Journal of the American Society of Cytopathology (2021) 10, 255e260

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.jascyto.org/

Cervical Papanicolaou tests in the female-to-

male transgender population: should the
adequacy criteria be revised in this population?
An Institutional Experience
Regina M. Plummer, DO, Sarah Kelting, MD, Rashna Madan, MBBS,
Maura O’Neil, MD, Katie Dennis, MD, Fang Fan, MD, PhD*
Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas
City, Kansas

Received 19 December 2020; received in revised form 20 January 2021; accepted 22 January 2021

KEYWORDS Introduction It is recommended that female-to-male (FTM) transgender patients with a cervix follow the same
Cervical cancer; cervical cancer screening guidelines as cisgender women. This study analyzes Papanicolaou tests, HPV results, and
HPV; follow-up histology in FTM patients, and compares those results to other atrophic populations at our institution.
Papanicolaou; Materials and methods A cohort of FTM patients receiving androgen therapy was identified through our institu-
Transgender; tion’s translational research database. We collected data on Papanicolaou tests, human papillomavirus (HPV) results,
Cytology follow-up surgical procedures, and duration of androgen therapy. ThinPrep slides were reviewed for cellularity and
cytomorphology. The results of these tests were compared with those of an atrophic control group consisting of post-
partum and postmenopausal cisgender women.
Results We identified 71 FTM patients with 77 Papanicolaou tests collected over 6 years. Papanicolaou interpre-
tations included: negative for intraepithelial lesion (69%), atypical cells of undermined significance (5%), low grade
squamous intraepithelial lesion (1%), atypical glandular cells (1%), and unsatisfactory due to inadequate cellularity
(23%). Five of 27 (18.5%) HPV tests were positive. Follow-up surgical specimens did not identify high-grade le-
sions. Unsatisfactory rates among FTM patients differed significantly from the atrophic group (P < 0.05), while
epithelial abnormality rates and HPV positivity did not (P > 0.05). Most FTM Papanicolaou tests reviewed showed
features of atrophy.
Conclusions FTM patients receiving androgen have high Papanicolaou test unsatisfactory rates secondary to at-
rophy. Epithelial abnormality and HPV rates do not differ significantly from atrophic cisgender patients. Lowering
the cellularity threshold for this population to 2000 like that of other atrophic groups should be considered.
Ó 2021 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.

*Corresponding author: Fang Fan, MD, PhD; Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, 3901 Rainbow
Boulevard, Kansas City, KS 66160; Tel.: 626-218-4829; Fax: 626-218-8145.
E-mail address: ffan@coh.org (F. Fan).

2213-2945/$36 Ó 2021 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jasc.2021.01.004
256
Introduction
Female-to-male (FTM) transgender individuals are assigned
female sex at birth, but their gender identity lies on the
masculine spectrum or as gender nonconformity.1 FTM
patients engage in a variety of masculinizing therapies and/
or gender-affirming surgeries. However, the majority choose
to keep their natal organs and as such, are at risk of cervical
cancer just as are cisgender women.2 Therefore, it is rec-
ommended that these patients follow a similar cervical
cancer screening schedule as cisgender women.3,4
Although a necessary step in the screening of cervical
intraepithelial neoplasia, various studies have documented
challenges that accompany Papanicolaou tests in FTM pa-
tients.3,5-9 FTM transgender patients have lower rates of
cervical cancer screening than cisgender women.5 The rea-
sons for this are multifactorial but include decreased access
to care, perceived discrimination and insensitivity by health
care providers, as well as significant emotional distress that
accompanies the Papanicolaou test procedure as the pro-
cedure itself is an acknowledgment of a part of them with
which they do not identify.3,5,6 In addition to this, the
likelihood of an unsatisfactory Papanicolaou test result
requiring repeat testing is significantly increased for FTM
patients, especially among those with androgen-induced
atrophy, which not only can decrease specimen cellularity,
but can also increase physical discomfort during the exam
necessitating the use of lubricant.5,7-9 As such, these patients
are less likely to return for the repeat testing required by an
unsatisfactory specimen.5 With these challenges in mind,
this study investigates the performance of Papanicolaou
tests in FTM transgender patients in our institution, a large
tertiary care center.
Materials and methods
This study was approved by the University of Kansas
Medical Center institutional review board. Using our in-
stitution’s translational research database, HERON
(Healthcare Enterprise Repository for Ontological Narra-
tion),10,11 we searched for patients within the University of
Kansas Health System with associated ICD-10 and ICD-9
codes for gender identity disorder in adolescence and
adulthood (F64.01 and 302.85, respectively) who underwent
Papanicolaou tests. Papanicolaou tests were performed at
family medicine, internal medicine, and obstetrics and gy-
necology outpatient clinics, some of which specialize in
transgender care. From this list of patients, those under 18
years of age, who had opted out of research endeavors, who
were male-to-female transgender, and who were not
receiving exogenous androgens were excluded.
From the patient’s electronic medical record, we docu-
mented relevant gynecologic history and duration of
androgen therapy. Using the Sunquest CoPathPlus (version
R.M. Plummer et al.
6.3.2008) (Sunquest Information Systems Inc, Tuscon, AZ)
program, our department's anatomic pathology information
system, we reviewed reports of Papanicolaou tests, human
papillomavirus (HPV) tests, and any relevant gynecologic
surgical procedures. Using c2 analysis, the results of these
tests were compared with those of an atrophic control group
that consisted of postpartum and postmenopausal cisgender
women who had undergone Papanicolaou tests during 2019.
All Papanicolaou tests were processed using the Thin-
Prep LBP system (Hologic, Inc, Bedford, MA) and inter-
preted using the Bethesda Cervical Cytology Reporting
System current at the time of diagnosis.12,13 High-risk HPV
(HR-HPV) DNA testing performed on samples prior to
2017 was performed at Mayo Clinic Laboratories using a
lab-developed polymerase chain reaction test. HR-HPV
DNA testing performed on samples from 2017 or later
were performed using the Aptima HPV assay on the Panther
system (Hologic, Inc).
All available cases from the FTM transgender group
were reviewed for cytomorphologic features. All slides
originally signed out as unsatisfactory for evaluation sec-
ondary to low cellularity were re-reviewed for cellularity.
An estimation of total cellularity was obtained by per-
forming representative field cell counts that included the
center of the preparation. The squamous and intermediate
cells in 50 high-power fields (20) were counted and
averaged. The average number of cells required to achieve a
minimum cell concentration of 2000 and 5000 cells per
preparation was calculated using the formula: number of
cells required per field Z minimum preparation concen-
tration/(area of preparation/area of field).
Results
We identified a group of 71 FTM patients with 77 associ-
ated Papanicolaou tests collected between 2013 and 2020.
Patients’ ages ranged from 18 to 57 years with a median age
of 26 years. Of 77 Papanicolaou tests, 53 (68.8%) were
interpreted as negative for intraepithelial lesion or malig-
nancy (NILM), 4 (5.2%) as atypical squamous cells of
undermined significance (ASC-US), 1 (1.3%) as low-grade
squamous intraepithelial lesion (LSIL), 1 (1.3%) as atypical
glandular cells (AGC), and 18 (23.4%) as unsatisfactory for
evaluation (Unsat). All unsatisfactory samples were desig-
nated as such due to inadequate cellularity. Duration of
androgen therapy among FTM patients ranged from 1 to
108 months. Median duration among patients with unsatis-
factory interpretations was 33.4 months.
The cisgender atrophic (CGA) control group consisted of
1974 Papanicolaou tests from 1941 patients whose ages
ranged between 21 and 89 years with a median age of 58
years. For information on patient characteristics, see Table 1.
Distribution of Papanicolaou test interpretations were as
follows: Of 1974 Papanicolaou tests, 1775 (89.9%) were
Papanicolaou tests in the female-to-male transgender population 257

Table 1 Patient and case characteristics.

FTM patients CGA patients
Number of Papanicolaou tests 77 1974
Number of patients 71 1941
Age in years, range 18-57 21-89
Average age in years 28 56
Median age in years 26 58
Papanicolaou tests with associated HR-HPV testing 27 (35%) 1729 (88%)
Number of Papanicolaou tests positive for HR-HPV 5 (18.5%) 155 (8.9%)
Abbreviations: CGA, cisgender atrophic; FTM, female-to-male; HR-HPV, high-risk human papillomavirus.

interpreted as NILM, 83 (4.2%) as ASC-US, 32 (1.6%) as
LSIL, 7 (0.4%) as atypical squamous cells cannot exclude a
high-grade squamous intraepithelial lesion (ASC-H), 7
(0.4%) as high-grade squamous intraepithelial lesion (HSIL),
2 (0.1%) as squamous cell carcinoma, 6 (0.3%) as AGC, 2
(0.1%) as adenocarcinoma (ADCA), 1 (0.1%) as small cell
carcinoma, and 60 (3.0%) as Unsat. Of the Unsat samples, 56
were due to inadequate cellularity, 2 were due to obscuring
inflammation, and 2 were due to a combination of obscuring
inflammation and inadequate cellularity. For a comparison of
Papanicolaou test results between groups, see Table 2.
HR-HPV testing was performed on 27 of 77 (35%) FTM
transgender Papanicolaou tests. HR-HPV was detected in 5
(18.5%) cases. Papanicolaou test diagnoses corresponding
to these positive HR-HPV tests included ASC-US (1) and
NILM (4). The patient with ASC-US and positive HPV
proceeded to colposcopy and cervical biopsy, which resul-
ted in a diagnosis of low-grade squamous intraepithelial
lesion (CIN1). One HPV-positive patient with a Papanico-
laou test diagnosis of NILM proceeded to total hysterec-
tomy with bilateral salpingo-oophorectomy (THBSO),
which on microscopic examination had no histopathologic
abnormality. There were no follow-up specimens on the
other 3 HPV positive cases.
Papanicolaou test diagnoses corresponding to the nega-
tive HR-HPV tests included ASC-US (2), AGC (1), NILM
(15), and Unsat (4). Of the patients who were tested and
negative for HR-HPV, 12 had follow-up Papanicolaou tests
or THBSOdall of which had no histopathologic abnor-
mality on microscopic examination. Of note, however, tubal
metaplasia was noted in the cervix of the THBSO specimen
that corresponded to the Papanicolaou test diagnosed as
AGC. HR-HPV results and corresponding cytomorphologic
diagnoses are summarized in Table 3. Of the remaining
FTM transgender patients who had not undergone HR-HPV
testing, 2 had a Papanicolaou test interpretation other than
Unsat or NILM. One patient with ASC-US proceeded to
THBSO, which on microscopic examination had no histo-
pathologic abnormality. One patient with LSIL had no
follow-up specimens for review.
Of the 18 FTM Papanicolaou tests interpreted as Unsat, 4
had follow-up gender-affirming THBSOdall of which had
no histopathologic abnormality on microscopic examina-
tion. Five had follow-up Papanicolaou tests performed.
Results of follow-up Papanicolaou tests are as follows:
Unsat (3), NILM (1), and ASC-US (1). As previously
mentioned, the patient with ASC-US was tested positive for
HR-HPV and proceeded to colposcopy.
By c2 analysis, the proportion of Papanicolaou tests that
were unsatisfactory for evaluation differed significantly
between groups (P < 0.05). The proportion of Papanicolaou
tests with associated positive HR-HPV test results and
Papanicolaou tests that resulted in an epithelial abnormality
did not differ significantly between groups (P > 0.05).
Of the 18 FTM Papanicolaou tests interpreted as Unsat,
17 were available for review. Cellular concentrations ranged

Table 2 Distribution of Papanicolaou test results between FTM patients and CGA patients.
UE NILM Other ASC-US/ASC-H LSIL HSIL SCCA AGC ADCA Any epithelial
abnormality
FTM Patients 23.4% 68.8% n/a 5.2% 1.3% n/a n/a 1.3% n/a 7.8%
(n Z 77) (n Z 18) (n Z 53) (n Z 0) (n Z 4) (n Z 1) (n Z 0) (n Z 0) (n Z 1) (n Z 0) (n Z 6)
CGA Patients 3.0% 89.9% 0.1% 4.6% 1.6% 0.4% 0.1% 0.3% 0.1% 7.2%
(n Z 1974) (n Z 60) (n Z 1775) (n Z 1) (n Z 90) (n Z 32) (n Z 7) (n Z 2) (n Z 6) (n Z 2) (n Z 140)
Abbreviations: ADCA, adenocarcinoma; AGC, atypical glandular cells; ASC-H, atypical squamous cells cannot exclude a high-grade squamous intraepithelial
lesion; ASC-US, atypical squamous cells of undermined significance; CGA, cisgender atrophic; FTM, female-to-male; HSIL, high-grade squamous intraepi-
thelial lesion; LSIL low-grade squamous intraepithelial lesion; NILM, negative for intraepithelial lesion or malignancy; Other, small cell carcinoma; SCCA,
squamous cell carcinoma; UE, unsatisfactory for evaluation.
258 R.M. Plummer et al.

Table 3 FTM patients’ HR-HPV results and corresponding cytomorphologic diagnoses.

Patient ID number Patient age Papanicolaou test result HR-HPV test result Follow-up result
1 27 ASCUS Negative NILM (THBSO)
2 24 AGC Negative NILM (THBSO)
3 51 NILM Negative NILM (THBSO)
4 29 NILM Negative NILM (THBSO)
5 36 NILM Negative NILM (THBSO)
6 29 NILM Negative NILM (THBSO)
7 51 NILM Negative NILM (THBSO)
8 26 NILM Negative NILM (Papanicolaou)
9 30 UE Negative NILM (THBSO)
10 46 UE Negative NILM (THBSO)
11 35 UE Negative NILM (THBSO)
12 44 UE Negative NILM (THBSO)
13 30 ASCUS Negative n/a
14 34 NILM Negative n/a
15 42 NILM Negative n/a
16 32 NILM Negative n/a
17 35 NILM Negative n/a
18 30 NILM Negative n/a
19 25 NILM Negative n/a
20 27 NILM Negative n/a
21 30 NILM Negative n/a
22 41 NILM Negative n/a
23 36 NILM Positive NILM (THBSO)
24 29 ASC-US Positive LSIL/CIN1 (Biopsy)
25 25 NILM Positive n/a
26 25 NILM Positive n/a
27 57 NILM Positive n/a
Abbreviations: AGC, atypical glandular cells; ASC-US, atypical squamous cells of undermined significance; CIN1, cervical intraepithelial neoplasia grade 1;
FTM, female-to-male; LSIL low-grade squamous intraepithelial lesion; n/a, not applicable; NILM, negative for intraepithelial lesion or malignancy; THBSO,
total hysterectomy with bilateral salpingo-oophorectomy; UE, unsatisfactory for evaluation.

from 628.3 to 4298.9 squamous and metaplastic cells per
slide. Five of the 17 cases had a cellular concentration
>2000 cells. None of the Unsat Papanicolaou tests had an
identifiable epithelial abnormality.
Sixty-eight of the 77 FTM cases were available for re-
view of cytomorphologic features. Features encompassing
atrophy were identified in 93% of FTM ThinPrep slides
reviewed (Fig. 1). These features included a preponderance
of parabasal/basal cells (81%), autolysis (26%), decreased
cellularity (31%), and transitional cell metaplasia (21%).
Inflammation and reactive/reparative changes were noted in
41% and 34% of cases reviewed, respectively. All epithelial
lesion diagnoses were noted and confirmed. Of note, 1 case
in which ASCUS was diagnosed featured abundant transi-
tional cell metaplasia, a previously documented feature by
Williams et al. that can be seen in Papanicolaou test slides
from FTM patients and a known cytomorphologic pitfall.9
Discussion
Cervical Papanicolaou tests are a major challenge for FTM
transgender patients. Although necessary to detect cervical
intraepithelial neoplasia, FTM patients often have lower
rates of cervical cancer screening owing at least in part to
perceived discrimination and the significant emotional and
psychological burden that accompanies the procedure. As
such, these patients are less likely to return for follow-up
after an unsatisfactory Papanicolaou test result.5,6 Of the
FTM patients in this study with an unsatisfactory Papani-
colaou test, 9 (50%) did not have a follow-up Papanicolaou
test within the 2-4 month interval recommended.4
Although current Bethesda guidelines recommend that a
minimum of 5000 well-visualized squamous or squamous
metaplastic cells be present on a liquid-based preparation in
order to be considered adequate, allowances are given to certain
patient populations. Papanicolaou tests from patients who have
received chemotherapy or radiation therapy, have a surgically
absent cervix, or have post-menopausaleinduced atrophy are
often not held to the same strict 5000 cell threshold with lower
degrees of cellularity considered acceptable based on the
assumption that low cellularity specimens from these patients is
relatively unavoidable.14-16 Indeed, studies have shown that
adhering to strict adequacy standards pertaining to specimen
cellularity leads to high unsatisfactory rates.15 Moreover, the
scientific evidence from which the 5000-cell threshold is based
is relatively limited.17,18
Papanicolaou tests in the female-to-male transgender population
Figure 1 Examples of changes associated with atrophy from female-to-male transgender patients. (A) Low power show preponderance of
parabasal/basal cells. (B) High power showing transitional cell metaplasia. (C) High power showing autolysis. (D) High power showing reac-
tive/reparative changes.
As seen in other studies that looked at cytomorphologic
findings of Papanicolaou tests in FTM patients receiving
androgen therapy, the patients in our study showed atrophic
changes similar to those seen in other atrophic groups.7,9
However, in our study, compared with CGA patients,
FTM patients were 7.8 times more likely to have unsatis-
factory Papanicolaou tests (3.0% versus 23.4%). Similar
studies that looked at Papanicolaou test results among FTM
patients found unsatisfactory rates that ranged from 5.9% to
13%.5,7,9 These studies attribute such levels of unsatisfac-
tory rates to use of lubricant, physical changes induced by
testosterone therapy, and provider/patient discomfort with
the exam.5,8 Rates of epithelial abnormality within FTM
patients in our study did not differ significantly from those
seen in the CGA patients (7.8% versus 7.2%) and were
similar to those detected in other studies that looked at
Papanicolaou test results in FTM transgender patients (7.8%
versus 6%-30%).5,7,9 Additionally, of the 23 patients that
had follow-up surgical specimens in our study, only 1 had
evidence of intraepithelial neoplasia (CIN1).
Cytomorphologic features encompassing atrophy were
seen in 93% of FTM cases reviewed. Given similar atrophic
cytomorphologic findings between FTM patients and other
CGA patients,13 and given that those Papanicolaou Tests
259
designated Unsat in both FTM and CGA patients in our study
were overwhelmingly designated as such due to inadequate
cellularity, one must ask about the large discrepancy in un-
satisfactory rates between the groups. The requisition forms
that accompany Papanicolaou tests at our institution offer the
option to select whether a patient is post-therapy (radiation or
chemotherapy), but they do not offer the option to designate
your patient as receiving androgen therapy. In addition to
this, among the 71 FTM patients in this study, 45 (63%) were
designated as female within CoPathPlus. Of those with Unsat
Papanicolaou tests, 11 (61%) were from FTM patients
designated as a female in CoPathPlus. The cytotechnologists
that screen the Papanicolaou tests account for a patient’s
post-therapy status and adjust their threshold for adequate
cellularity accordingly whereas FTM transgender patients are
not given the same dispensation. Indeed, if FTM patients in
this study were held to the same amended cellularity standard
as the postmenopausal and postpartum patients (>2000 well-
preserved/well-visualized squamous and metaplastic cells per
preparation), 5 additional Papanicolaou tests would have
been considered adequate, which would have reduced the
unsatisfactory rate from 23.4% to 16.9%.
Additionally, this study looked at HPV test results. The
prevalence of HR-HPV within FTM patients (18.5%) was
260
higher than the prevalence within the CGA patients (8.9%)
and the age matched general non-atrophic population
(9.3%), but not in a statistically significant manner. The
median age of the patients within the FTM group was 26
years of age. Of those tested for HPV, patient age ranged
from 24-51 years with a median age of 30 years. When
compared to population studies of female patients in the
United States,19-22 the prevalence of HR-HPV among FTM
patients in our study is similar (18.5% versus 4.7%-23.7%).
However, the prevalence of HR-HPV in FTM patients in
our study is slightly higher than that detected among FTM
patients in other studies (18.5% versus 13%-16%).8
In conclusion, this study reaffirmed that FTM trans-
gender patients who receive androgen therapy have a high
rate of unsatisfactory Papanicolaou test results due to
atrophy-induced reduced cellularity. Although the Bethesda
criteria recommend that liquid-based preparations contain a
minimum of 5000 well-visualized squamous or squamous
metaplastic cells in order to be considered adequate, certain
patient groups are granted allowances in the number of cells
required to be present. For these patients, liquid-based
preparations with at least 2000 cells are considered
adequate.14 This study also highlighted epithelial abnor-
mality rates and HR-HPV rates among FTM patients and
how they do not differ significantly from those seen in CGA
patients. Given the minimal impact of cellularity in detect-
ing abnormalities in this population, difficulty of acquiring
an adequate Papanicolaou test in FTM transgender patients,
and the emotional and psychological burden that accom-
panies the procedure, we propose revising the adequacy
requirement for FTM transgender patients receiving
androgen therapy. A threshold of 2000 cells should be
considered adequate in these patients. In an attempt to aid in
this endeavor, we also recommend modifications to Papa-
nicolaou test requisition forms that reflect a patient’s
androgen therapy status.
References
1. Reisner SL, Murchison GR. A global research synthesis of HIV and
STI biobehavioural risks in female-to-male transgender adults. Glob
Public Health. 2016;11:866e887.
2. Bauer GR, Travers R, Scanlon K, Coleman TA. High heterogeneity of
HIV-related sexual risk among transgender people in Ontario, Canada:
a province-wide respondent-driven sampling survey. BMC Public
Health. 2012;12:292.
3. Committee on Health Care for Underserved Women. Health care for
transgender individuals. Obstet Gynecol. 2011;118:1454e1458.
4. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society,
American Society for Colposcopy and Cervical Pathology, and Amer-
ican Society for Clinical Pathology screening guidelines for the preven-
tion and early detection of cervical cancer. Am J Clin Pathol. 2012;137:
516e542.
5. Peitzmeier SM, Reisner SL, Harigopal P, Potter J. Female-to-male pa-
tients have high prevalence of unsatisfactory Paps compared to non-
R.M. Plummer et al.
transgender females: implications for cervical cancer screening. J
Gen Intern Med. 2014;29:778e784.
6. Peitzmeier SM, Agénor M, Bernstein IM, et al. “It can promote an exis-
tential crisis”: factors influencing papanicolaou test acceptability and
utilization among transmasculine individuals. Qual Health Res. 2017;
27:2138e2149.
7. Adkins BD, Barlow AB, Jack A, et al. Characteristic findings of cervi-
cal Papanicolaou tests from transgender patients on androgen therapy:
challenges in detecting dysplasia. Cytopathology. 2018;29:281e287.
8. Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and
acceptability of self-versus provider-collected swabs for high-risk HPV
DNA testing in female-to-male trans masculine patients. PLoS One.
2018;13:1e21.
9. Williams MPA, Kukkar V, Stemmer MN, Khurana KK. Cytomorpho-
logic findings of cervical Papanicolaou smears from female-to-male
transgender patients on testosterone therapy. Cancer Cytopathol.
2020;128:491e498.
10. Waitman L, Warren J, Manos E, Connolly D. Expressing observations
from electronic medical record flowsheets in an i2b2 based clinical data
repository to support research and quality improvement. AMIA Annu
Symp Proc. 2011;2011:1454e1463.
11. Murphy SN, Weber G, Mendis M, et al. Serving the enterprise and
beyond with informatics for integrating biology and the bedside
(i2b2). J Am Med Inform Assoc. 2010;17:124e130.
12. Solomon D, Nayar R, eds. The Bethesda System for Reporting Cervical
Cytology, Definitions, Criteria, and Explanatory Notes. 2nd ed. Berlin:
Springer Science & Business Media; 2004.
13. Kurtycz D, Staats P, Young N, et al. Non-neoplastic findings. In:
Nayar R, Wilbur D, eds. The Bethesda System for Reporting Cervical
Cytology, Definitions, Criteria, and Explanatory Notes. 3rd ed. Berlin:
Springer Science & Business Media; 2015.
14. Birdsong G, Davis D. Specimen adequacy. In: Nayar R, Wilbur D, eds.
The Bethesda System for Reporting Cervical Cytology, Definitions,
Criteria, and Explanatory Notes. 3rd ed. Berlin: Springer Science &
Business Media; 2015.
15. Gupta S, Sodhani P, Sardana S, Singh V, Sehgal A. Clinical determi-
nants and smear characteristics of unsatisfactory conventional cervico-
vaginal smears. Eur J Obstet Gynecol Reprod Biol. 2013;168:
214e217.
16. Lu CH, Chang CC, Ho ESC, et al. Should adequacy criteria in cervi-
covaginal cytology be modified after radiotherapy, chemotherapy, or
hysterectomy? Cancer Cytopathol. 2010;118:474e481.
17. Geyer J, Carrico C, Bishop J. Cellular constitution of autocyte PREP
cervicovaginal samples with biopsy-confirmed HSIL. Acta Cytol.
2000;44:505.
18. Studeman KD, Ioffe OB, Puszkiewicz J, Sauvegeot J, Henry MR. Ef-
fect of cellularity on the sensitivity of detecting squamous lesions in
liquid-based cervical cytology. Acta Cytol. 2003;47:605e610.
19. Sargent A, Bailey A, Almonte M, et al. Prevalence of type-specific
HPV infection by age and grade of cervical cytology: data from the
ARTISTIC trial. Br J Cancer. 2008;98:1704e1709.
20. Dunne EF, Sternberg M, Markowitz LE, et al. Human papillomavirus
(HPV) 6, 11, 16, and 18 prevalence among females in the United States
- National Health and Nutrition Examination Survey, 2003-2006: op-
portunity to measure HPV vaccine impact? J Infect Dis. 2011;204:
562e565.
21. Chesson HW, Dunne EF, Hariri S, Markowitz LE. The estimated life-
time probability of acquiring human papillomavirus in the United
States. Sex Transm Dis. 2014;41:660e664.
22. Hariri S, Unger ER, Sternberg M, et al. Prevalence of genital human
papillomavirus among females in the United States, the National
Health and Nutrition Examination Survey, 2003-2006. J Infect Dis.
2011;204:566e573.