Frequency of abnormal Pap smear in patients presenting with postcoital bleeding in Tertiary Care Hospital,Karachi,Pakistan

Abstract

Postcoital bleeding increases the chance of detecting cervical dysplasia and cancer; and the Pap smear is the recommended screening test in these patients. We conducted a cross-sectional study that included 110 women to find out the frequency of abnormal Pap smear in such patients. Their age range was 15–65 years with a mean age of 31.2 ± 11.2 years. Abnormal Pap smear was found in 54 (49%) women. Atypical squamous cells of unknown significance (ASCUS) were found in 13.6%, low-grade squamous intraepithelial lesion (LSIL) in 20.9%, high-grade squamous intraepithelial lesion (HSIL) in 11.8% and carcinoma in 2.7% of those. Because of the high frequency of abnormal Pap smear associated with postcoital bleeding in our population, cervical screening and strict monitoring are suggested as the important screening indications.

Keywords

Abnormal cervical cancer pap smear postcoital bleeding women

Introduction

Postcoital bleeding is defined as bleeding in the course of, or instantly after, sexual intercourse other than during the period of menstruation. Its prevalence ranges from 0.7% to 9%.^1,2 Women reporting postcoital bleeding are at higher risk of being diagnosed with cervical dysplasia and cervix cancer compared with an asymptomatic individual. Its prevalence in cervix cancer has been reported as 0.7%–39%. It may be the result of cervical erosion, ectropion, vaginitis or vulvovaginitis. In addition, postcoital bleeding has been associated with leukoplakia of the cervix, cervical polyps, cervicitis, having an intrauterine contraceptive device in situ, dyspareunia, menopause and vulvodynia.³

Cervical cancer screening by cytology helps to identify premalignant and malignant cervical disease. Colposcopy is not recommended owing to its unfeasibility, expense and discomfort in comparison to the Pap smear,^4,5 which was abnormal in 17.7% of patients with postcoital bleeding in one study.⁶ All women <65 years of age with symptomatic cervical cancer had postcoital bleeding.⁷ The incidence of cervical intraepithelial neoplasia (CIN) and cervical cancer in postcoital bleeding patients is documented as 17% and 3%, respectively.⁸ Richer countries have a lower prevalence of CIN and cervical cancer owing to effective screening programmes,⁹ whereas Pakistan has transitioned from low to moderate risk country for cervix carcinoma, which is now the fourth common cancer among Pakistani women.¹⁰ The Pap smear, which is a strong tool for detection of carcinoma cervix at initial stages, is evidently not being used as much as it should.¹¹ The earlier diagnosis and the management of cervical cancer have a significant effect on the reduction of the mortality rate.¹² Our study therefore set out to determine the frequency of abnormal Pap smear in women presenting with postcoital bleeding.

Material and methods

Our cross-sectional study was conducted from September 2018 to March 2019 at the Department of Obstetrics & Gynecology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan. The study was approved by the Research Evaluation Unit and the Ethical Review Committee of College of Physicians and Surgeons, Pakistan (CPSP) and the JPMC.

Taking the prevalence of abnormal Pap smear in patients with postcoital bleeding as 5.7%¹⁰ and confidence interval at 95%, the sample size calculated was 83. To increase the confidence interval, the sample size was increased to n = 110.

Patients were selected by a non-probability consecutive sampling method after taking written informed consent. Inclusion criteria were sexually active women presenting with postcoital bleeding of >3 months’ duration. Exclusion criteria were inadequate samples, pregnancy, previously diagnosed pre-invasive or invasive cervical lesions on biopsy, active infections and any structural uterine pathology noted on ultrasound scanning. Postcoital bleeding was determined on the basis of history and defined as any amount of bleeding (whether streaking or frank bleeding) occurring during or instantly after intercourse, other than on account of menstruation. An abnormal Pap smear was classified according to the Bethesda system as atypical squamous cells of unknown significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL) and carcinoma.¹³ For the analysis, all Pap smears categorized as ASCUS or higher grade were considered abnormal.

A detailed history, examination and pelvic ultrasound were performed to assess uterine and ovarian status. The Pap smear was obtained from transformation zone pre-menstrually. The sample was not obtained if the patient had vaginal douching, had sexual intercourse or had taken antibiotics recently (<2 weeks after treatment has ended). Samples were sent for histopathological examination in the Pathology Department of the JPMC by a pathologist having experience of >5 years.

Frequency and percentage were calculated for categorical variables. To find the association of study variables such as age, BMI, parity, smoking, contraception, duration since marriage and duration of symptoms with an outcome variable (abnormal Pap smear), the Chi-squared test was applied. A two-tailed P-value ≤0.05 was considered as significant. Data were analysed on IBM SPSS 23.0 (IBM SPSS Inc., IBM Corp., Armonk, NY).

Results

The age range among women sampled was 15–65 years with a mean age of 31.2 ± 11.2 years. As shown in Table 1, most women were married <5 years of marriage duration, ≤3 parity and ≤27 kg/m² of BMI. Most women (73.6%) had 4–6 months of postcoital bleeding. The majority were non-smokers (80.9%) and contraceptive users (58.2%).

Table 1.

Characteristics of patients presented with postcoital bleeding.

Variables	Groups	Number (n = 110)	Percentage
Age (years)	<20–30	76	69.1
Age (years)	31–>45	34	30.9
Duration of marriage	≤5 years	74	67.3
Duration of marriage	>5 years	36	32.7
Parity	≤3	90	81.8
Parity	>3	20	18.2
Duration of postcoital bleeding (months)	4–6	81	73.6
Duration of postcoital bleeding (months)	>6	29	26.4
BMI (kg/m²)	≤27	61	55.5
BMI (kg/m²)	>27	49	44.5
Smoking	Yes	21	19.1
Smoking	No	89	80.9
Contraception usage	Yes	64	58.2
Contraception usage	No	46	41.8

Abnormal Pap smear was found in 54 (49%) (Figure 1). Pap smear findings, according to Bethesda system, are shown in Table 2; ASCUS was found in 15 (13.6%), LSIL in 23 (20.9%), HSIL in 13 (11.8%) and carcinoma in 3 (2.7%). Out of 56 (51%) patients with normal Pap smear, an inflammatory smear was observed in 10 (9.1%) patients whereas the rest (46; 41.9%) had no abnormality. On clinical examination, cervical polyps were diagnosed in 13 and ectropion in 10. Patients with an unexplained cause for postcoital bleeding were counselled for follow up and further investigations, including referrals for colposcopy.

Figure 1.

Frequency of abnormal Pap smear in patients with postcoital bleeding.

Table 2.

Pap smear findings according to Bethesda system.

Pap smear	Number (n = 110)	Percentage
Normal	56	51
ASCUS	15	13.6
LSIL	23	20.9
HSIL	13	11.8
Carcinoma	3	2.7

ASCUS, atypical squamous cells of unknown significance; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion.

We did not find a significant association of abnormal Pap smear with study variables, i.e., age, duration of marriage, parity, body mass index (BMI), duration of postcoital bleeding, smoking and contraception (Table 3). We could not find association of condom use and abnormal Pap smear, as only 7 patients reported to use it as mode of contraception in our study.

Table 3.

Distribution of abnormal Pap smear according to study variables.

Variable	Groups	Abnormal Pap smear		P-value
Variable	Groups	Yes (n = 54)	No (n = 56)	P-value
Age (years)	<20–30	38	38	0.78
Age (years)	31–>45	16	18	0.78
Duration of marriage (years)	≤5	32	42	0.08
Duration of marriage (years)	>5	22	14	0.08
Parity	≤3	44	46	0.93
Parity	>3	10	10	0.93
BMI (kg/m²)	≤27	31	31	0.83
BMI (kg/m²)	>27	23	25	0.83
Duration of postcoital bleeding (months)	4–6	38	43	0.45
Duration of postcoital bleeding (months)	>6	16	13	0.45
Smoking	Yes	10	11	0.88
Smoking	No	44	45	0.88
Contraception usage	Yes	32	32	0.82
Contraception usage	No	22	24	0.82

Discussion

Though invasive cancer is an infrequent presentation in postcoital bleeding, it is common in contrast to its incidence in the general population. The detection of CIN with postcoital bleeding may occur as a result of the detachment of the fragile cervical epithelium during intercourse. While benign aetiology is varied, cervical intraepithelial neoplasia and cervical cancer remains are the serious revelations of postcoital bleeding. Cervical carcinoma is, in theory, a preventable cancer because of its extended premalignant phase. A good screening test with high sensitivity and specificity may diagnose early stages, and appropriate management of premalignant lesions may prevent cervical cancer.^14,15

Prior to the introduction of the Bethesda classification in 1988, a variety of non-reproducible terms were used for reporting cervical cytology, but now a standardized classification for reporting cervical cytology exists.¹⁶

Conclusion

The frequency of abnormal Pap smear in patients presenting with postcoital bleeding is significantly high in our population. We recommended that all such patients should be screened with a Pap smear. Furthermore, cervical screening programmes should be set up to increase awareness, so that early recognition and management may reduce the incidence and mortality of cervical carcinoma.

Footnotes

Author contribution statement

SR: Study design, planning, conduction, supervision and data collection. FN: Data collection and data interpretation. TAW: Data collection and data analysis. FFK: manuscript writing and revision. HR: Data analysis and critical review. NA: Drafting and critical review. All the authors reviewed, and approved the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

The study protocol was approved by the Institutional Ethics Committee in accordance with the Declaration of Helsinki. The written informed consent has been obtained from all the patients included in this study

Availability of data

The data will be available on request from the corresponding author.

ORCID iD

Feriha Fatima Khidri

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