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\title{Correlational Analytical Study of Symptomatology, Pap and Colposcopic Findings in Reproductive Age Group Women in a Tertiary Care Centre}
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\begin{document}

             \author[1]{Dr. Qazi Jaweria  Amber}

             \author[2]{Dr. Tushar T  Palve}

             \author[3]{Dr. Shreya  Chinchoriya}

             \affil[1]{  Cama And Albless hospital under Grant Medical College And JJ Groups Of Hospital}

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\date{\small \em Received: 16 December 2018 Accepted: 4 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Background: The current study is done to study cervical epithelial changes in a reproductive age group women at tertiary care center through investigation modality called Pap smear and its correlation with various symptoms and colposcopic findings.Methods: This is a retrospective analytical study of 79 women of reproductive age group done at CAMA AND ALBLESS HOSPITALS. The cervical smear was taken from all patients using the Ayre's spatula by scrape cytology method. Then we did Colposcopy for patients with highly suspicious malignant and unhealthy cervix and with inflammatory pap smear not relieved on antibiotics. Finally, cervix biopsy was done for cases for suspected malignancy on the Pap smear.Results: Inflammatory smears were seen in 35.44 %, ASCUS in 5.06%, LSIL in 3.7% and invasive carcinoma in 5.06% patients. The patients having white discharge PV or menorrhagia had ASCUS and AGCUS on Pap smear which had squamous metaplasia (3.3%), HPV infection (1.6%) and invasive cancer. HSIL and Invasive carcinoma showed invasive carcinoma.

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
ervical cancer continues to be a worldwide problem. In developing countries, with limited health care facilities, cervical carcinoma is the second most common cause of cancer death in women. Invasive cancer of cervix is considered a preventable disease because it has a prolong preinvasive state and with the help of cervical cytological screening programmes and treatment of preinvasive lesions, we can reduce the incidence of cervical cancer. It is anticipated that in developing countries the percentage of women who never had PAP test; leading to cervical cancer is around 60\%. \hyperref[b0]{(1)}. It accounts for 80\% of deaths in a developing country like India. \hyperref[b1]{(2)} However worldwide the incidence of cervical cancer is decreasing and it is being diagnosed at an earlier stage.\par
Epidemiological data indicate that the incidence of cervical cancer will continue to be high due to poor hygiene, early marriage, multiparity, lack of screening facility. In order to control the disease, cytological screening should be undertaken routinely and intensively \hyperref[b2]{(3)}. The dramatic reduction in the incidence of cervical cancer in developed countries is because of the widespread use of cytological screening test. (  {\ref 4}) Various screening methods are available like cytology by Pap smear, visual inspection of the cervix with acetic acid and/or Lugol's iodine, HPV-DNA Test, Liquidbased cytology, etc.\par
Pap smear is an effective method of cervical cancer screening with a low sensitivity rate. It is the laboratory method to examine the exfoliated or scraped cells to detect dysplasia. It is a simple routine outpatient procedure which is less expensive and popular screening modalities at various centers. PAP smear and gynecological examination should be performed for any unexplained discharge or irregular bleeding as they may be signs of cervical and other genital malignancies as there have been cases who had bleeding PV and were denied Pap smear many times only to present with advanced cervical cancer.\par
In 2012, all the three-organization the American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS) and U.S. Preventive Services Task Force (USPSTF) recommended that: (5) The cytology-based screening programmes have been successful in reducing the incidence of cancer cervix by 80 \% and deaths due to it by 70\%. 
\section[{II.}]{II.} 
\section[{Methods}]{Methods}\par
We did a retrospective analytical study of 79 women in reproductive age group women over one year at Cama and Albless hospitals, Mumbai.\par
We established the correlation of clinical symptomatology and Pap smear findings and colposcopic findings. The patients in the reproductive age group that is 18-45 were selected. We included patients with chief complaints of pain, menstrual complaints, patients who had come for follow up and patients who had come for infertility consultation. A detailed history taken and per speculum examination of the patient was done. Patients who came to the Gynaecology OPD the procedure was explained to the patient in detail and examination done in dorsal position after emptying the bladder. Per speculum examination was done without using lubricants. Naked eye examination of the cervix was done to evaluate its color, shape, size, the presence of any lesions, discharge. The cervical smear was then taken using the scrape technique using the Ayre's spatula.\par
The longer end of the spatula was inserted into the external Os and rotated through 360 º maintaining firm pressure so as to scrape the squamocolumnar epithelial junction throughout its circumference. Care was taken to include all abnormal looking areas. Then we withdraw the spatula without touching the vaginal walls to avoid contamination with cells from the lower genital tract. The smear was made by spreading the scraped material evenly, with a circular motion on a glass slide having the patients' identity labeled then we fixed it in a fixative solution, which contains 95\% alcohol and ether for 15-30 minutes and then sent to the cytopathology laboratory. The smears were stained according to the modification of Papanicolaou (1942). (  {\ref 6})\par
The patients who had completed a course of antibiotics, but continued to have symptoms, patients who had high suspiciousness of cervical cancer underwent colposcopy. A colposcopic examination in which whole of transformation zone visualized completely we labeled to be a satisfactory colposcopy. If a squamo-columnar junction is inside the endocervical canal and complete transformation zone is not visible it is an unsatisfactory colposcopy.\par
We then correlated the findings of symptoms of the patients with PAP and colposcopic findings. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
We did highest pap screening in the age group of 40-45 years followed by 35-39 years. As the parity increases we found a higher incidence of pap and colposcopy.    As per this study, PAP screening was most commonly done in 40-45 years age group followed by 35-40 years. The most common symptom for which this reproductive age group underwent PAP screening was white discharge per vagina followed by pain in the abdomen and menorrhagia. The PAP results revealed that most patients presenting with a complaint of white discharge had an inflammatory smear, cervicitis. Some patients around 11.39\% (no-9) had HPV infection which was confirmed by HPV DNA and colposcopy.- - 2 1 - - - 10 Infertility 1 1 - - 1 1 4 Menstrual Irregularities 1 2 1 1 - - 1 - - 6 SCOPV 3 1 - - - - - - - 4 Postcoital Bleeding - - - - - 1 - - - 1 Spotting pv - - 1 1 - - 2 - 4 Others - 1 - - - 1 - - -\textbf{2}\par
The patients presenting with menorrhagia had an inflammatory smear in 7.59 \%, some had endocervical cells in 4.08\% present and were advised repeat Pap, but did not follow up.\par
The patients who presented with something coming out per vagina had an inflammatory smear in most of them. (Around 75\%)\par
Patients having HPV infection had the most common complaint of white discharge PV and few of them presented with other complaints like pain, menorrhagia and post-coital bleeding PV.\par
Amongst this reproductive study group, 5.06\% of patients had invasive cervical cancer .75\% of them we diagnosed on Pap smear showing necrotic cells Malignant cells and with a hemorrhagic background.  Amongst the four cases which were identified to be invasive carcinoma on colposcopy, 75 \% were true positive results. One case was diagnosed to be HPV positive presenting with a chief complaint of white discharge and was confirmed on histopathological reports. 70\% of endometrial cancers. Single testing detects 10-15\% false negative reading. Hence a repeat PAP testing is advised every three yearly. \hyperref[b6]{(7)} In this retrospective analytical study we studied the pattern of cervical cytology in patients presenting with various symptomatology and their correlation with colposcopy. The Pap smear results showed normal cervical cytology findings in 21.51 \%, inflammatory smears in 32.91 \%, ASCUS in 5.06\%, LSIL in 3.7\% and invasive carcinoma in 5.06\% patients. The results were similar to Thobbi VA et al. and Ghazal et al. \hyperref[b7]{(8)}. Another study done by Suma R shows normal 36\% inflammatory smear 61.9\% ASCUS 0.3 \% LSIL 0.6\% HSIL 1.2\%. \hyperref[b8]{(9)} As the PAP smear screening is advised from 21 years, hence patients within the age group of 21 to 45 years were studied. The commonest age group which was screened by us was 40-45 years with 34.3 \% of patients belonging to this age group. Most of the patients who were studied were multipara with parity > 2. It was similar to observations made by Thobbi VA et al. \hyperref[b7]{(8)} It was observed that amongst the study subject number of patient symptomatic were 35\% parity 2 and above similar to observation by Dasgupta A et al. \hyperref[b9]{(10)} The various epithelial cell abnormalities were studied. ASCUS smear was advised to repeat cytology after 6 and 12 months and HPV DNA testing. ASC-H, HSIL, and LSIL we advised colposcopy.- - - - - Ectropion 2 2 - - 1 - - - - Cervicitis 8 1 - - - - - - - HPV 5 - - - 1 - - 1 - Squamous Metaplaisa 7 4 - 2 - 1 1 - - Invasive Cancer - - - - 1 - - 3 - CIN I - - 3 - - - - - 1 
\section[{IV.}]{IV.} 
\section[{Discussions}]{Discussions}\par
Colposcopy was introduced in 1927 by Hinselmann in 1927.Colposcopy is the visualization of cervix under magnification for cervical lesions. In developing countries like India, it is not economic and possible to have universal cervical cancer screening due to low sources. WHO has recommended at least one smear for all women at about 40 years to reduce cancer deaths by 50 \% \hyperref[b10]{(11)}.\par
In this study correlation between PAP and colposcopic findings revealed that most patients presenting with symptom of white discharge PV had inflammatory smear which had either normal colposcopy or showed findings suggestive of HPV infection and squamous metaplasia. We further advice HPV DNA testing. Some cases had polyp and ectopion on colposcopy. Most of the patients with abnormal PAP presented with the complaint of white discharge PV and menorrhagia.\par
Patients having HPV infection had the most common complaint of white discharge PV and few of them presented with other complaints like pain, menorrhagia and post-coital bleeding PV.\par
The correlation between Pap smear, symptomatology, and colposcopic findings suggested that most patients presented with white discharge PV, menorrhagia or pain in the abdomen. The PAP results showed inflammatory findings with evidence of metaplasia and cervicitis and infection of HPV DNA.\par
The patients having white discharge PV or menorrhagia had ASCUS and AGCUS on Pap smear which had squamous metaplasia (3.3\%), HPV infection (1.6\%) and invasive cancer.\par
V. 
\section[{Conclusions}]{Conclusions}\par
The Pap smear is a simple, safe, practical and cost-effective method for early detection of cervical cancer and its precursors. In low resource countries like India, it is the most logical screening modality although it has a very low sensitivity; detection rates could be further improved using liquid-based cytology and the use of endocervical cytobrush.\par
We can increase the specificity of this screening test by a repeat Pap test at least every three yearly. As the progression from pre-invasive to invasive cancer is very slow, hence repeat PAP can detect early invasive cancers and eventually decrease morbidity and mortality following cervical cancers. Women education and awareness regarding cervical cytology testing should be encouraged. At the same time, the false negative of Pap smear unreported needs consideration.\par
Thus Pap smear along with colposcopy can be an efficacious tool for screening to diagnose the early invasive cancer stages which stay relatively asymptomatic.\begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.38413461538461535\textwidth}P{0.22884615384615384\textwidth}P{0.23701923076923076\textwidth}}
Age\tabcellsep No of cases studied\tabcellsep Percentage\\
21-24yrs\tabcellsep 3\tabcellsep 3.8\\
25-29 yrs\tabcellsep 11\tabcellsep 13.9\\
30-34 yrs\tabcellsep 15\tabcellsep 18.9\\
35-39 yrs\tabcellsep 23\tabcellsep 29.1\\
40-45 yrs\tabcellsep 27\tabcellsep 34.3\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.17\textwidth}P{0.306\textwidth}P{0.374\textwidth}}
Parity\tabcellsep No of cases screened\tabcellsep Percentage\\
p0\tabcellsep 6\tabcellsep 7.5\%\\
P1\tabcellsep 21\tabcellsep 26.5\%\\
P2\tabcellsep 24\tabcellsep 30.3\%\\
>p2\tabcellsep 28\tabcellsep 35.7\%\end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.18888888888888888\textwidth}P{0.16527777777777777\textwidth}P{0.014166666666666666\textwidth}P{0.009444444444444445\textwidth}P{0.009444444444444445\textwidth}P{0.08972222222222222\textwidth}P{0.07555555555555556\textwidth}P{0.11805555555555555\textwidth}P{0.10388888888888888\textwidth}P{0.056666666666666664\textwidth}P{0.01888888888888889\textwidth}}
Symptom\tabcellsep \multicolumn{4}{l}{Inflammatory Normal ASCUS AGCUS}\tabcellsep Endometrial Cells\tabcellsep HPV Koilocytes\tabcellsep Reactive Cells Columnar\tabcellsep Necrotic Cells Malig\tabcellsep \multicolumn{2}{l}{LSIL Total}\\
Pain\tabcellsep 6\tabcellsep 2\tabcellsep -\tabcellsep -\tabcellsep 2\tabcellsep 1\tabcellsep -\tabcellsep -\tabcellsep -\tabcellsep 11\\
White discharge pv\tabcellsep 11\tabcellsep 7\tabcellsep 2\tabcellsep 1\tabcellsep 4\tabcellsep 6\tabcellsep 2\tabcellsep 1\tabcellsep 3\tabcellsep 37\\
Menorrhagia\tabcellsep 6\tabcellsep 1\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.051\textwidth}P{0.1105\textwidth}P{0.24649999999999997\textwidth}P{0.0085\textwidth}P{0.0085\textwidth}P{0.153\textwidth}P{0.153\textwidth}P{0.11900000000000001\textwidth}}
\tabcellsep Inflammatory\tabcellsep \multicolumn{3}{l}{Normal LSIL AGCUS ASCUS HSIL}\tabcellsep Endocervical cells\tabcellsep Haemarrhagic smear\tabcellsep Columnar cells\\
Normal\tabcellsep 6\tabcellsep 8\tabcellsep -\tabcellsep 1\end{longtable} \par
 
\caption{\label{tab_4}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.06824817518248175\textwidth}P{0.16255474452554744\textwidth}P{0.26182481751824815\textwidth}P{0.25437956204379564\textwidth}P{0.102992700729927\textwidth}}
\tabcellsep Case 1\tabcellsep Case 2\tabcellsep Case 3\tabcellsep Case 4\\
Age\tabcellsep 42 years\tabcellsep 45 years\tabcellsep 40 years\tabcellsep 37 years\\
Complaint\tabcellsep Menorrhagia\tabcellsep Reddish discharge pv\tabcellsep Menorrhagia\tabcellsep White discharge pv\\
Comorbidity\tabcellsep Hypothyroidism\tabcellsep Seropositive, thrombocytosis\tabcellsep \tabcellsep HPV Positive\\
Parity\tabcellsep P3L3\tabcellsep P5L5\tabcellsep P3L3\tabcellsep \\
Pap\tabcellsep Haemorrhagic smear\tabcellsep Normal\tabcellsep ASCUS-H\tabcellsep Haemorrhagic smear\\
Colposcopy\tabcellsep Invasive cancer\tabcellsep Invasive cancer\tabcellsep Invasive cancer\tabcellsep Invasive cancer\\
\tabcellsep \tabcellsep Ut bulky, growth bleeds on\tabcellsep Ut normal, proliferative\tabcellsep \\
Eua\tabcellsep Growth on post lip\tabcellsep touch, medial parametrium\tabcellsep growth on the cervix which\tabcellsep \\
\tabcellsep \tabcellsep involved\tabcellsep bleeds on touch\tabcellsep \\
Surgery\tabcellsep TAH +BSO\tabcellsep Cervical biopsy\tabcellsep Modified radical hysterectomy\tabcellsep Adv RT\\
HPR\tabcellsep Chronic cervicitis, leiomyoma\tabcellsep Large cell keratinising mod diff sq cell carcinoma\tabcellsep Mod diff sq cell carcinoma involving a lower uterine segment\tabcellsep \end{longtable} \par
 
\caption{\label{tab_5}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Volume XIX Issue II Version I\\
D D D D ) E\\
(\\
Medical Research\\
Global Journal of\\
© 2019 Global Journals\end{longtable} \par
 
\caption{\label{tab_6}}\end{figure}
 			\footnote{Correlational Analytical Study of Symptomatology, Pap and Colposcopic Findings in Reproductive AgeGroup Women in a Tertiary Care Centre} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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