Menstrual hygiene and cervical cancer: two intertwined pertinent societal problems needing attention!

A close encounter!

In 2000, one fine evening while returning back from school, I heard mother was not well and needed to visit a gynaecologist. Newly introduced to the human reproductive system in school, I could make out that she had a problem with her menopause. I started accompanying her to the clinic to understand what was wrong. She had mild fever and vaginal bleeding even after menopause. Initially, the doctor suggested a Pap smear. Results showed a presence of abnormal cells. Finally, it was decided that a hysterectomy would be best considering that she was already post-menopausal. Although everything went well during the operation, we were anxiously waiting for the biopsy result. Luckily the cervical lesion was precancerous and was treated at the right time! My mother is fine. However, there are many women who fall prey to cervical cancer every day and die!

National scenario:

A recent study published in The Lancet Global Health¹, has revealed that India witnessed the highest number of cervical cancer deaths in 2018. It is a major health burden and every year almost 120,000² new cases are registered. The incidence of carcinoma cervix has considerably declined in the urban areas but the rate of incidence in rural areas is stable and alarming. Unfortunately, many women do not even understand what the cervix is³ and do not understand the physiology of menstruation and menopause due to illiteracy. Most of the cases come to notice due to opportunistic screening or due to the presence of symptoms and thus are mostly presented at an advanced stage. Due to improvement in standard of living and spread of awareness through audiovisual and print media, the disease rate is expected to decrease considerably by 2020⁴in women living in urban areas. But the rural women are still suffering⁵ due to lack of awareness, illiteracy about the contributing factors, poor hygiene, early marriage, multiple pregnancies and dearth of proper cancer screening programmes. Therefore, it is important to channelize efforts and funds toward spreading awareness and implementation of cost-effective screening methods.

Risk factors and social barriers:

Menstruation is considered a taboo⁶even now and this impacts girls and women in various ways. In many parts of India, it is considered unhealthy and dirty⁷. This is compounded by lack of knowledge in women regarding the scientific cause of it. In certain cultures, women are made to bury⁸ the cloths used during menstruation to stop evil spirits. In some parts of India, women are not allowed to take bath⁷ for the first few days of their menstruation. Women often use unclean cloths. All these misconceptions create a huge hindrance and help in propagation of deadly infections. The mere discussion of periods and reproductive health is a big no! These lead to a lack of screening and timely diagnosis. Almost always, cervical cancer is triggered by oncogenic human papillomavirus⁹(HPV) strains. Worldwide, HPV is highly prevalent (~9 -13 %¹⁰) and is the mostly sexually transmitted infection. Genital HPV infections are asymptomatic with no treatment options. HPV 16 and HPV 18 are the main causative agents¹¹ of cervical cancer. In India, currently two forms of vaccine are available viz. Cervarix which is a bivalent vaccine and Gardasil which is a quadrivalent vaccine that provides protection³ against four oncogenic strains of HPV. Although, it has been advised by The National Technical Advisory Group on Immunization (NTAGI) to include the anti-HPV vaccine in the Universal Immunization Programme, there has been several pushbacks to it. The vaccine has been included in the Universal Immunization schedule for children by Indian Academy of Paediatrics (IAP)¹². However, it has been listed as an optional vaccine that may be given to girls between ages 10 and 12. Parents are doubtful about the vaccine and its utility. Cost is another factor as the price varies between Rs. 2000 to Rs. 3000³ and 3 doses are recommended. In adults, the upper age limit is 26 years³. But depending on individual cases, it may be administered beyond that.

What next?

First and foremost, awareness and screening camps need to be regularly set up in government-based hospitals, rural and urban areas to facilitate early detection. It is important to educate women about the biological cause of menstruation, menopause and break the myths around it. Physicians and scientists need to collaborate and jointly put in their efforts to discuss the causes, early symptoms and screening tests available for cervical cancer. Rural cancer registries and low tech cost effective screening tests⁷ like visual inspection with lugol’s Iodine, inspection with acetic acid, Pap smear, inspection with magnification devices, HPV-DNA typing and Argyrophilic Nucleolar Organizer Region (AgNOR) counts should be promoted and implemented with a focus on rural areas. Government should channelize funds for the identification of other oncogenic HPV strains in the Indian cohort and development of cost-effective vaccines such that it is within the reach of poor girls and women. Sensitive blood biomarkers need to be identified. Utility of HPV vaccine needs to be circulated to educate people. The HPV vaccination programme should also include boys as infection spreads both ways. It is important to teach women proper menstrual hygiene. It is equally important to sensitize men regarding these. A majority of rural women use unclean cloths during periods that raise the chances of infection. Rural women may be taught to make biodegradable sanitary napkins made from bamboo, corn, banana fibres¹³etc. for their own use and for commercialization. This would in a way offer them with personal hygiene and job opportunity thereby helping with women empowerment too. India has recently issued a draft policy for scientific social responsibility¹⁴ (SSR) that aims to promote scientific solutions to societal problems. Menstrual taboo and high prevalence of cervical cancer are two of the pertinent societal problems that need to be addressed. It is my belief that scientists and physicians with the support of the Indian Government will be able to eradicate them in our near future.

References:

1. Arbyn, M., Weiderpass, E., Bruni, L., de Sanjosé, S., Saraiya, M., Ferlay, J., & Bray, F. (2020). Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health, 8(2), e191-e203.
2. Jacob, M. (2012). Information, education & communication: Corner stone for preventing cancer of the cervix. The Indian journal of medical research, 136(2), 182.
3. Why has the beneficial HPV vaccine not been included in national immunisation programme?https://www.thenewsminute.com/article/why-has-beneficial-hpv-vaccine-not-been-included-national-immunisation-programme-87362
4. Takiar, R., Nadayil, D., & Nandakumar, A. (2010). Projections of number of cancer cases in India (2010-2020) by cancer groups. Asian Pac J Cancer Prev, 11(4), 1045-9.
5. Badwe, R. A., Dikshit, R., Laversanne, M., & Bray, F. (2014). Cancer incidence trends in India. Japanese journal of clinical oncology, 44(5), 401-407.
6. Patil, R., Agarwal, L., Khan, M. I., Gupta, S. K., Vedapriya, D. R., Raghavia, M., & Mittal, A. (2011). Beliefs about menstruation: a study from rural Pondicherry. Indian Journal of Medical Specialties, 2(1), 23-26.
7. Garg, S., & Anand, T. (2015). Menstruation related myths in India: strategies for combating it. Journal of family medicine and primary care, 4(2), 184.
8. https://www.unicef.org/wash/files/10_case_study_BANGLADESH_4web.pdf
9. Das, B. C., Gopalkrishna, V., Sharma, J. K., Roy, M., & Luthra, U. K. (1992). Human papillomavirus DNA in urine of women with preneoplastic and neoplastic cervical lesions. The Lancet, 340(8832), 1417-1418.
10. Hussain, S., Bharadwaj, M., Nasare, V., Kumari, M., Sharma, S., Hedau, S., & Das, B. C. (2012). Human papillomavirus infection among young adolescents in India: impact of vaccination. Journal of medical virology, 84(2), 298-305.
11. Schiffman, M., Castle, P. E., Jeronimo, J., Rodriguez, A. C., & Wacholder, S. (2007). Human papillomavirus and cervical cancer. The Lancet, 370(9590), 890-907.
12. Roy, S., Shankar, A., & Rath, G. K. (2018). HPV Vaccination of Girl Child in India: Intervention for Primary Prevention of Cervical Cancer. Asian Pacific journal of cancer prevention: APJCP, 19(9), 2357.
13. These two IIT Delhi boys created a reusable, biodegradable sanitary napkin made of banana fibre!https://www.indiatoday.in/education-today/how-i-made-it/story/iit-delhi-boys-create-reusable-biodegradable-sanitary-napkin-made-of-banana-fibre-1593506-2019-08-30
14. Rajput, A. S. (2019). India’s Scientific Social Responsibility Policy.

Feature image courtesy: The News Minute