Open Journal of Obstetrics and Gynecology, 2011, 1, 21-24
doi:10.4236/ojog.2011.12005 Published Online June 2011 (http://www.SciRP.org/journal/ojog/ OJOG ).
Published Online June 2011 in SciRes. http://www.scirp.org/journal/OJOG
Evaluation of a public expense-covered gynecologic screening
program in Japan 2005-2009
Hiroshi Takagi, Satoshi Ichigo, Kazutoshi Matsunami, Atsushi Imai*
Department of Obstetrics and Gynecology, Matsunami General Hospital, Kasamatsu, Gifu, Japan.
Received 14 April 2011; revised 31 May 2011; accepted 8 June 2011.
ABSTRACT
Introduction: In Japan, there is free physical check-
up programs of cancer screening, by which asymp-
tomatic participants undergo a medical examination
at public expense. The present study aims to describe
their gynecologic findings and compare them with the
literatures reported from general hospitals and self-
paid check-up programs. Methods: Medical records
of Japanese women, who underwent gynecological
examinations at public expense between 2005 and
2009, were retrospectively reviewed. Results: Of the
cervical smears from 2850 women aged 21 - 82 years,
33 (1.1%) were classified as dysplastic and malignant
changes: 28 of low-grade squamous intraepithelial
lesion (LSIL), 3 high-grade squamous intraepithelial
lesion (HSIL), 2 atypical squamous cells of unde-
terimined significance (ASC-US). No case of cervical
squamous cell carcinoma or adenocarcinoma was
found. Ultrasonographic examination detected uterus
enlargements and ovary tumors in less than 1% of
cases. Most of participants (98%) revealed no gyne-
cologic abnormalities. Conclusion: Annual gyneco-
logic screening and proper follow-up programs even
against asymptomatic women may remarkably re-
duce the probability of (pre)malignant disease.
Keywords: Cervical Smear Screening; Transvaginal
Sonography; Gynecologic Check-up; Oncology
1. INTRODUCTION
Cervical intraepithelial neoplasia typically develops into
invasive cancer over a 10-year period and apparent cases
of rapidly progressive cervical cancer are likely to be
among women who have escaped screening and proper
follow-up [1-6]. The cervical smear (Papanicolaou, Pap
smear) is a routine screening test used for the detection
of early cervical abnormalities, namely precancerous
dysplastic changes of the uterine cervix [1-6]. Organized
screening programs for cervical cancer using the cervical
smears have been shown to be effective in decreasing
mortality and incidence from the disease [1,7]. The cer-
vical screening is a relatively simple, low cost and non-
invasive method. Together with transvaginal ultrasono-
graphy for detection of ovarian and uterine tumors, a
routine cervical screening reduces the probability of de-
veloping gynecological m a li gnant di seases .
In many countries, undergoing cancer screening is not
mandatory but voluntary. The level of knowledge and
attitude toward screening are related to multiple factors
such as ethnicity, place of residence, income, and social-
economic status [8-12]. In Japan, there are free physical
check-up programs of cancer screening, by which as-
ymptomatic participants undergo a medical examination
at public expense. The present study aims to describe
their gynecologic findings and compare them with the
literatures reported from general hospitals and self-paid
check-up programs.
2. METHODS
Between January 2005 and December 2009, 2850 as-
ymptomatic women, age 21-82, visited one of four Ka-
samatsu City-agreed gynecologic physicians for their
physical check-up. The cost was fully covered by the
municipal corporation. Gynecologic examinations in-
cluded routine cancer screening (Papanocolaou test),
transvaginal ultrasonography, and pelvic examination by
a gynecologist. Cervical and endometrial smears were
taken using a speculum and brush and classified into 6
categories: normal, low-grade squamous intraepithelial
lesions (LSIL), high-grade squamous intraepithelial le-
sions (HSIL), atypical squamouse cells of undetermined
significance (ASC-US), cervical carcinoma, cervical
adenocarcinoma. When classified as inadequate, the par-
ticipants were soon resubmitted to smear examination.
Their records of gynecologic findings were retrospec-
tively reviewed.
3. RESULTS
Table 1 shows the cytologic and ultrasonografic f indings

H. Takagi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 21-24 22
Table 1. Gynecologic findings of participants distributed by age.
Cytology
Cervix Endometrium
Age group,
years No. (%)
LSIL HSIL ASC-USSCCHyperplasia/cancer
Uterine tumor
and abnormalities1) Ovarian tumor2) Others3)
20 - 24 26 (0.9) 1 (3.8) 0 0 0 0 0 0 0
25 - 29 94 (3.3) 1 (1.1) 0 0 0 0 0 1 (1.1) 0
30 - 34 282 (9.9) 5 (1.8) 0 1 (0.3) 0 0 0 1 (0.3) 0
35 - 39 400 (14.0) 5 (1.8) 1 (0.3) 0 0 0 0 1 (0.3) 0
40 - 44 398 (14.0) 4 (1.3) 1 (0.3) 0 0 0 1 (0.3) 1 (0.3) 2 (0.5)
45 - 49 259 (9.1) 3 (1.0) 1 (0.4) 1 (0.4) 0 0 6 (2.3) 1 (0.4) 1 (0.4)
50 - 54 257 (9.1) 3 (1.1) 0 0 0 0 3 (1.1) 0 1 (0.4)
55 - 59 299 (10.5) 1 (1.3) 0 0 0 0 1 (0.3) 0 0
60 - 64 287 (10.1) 1 (0.3) 0 0 0 0 1 (0.3) 0 0
65 - 69 281 (9.9) 1 (0.3) 0 0 0 0 1 (0.3) 1 (0.6) 0
70 - 74 172 (6.0) 2 (1.2) 0 0 0 0 0 1 (0.6) 1 (0.6)
75 - 79 76 (2.7) 1 (1.3) 0 0 0 0 0 0 0
<80 19 (0.7) 0 0 0 0 0 0 0 0
28 (1.0) 3 (0.1) 2 (<0.1) 0 0 13 (0.5) 7 (0.2) 5 (0.2)
Total 2850 (100) 56 (2.0)
1) adenomyosis and uterine myoma (measuring 5 to 9 cm). 2) unilobular cyst (measuring 3 to 5 cm) suggestive for benign mass. 3) including vaginosis, cervical
polyp, prolaps uteri.
of all subjects distributed by age class. Of the cervical
smears, 33 (1.1%) were classified as abnormal. Low-
grade cervical abnormalities were seen in 31 cases: 28
cases were classified as low-grade squamous intraepi-
thelial lesion (LSIL) and 3 as high-grade squamous in-
traepithelial lesion (HSIL), 2 were atypical squamous
cells of undetermined significance (ASC-US). No ma-
lignant case was detected within this study period. No
case of cervical adenocarcinoma was found. None of the
categories were clustered in any specific age group.
The most frequently detected gynecologic finding was
uterine enlargement, with a peak reaching approximately
10% for age group 45 - 49 years. After 55 years, the
frequency of uterine abnormalities decreased (Ta b l e 1 ).
Ovarian tumor was detected in less than 1% of those
aged 25 to 49 years, while those aged over 50 years
showed less frequent. Ta b le 1 summarized all other ab-
normal findings pointed out. No gynecologic abnormal-
ity was detected in 98% of cases.
4. DISCUSSION
The cervical smear is a widely used routine test with
many benefits, especially in detecting early cervical
changes that can be treated to limit dysplastic processes
developing into cancer. The previous literatures found
squamous intraepiterial lesion (SIL) in 3% - 8% of
women aged 20 - 29 years and 1% - 5% of over 30-year
age group [1-6]. Of the cervical smear tests on 7585
subjects in our study, 98.2% were negative. The inci-
dence of abnormal cytologic findings (dysplastic
changes and cervical cancer) in our study (1.2%) was
extremely low compared with other studies performed in
developed countries [1-6].
Substantial data point to persistent human papillo-
mavirus (HPV) infection as cervical cancer cause. The
mean time between HPV infection and invasive cancer is
about 15 years, and within 2 to 4 years of detection 15.5
to 25.5% of low-grade epithelial lesions become high-
grade lesions [13-15]. The most frequently sexually
transmitted disease (STD) worldwide is HPV infection
[16,17]. Societies where sexual activity starts at a young
age and where multiple partners are common are at high
risk of exposure to HPV than in conservative societies.
For example, a study in Jordan, one of the most conser-
vative and religious countries, found that of the smears
from 1176 women aged 18 - 70 years, 9 cases (0.8%)
were classified as ASC-US and 2 cases (0.2%) were
LSIL. Based on our result of city-agreed check-up, as-
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opyright © 2011 SciRes. OJOG

H. Takagi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 21-24 23
ymptomatic participants undergo a medical examination
at public expense. The cultural tradition and high con-
cern on check-up of our subjects restrict the likelihood
of multiple sexual partners. This may explain why very
low incidence of dysplastic changes and cervical cancer
were found in our study group of women.
Of pelvic mass, uterine myomas and/or adenomyosis
are estimated to be present in 20% - 25% or reproduc-
tive-age women, indicating that they are one of the most
common human neoplasma [18-20]. A myoma does not
necessarily produce symptoms, and even very large ones
may go undetected by the patient, particularly if she is
obese. Symptoms from myomas depend on their location,
size and state of presentation; symptoms are present in
35% - 50% of patients with myomas. Ovarian tumors,
cystic or solid, are also frequently asymptomatic and
undetected by themselves. The diagnosis of these tumors
is not usually difficult using ultrasonography at physical
check-up. We observed lower frequency of uterine en-
largement and ovarian tumors in our subjects.
The present study based on symptom-free population
suggested annual gynecologic screening and proper fol-
low-up programs even against asymptomatic women
may remarkably reduce the probability of (pre) maliga-
nant disease. Since the study sample was shown to be
representative populatio n of high-attitu de toward screen-
ing but non-high income, most of our observations may
have important implications in terms of public health.
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