By Author
  By Title
  By Keywords

September 1988, Volume 38, Issue 9

Original Article


Javaid H. Rizvi  ( Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi - 5, Pakistan. )
Sheema Hasan  ( Department of Pathology, The Aga Khan University Hospital, Karachi - 5, Pakistan. )
Saadia Rasul  ( Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi - 5, Pakistan. )
Basit Ghazali  ( Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi - 5, Pakistan. )
Abid Jamal  ( Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi - 5, Pakistan. )


Between November 1986 and February 1988, 2806 cervical smears were taken from every patient attending the Obstetrics and Gynaecology consulting clinics at The Aga Khan University Hospital (AKUH) Karachi.
Of 2806 smears 2774 (98.9%) were adequate, cytology was positive in 35, a prevalence rate of 12.6  per 1000. The highest incidence was in the age group of 2544 years. Eighty percent patients with positive cytology had no symptoms related to micro-invasive or invasive disease of cervix (JPMA 38: 229, 1988).


Cervical cancer may be indentified by means of appropriate techniques in its pre-invasive forms, namely mild to severe dysplasia and carci­noma in situ. These pre-invasive forms are thought to be part of a continum recently termed cervical intra-epithelial neoplasia (CIN). Although not all the dysplasias progress to carcinoma in situ and ultimately invasive carcinoma, to date there is no means available whereby the behaviour of a given dysplastic lesion can be predicted. Usually the time lag between the appearance of precursor cervical lesion and the development of invasive carcinoma is 10-15 years1-2. According to the results of various epidemiological studies, the risk of cervical cancer is highest for women who marry early, have multiple marriages and are of low socio-economic group3-4
Comparisons of screened and unscreened women have consistently formed lower incidence and mortality among screened women, and have also demonstrated that more intense the screening efforts, the greater the decline in both incidence and mortality5-7
Carlo8 has summarized the role of Pap smears in reducing the frequency of cervical neop­lasia. In Iceland practically 100% of the eligible population is screened every 2-3 years and the incidence of cervical cancer in 1980 had fallen to less than a third of that in 1965. Cramer showed that the fall in mortality in different areas of the United States were also related to the level of screening9.
The incidence of CIN and microinvasion among Pakistani women is difficult to assess as no screening reports have yet been published. The present study was done to determine the usefulness of assessment of cervical cytology in identifying asymptomic pre-malignant cervical epithelial changes, and to have a preliminary study on a small group of population to initiate the awareness and stress the importance of cervical cytology screening on national basis.


All patients (2806) attending the Obste­trics and Gynaecology consulting clinics had a Pap smear taken before a bi-manual pelvic exami­nation. These smears were taken irrespective of their reason for consultation.
The cervical smear was prepared according to the procedure described byPapanicolaou10. A bivalve vaginal speculum (Cusocos) was gently inserted into the vagina to expose the cervix. The cervix was visualised and a cervical scrape was taken from the squamo-columnar junction, anterior and posterior lip of the cervix. The smear was immediately sprayed with a fixative, (Vale Smear Fix) labelled and sent to the ayto pathologist for assessment. A cytological report was available to the patient on her next visit to the clinic.


The cervical smear results are listed in Table 1.

Out of 2806 smears, cytological reports were inconclusive in 32 smears (1.1%) because of being technically inadequate.
Ages of the patients ranged from 16 upto 70 years (Table II).

Of the women with positive smears 40% were between 35 and 44 years and a further 34% were between 25-34 years and 45-54 years. Thus 74% of abnormal smears were obtained in women between 25-54 years of age.
The youngest patient with positive cytology was 21 years and the oldest 66 years. The positive smears were classified as shown in Table III.

Thirty five patients had positive smears (12 .6/1000) confirmed by subsequent histological examination of colposcopic directed biopsies or cone biopsies. In one patient with mild dysplasia the cytology report was considered as false posi­tive (2.8%) as no histological confirmation was obtained on cone biopsy. This patient was post menopausal and had attended the clinic because of abdominal/pelvic pain.
Out of 35 patients with positive smears only 7 (20%) had symptoms which could be attributed to a pre-invasive or invasive cervical disease. In this group 3 patients had an invasive carcinoma, 1 had perineal and vaginal warts and 3 complained of post coital bleeding. All of these patients were married except one who had been using pill for contraception. Two patients were Europeans.


As cervical smears are not routinely per­formed in Pakistan, results of a screening study on abnormal smears and CIN and its prevalence cannot be obtained. One of the possible reasons for that is the belief that squamous cell carcinoma of cervix is not common among Muslim women.
Knowing the epidemiological factors rela­ting to the etiology of the disease i.e. low socio­economic class, early marriages, multiparity and poor standard of hygiene, it is difficult to accept this belief. The present argument is further strengthened by two Pakistani studies, on the frequency of malignant disease in Pakistan, which show that carcinoma of cervix is the third biggest killer of women11-12
Similar beliefs are held about Jewish women13. The present incidence of 12.6/1000 abnormal smears is lower compared to Isreali study’3 but this may be a artificially low figure. It is true that we are dealing with a selected population who are theoretically low risk patients. Majority of the patients belong to upper and middle class and therefore carry an inherent bias of health awareness. We therefore cannot extra­polate the incidence of CIN in our population from this data.
This data however re-enforces the facts that the disease (CIN) may be present among asymptomatic women. (80% of women with positive smears were asymptomatic). Pap smears are an effective method of screening for cervical carcinoma in a given population, provided an experienced cytopathologist is available, right instruments (Cuscos speculum and an Ayres spatula) are used. Proper procedure for sampling is followed (our incidence of inadequate smears was only 1.1% which is comparable with other studies14.
It is therefore recommended that efforts should be made to screen as many women as pos­sible and a cervical cytology screening programme should be a routine in all teaching hospitals. Physi­cians should encourage female patients to parti. cipate in these programmes. Internists, whe seeing female patients for non-gynaecologic problems, should not miss the opportunity to obtain a Pap smear whenever appropriate.


1. Benedet, J. L. and Murphy, J. Cervical cancer screening who needs a pap test? How often?Post­grad. Med., 1985;78:69-71,74-6,78-9.
2. Barrow, B.A. and Richart, R.M. Statistical model of the natural history of cervical carcinoma. II. Estimates of the transition time from dysplasia to carcinoma in situ. JNCI., 1970; 45 : 1025.
3. Rotkin, 1.D. A comparison review of Key epide­miological studies in cervical cancer related to current searches for transmissible agents. Cancer Res., 1973; 33 :1353.
4. Harris, R.W.C., Brinton, L.A., Cowdell, R.H.,Skegg, D.C.G., Smith, P.G., Vessey, M.P. and Doll, R. Characteristics of women with dysplasiaor carcinoma in situ of the cervix uteri. Br. J. Cancer, 1980;42 : 359.
5. Michielutte, Diseker, R. A., Young, L. D. and May, W. j. Non compliance in screening followup among family planning clinic patients with cervical dys­plasia.Prev. Med., 1985; 14 : 248.
6. Bourne, R.G. and Grove, W.D. Invasive carcinoma of the cervix in Queensland; change in incidence and mortality 1959480. Med. J. Aust., 1953; 3: 156.
7. Boyes, D.A. The value of a pap smear programand suggestions for its implementation. Cancer,1981; 48:613.
8. La Vecchia, C., Franceschi, S., Decarli, A., Fasoli,M., Gentile, A. and Tognoni, G. Pap smear andthe   risk of cervical neoplasia ; quantitative estima­tes from a case-control study. Lancet, 1984; 2779.
9. Cramer, D.W. The role of cervical cytology in thedeclining morbidity and mortality of cervicalcancer.  Cancr, 1974; 34 : 2018.
10. Papanicolaou, G. N. and Traut, H.F. The diagnosticvalue of vaginal smears in carcinoma of the uterus.Am. J. Obstet. Gynaecol., 1941; 42 : 193.
11. Jafarey, NA. and Zaidi, S.H.M. Frequency ofmalignant tumours in Jinnah Postgraduate Medical Centre, Karachi. JPMA., 1976; 26 : 57.
12. Pakistan Medical Research Council Cancer StudyGroup. Frequency of malignant tumours in seven centres of Pakistan. JPMA., 1977; 27 : 335.
13. Baram, A., Galon, A. and Schachter, A. Premali­gnant lesions and mtcroinvasive carcinoma of the cervix in Jewish women; an epidemiologicalstudy. Br. J. Obstet. Gynaecol., 1985; 92 : 4.
14. Yobs, A.R., Swanson, R.A. and Lomotte, L.C.Jr. Laboratory reliability of the Papanicolaou smear. Obstet. Gynaecol., 1985; 65 : 235.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: