Vaginal Discharge and Abnormal Cervical Smears - Term Paper Example

VAGINAL DISCHARGE AND ABNORMAL CERVICAL SMEARS Abstract There is an increasing awareness among females of cervical screening after the implementation of the national cervical screening progrmamme. Having been implemented in 2008 it aims to reduce the incidence of cervical cancer in women aged 25- 60 yrs. It is based in routine primary care practice. The amount of mucus produced by the cervical glands varies throughout the menstrual cycle. Vaginal discharge that suddenly differs in colour, odour and amount indicate an underlying problem, infection or abnormal smear. Diagnostic test in those cases should be performed, such as culture of cervix, examination of discharge under microscope or Pap smear.  Key words - Abnormal cervical smear, vaginal discharge, epithelial dysplasia CHAPTER I 1.1. INTRODUCTION Women naturally produce vaginal discharge during their reproductive years (Massey & Winterburn, 2008). However, vaginal discharge is also considered as one of the primary gynecological symptoms that prompt women to seek consultation in primary care (Anderson & Karasz, 2004; Mitchell, 2004). Since, abnormal vaginal discharge maybe caused by physiological and pathological conditions (Massey & Winterburn, 2008). As such, the presence of vaginal discharge, though naturally produced by women in their reproductive years, is still perceived as a cause of concern and distressed to patients (Anderson & Karasz, 2004). Furthermore, the condition of distress is compounded by the fact that worldwide, cervical cancer is the third most common cancer among women and that “Failure to obtain regular Pap smears is the single greatest risk factor for development of invasive cervical cancer.” (Steigman & Vernick, 2002: 9). Being such, the apprehension pertinent to vaginal discharge and abnormal cervical smears (Gray et al 2006) which may be caused by asymptomatic sexually transmitted infections points to the probability of interrelation or connection between the two. In this regard, the knowledge of the possibility of the link between vaginal discharge and cervical cancer or sexually transmitted infections creates the venue for the understanding of one of the most important concerns regarding women’s health. 1.2. CAUSES OF VAGINAL DISCHARGE AND INFECTION. The vagina of women in their reproductive years are lined by stratified epithelium approximately 10-30 cells thick. The superficial cells of vagina shed constantly and by the action of Doderlein's bacilli produce lactic acid and hydrogen peroxide, a natural defence against vaginal infection and maintain vaginal pH between 3.5 and 4.5.The vagina harbours a large number of bacteria which constitute its normal flora. However a number of women due  to various factor harbor potential pathogens.Normal vaginal flora are - lactobacillus , Staphylococci, urea plasma, Anaerobe , streptococci, Gardenella, E- coli, Canadiasis , Bacteroids, trichomonas. The vagina is normally kept moist by transudation of fluid through its wall, exfoliated vaginal cells, aliphatic acid and microorganisms The quantity of vaginal secretion varies throughout the menstrual cycle. However, if quantity, color or consistency change or begin to cause problems for the women 1.3. CAUSES OF PATHOLOGICAL VAGINAL DISCHARGE. HPV trichomonas Candidasis Bacterial Vaginosis chlamydia Gonococcal Actinomyces. Hepes simplex IUCD Foreign body. 1.4.REPORTING ON SMEAR. Cytologists have agreed that nuclear abnormalities should form the basis of a cytological diagnosis. Smears are classified as follows: Unsatisfactory - A diagnosis cannot be made as there are too few cells, no endocervical cells, or the slides have been processed incorrectly. Inflammatory or inconclusive - The nuclei are distorted by the effects of a vaginal infection.  Mild dyskariosis - Predictive of CIN-1 dyskariosis with or without HPV Moderate dyskariosis - Predictive of CIN-2 Sever dyskariosis - predictive CIN  -3 THE BETHESDA CLSSIFICATION (Classification used in the United States) Squamous cell- Atypical squamous cell of uncertain significance  (ASCUS) Low-grade squamous intra epithelial lesion (SIL) - Includes HPV and mild dyskariosis. High-grade squamous epithelial lesion - squamous cell carcinoma GLANDULAR CELL Endometrial cells Atypical glandular cell of Undermined significance Adenocarcinoma The cervical epithelium undergoes changes through out the menstrual cycle and readily accessible for examination. The epithelium covering the endocervix is stratified and identical to that of vagina. The inner lining of uterus is columnar epithelium. The 1st change takes place at squamo-columnar junction. 1.4. SIGNIFICANCE OF THE STUDY I have chosen to write on the subject of vaginal discharge and abnormal smears because I am working in general practice where I take cervical smear on the National Cervical Check Program and of private patients. I noticed that if a patient complains of discharge or has seen vaginal discharge during smear taking, when the smear results of that patient came some of results were abnormal. After completion of this study there will be more evidence to assess whether or not conditions apart from HPV can cause abnormal smears. It need to first find the cause and treat after which I will again repeat the smear test. CHAPTER II LITERATURE REVIEW This literature review will focus on research concerning vaginal discharge, genital tract infection and abnormal smear results. Repeat smear test results after treatment of vaginal discharge and infection in International, British and American studies will be evaluated. 2.1. BACKGROUND INFORMATION Pap smear invented by Dr. George Nicholas Papanicolaou is one of the most significant advancements in medical technology since it is considered as one of the most effective cancer-prevention tool ever devised (Steigman & Vernick, 2002). In fact, in the United States ever since it has been used as a cancer screening tool it has reduced the incidence and mortality of cervical cancer (Carulli, 2003; Singhal et al ,2008). Likewise, “Pap smear alone accounts for the 70% decline of invasive cancer over the past 40 years" (Starr 1999 as cited in Carulli, 2003:444). In lieu with this, it is not surprising that Pap smear is the primary screening tool for cervical cancer. Although, there are certain recognised limitations of Pap smear. These are; first, as it is only a screening tests and not diagnostic. Second, there is an increase rate of false –positive and false negative (Steigman & Vernick, 2002). Thus, currently opening doors for litigation, but still it is undeniable that pap smear is the frontliner for early detection of cervical cancer for women (Wagner et al, 2007;Eggleston et al, 2007). On the other hand, the condition of vaginal discharge, although naturally produced by women during their reproductive years making it a natural physiological occurrence (Anderson & Karasz, 2004; Mitchell, 200 8; Massey & Winterburn, 2004; Edwards, 2007), is still perceived as a red flag if there is an abnormal vaginal discharge. This is due to the fact that abnormal vaginal discharge is one of the first clues for infection especially if the woman is sexually active (Gibson & Russell, 2005). This is a cause of concern since there is an 80% increase in the prevalence of human pappilomavirus among sexually active young women (Kahn et al, 2005). Human pappilomavirus is a sexually transmitted infection and there are stains of HPV that directly causes “cervical intraepithelial neoplasia (CIN) and cervical cancer” (Kahn et al, 2005;651). Thus, this condition creates the scenario for the need to better understand the link between abnormal cervical smear and abnormal vaginal discharge. 2.2. CORRELATION OF VAGINAL DISCHARGE AND ABNORMAL CERVICAL SMEAR The studies that have particular relevance to this study will be discussed individually According to one study – Accuracy of cervical /vaginal cytology in diagnosis of Bacterial vaginosis, the findings support the validity of a pap smear and suggest screening of disease. Another study demonstrated the incidence of vaginal discharge in abnormal smears. This study was done among females who were attending STD clinics and found the presence of clinical signs, concomitant infection and abnormal cytology – Derma venerology Sweden. It has been shown that inflammatory and infective vaginal causes can cause abnormal smear results - British Journal of General Practitioners. In one study it has been shown that the prevalence of bacterial vaginosis (BV) and trichomonas vaginalis is higher in cytology with abnormal smears – Cytology clinic at Ibandon, Nigeria Other study - An association of Cervical inflammation with high grade cervical neoplasia in women infected with oncogenic HPV In A case controlled study there is non – specific genital infection /or vaginal discharge associated with cervical cancer, suggest a possible link between either genital tract infection or change is consistent with bacterial vaginosis and cervical cancer. In one study shows co relation between cervical cytology result and gram stain as diagnostic test for bacterial vaginosis . study design was conducted a prospective cross sectional study. The correlation between vaginal discharge and abnormal cervical smear does not present a direct link between the two. What is seemingly presented in current existing literature is that HPV, which is the primary cause of cervix cancer, but is one of the less common causes of abnormal vaginal discharge (Mitchell, 2004), while it is one of the major causes of abnormality in cervical smears (Kahn et al, 2005). Although this may be the more predominant way of looking at the correlation between the two (Safaeian & Solomon, 2007; Kahn et al,2005; Clouse, 2004), it does not preclude the possibility of other link or correlation between abnormal vaginal discharge and abnormal cervical smear. 2.8. SOCIODEMOGRAPHIC – AGE, EDUCATION For this study, the sociodemographic criteria to be used are the following: Age – 24 – 60 Ethnic group – white, non-white, missing Marital status – married, single, separated/divorced, widowed, missing Number of children 2.9. STUDIES WITH RELEVANCE TO THIS STUDY As mentioned, studies that directly correlates abnormal vaginal discharge with abnormal cervical smear is wanting. As such, in order to find the correlation between abnormal vaginal discharge and abnormal cervical smear studies regarding abnormal vaginal discharge and studies pertinent to abnormal cervical smears are searched and read in order to be able to understand the possibility of a direct or even an indirect correlation or link between the two. 2.10. SUMMARY OF LITERATURE Vaginal discharge is common in reproductive years of females and also depends on age, socioeconomic condition, life style, and environment. Apart from precancerous cause there are other causes that can cause abnormal smears that require treatment and a repeat smear. There is correlation between vaginal discharge due to any cause and abnormal smear. The aim of this study is to assess whether there is a correlation between vaginal discharge due to causes other than HPV and abnormal smear results. A vast body of work has already proven that HPV is a precancerous cause of abnormal smears. But other genital tract infections causing vaginal discharge can also cause abnormal smears. Current existing literatures discusses abnormal vaginal discharge and abnormal cervical smears separately. Scholars tend to focus on one of the two subjects but not both (Safaeian & Solomon, 2007; Glaser, 2000; Mays et al 2000; Oscarsson et al, 2008;Hardy, 2007; Anderson & Karasz, 2004; Mitchell, 2004; Gibson & Russell, 2007; Massey & Winterburn, 2008). If there is an allusion to the possibility of correlation between the two is proposed an additional important factor sited and that it the sexual activity of the woman (Kahn et al, 2005; Edwards 2007, 2008; Feder, 2006; Tiffen & Mahon, 2006) is always necessitated as a further significant information. 2.11. AIM OF STUDY The aim of the study are: first, to understand the nature, causes, signs and symptoms of abnormal vaginal discharge. Second, to identify and apprehend the nature, definition, causes and different types of abnormal cervical smear. Third, is to find and elucidate the correlation between abnormal vaginal discharge and abnormal cervical smear. Finally, fourth to come up with a health care proposal that is both ethical and authentically responsive to the needs of women who are further vulnerated by these two conditions. 2.12. RESEARCH OBJECTIVE The research objectives for this study are: The main objective of this research is to find causes of vaginal discharge and its correlation with abnormal smear results. To be able to clarify, elucidate and distinguish the nature, causes, signs and symptoms of abnormal vaginal discharge and abnormal cervical smear. To find and understand the correlation between abnormal vaginal discharge and abnormal cervical smear To come up with a health care proposal that is ethically and authentically responsive to the needs of the vulnerated female patients. CHAPTER III RESEARCH METHODOLOGY This chapter focuses on the research design and methodology including setting, population sampling, data collection and ethical issues. 3.1. STATEMENT OF PURPOSE This study intends to learn and understand the nature, causes, signs and symptoms of abnormal vaginal discharge and abnormal cervical smear. Furthermore, it seeks to find the correlation between abnormal vaginal discharge and abnormal cervical smear. Finally, it will attempt to come up with a health care proposal that will be both ethical and authentically responsive to the real needs of women who are further vulnerated the conditions of abnormal vaginal discharge and abnormal cervical smear. 3.2. RESEARCH DESIGN As the aim of the research is to know the whether the group of women who visit in my family practice setting have some gynecological problem and give required treatment and follow up. Being such, the two categories of research design will be employed - – qualitative and quantitative In quantitative research is the systemic and scientific investigation of quantitative properties and phenomena and their relationships. While, in the qualitative research – it is expressed in term of quality. It is based on peoples subjective analysis In this study a quantitative design will be adopted with qualitative analysis of patients smear results. There will be also some qualitative part of research in this study. There will be also semi structured interview. 3.3. STUDY SETTING The study will takes place in a general practice setting where women come for a general check up and with other gynecological problems. Cervical smears will be taken under the national cervical check programme. Both private and general medical services patients will be included. Visit status will be key in the sampling with only patients between the ages of 24-65 yrs who come for a cervical smear being selected. 3.4. STUDY POPULATION In statistics, a population is defined as any group of people who share a common characteristic in which researcher is interested. The population of this study are women between 24 and 65 years old who will present themselves for a smear test or are symptomatic due to vaginal discharge. Responders will be recruited by personal invitation with an explanation of aim objective and benefits of study. 3.5. ASSESSMENT The aim is to gather valid, reliable and unbiased data from responders. They will be given confidential questionnaires, while they are sitting in the waiting room. Likewise, they will be informed about the purpose of the questionnaire. The responders will be told that questionnaire for fulfillment of an MSc in Women’s Health and to gain knowledge and new information to improve future healthcare 3.6. DATA COLLECTION For the data collection three approaches will be used. First, is the survey of existing literature that will shed light on nature, pathology, physiology, definition, causes, signs and symptoms of both abnormal vaginal discharge and abnormal cervical smear. The electronic databases PubMEd , CINAHL and BioMed Central will be searched using the combination of the following key terms: vagina, pap smear, discharge, secretion, vaginal discharge, cervix, cervical smear, abnormal cervical smear, carcinoma in situ, dysplasia, dysuria and dyspareunia. Articles written only in English and publish from the period of 1985 – 2009 will be searched. Likewise, books, and articles that deal with pathophysiology and developments for both conditions, guidelines for the implementations of health care programs will be included in the searched. Correspondingly, excluded from the searched are opinions, editorials and position papers. The reference list of the articles will be searched to look for additional sources. Questionnaires will be used for the data collection method. This method of collecting data is chosen to avoid interview bias and to avoid self-completed questionnaire bias. Furthermore, an index list of all patients presenting for cervical smear will be isolated from record by numerical identification. Data extracting and report writing will be carried out between 2009 June to 2010 June. 3.7. PILOT STUDY A pilot study is defined as smaller version of a proposed study conducted to refine methodology. In the pilot study an introduction covering letter, which will briefly introduce the purpose of the survey and explain the importance of responder participation, will be given to potential subjects. Confidentiality will be guaranteed. The purpose of the pilot is to identify any potential problems with the questionnaire such as clarity and its ease of use by the participants of the study. 3.8. DATA ANALYSIS Data analysis is a process of gathering, modeling and transforming data for useful information that will support decision-making. Moreover, data analysis helps the researchers to organize structure and elicit meaning from data . 3.9. ISSUES OF RELIABILITY AND VALIDITY The practical value of a questionnaire depends on the reliability and validity of information collected. Whatever procedure for collecting data is selected it should always be examined critically to assess to what extent it is reliable and valid. Reliability refers to how well data collected by using a questionnaire can be reproduced. Validity assesses whether an item measures or describes what it suppose to measure or describe. In relation to questionnaire, this determines whether the instrument accurately measures the research question, objective and hypothesis 3.10. ETHICAL CONSIDERATIONS The four most common principles of ethics is respect for autonomy, beneficence, non – malfeasance and justice ensuring people are treated fairly and equally. To this end it will be ensured that participation in the study will be voluntary and confidentiality guaranteed and participants will be made informed of this from the beginning. Participant in the study will be strictly voluntary, the study procedure involved will not do any harm and all information collected will be confidential Furthermore, due to the sensitivity of abnormal vaginal discharge and abnormal cervical smear in terms of it being connected to the sexual life and activities of the woman who are undergoing this condition, it is important that ethical considerations are recognised. These are: first, the informed consent of the patient should be secured before any further diagnosis or tests be done (Bishop, 2008). Second, respect for the dignity of the woman should be upheld at all times(Hughes, 2001). It is not just the taking of a specimen but it is an opening of one’s self to the health care provider. Third, women should be empowered in the entire process of health screening, diagnosis and treatment. They should not be passive receptors of information (Oscarsson et al, 2008) but they should be made active participants in the decision-making as it is their bodies, it is their lives (Dekkers, 2001). And finally, for patients to treated in a friendly way and not to be subjected to bias or judgments in the giving of the health care to women who are afflicted. 3.11. PROPOSED OUTCOME OF THE STUDY The proposed outcomes of the study are: 1. Current discussions of abnormal vaginal discharge and abnormal cervical smear focuses independent of one another. 2. There exists a close correlation between abnormal vaginal discharge and abnormal cervical smear. 3. Women who are suffering from this condition are further vulnerated by exposure of their sexual life and activities as such care must be undertaken in order to be not judgmental and bias in dealing with the vulnerated women. 3.12. TIME SCALE Week 1 – Week 4 Library research Week 5 Construction of questionnaire Try to contact possible primary health care centers Week 6 Re-checking of questionnaire Setting of dates for interview Week 7 Distribution of questionnaires Interview with participants Week 8 Interview with participants Collation of questionnaires Week 9 Transcription of interviews Analysis of questionnaires Distribution of the copies of the interview to the patients Week 10 – Week 13 Writing of the manuscript CHAPTER IV: 4.1. DISCUSSION OF FINDINGS Genital tract infection with symptoms is common presentation in a primary care setting in reproductive age females and is a cause of significant anxiety. If a smear test result is abnormal it can result in even higher levels of anxiety so by treating the infection, repeating the smear and finding a negative result some of the patients anxiety should be allayed. 4.2. STRENTH AND LIMITATION OF STUDY The study will be limited by the sample size and only those patients who came due to a complaint of vaginal discharge or in whom discharge was found during smear taking will be taken in this study. In some cases, it will no doubt be difficult to differentiate genital discharge from inflammation of other causes. CONCLUSION I am a general practitioner with special interest in women health and pursuing an MSc in Women’s Health. I have very strong desire to improve the quality of health care in women of all age groups and ethnic origins. Still female health is a great concern worldwide. Women are perhaps burdened with more responsibility in modern times than at any other time in history with increased career and financial expectations often with the additional pressure to still fulfill the more traditional roles of mother and homemaker. I do hope my this research will bring some more information . REFERENCES: Anderson, M., & Karasz, A. 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(2009). “Psychosocial factors in risk of cervical intraepithelial lesions”, Journal of Women’s Health, Vol. 18, No 4, 513 – 518. E-sources http://www.ncbi.nlm.nih.gov/pubmed/ http://scholar.google.co.uk/ http://www.cochrane.org/ BIBLIOGRAPHY Cervical check British Journal of General Practice British Journal of Obstetrics and Gynaecoloigy . American Journal of Obstetrics and Gynaecology . Jeffescoat’s Principal of Gynaecology. Fundamental of Obstetrics and Gynaecology – Jeremy Oats . Doing yours Research project – Judith well. British Medical Journal. Cancer Epidiomology - biomarker prevention APPENDIX 1 GUIDE FOR THE RESULTS “Result Interpretation Action Inadequate Insufficient cells Repeat smear as soon as convenient Negative Normal Routine recall Borderline Cell changes Repeat smear in nuclear changes 6 months Mild dyskaryosis Cell changes consistent Repeat or refer with CIN 1 for colposcopy Moderate Cell changes consistent Refer for dyskaryosis with CIN 2 colposcopy Severe dyskaryosis Cell changes consistent Refer for with CIN 3 colposcopy Severe Possibility of invasive Urgent referral dyskaryosis/ cancer for colposcopy invasive carcinoma Glandular Possible glandular Urgent referral neoplasia abnormality. May for colposcopy indicate a glandular cancer Read More