Obstetrics and Gynaecology Insights (OGI) Should Women with Utero-Vaginal Prolapse be Screened for Pre-Malignant/ Malignant Lesions of The Cervix before Vaginal Hysterectomy?

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INTRODUCTION
Vaginal Hysterectomy is a common gynaecological surgery carried out for women who have utero-vaginal prolapse and other benign gynaecological conditions in our practice.It is considered a better and safer route for hysterectomy compared to laparoscopic or abdominal hysterectomy when feasible [2] .It's also associated with fewer complication [2] .At the University of Uyo Teaching Hospital, elective hysterectomy constituted 10.5% of all major surgeries, and 24.9% of all major gynaecological surgeries [1] .Utero-vaginal prolapse (24.4%) was only second to uterine fibroids as indications for elective hysterectomies in our locality [1] .Total hysterectomy is supposed to reduce the risk for developing diseases involving the myometrium, endometrium and the cervix.To further reduce the likelihood of post hysterectomy cervical dysplasia or cancer, post hysterectomy vaginal vault smears have been advocated even though this is not generally accepted [5] .However, post hysterectomy vault smears cannot differentiate between a lesion that was present before the surgery or developed later on in the course of follow-up.Where a patient is already enrolled in a cervical cancer screening program, more clinical data is available to influence management options.This is clearly lacking in our environment where most of the older patients presenting with Utero-vaginal prolapse have never had cervical cancer screening.In spite of this unfortunate circumstance, cervical cancer screening prior to vaginal hysterectomy is a good opportunity to pick up cases of cervical dysplasia or subclinical malignant lesions among this subset of women and shed light on the prevalence of cervical dysplasia or subclinical malignant lesions of the cervix.
In this study, we evaluated the vaginal hysterectomy specimens from Pope John II Family Life Centre (popularly referred to as VVF Hospital), Mbribit Itam in Uyo local government council of Akwa Ibom state for cervical dysplasia and/or cancers.

AIMS OF STUDY
1. To determine the presence of cytologic anomalies in vaginal hysterectomy specimens for utero-vaginal prolapse at VVF Hospital, Mbritbit Itam, Uyo. 2. To determine associated risk factors for such anomalies

MATERIALS AND METHODS
The study period was between January 2014 through December 2015 involving patients who presented at the Pope John II Family Life Centre, Mbribit Itam in Uyo local government council of Akwa Ibom State.These patients reported having never heard of pap smear for cervical cancer screening.These Patients with utero-vaginal prolapse usually present to the gynaecologic outpatient clinic where they are evaluated and management options chosen.All patients that had a vaginal hysterectomy during the study period were counselled about the surgery and verbal consents were obtained for histological examination of the post hysterectomy specimens after assuring them of their confidentiality.The inclusion / exclusion criteria for participation in this study include the following: 1.Any patient with suspected or confirmed cervical pathology 2. Any patient who declined participation in the study 3. Surgical specimen not suitable for Histological examination All patients whom fulfilled the conditions above were selected for the study.Information obtained include the biodata, indications for the surgery and specific risk factors for abnormal cervical cytology/cervical cancer.Obtained data were presented in tables and percentages.

RESULTS
Sixty-five women were recruited for this study.However, 9 were excluded because the surgical specimens were poorly preserved and the tissues were not suitable for histology.Table 1 shows the sociodemographic data of patients used for this study.All the women were aged 40 years and above and 42 (75.00%)were married.The indication for surgery for all the patients involved in this study was Uterovaginal prolapse.Over 50% of the women had delivered 4 or more times.However, only 4 (7.14%)delivered their babies in a hospital; the remaining gave birth at home, in a church or at a traditional birth attendant's place.None of the women smoked cigarette or complained of post coital bleeding.
Report of 56 specimens were obtained after histological evaluation.Six specimens (10.71%) had abnormal cytology; two were cervical intra epithelial neoplasia (CIN) I, one CIN II and three were stage 1 carcinoma of the cervix (Table 3).Abnormal cervical cytology was found in women that got married early (<18 years).Two of the patients were involved in a second marriage (Table 2).The three patients with abnormal cytology were of low educational status (<FSLC).

DISCUSSION
Cervical dysplasia was present in 10.71% of the women who had Vaginal hysterectomy on account of utero-vaginal prolapse at the Pope John Paul II Family Centre.Three of them (half of those with dysplasia) had subclinical cervical cancer (table 3).The above results show clearly that subclinical cervical pathology may coexist with utero-vaginal prolapse.This is not surprising as the uptake of cervical cancer screening is low in our environment and compliance with follow up is a challenge.
Subclinical cervical pathologies may be missed in women with indications for vaginal hysterectomy if they are not screened prior to surgery.Even though vaginal hysterectomy may cure subclinical cervical dysplasia, these women may still be at risk of developing vaginal cancers [3] .This is because human papilloma virus, the risk factor for cervical cancer also causes vaginal cancer [3] .The American College of Obstetrics and Gynecology (ACOG) recommends vault smears for individuals with abnormal cervical cells.Prior knowledge of these subclinical cervical pathologies may alter the management and follow up plans (especially vault smears) of these women significantly.Given the poor compliance rate with post-operative follow up following hysterectomy, it may actually be better to screen these patients preoperatively [4] .Therefore a diagnosis of utero-vaginal prolapse provides the opportunity to detect cervical lesions and affords the opportunity for a more comprehensive management of the patient concerned.Indeed, clinic consultations, especially in Obstetrics and Gynecology should be viewed as an opportunity to screen for premalignant and malignant cervical lesions.This applies especially to areas where cervical screening programs are lacking or individuals who have not had any form of cervical cancer screening.The awareness and uptake of cervical cancer screening using pap smear is disappointingly poor in our environment.A study at the University of Uyo Teaching Hospital found only 7.4% of nurses had undergone screening for cervical cancer [6] .

OGI
Volume-1 | Issue-1 May, 2017 Some of the screening methods for premalignant and preclinical malignant cervical lesions include Pap Smear, Visual Aided inspection with acetic acid (VIA) or lugol's Iodine and Human Papilloma Virus (HPV) testing.However, the World Health Organization expert panel suggests that for cervical cancer screening, the use of "a strategy of screening with an HPV test and treat, over a strategy of screening with VIA and treat.In resource-constrained settings, where screening with an HPV test is not feasible, the panel suggests a strategy of screening with VIA and treatment [7] .Vaginal hysterectomy on its own would suffice as a form of treatment for subclinical HPV associated lesions of the cervix following HPV testing or VIA.However, screening for premalignant and malignant lesions of the vagina and vulva in addition to vaginal vault smears would need to be instituted because HPV is also an etiological factor for these lesions 99 [3] .

CONCLUSION
Ten percent of cervical dysplasia is in our opinion just too much to ignore, therefore we recommend preoperative cervical cancer screening for women undergoing vaginal hysterectomy in areas where cervical cancer screening is still suboptimal.This may suffice for now until cervical cancer screening is scaled up in our locality and other areas with a high burden of cervical cancer.This approach, however, may increase cost of medical care for these group of patients in resource poor settings.The small sample size in this study is a substantial source of limitation and larger studies may be required to properly answer the question "should women with utero-vaginal prolapse be screened for pre-malignant/ malignant lesions of the cervix before vaginal hysterectomy?"

2 .
Consent to participate in the study 3. Willingness to come back for follow up EXCLUSION CRITERIA:

Table 1
Sociodemographic characteristics of patients who had hysterectomy

Table 3
showing types of cervical dysplasia present