (\20 years) had significantly more positive results on VIA examination, while women who had their first pregnancy at relatively older age had significantly more negative results on VIA examination. Table 7 shows that among studied women with positive VIA examination, the range of pregnancies was 1–3 times with a mean of 1.13 ± 0.39 times and a median of one pregnancy, while among studied women with negative VIA examination, the range was 1–6 with a mean of 2.01 ± 1.20 times and a median of two pregnancies. The mean number of pregnancies was significantly higher among women with negative VIA results than among those with positive VIA results. Among studied women, the mean number of deliveries was significantly higher in women with positive VIA results than in women with negative VIA results.
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Indian J Gynecol Oncolog Table 4 Distribution of the studied cases according to their use of hormonal contraception
Number of cases (n = 300)
Percentage
Never use
170
56.7
Ever use
130
43.3
Combined estrogen and progesterone pills
65
50.0
Progesterone-only pills
13
10.0
Progesterone-only injections
10
7.7
Mixed use
42
32.3
Use of hormonal contraception
Type of hormonal contraception (n = 130)
Duration of use of hormonal contraception (n = 130) Min–max
1.0–144.0
Mean ± SD
32.41 ± 33.61
Table 5 Distribution of studied cases according to medical gynecological history and results of gynecological examination Number of cases (n = 300)
Percentage
Past history of gynecological problem No
253
84.3
Yes
47
15.7
Type of gynecological history (n = 47) Fibroid
26
55.3
Polycystic ovary
14
29.8
Cervical erosion
5
10.6
Bleeding
2
4.3
Result of speculum examination Free
228
76.0
Vaginal discharge
39
13.0
Cervical erosion
19
6.3
8 6
2.7 2.0
Bleeding on touch Ectropion
Table 6 Distribution of studied cases according to results of VIA examination and results of Pap smears Number of cases
Percentage
Positive VIA
112
37.3
Negative VIA
188
62.7
Positive Pap smears
30
36.1
Negative Pap smears
53
63.9
Results of VIA examination
Result of Pap smears (n = 83)
2.
Relation between results of VIA examination and pattern of use of hormonal contraception: Table 8 shows that among users of hormonal contraception, a significant high percentage of women with positive VIA results used progesterone-only injections compared to other types of hormonal contraception (P = 0.007).
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3.
Relation between results of VIA examination and results of speculum examination: Table 9 shows that among studied women, women who had negative results on VIA examination and were free on speculum examination represented 97.9 %, whereas those who had positive results on VIA examination and were free on speculum examination represented only 39.3 %. Again, the percentage of women who had positive VIA examination and had abnormal findings on speculum examination (60.7 %) were significantly higher than the percentage of women who had negative VIA examination and had abnormal findings on speculum examination (2.1 %) p \ 0.001.
III. Relation Between Results of VIA Examination and Results of Pap Smears Table 10 shows that among women who had Pap smears and after excluding all women who had abnormalities on speculum examination, those with positive VIA examination had significantly higher percentage of positive Pap smears and those with negative VIA examination had significantly higher percentage of negative smears (p \ 0.001). The percentage of false-positive results on VIA examination for this group = 12.5 %. The estimated positive predictive value for this group was 77.77 %. The sensitivity of VIA examination in women who had normal speculum examination was 82.4 %, and the specificity of VIA examination in this group was 87.5 %.
Discussion Cancer cervix can be prevented due to its long preinvasive period [6]. It has been estimated that from 2000 to 2005, only about 5 % of women in developing countries have been screened for cervical dysplasia, compared with about
Indian J Gynecol Oncolog Table 7 Relation between result of VIA examination and marital history and reproductive profile Result of VIA examination Positive VIA (n = 112)
Negative VIA (n = 188)
No.
No.
%
Test of significance
p
Z = 2.581*
0.010*
Z = 5.213*
\0.001*
MC
p
%
Age at first marriage Min–max
12.0–29.0
12.0–43.0
Mean ± SD Median
20.50 ± 4.18 20.0
22.18 ± 4.84 22.0
Duration of marriage Min–max
3.0–36.0
3.0–36.0
Mean ± SD
18.13 ± 9.29
12.54 ± 7.46
Median
17.0
12.0
Age of pregnancy \20
44
41.5
46
26.6
20–25
50
47.2
100
57.8
26–30
12
11.3
21
12.1
31–35
0
0.0
3
1.7
[35
0
0.0
3
1.7
8.615*
0.046*
Gravidity Min–max
1.0–3.0
1.0–6.0
Mean ± SD
1.13 ± 0.39
2.01 ± 1.20
1.0
2.0
Median Parity Min–max
0.0–5.0
0.0–7.0
Mean ± SD
3.04 ± 1.30
2.43 ± 1.21
Median
3.0
2.0
Z = 5.105*
\0.001*
Z = 4.044*
\0.001*
* means statisitically significant result
Table 8 Relation between result of VIA examination and pattern of use of hormonal contraception Type of hormonal contraception (n = 130)
Result of VIA examination
Test of significance
p
Positive VIA
Negative VIA
No.
%
No.
%
Combined estrogen and progesterone pills (n = 65)
23
35.4
42
64.6
v2 = 0.135
0.714
Progesterone-only pills (n = 13)
3
23.1
10
76.9
v2 = 1.181
FE
p = 0.384 p = 0.007*
2
Progesterone only injections (n = 10)
8
80.0
2
20.0
v = 8.049*
FE
Mixed use (n = 42)
18
42.9
24
57.1
v2 = 0.637
0.492
v2 (p)
9.866* (0.043*)
* means statisitically significant result
85 % in developed countries [7]. Visual inspection of the cervix after acetic acid application (VIA) has long been regarded as the most promising method for screening in resource-limited settings [8, 9]. In this study, prevalence of acetowhite area with VIA was much higher than another study done in India by Hedge et al. published in 2011 with a prevalence of positive VIA 12 % [10]. Another study
done in Sudan by Ibrahim et al. published in 2012 [11] estimated that VIA was positive in 12.7 % of studied sample. These differences could be explained by the fact that in the current study, the prevalence rate of positive VIA test was estimated for all women who had acetowhite patches on the cervix after applying acetic acid regardless the presence or the absence of normally appearing cervix
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Indian J Gynecol Oncolog Table 9 Relation between result of VIA examination and results of speculum examination
Result of VIA examination Positive VIA (n = 112)
Negative VIA (n = 188)
No.
%
No.
%
v2
p
132.077*
\0.001*
Results of speculum examination Free (n = 228)
44
39.3
184
97.9
Present (n = 72)
68
60.7
4
2.1
* means statisitically significant result Table 10 Relation between PAP smears and result of VIA examination in cases with free results on speculum examination (n = 49)
Result of PAP smears Positive (n = 17)
Negative (n = 32)
No.
No.
%
v2
p
23.309*
\0.001*
%
Result of VIA examination Positive
14
82.4
4
12.5
Negative
3
17.6
28
87.5
Positive predictive value = 14/(14 ? 4) = 77.77 %. Sensitivity of VIA with normal cervix on speculum examination = 14/(14 ? 3) = 82.4 %. Specificity of VIA with normal cervix on speculum examination = 28/(28 ? 4) = 87.5 % * means statisitically significant result
upon speculum examination. In this study, the relation between results of VIA and duration of marriage showed that positive VIA results are significantly more among women with longer duration of marriage. This could be explained by that longer duration of marriage leads to greater opportunities for sexual activity which is a known risk factor for cancer cervix and genital infections [12–14]. Both conditions cause positivity of VIA. According to the relation between results of VIA examination and age at first pregnancy, this study showed that positive results on VIA are higher among women who had their first pregnancy at young age (younger than 20 years). This was in agreement with a study done in Nepal on 2003 [15] which stated that 40 % of cases of CIN I and 75 % of cases of CIN II had the first childbirth below the age of 19 years. Regarding relation between results of VIA and gravidity, parity, and use of hormonal contraception, this study showed that the mean number of pregnancies among women who had negative VIA results was higher than the mean number of pregnancies among women with positive VIA results, while this study also showed that higher parity was more among women with positive VIA and positivity of VIA increased among women who had used progesterone only injections. This might be explained by the fact that not all pregnancies end with vaginal delivery is an insult on the cervix that may predispose to CIN. High parity and use of progesterone only injections were considered as risk factors for CIN I in the former study mentioned which was done in Nepal [15]. According to the relation between results of
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VIA and results of speculum examination, this study showed that abnormal findings on speculum examination mostly were associated with positive VIA test. Abnormal vaginal discharge and cervical erosion were the most encountered abnormal findings on speculum examination which resulted in positive VIA test. This was in agreement with a study done in India in 2010 [16] stated that VIA positivity increased in women with cervical inflammation by naked eye.
Conclusion From this study, we can conclude that the prevalence of acetowhite lesions on using VIA test is 37.3 %. Early age of marriage, longer duration of marriage, multiparty, and use of progesterone only injections are associated with positivity of VIA test. VIA is an easy, applicable, and affordable screening tool for cancer cervix with sensitivity rate of 82.4 % and specificity rate of 87.5 % compared to Pap smear test; VIA can be used in primary care centers with low resources.
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Ahmed Samy Elagwany lecturer and assistant consultant of obstetrics and gynecology, faculty of medicine, Alexandria, Egypt. He has authored more than 60 publications in gynecologic oncology, pelvic floor surgery and minimal invasive surgery. https://www.research gate.net/profile/Ahmed_El-agwany, https://alex.academia.edu/ahme delagwany, http://scholar.google.com.eg/citations?user=xocPlbwAA AAJ&hl=en
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