the possible presence of infection in cervical smear tests is usually reported by the cytologists based on cytological criteria
. therefore , non - specific cervicitis or inflammatory changes in a smear report are common .
these findings are usually unclear for clinical approaches and there is not an appropriate guideline for management of such patients .
it is not known if these women should be recalled for cultures and treatment or inflammatory change should be considered as minor .
changes in balance of normal vaginal flora can cause an overgrowth of pathogens that lead to discharge .
although it is a common complain among sexually active women , there are still gaps in our knowledge about it . bacterial vaginosis ( bv ) , vaginal candidiasis ( vc ) and trichomoniasis are the three infections most commonly associated with vaginal discharge ( 1 ) .
a number of studies have indicated the association of bv with postoperative complications after gynecologic surgery as well as pregnancy complications ( 25 ) .
trichomonas vaginalis ( tv ) is also another common cause of vaginal discharge , but some studies have not found its association with pregnancy complications ( 3 ) or some other indicated that tv during pregnancy was a predisposing factor for preterm delivery and delivering low - birth weight infants ( 6 ) . the pap smear test for detection of bv has showed a sensitivity of 88.2% , a specificity of 98.6% , and a positive predictive value ( ppv ) of 96.8% ( 7 ) . the sensitivity , specificity , and ppv of pap test for tv diagnosis has been reported 98% , 96% , and 88% , respectively ( 8) . also , some recent studies have demonstrated the co - infection of vaginal pathogenic organisms in pap tests ( 2 , 9 , 10 ) .
this study aimed to investigate the prevalence of pathogenic vaginal microorganisms and the presence of inflammation in pap smear among an iranian women sample and to evaluate the possible co - infection of these organisms .
this cross - sectional study was carried out on pap smear samples of women referred to gynecological clinic of taleghani hospital in tehran , iran , between october 2008 and march 2009 .
exclusion criteria were pregnancy , smoking , use of oral contraception and/or corticosteroids , regular use of vaginal douche , and women with chronic systemic diseases or systemic immunosuppression .
prior to data collection , the objectives of the study were explained in community meetings .
all women received their laboratory results in written form , and results were explained during a consultation .
the study protocol was also approved by the institutional review boards of department of gynecology and obstetrics .
data were obtained in privacy using an information form applied by one investigator , followed by gynecological examination and specimen collection all done by one gynecologist .
cervical smear samples , based on the conventional method , were prepared with a spatula and fixed on glass slides and were stained with the papanicolaou technique .
tv was defined as the presence of trophozoites in pap smears ; vc was diagnosed if fungal hyphae or budding yeasts were present in pap smears .
the presence of inflammation in the smears was divided into mild , moderate , and severe categories .
mild inflammation was defined as less than 30 inflammatory cells / high - power field ; moderate inflammation was defined as 30 to 100 inflammatory cells / high - power field ; and severe inflammation was defined as more than 100 inflammatory cells / high - power field .
the frequency of pathogenic microorganism included bv , tv , and vc were determined in specimens .
statistical significance was analyzed using statistical package for social sciences ( spss software version 17 ) .
the comparison between data was performed with the pearson 's chi square or fisher 's exact test .
mild inflammation was noted in 136 ( 26.1% ) , moderate in 155 ( 29.4% ) and severe in 117 ( 22.2% ) of them ( table 1 ) . 
  the frequency of pathogenic vaginal microorganisms and inflammation among pap smear samples among all samples , bv ( the presence of clue cells ) was the most common pathogenic microorganism which was seen in 91 samples ( 17.2% ) , followed by vc ( n = 56 ; 10.6% ) .
tv ( n = 2 ; 0.4% ) was shown to have a low prevalence among our patients ( table 1 ) .
the overall prevalence of pathogenic microorganisms was greater among reproductive age participants , meanwhile the prevalence of bv as well as vc was significantly different ( p = 0.042 and p = 0.006 , respectively ) between non- and post- menopausal women .
inflammation was detected in 76% ( n = 402 ) of pap smears , in which 80.1% ( n = 322 ) were reported among reproductive age women . however , the severity of inflammation was not significantly different between non- and post- menopausal women .
overall , the presence of inflammation was significantly associated with vc ( p = 0.002 ) , but its severity was not correlated to the infection .
although , there was no significant relation between the presence of inflammation and bv , the severity of inflammation in specimen was significantly increased in association with bv ( p < 0.001 ) .
in our study , the prevalence of bv among pap smear specimens of women living in tehran was 17% which is similar to azargoon 's study ( 16% ) on a population in semnan ( another city in center of iran ) ( 3 ) , but it had a higher rate in hamadan ( a western city of iran ) and has been reported 28.5% ( 11 ) . in comparison with other asian countries , in india ,
but it was 38% in an african study in botswana on 703 pregnant women ( 13 ) .
some predisposing factors for bv include having sexual relationship with more than one partner , early onset of sexual activity , orogenital sexual contacts , coitus during menstruation , use of iud , and smoking ( 2 , 14 ) .
differences in sexual behavior and risk factors in different societies can justify the differences in bv prevalence of mentioned studies .
reproductive age women indicated that the prevalence of bv in muslim women was lower than non - muslims .
although the prevalence of tv in pap samples of our study was much less than several studies , similar reports demonstrated by depuydt et al in flanders detected by real - time pcr ( 0.37% ) ( 15 ) . however , this rate was 18% in the study in hamedan ( 11 ) , 8.5% among indian women ( 16 ) , and 19% in the african study ( 13 ) .
a probable reason for these variations could be differences in pap sampling quality and cytologists skill .
several studies show an increased vaginal ph ( 5 ) in both bv and tv infection ( 3 , 5 , 17 ) .
demirezen et al in turkey on 600 pap tests detected tv in 6% of women and bv in 44% of tv cases .
they also found a significant relationship between tv and bv infection , which might be due to this hypothesis that tv by phagocytosis the vaginal lactobacilli increases the vaginal ph and generates an anaerobic environment , providing an appropriate condition for the growth of anaerobic microorganisms ( 18 , 19 ) .
also , it was confirmed by heller 's study on 400 pap samples which concluded that bv diagnosis should be considered at the presence of tv in pap smears ( 2 ) . in our study , we found no significant association between bv and tv in conventional pap smear sampling , which might be because of low prevalence of tv in our samples .
the effect of habits and behaviors on vaginal flora among different population can be evaluated in further assessments . in our study , only the presence of candida in pap smear samples was associated with the report of inflammation . therefore , reporting inflammation in pap smear test might be considered for candidiasis evaluation and treatment .
several studies investigated the association between infection and existence of inflammation in cervical smears ( 2023 ) .
some of them found that inflammation on pap smear had a relatively low predictive value for the presence of infection ( 21 ) .
they stated that the inflammation was not exactly a consequence of infection and other causes might be responsible for this appearance ( 20 ) .
in contrast , others indicated a significant association between inflammatory smear and reproductive tract infections ( 22 , 24 ) .
as burke et al ( 22 ) in their study on 256 women found an evidence of inflammation in 9.7% of smears and genital tract infection in 29.2% of their participants overall .
they found infection in 48% of women having inflammatory changes on smear test vs. 27.3% of women whose smear tests showed no evidence of inflammation .
they discovered that the prevalence of infection with chlamydia trachomatis , candida , bacteroides and gardnerella vaginalis was higher in the inflammatory smear group .
they concluded that women with an inflammatory smear were more likely to mask the infection than women whose smear shows no evidence of inflammation ( 22 ) .
prevalence of bv infection ( 17% ) in this study was similar to most other studies , which was not true for tv ( < 1% ) .
the use of other diagnostic methods may be probably more valuable than conventional pap smear for evaluation of tv among iranian women and it needs further investigations . as the report of inflammation in our samples was very high ,
use the newer pap smear techniques such as thinprep ( liquid base preparation ) in the further studies is recommended . based on our results ,
inflammation reported in the pap smears demands the evaluation for vc and its proper treatment .
 objectivenon - specific cervicitis or inflammatory changes in a smear report are common which are usually unclear for clinical approaches . to investigate the frequency of inflammation and pathogenic vaginal microorganisms in cervical smears among an iranian population sample.materials and methodsthis cross - sectional study was carried out on pap smear samples of women referred to gynecological clinic of taleghani hospital in tehran , iran , between october 2008 and march 2009 . 
 this study was conducted on 528 conventional papanicolaou cervical smears . 
 the frequency and severity of inflammation and prevalence of bacterial vaginosis ( bv ) , trichomonas vaginalis ( tv ) , and vaginal candidiasis ( vc ) was determined in the samples . 
 also co - infection of the microorganisms in pap samples was evaluated . 
 percentage , meanstandard deviation of the outcome parameters were calculated . 
 the comparison between data was performed with the pearson 's chi square or fisher 's exact test.resultsthe prevalence of bv , vc , and tv in pap samples was 17% , 11% , and 0.4% respectively . 
 overall , the prevalence of these microorganisms in women of reproductive age was higher than menopausal women . 
 there was a significant association between vc and the presence of inflammation in our samples.conclusionbased on our results , inflammation in the pap smears can suggest an infection of vc and the patients should be considered for proper vc treatment . 
Introduction
Materials and methods
Results
Discussion
Conclusion