|Ahead of print publication
Correlation of menstrual hygiene management with cervical intraepithelial neoplasia and cervical cancer
Nisha Singh, Sapana Rajput, SP Jaiswar
Department of Obstetrics and Gynecology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||27-Jun-2021|
|Date of Acceptance||09-Jul-2021|
|Date of Web Publication||06-Jan-2022|
A-172, South City Raibareli Road, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: To find the correlation of menstrual hygiene management (MHM) with cervical intraepithelial neoplasia and cervical cancer.
Materials and Methods: This case-control study was conducted in a tertiary care teaching hospital for 1 year. One hundred cases (CIN or cervical cancer) and 135 controls (normal cervical cytology, Swede's score below 5, or normal cervical histology) were surveyed about MHM practices through a predesigned, semi-structured questionnaire by interview method. Data were analyzed on SPSS version 17.0 statistical analysis software through Chi-square test and bivariate regression analysis.
Results: All Poor MHM practices except frequency of change of absorbent were significantly more commonly seen in women with CIN or Cervical cancer as compared to controls (P < 0.001). The bivariate regression analysis showed that old age, illiteracy, and the use of old cloth are significant risk factors for cervical cancer.
Conclusion: Poor menstrual hygiene practices of using old cloth and disposal in open are significant risk factors of cervical cancer. Good MHM practices should be widely publicized and implemented in the community to reduce the risk of cervical cancer.
Keywords: Cancer prevention, hand washing, human papilloma virus infection, menstrual hygiene, sanitary napkin, waste disposal
| > Introduction|| |
Cervical cancer becomes the fourth most frequently diagnosed and the fourth leading cause of cancer death in women. Cervical cancer becomes second in incidence and mortality after breast cancer in lower human development index settings. In India, this is the second most common cancer in women accounting for 96,922 new cases and 60,078 deaths annually. Nandakumar et al. reported that all the urban population-based cancer registries (PBCR) had shown a statistically significant decrease in incidence rates of cervical cancer but rural areas are the residence of over 70% of the Indian population so even now cervical cancer is the number one cancer in the female sex. Based on the data of the PBCR, the estimated number of new cancers during 2007 in India was 90,708.
World Health Organization (WHO) has given a call for the elimination of cervical cancer by 2030 through primary prevention (Human papillomavirus vaccination), secondary prevention (twice lifetime screening for CIN), and tertiary prevention (treatment of CIN and cervical cancer). The treatment of CIN is accomplished through cold coagulation, thermal ablation, loop electrosurgical excision procedure (LEEP), and cold conization. Surgery and concurrent chemo-radiation are the treatment modalities for cervical cancer.
Infection with HPV, particularly types 16 and 18 causes 75% of cervical cancer. Although almost all women get infected with HPV, HPV persistence is seen in only about 10%–15%, which leads to CIN followed by cervical cancer. The factors that lead to the persistence of HPV infection in this small proportion of people are not well understood. The various known risk factors for cervical cancer may actually be responsible for persistent HPV infection. These include low socioeconomic status, low educational status, early age at first intercourse, high parity, multiple sexual partners, smoking, sexually transmitted infections, and immunocompromised status. Some of the demographic risk factors are interrelated and are commonly associated with poor menstrual hygiene management (MHM). It has been emphasized that a primary prevention approach is needed to promote a healthy lifestyle and behaviors that will minimize the risk of developing cervical cancer. Yet, the role of MHM as a risk factor for cervical cancer has not been well studied.
The WHO and United Nations international children's emergency fund in 2012, defined MHM as: Women and adolescent girls using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstrual period, using soap and water for washing the body as required and having access to facilities to dispose off used menstrual management material. In impoverished communities, menstruation is often poorly managed due to lack of water, proper sanitation and lack of affordable sanitary materials. Drakshayani et al. found that unhygienic practices are employed during menstruation, with old cloth mainly being used during menstruation. van Eijk et al. performed a meta-analysis of 138 studies from India involving 97,070 girls. Commercial pad use was more common among urban than rural girls (P < 0.0001), with use increasing over time (P < 0.0001). Inappropriate disposal was common and menstruating girls experienced many restrictions. About one-fourth were missing school during periods and only half of the girls' homes had a toilet. They concluded that the strengthening of MHM programs in India was needed through awareness, access to hygienic absorbents, and disposal facilities.
Since the review of the literature did not show any study on the direct correlation between MHM and cervical cancer, this study was conducted to prove this hypothesis. The objectives included survey of menstrual hygiene practices in women with CIN or cervical cancer and its comparison with healthy women with normal cervical cytology.
| > Materials And Methods|| |
This study was conducted in a tertiary care teaching hospital from August 2018 to September 2019 in accordance with the Helsinki declaration. The research protocol was approved by the Institutional ethical committee before the study began. The authors agree to provide copies of appropriate documentation if requested. Women aged 25–65 years attending gynecological OPD were included after written informed consent.
Since there were no other studies available on the direct correlation of menstrual hygiene and cervical cancer, the sample size could not be calculated. For practical and implementation purposes, we have taken 100 cases and 135 controls.
The cases included 13 women with histological diagnosis of CIN and 87 women with cervical cancer. The controls included 135 women with normal cervical cytology, swede score <5 or normal histology on cervical biopsy. Women with ovarian, endometrial, vulval, or vaginal cancer; cervical tuberculosis or cervical polyp were excluded from the study.
All recruited women underwent general, physical, and gynecological examination. Cervical cytology sample was taken from all women with normal-looking cervix and sent for Liquid-based cytology evaluation. Those having any growth or ulcer on the cervix underwent punch biopsy and the tissue was sent for histopathological examination (HPE).
Cervical cytology results were classified according to the Bethesda system. Women with normal cytology were taken as controls and those with abnormal cytology underwent colposcopic examination. Colposcopy findings were reported according to Swede's score. Cervical biopsy was taken if Swede's score was 5 and above. Those with normal score (0–4) were taken as controls. All HPE reports were assessed to classify the women as cases (CIN/cervical cancer) and controls (normal histology).
The treatment of 13 cases of CIN was done by cryotherapy (2 cases of CIN I), LEEP (3 cases of CIN II), and hysterectomy (8 cases of CIN III). Eighty-seven cervical cancer cases were treated with surgery (8) and chemo-radiation (79).
All women were surveyed about MHM practices through a predesigned, pretested, semi-structured questionnaire that included details about age, residence, socioeconomic status, education, age at marriage, parity, and history of smoking. MHM was assessed by the type of absorbent, frequency of changing absorbent, washing and drying practices of reused absorbent, use of damp absorbent, disposal of absorbent and privacy concerns.
The data was analysed using the statistical package for social sciences (SPSS 17.0) software. The statistical tests used were Chi-square test and Odd's ratio. Multinomial logistic regression analysis was done to find independent role of various MHM parameters as risk factors for CIN and cervical cancer. Statistically significant parameter have P < 0.05.
| > Results|| |
[Table 1] shows the comparison of various demographic and cervical cancer risk factors in cases and controls. All risk factors were significantly more common in cases as compared to controls.
|Table 1: Comparison of demographic and risk factors in cases and controls|
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[Table 2] compares the type of absorbent used in cases and controls. The use of sanitary pad was significantly lower in cases (5.2%) as compared to controls (62.2%) (P < 0.001).
[Table 3] compares the frequency of change of absorbent, the reuse of absorbent, and the washing of absorbent among cases and controls.
|Table 3: Comparison of frequency of change, reuse, and washing of absorbent in cases and controls|
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[Table 4] compares the disposal methods among cases and controls. The disposal of absorbent in open was more prevalent in cases as compared to control (P < 0.001).
[Table 5]a shows that on bivariate logistic regression analysis; older age, iliteracy, old cloth, and disposal in open were all independent significant risk factors for cases (CIN and cervical cancer).
Regression analysis was also done separately for CIN and cervical cancer against controls. It showed that age above 40 years, illiteracy, and use of old cloth were independent significant risk factors for cervical cancer but not for CIN as shown in [Table 5]b and [Table 5]c.
| > Discussion|| |
Thulaseedharan et al. found that the risk of cervical cancer increased significantly with increasing age (P < 0.001) and decreased with increasing education level (P = 0.017). Brinton et al. showed that high parity women were at increased risk of cervical cancer (odds ratio [OR] = 0.8) and smoking was also associated with an increased risk of cervical cancer, with a greater elevation in risk for current than former smokers (OR = 1.9). Graaff et al. found that cervical cancer patients had a markedly early age at marriage (P < 0.005). As per the above studies, risk factors for cervical cancer are increasing age, increasing parity, low education, lower socioeconomic status, smoking, and early age at marriage. They were all found to be significantly more common in our cases as compared to controls.
Adjorlolo-Johnson et al. showed that in logistic regression analysis when controlling for age, socioeconomic status, lifetime number of sexual partners above six, the variable that remained associated with cervical cancer included parity above two. In the present study also, 92.8% of cases had parity above 3 as compared to only 30.4% controls. The P < 0.001. On multivariate analysis also, parity more than three was significantly associated with CIN and cervical cancer (P = 0.002).
In the present study, significantly (P < 0.001) higher proportion (94.8%) of CIN and cervical cancer cases were using old cloth as compared to controls. It was disheartening to know that in the current scenario too, large proportion of women were still not using disposable hygienic absorbents.
Single-use absorbent such as sanitary pad is easily classified as clean; however, reusable absorbent such as cloth or menstrual cup if cleaned appropriately could be considered hygienic. One important criterion may be washing with soap. Drying practices are also important, with exposure to ultraviolet rays through sunlight known to have microbicidal effect. Leaving fabrics damp has been found to encourage microbial survival and wearing absorbent wet has frequently been considered unhygienic. Women and girls need privacy for all aspects of MHM, such as washing the body and absorbent. Our findings are similar to Zhang et al. who found that in women who regularly used sanitary napkins, the relative risk of preinvasive and invasive cervical lesions was decreased to 0.28 (P = 0.01). Varghese et al. also found that Sanitary pads were not used by 90% of women who had an excess risk of cervical dysplasia.
Maree and Wright also showed that the use of old cloth increased the incidence of cervical cancer.
In the present study, 61.9% of cases were changing their absorbent more frequently as compared to controls (47.4%) but the difference was not statistically significant (P = 0.052). This may be probably because sanitary pads have more absorption capacity and they need to be changed less frequently. Maree and Wright found that the frequency of changing of absorbent ranged from more than six times per day (10%) to once daily (6.8%). The majority of cases (58.4%) in their study changed their sanitary protection between two and four times per day. Budukh et al. found that more than 90% of women used a piece of old cloth as a menstrual device, and the pad was changed only 1.3 times as compared to the standard practice of three pads per day. They also showed that reused cloth increased the persistence of HPV infection which leads to cervical cancer.
More than one-fourth (27.7%) of all our subjects were reusing the sanitary protection after washing. This included significantly higher (24.7%) proportion of cases as compared to 3% of controls (P < 0.001). Bayo et al. also found that re-using sanitary napkins or tampons was only restricted to cases of cervical cancer and the resulting OR was one of the strongest found in the analysis (OR = 46). Maree and Wright stated that materials used for protection during menstruation could contribute to heighten the risk of HPV infection. The reuse of washed clothes is particularly risky as HPV has been detected in menstrual blood. 7.2% of the respondents indicated that they re-used sanitary protection.
There are few MHM practices which have not been studied so we were not be able to compare our findings with others. One of them is washing the absorbent with soap and water if available. We found that washing of absorbent with soap and water was significantly less common in CIN and cervical cancer cases (P = 0.007).
The MHM practice of disposal of absorbent is directly associated with community health if it is disposed of in open. In the present study, significantly higher (P < 0.001) proportion of cases (91.8%) were throwing the absorbent in open as compared to controls (35.6%).
Bivariate regression analysis of four major factors, i.e., illiteracy, age more than 40 years, usage of old cloth, and disposal in open showed that each one of them was an independent risk factor for CIN and cervical cancer.
| > Conclusion|| |
Hence, it was concluded that poor MHM practices with the usage of old cloth and disposal in open are significantly associated and are independent risk factors for cervical cancer. Menstrual hygiene practices of using the sanitary pad and proper disposal may significantly reduce the risk of cervical cancer.
We acknowledge the support of all the patients who consented for the study and all doctors who contributed in patient management during the hospital stay.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]