Cervical cancer remains a worldwide health burden despite being highly preventable and treatable if detected early. Chronic infection with high risk human papillomavirus (HPV) has been accepted as the required cause of cervical cancer, and HIV-positive women have a six-fold risk compared to HIV-negative women [1]. In 2022, there were an estimated 660 000 diagnoses and 350 000 deaths due to cervical cancer globally, ranking it the fourth most frequent cancer in women and highlighting stark inequities: 94% of deaths had taken place in low and middle income countries. In India, cervical cancer is the second most common female cancer and causes about 123,907 new cases and 77,348 deaths every year, with an age standardized incidence rate of 18.7 per 100,000 women [2]. In turn, the World Health Organization (WHO) released its Global Strategy for Cervical Cancer Elimination in 2020, with targets of 90-70-90 by the year 2030:90% of girls vaccinated against HPV at age 15 years, 70% of women screened with a high performance test between ages 35 and 45 and 90% of women with cervical disease appropriately treated [3]. Modelling has suggested that meeting these goals may prevent 74 million cases and 62 million deaths by the year 2120. To achieve a global elimination level, an incidence of ≤ 4 per 100 000 women-years, nations have to improve vaccination, screening, and treatment services [1]. Cytology-screening (Pap smear) launched in the mid-20th century has contributed enormously to incidence and mortality decline in high-income countries. For example, population-based Pap programs have achieved mortality declines of 80% in Iceland, 50% in Finland, and 34% in Sweden within two decades [4]. In India screening prevalence is low comprising only 1.97% of women aged 30–49 years in NFHS-5 (2020–21) with wealth-based differentials between 0.2% in West Bengal and 10.1% in Tamil Nadu [5]. WHO suggests primary HPV DNA testing as the screening test of choice due to greater sensitivity for high-grade lesions [6]. Yet cytology content remains suboptimal in most resource-constrained settings. This study aimed to evaluate the cytopathological spectrum of cervical lesions among women attending the outpatient department (OPD) in a tertiary care medical college hospital. Objective The main objective of this study is to assess the cytopathological spectrum of cervical lesions using Pap smear screening at the gynaecology outpatient department and categorize them by The Bethesda System (TBS) and relating cytological findings with demographic and clinical parameters. Thus guiding strategies for maximizing cervical screening programs and moving towards WHO elimination targets in low-resource tertiary care settings.

This is a prospective observational study done between January 2023–June 2025 in Nandha Medical College Hospital, Erode, Tamilnadu. A total of 1042 female patients who attended gynecology OPD and for whom pap smear testing was performed were included, and those with a known diagnosis of cervical carcinoma and active vaginal bleeding at the time of examination were excluded from the study. Inclusion Criteria • Women attending the gynaecology outpatient clinic. • Those who consented to undergo Pap smear testing. Exclusion Criteria • Women with a known diagnosis of cervical carcinoma. • Patients with active vaginal bleeding at the time of examination. Sample Collection: Cervical smears were collected by trained clinicians using Ayre’s spatula and endocervical brush from the ectocervix and endocervical canal. Smears were immediately fixed using 95% ethanol to prevent drying and stained by the Papanicolaou technique. All smears were evaluated in the pathology department and reported using The Bethesda System 2014 for cervical cytology reporting.The Bethesda System (TBS), originally published in 1988 and most recently revised in 2014 by Nayar and Wilbur, ensures standardized cervical cytology reporting, allowing reproducible results, research, and correlation with histology and management guidelines7. Data Collection and Analysis Data were entered into MS Excel and analyzed using JAMOVI (v 2.7.5). Categorical data were expressed as percentages, while continuous data were expressed as Mean ± Standard Deviation if normally distributed, or as median and interquartile range if not normally distributed. Fischer exact test was used to find the p – value.p – value less than 0.05 was considered statistically significant.

The majority of the participants belonged to the 40–59 years age group (54.8%), followed by those in the 20–39 years group (37.9%). Participants aged 60 years and above comprised the smallest proportion (7.3%). This indicates a predominance of midlife women (Table 1) in the study cohort, which may reflect the age group most commonly accessing screening or reproductive health services. Only 1 case of squamous cell carcinoma (0.09%) was reported. These findings (Table 2) suggest a low burden of cytological abnormalities in the screened population, which may be attributed to early detection, healthy behaviors, or a screening bias toward low-risk individuals. Out of 1042 patients tested, 119 tested positive for infective organisms. Of all the organisms, the predominance of bacterial vaginosis (Table 3 & Figure 1) may reflect disruptions in vaginal flora or hygiene practices among the study population and warrants public health attention for preventive strategies. There was a statistically significant association (p = 0.039) between age and type of infective organism identified (Table 4). Bacterial vaginosis was prevalent across all age groups but was particularly dominant in the 40–59 age group (98.6%). Candida infections were more evenly distributed but peaked in the 60–79 age group (50%). Trichomonas was detected only in the youngest age group (20–39 years). These findings suggest age-related variation in vaginal microflora and potential hormonal or behavioral influences. The most common indication for pap smear examination was Routine PAP smear examination (Table 5) followed by Abnormal uterine bleeding. Table 1: Age-wise Distribution of Study Participants Age categorised n Proportion 20-39 395 37.908 % 40-59 571 54.798 % 60-79 76 7.294 % Table 2: Distribution of Smear Cytology Reports among Participants (The 2014 Bethesda system): Smear interpretation n Proportion Atypical Squamous Cell of Undetermined Significance 3 0.28% Atypical endocervical cells NOS 2 0.19% Atypical glandular cells NOS 5 0.47% Squamous cell carcinoma of cervix 1 0.09% High grade Squamous Intraepithelial Lesion 2 0.19% Low grade Squamous Intraepithelial Lesion 1 0.09% Negative for Intraepithelial Lesion or Malignancy 1024 98.27% Unsatisfactory 4 0.38% Table 3: Distribution of Detected Infective Organisms in Vaginal Smears Infective Organism n Proportion Bacterial Vaginosis 113 10.8% Candida 4 0.38% Trichomonas 1 0.095% Herpes 1 0.095% Table 4: Age-wise Distribution of Infective Organisms in Vaginal Smears Age Category (years) Bacterial Vaginosis Candida Trichomonas Herpes p -value 20–39 41 (93.2%) 2 (4.5%) 1 (2.3%) 0(0.00%) 0.039 40–59 71 (98.6%) 1 (1.4%) 0 (0.0%) 1(1.00%) 60–79 1 (50.0%) 1 (50.0%) 0 (0.0%) 0(0.00%) Table 5: Indications for taking pap smear: Indications n proportion Chronic pelvic pain 9 0.86% Routine PAP smear 768 73.70% Abnormal Uterine bleeding 107 10.27% Intermenstrual spotting 33 3.17% Postmenopausal bleeding 48 4.61% Chronic PID 28 2.69% Previous abnormal pap smear 17 1.63% Post coital bleeding 32 3.07% Figure 1: Distribution of Detected Infective Organisms in Vaginal Smears

In this study, Bacterial vaginosis (BV) was identified as the most common infection, consistent with prior studies reporting prevalence rates between 10.8% and 18.34% as shown in Table 3 [8-11]. Candida species and Trichomonas vaginalis were less frequently observed, with detection rates below 1% in this study, aligning with reported ranges of up to 11.16% and 5.9% by Narasimha et al, respectively. Herpes simplex virus remained exceedingly rare, with detection rates consistently under 0.2% across studies as shown in Table 3 [9,11]. These findings reinforce the diagnostic utility of Pap smear in identifying a broad range of lower genital tract infections in routine gynecological care. Cytological abnormalities were rare in this study, with most smears classified as negative for intraepithelial lesion or malignancy (NILM) as shown in Table 2, a pattern supported by other studies that report abnormal cytology in fewer than 5% of cases [8,12-14]. Nonetheless, the presence of moderate to severe inflammation, particularly cases of aerobic vaginitis, was more strongly associated with high-grade lesions than infections such as bacterial vaginosis alone [15] . Age-wise distribution patterns observed in this study as shown in Table 4 were also consistent with earlier reports, showing a peak in infection rates among women aged 31–50 years, with a gradual decline thereafter [8,10,11]. This age trend may be attributed to reproductive hormonal fluctuations, increased sexual activity during midlife, and associated changes in vaginal flora. BV was most prevalent in this age group, while Candida showed a broader age distribution, sometimes peaking among older women, possibly due to postmenopausal mucosal changes. In contrast, Trichomonas vaginalis was more frequently identified in younger women, possibly due to higher transmission risk in sexually active populations [10]. In terms of clinical presentation, routine screening was the most common reason for cytological evaluation as shown in Table 5, although many women presented with symptoms such as abnormal vaginal discharge, bleeding, or pelvic discomfort [12,16]. This highlights the dual diagnostic and preventive role of the Pap smear, extending its value beyond the detection of cervical neoplasia to encompass the management of infectious and inflammatory conditions that contribute substantially to gynecological morbidity. While cytological screening remains effective and accessible, its limitations must be acknowledged, particularly in detecting intracellular and fastidious organisms. The use of molecular techniques such as PCR can complement cytological findings, especially in cases of persistent inflammation without identifiable pathogens. Integrating such diagnostics into public health strategies could enhance the sensitivity and specificity of cervical infection surveillance and further reduce the burden of undetected reproductive tract infections.

This prospective observational study demonstrate a predominance of negative for intraepithelial lesion or malignancy (NILM) results and a low burden of high-grade cervical lesions among screened women. However, the notable detection of bacterial vaginosis and other cervico-vaginal infections highlight the broader diagnostic utility of Pap smears in gynecological care. The findings call for health system strengthening to expand screening coverage, especially among underserved populations, and advocate for a dual-purpose screening model addressing both neoplastic and infectious gynecological conditions. These efforts are essential to move toward equitable, evidence-informed cervical health strategies in India and similar high-burden regions.

1. Fact Sheet Cervical Cancer [Internet]. World Health Organisation; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer 2. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in the World: Summary Report [Internet]. 2023. Available from: https://hpvcentre.net/statistics/reports/XWX.pdf?t=1693242823846 3. Initiative - Cervical Cancer Elimination [Internet]. World Health Organisation; 2018. Available from: https://www.who.int/initiatives/cervical-cancer-elimination-initiative 4. Lăără E, Day NicholasE, Hakama M. Trends in mortality from cervical cancer in the nordic countries: association with organised screening programmes. The Lancet. 1987;329:1247–9. 5. Muthuramalingam MR, Muraleedharan VR. Patterns in the prevalence and wealth-based inequality of cervical cancer screening in India. BMC Womens Health. 2023;23:337. 6. World Health Organization, Special Programme of Research, Development, and Research Training in Human Reproduction (World Health Organization). WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. Second edition. Geneva: World Health Organization; 2021. 1 p. 7. Nayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology: A Historical Perspective. Acta Cytologica. 2017;61:359–72. 8. Tamrakar R, Ranabhat S, Shrestha M, Poudel S, Shrestha S, Khanal B, et al. Clinico-pathological Analysis of Cervical Pap Smear in Patients Attending Gynecology OPD of a Medical College. Europasian Journal of Medical Sciences [Internet]. 2021; Available from: https://www.europasianjournals.org/ejms/index.php/ejms/article/view/288 9. Narasimha A, C N, B C, N N, L H. Spectrum of infections in cervico-vaginal pap smears. Journal of clinical and biomedical sciences [Internet]. 2014; Available from: https://dx.doi.org/10.58739/jcbs/v04i1.4 10. Kumar U, Singhal U, Jain P, Trivedi S. Cytomorphological spectrum of cervicovaginal infections and their prevalence with clinical correlation on pap smears: A three-year retrospective study. Panacea Journal of Medical Sciences [Internet]. 2022; Available from: https://doi.org/10.18231/j.pjms.2022.019 11. Bukhari M, Majeed M, Qamar S, Niazi S, Syed S, Yusuf A, et al. Clinicopathological study of Papanicolaou (Pap) smears for diagnosing of cervical infections. Diagnostic Cytopathology [Internet]. 2012;40. Available from: https://doi.org/10.1002/dc.21498 12. Naik K. Cytology screening for cervical cancer by conventional Pap smear: Experience at private hospital and diagnostic centre catering to sub urban population. International Journal of Clinical and Diagnostic Pathology [Internet]. 2020; Available from: https://doi.org/10.33545/pathol.2020.v3.i1g.376 13. Bal M, Goyal R, Suri A, Mohi M. Detection of abnormal cervical cytology in Papanicolaou smears. Journal of Cytology / Indian Academy of Cytologists [Internet]. 2012;29:45–7. Available from: https://journals.lww.com/jocy/fulltext/2012/29010/detection_of_abnormal_cervical_cytology_in.10.aspx 14. Mishra R, Bisht D, Gupta M. Primary screening of cervical cancer by Pap smear in women of reproductive age group. Journal of Family Medicine and Primary Care [Internet]. 2022;11:5327–31. Available from: https://journals.lww.com/jfmpc/fulltext/2022/09000/primary_screening_of_cervical_cancer_by_pap_smear.60.aspx 15. Vieira-Baptista P, Lima-Silva J, Pinto C, Saldanha C, Beires J, Martinez-De-Oliveira J, et al. Bacterial vaginosis, aerobic vaginitis, vaginal inflammation and major Pap smear abnormalities. European Journal of Clinical Microbiology & Infectious Diseases [Internet]. 2016;35:657–64. Available from: https://doi.org/10.1007/s10096-016-2584-1 Download citation 16. Nikumbh D, Nikumbh R, Dombale V, Jagtap S, Desai S, Medical S. Cervicovaginal Cytology: Clinicopathological and Social Aspect of Cervical Cancer Screening in Rural (Maharashtra) India. International Journal of Health Sciences and Research [Internet]. 2012;1:125–32. Available from: https://consensus.app/papers/cervicovaginal-cytology-clinicopathological-and-social-nikumbh-desai/c425d68fb3885a429d7f11f7c859c8a7/