Cancer of cervix is the third most common cancer in women and is the second most common cause of death from cancer in women [1,2]. It is estimated that in India,1,26,000 new cases occur each year [3]. India also has the highest age standardized incidence of cervical cancer in South Asia, Bangladesh and Iran[4].The incidence of cervical cancer has decreased by more than 50% in the past 30 years, due to increasing use of cervical cancer screening with cervical cytology [5].

Cancer of cervix is readily preventable, by early detection and appropriate timely treatment of its precursor lesions by simple Pap screening test. Women usually present to the clinic with the symptoms, such as pain, discharge, and/or abnormal bleeding.[6]

The mainstay of cervical cancer screening has been the Papanicolaou test, also known as the Pap test or the Pap smear. It was developed by Dr. George Papanicolaou in the 1940s who discovered that precancerous and cancerous cells could be identified in cytologic samples from vaginal aspirates [7]. Unlike most other malignancies, cancer of cervix is readily preventable when effective programmes are conducted to detect and treat its precursor lesions [8].

Cervical epithelial cell abnormalities in the Pap smear represents a spectrum of intraepithelial lesions that lie along the pathway from mild-to-severe dysplasia to invasive cancer.[9] Though Pap smear is a routine screening test, the overall sensitivity in detection of high grade squamous intraepithelial lesion (HSIL) is 70 - 80%[10]. The Bethesda System (TBS) for reporting the results of cervical cytology was developed as a uniform system of terminology that could provide clear guidance for clinical management.

In the present study we will find the distribution of various cervical lesions by conventional Pap smear and classify them according to the Bethesda system.

The study is a one month observational study conducted in Department of Pathology, JLN Medical College, Ajmer to evaluate all the conventional Pap smears reported during 1st September 2024 to 30th September 2024. Informed consent was obtained from the participants and the study was approved by Institutional Ethical Committee.

Inclusion Criteria:

1. Sexually active women.
2. Age group: 21 to 80 years.
3. Presenting to the gynaecology department.
4. Complaints such as vaginal discharge, intermenstrual bleeding, postmenopausal bleeding, abdominal pain, irregular menses, or prolapse.
5. Provided informed consent for the Pap smear test.

Exclusion Criteria:

1. Women aged less than 20 years.
2. Pregnant females.
3. History of cervical cancer treatment.
4. Women who have undergone hysterectomy.
5. Presence of cervical growths.
6. Presence of menstrual bleeding.

Gynaecologists instructed patients to abstain from coitus, local douching, and antiseptic use before the cytological examination. Patients were positioned in the lithotomy position and a sterile bivalve speculum was inserted for proper visualisation of the cervix and vaginal wall. The posterior and anterior vaginal walls were retracted to facilitate examination. After a per speculum assessment, the longer projection of Ayers spatula was inserted near the squamocolumnar junction and rotated 360°. Gynaecologists collected cytological smears using the conventional method for routine screening. All slides were immediately labeled and

placed in 95% ethyl alcohol jars. Pap staining and H&E was performed by trained cytotechnologists followed by light microscopy and interpretation by cytopathologists.

The study included 187 patients categorized into four age groups: 20-35 years (45.99%), 36-50 years (42.25%), 51-65 years (9.63%), and 66-80 years (2.14%), with a mean age of 38.16 ± 9.96 years. The majority (88.24%) were aged between 20-50 years. The most common clinical complaint was white discharge (22.46%), followed by lower abdominal pain (12.83%) and Pelvic Inflammatory Disease (7.49%). Abnormal Uterine Bleeding, cervicitis, and irregular menstrual bleeding were reported in 6.42%, 4.81%, and 3.74% of cases, respectively. Less frequent conditions, including heavy menstrual bleeding, prolapse, and post-coital bleeding, were noted in 1.60% of cases each. Cytological evaluation revealed inflammatory smears in 52.66%, NILM in 23.40%, and unsatisfactory samples in 11.70%. Bacterial vaginitis was found in 5.85%, while normal cytology was observed in 2.13%. Altered bacterial flora and HSIL were each identified in 1.60%, with atrophic inflammatory smears present in 0.53% of cases.

Table 1: Distribution of cases according to age.

Table 2: Distribution of cases according t o Clinical Diagnosis.

Table 2 presents the distribution of clinical signs symptoms as well as provisional clinical diagnosis among patients. The most common complaint was white discharge, affecting 22.46% of patients, followed by lower abdominal pain in 12.83%. Pelvic Inflammatory Disease (PID) was noted in 7.49%, while Abnormal Uterine Bleeding (AUB) was reported in 6.42%. Cervicitis accounted for 4.81% of cases, irregular menstrual bleeding for 3.74%, and heavy menstrual bleeding, prolapse, and post-coital bleeding each for 1.60%. Other diagnosis, including menorrhagia, fibroids, carcinoma of the uterus, cervical erosion, chronic cervicitis, endometriosis, vaginitis, and various menstrual and pelvic complaints, were observed at lower frequencies (0.53%-1.07%).

Table 3: Distribution of cases according to Microscopic Diagnosis.

Table 3 represents the clinical diagnosis distribution among patients based on cytological evaluation by conventional Pap smear as per The Bethesda system. The majority (52.66%) were diagnosed with an inflammatory smear followed by NILM (Negative for Intraepithelial Lesion or Malignancy) in 23.40% of cases. Samples deemed unsatisfactory for evaluation accounted for 11.70%. Bacterial vaginitis was observed in 5.85% of patients, while normal

cytology was seen in 2.13%. Altered bacterial flora and HSIL (High-Grade Squamous Intraepithelial Lesion) were each identified in 1.60% of cases. Atrophic inflammatory smear and general inflammation were noted in 0.53% of cases each.

The age range in present study is 20 years to 80 years compared to age range 20 years to 70 years in study done by Bhagya Lakshmi Atal et al[11].

White discharge is the most commonly present sign and symptom in our study of patients put to cervical screening by conventional Pap smear similar to study done by Bhagya Lakshmi Atal et al[12]. Inflammatory smear and NILM is the most common cytological pattern observed by conventional Pap smear according to TBS in our study concordant to finding in study by Selvanayaki K. et al[13]. However LSIL was most common cytological pattern observed in study by Bhagya Lakshmi Atal et al.

Fig.1: Inflammatory smear

Fig.2: Bacterial vaginosis

Fig.3: Atrophic smear

Fig.4: LSCL

Our study highlights the necessity and significance of cervical screening, emphasizing its role in the early detection of cervical cancer. It also paves the way for further research on improving early diagnostic methods. The primary objective of the Pap smear screening process is to identify women with precancerous lesions, allowing timely intervention before the disease progresses to invasive cancer. As a widely used simple and cost effective routine test, the Pap smear plays a crucial role in early detection and effective management of cervical abnormalities. Although our study represents only a small segment of the population, the findings underscore the need to actively encourage and motivate women to participate in regular screening programs.

1. Bamanikar, S. A., et al. "Study of Cervical Pap Smears in a Tertiary Hospital." Indian Medical Gazette, July 2014, pp. 250-254.
2. "Cervical Cancer, Human Papilloma Virus (HPV), and HPV Vaccines: Key Points for Policy-Makers and Health Professionals." World Health Organization, who.int.
3. Bal, M. S., et al. "Detection of Abnormal Cervical Cytology in Papanicolaou Smears." J Cytol, vol. 29, no. 1, 2012, pp. 45-47.
4. ICO Information Centre on HPV and Cancer. "Human Papillomavirus and Related Diseases in India (Summary Report 2014-08-22)." ICO Information Centre, 2014.
5. American College of Obstetricians and Gynaecologists. "Cervical Cancer Screening and Prevention." Practice Bulletin No. 157, Obstet Gynecol, Jan. 2016, vol. 127, no. 1, pp. 20-35.
6. Bamanikar, S. A., et al. "Study of Cervical Pap Smears in a Tertiary Hospital." Indian Medical Gazette, 2014, pp. 250-254.
7. Gibb, R. K., and M. G. Martens. "The Impact of Liquid-Based Cytology in Decreasing the Incidence of Cervical Cancer." Rev Obstet Gynecol, vol. 4, suppl. 1, 2011, pp. S2-S11.
8. Toews, H. A. "The Abnormal Pap Smear: A Rationale for Follow-Up." Can Fam Physician, vol. 29, 1983, pp. 759-762.
9. Maryem, A., et al. "Smear Pattern and Spectrum of Premalignant and Malignant Cervical Epithelial Lesions in Postmenopausal Indian Women: A Hospital-Based Study." Diagnostic Cytopathology, vol. 40, no. 11, 2011, pp. 976-983.
10. Rajput, N., et al. "Detection of Abnormal Cervical Cytology by Pap’s Smear and Comparison Between Rural and Urban Women." Journal of Evolution of Medical and Dental Sciences, vol. 2, no. 41, 2013, pp. 7923-7930.
11. Atla, B. L., et al. "Cytological Patterns of Cervical Pap Smears with Histopathological Correlation." Int J Res Med Sci, vol. 3, no. 8, 2015, pp. 1911-1916.
12. Atla, B. L., et al. "Cytological Patterns of Cervical Pap Smears with Histopathological Correlation." Int J Res Med Sci, vol. 3, no. 8, 2015, pp. 1911-1916.
13. Selvanayaki, K., and A. Archana. "A Comparative Study of Pap Smear Cytological and Histopathology of Cervix Biopsy." Tropical Journal of Pathology and Microbiology, vol. 6, no. 3, 2020, pp. 1-5.