The Association between Genital Hygiene and Cytological Papsmear

between Women in Takengon

Lita Feriyawati

, Tetty Aman Nasution

and Dwi Rita Anggraini

Anatomic Department, Faculty of Medical, Universitas Sumatera Utara, Medan, Indonesia

Microbiology Department, Faculty of Medical, Universitas Sumatera Utara, Medan, Indonesia

Keywords: Genital hygiene, Papsmear

Abstract: Genital hygiene is part of women's reproductive health and contributesto the protection of cervix

inflammatory. Several studies reveal that poor genital hygiene was one of condition that leads to developing

incidence of cervical squamous intraepithelial lesions (SIL). Papsmear has known as a screening method to

detect cervical cancer. The objective of this study was to assess the association between genital hygiene and

cytological papsmear between women in Takengon.

The study design

was

a cross-sectional approach

collecting cervical swab of 73 women

and evaluate genital hygiene by observed cervical hygiene, presence

of erosion, and fluor albus. Cytopathological papsmear was reported according to the Bethesda

classification. The study found that 10(13.7%) women had good genital hygiene, while 29(39.7%) women

had moderate genital hygiene and poor genital hygiene found in 34(46.6%) women. The study also showed

that cytological papsmear of 8(11.0%) women were NILM (negative for intraepithelial lesion or

malignancy) with normal smear, and 65(89.0%) women were NILM with inflammation. Chi-square test

reveals no association between genital hygiene and cytological papsmear.

1 INTRODUCTION

The female genital tracts of microorganisms as

knowns as microflora which the mostly occupied by

lactobacilli, contributed in the healthy state of the

vagina and may play a beneficial role in body sites

without causing infection even protect reproductive

health (Pete et al., 2019)(Hamed, 2015)(Reid et al.,

2015).

Several studies showed that genital hygiene plays

a role in decreasing the chances of yeast infections,

bacterial vaginosis, and Human Papillomavirus

(HPV) (Jeevita et al., 2018). While some hygiene

behavior actually could disrupt by using specific

products applied to genital such as vaginal douching,

which could change the vaginal microbiome and

lead yeast and bacterial infections (Crann et al.,

2018).

According to WHO, 2016, over 90% of cervical

cancers are caused by HPV, and type 16 and 18 have

a significant role in causing cervical cancer.

The incidence of cancer in Indonesia (136.2 /

100,000 population) ranks 8th in Southeast Asia,

while in Asia ranks 23rd. The highest incidence of

breast cancer in women is 42.1 per 100,000

population, with an average death rate of 17 per

100,000 population followed by cervical cancer of

23.4 per 100,000 population with an average death

rate of 13.9 per 100,000 population (Bray et al.,

2018). Based on Riskesdas data, 2018, the

prevalence of tumors/ cancers in Indonesia shows an

increase from 1.4 per 1000 population in 2013 to

1.79 per 1000 population in 2018.

Since the implementation of widespread

screening with the Papanicolaou test, rates of

cervical cancer in the United States have decreased

from 14.2 per 100 000 in 1973 to 7.8 per 100 000 in

1994 (Landis et al., 1999).

Papanicolaou cervical cytology test is used

widely in developed countries due to the simple and

cost-effective technique. Unfortunately, most

developing countries cannot perform wide-ranging

Pap screening (Bukhari et al., 2012).

Poor genital hygiene due to illiteracy and poverty

prevailing may lead to vaginal infections, which

persist being undetected and untreated-emphasized

illiteracy as a contributing factor in the development

of carcinoma cervix (Koteswari et al., 2015)(Misra

et al., 2019).

292

Feriyawati, L., Aman Nasution, T. and Rita Anggraini, D.

The Association between Genital Hygiene and Cytological Papsmear between Women in Takengon.

DOI: 10.5220/0010152400002775

In Proceedings of the 1st International MIPAnet Conference on Science and Mathematics (IMC-SciMath 2019), pages 292-296

ISBN: 978-989-758-556-2

Vaginal discharge is a common issue among

women. Changes in the balance of normal vaginal

flora due to genital hygiene can cause an overgrowth

of pathogens that lead to discharge.The previous

study showed that cytological smear with

inflammatory was higher among women with an

unhealthy cervix in comparison to the healthy cervix

(Valiya et al., 2015).

The objective of this study was to assess the

association between genital hygiene and cytological

papsmear between women in Takengon.

2 MATERIALS AND METHODS

2.1 Study Population and Study Design

This study was a cross-sectional study conducted at

a health facility in Takengon, Aceh Tengah district,

from April to May 2019. This study has recruited 73

participants who were reproductive women, married,

and aged above 18 years for consented information

and willing to undergo a pelvic examination.

Women who were pregnant or had vaginal bleeding

were excluded from the study. Participants in this

study were chosen and instructed not to have sexual

intercourse three days earlier and were recruited

based on the above requirements, in collaboration

with local health workers, and then the eligible

participants were led to a research interviewer who

described the study in more detail.

2.2.1 Ethics Statement

This study was approved by the Medical Ethics

Committee University of Sumatera Utara (No

490/TGL / KEPK FK USU-RSUP HAM/2019), and

all participants were given written, informed consent

to participate in the study.

2.3 Data Collection Procedure

Health workers at the health facility were recruited

and trained in the interview process and data

reporting. After a signed informed consent was

obtained, socio-demographic characteristics and

awareness of hygienic practices were collected from

participants using a paper-based standardized

questionnaire directly self-administered under the

supervision of the interviewers.

All participants underwent a speculum

examination, and we evaluate the genital hygiene by

observed cervical hygiene, presence of erosion and

fluor albus with previously cleared excess mucus

around the cervical using a filamented swab. The

degree of cervical erosion divided into mild,

moderate, and severe erosion, and as well as the

degree of fluor albus. Genital hygiene classified as

‘good’ if cervical erosion and fluor albus were not

found, ‘moderate’ if cervical erosion was mild or not

found, and fluor albus was mild or not found, and

‘poor’ if cervical erosion was moderate or severe

and fluor albus was moderate or severe.This study

was accompanied by extracting the cervical frottis

for Papanicolaou (Pap) by inserting the cytobrush

into the mouth of the cervix and spinning the

cytobrush at 360 degrees three times and

immediately scraping the object-glass slip, then

fixing it using absolute alcohol.

2.4 Statistical Analysis

Data analysis was performed using SPSS. A

descriptive analysisof participants' characteristics

was conducted with the participant socio-

demographic data. Correlation between genital

hygiene with cytological papsmear was analyzed

using Chi-square test (with two-tailed p-value)

3 RESULTS AND DISCUSSION

3.1 Socio-demographics Background

In this study, most participants above 40 years old

(42.5%), followed by under 35 years old (34.2%)

and at least between 35-40 years old (23.3%). Most

participants were a housewife (83.5%), and the rest

were working women

3.2 Genital Hygiene

The majority of the participants (46.6%) had poor

genital hygiene, followed by 39.7% had moderate

genital hygiene; meanwhile, only 13.7% had good

genital hygiene.

The data summarized in Table 1 showed the

distribution of age according to genital hygiene. This

study showed that good genital hygiene was higher

in women aged >40 years old (

22.6%) while that

moderate and poor genital hygiene were found

higher as well as the same group (

45.2% and 67.7%).

The Association between Genital Hygiene and Cytological Papsmear between Women in Takengon

293

Table 1: Distribution of age class interval in genital

hygiene

Genital

Hygiene

Total

n=73

Age in years

<35

n=25

(34.2)

35-40

n=17

(23.3%)

>40

n=31

(42.5%)

Good

Moderate

Poor

10(13.7)

29(39.7)

34(46.6)

3(12)

9(36)

13(52)

0(0)

6(35.3)

10(58.8)

7(22.6)

14(45.2)

21(67.7)

The result of this study was not in line with the study

from India by Misra et al. in June 2019 which

revealed that poor genital hygiene as shown by a

present of vaginal discharge was higher in women

which younger group between 21-30 years old and

lowest in the older women beyond 40 years old. The

study also concludes that poor genital hygiene due to

illiteracy and poverty of rural women population

may lead to vaginal infections and lead to the

development of premalignancy.

The result was consistent with the previous study

by Hamed, 2015 conducted in Zagazig University

Hospitals showed that an association between

vaginal infection which most common symptom was

vaginal discharge with increasing age, which was

more likely to be 35 years old and more, explained

by the fact that low income and increased parity is

associated with unhealthy diet and poor nutritional

status that make woman vulnerable to infection.

3.3 Cytological Papsmear

Cervical smears were stained according to the

papanicolaou technique, then cytopathological

changes observed by two patologist to evaluate

cervical epithelial cells. The cytological papsmear

report, according to the Bethesda system.

Figure 1: Cervical smear: NILM with normal smear (Pap

stain x200)

Figure 2: Cervical smear: NILM with inflammatory smear

(Pap stain x200).

In this study, all participant's cervical smear showed

negative for intraepithelial lesion or malignancy

(NILM), 11% of participants with normal smear

while the rest with inflammation. Three participants

were diagnosed with inflammation with bacterial

vaginosis (BV).

The data summarized in Table 2 showed no

association of genital hygiene with cytological

papsmear (Chi-square test, p-value 0.979).

In this study, the high percentage of smears was

inflammatory (46.6%) found in 34 participants

which 30 participants with poor genital hygiene, yet

found no association (p-value 0.979). This study was

not consistent with the study by Jeevitaa et al., 2018,

noted that genital hygiene plays a role in decreasing

the chances of yeast infection, bacterial vaginosis,

and HPV, verified with the study by Shaw et al.,

2016 that examined the determinants of genital

health related to cohort HPV infection.

As well as a study conducted in India concluded

reproductive tract infection is exacerbated by poor

genital hygiene, which has a role in the development

of cervical dysplasia and cervical cancer (Yasmeen

et al., 2010).

This study showed that not all participants with

moderate and poor genital hygiene had

inflammatory smear in their papsmear result. There

were 10.3%, and 11.8% had a normal smear. As well

as study by Rahman et al, 2017 held cytological

evaluation of cervical that carried out in 230 women

with complaint of vaginal discharge in Bangladesh

with the age ranging from 15-45 years found as

normal were 4(1.7%), inflammatory were

204(88.3%), cervical squamous intraepithelial

lesions (SIL) were seen in 22 cases (10%).

IMC-SciMath 2019 - The International MIPAnet Conference on Science and Mathematics (IMC-SciMath)

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Table 2: Association of genital hygiene with cytological

papsmear

A study in Kashmir India by Yasmeen et al.,

2010 revealed cytological examination from 270

married women aged 20-65 years were reported as

normal in 91.4%. Inflammation was seen in 2.5%,

and none of the study subjects had evidence of

intraepithelial lesion,emphasizes the fact that socio-

cultural factors play an important role in the low

prevalence of cancer cervix despite the presence of

the risk factors. Their study was the similarity of

characteristic samples with our study in which

majority religions were Muslim that had socio-

cultural factors like the absence of promiscuity and

male circumcision, which are directly related to the

acquisition of infection by oncogenic strains of

HPV.

Similar to a study from 340 women in

Bhavnagar, Gujarat, India by Valiya et al. in 2015

showed inflammatory smears were higher among the

women with unhealthy cervix in comparison to the

healthy cervix but were statistically non-significant

in epithelial abnormalities differences.

The study by Raychaudhuri et al., 2012 reviewed

that acute lack of awareness and knowledge,

including poor personal hygiene and low socio-

economic status, are the principal risk factors for

cervical cancer.

4 CONCLUSION

The study found that 10(13.7%) women had good

genital hygiene while 29(39.7%) women had

moderate genital hygiene and poor genital hygiene

found in 34(46.6%) women. The study also showed

that cytological papsmear of 8(11.0%) women were

NILM with normal smear and 65(89.0%) women

were NILM with inflammation. Chi square test

reveals that no association between genital hygiene

and cytological papsmear.

ACKNOWLEDGEMENTS

The authors would like to thank the funding support

from the University of Sumatera Utara (No

240/UN5.2.3.1/PPM/KP-TALENTA USU/2019).

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