HORMONAL CYTOLOGY

MENSTRUAL CYCLE
• The function of the female genital tract is controlled
by:
• Steroid hormones
– Oestrogen
– Progesterone
• Proteohormones
– Follicle-stimulating hormone
– Luteinizing hormone
• Steroid hormones control the growth and
maturation of the endometrium
• Proteohormones:
– control the growth of the graafian follicles – FSH
– their transformation into the corpus luteum, which
produces the progestational hormone – LH
• During maturation of the ovum in the graafian
follicle, the ovary produces and secrete oestrogen
– Proliferation of endometrium
– Endometrium becomes thick
– Proliferative or oestrogenic phase
• After ovulation
– Ruptured follicle transforms into corpus luteum
– CL produces and secrete progesterone
 – Endometrial glands produce secretion – secretory phase
or luteal phase
• Corpus luteum functions for 14 days
– No implantation – CL ceases function, no progesterone,
menstruation occurs, CL becomes corpus albicans
– Conception – CL persists as CL of pregnancy, produces
oestrogen and progesterone in relatively large quantities.
– Developing placenta takes over function of CL, especially
after 3rd month
– After birth dramatic decrease in oestrogen and
progesterone
• At end of reproductive years, ovulation ceases, some
MENSTRUAL CYCLE
 CYTOLOGIC PATTERNS IN VAGINAL SMEAR
• Basically, 3 major squamous epithelial cell types:
– Superficial cells – mature, usually polygonal with
pyknotic nuclei, cytoplasmic staining reaction inmaterial
– Intermediate cells – mature, usually polygonal, contains
vesicular nucleus with finely granular chromatin,
cytoplasmic staining reaction also immaterial
– Parabasal cell – immature, usually round or oval, contain
one, rarely more than one, relatively large nucleus,
cytoplasm stains more deeply than other two
• Anucleate squames are not seen in smears from
proximal 2/3rds of vagina; presence due to either
cervical hyperkeratosis or contamination from vulva
• Ectocervical squamous epithelium not useful for
hormonal assessment
– Less sensitive to steroid hormones than vaginal
squamous epithelium
– Involved in metaplasia and inflammation
• Smear from upper (proximal) part of vagina used for
hormonal evaluation
• Smears showing inflammatory changes or presence
of significant non-resident bacteria should not used
for hormonal evaluation
• Clinical information useful
– Age
– Menstrual history
– Medication with sex steroid hormones
 – Contraceptive medication
– History of gynaecologic surgery – hysterectomy,
oophorectomy
– Pelvic irradiation
• Absence of adequate history renders request
unsatisfactory
AIR DRYING ARTIFACT
ANUCLEATE SQUAMES
CERVICAL SCRAPE – DAY 13
INFLAMMATORY CHANGES
LARGE NUMBERS OF NON-RESIDENT
BACTERIA
TRICHOMONIASIS
HERPES SIMPLEX INFECTION
SQUAMOUS METAPLASIA
 INDICES
• Several sets of cellular indices developed for
purposes of hormonal evaluation
• Multiplicity of indices shows their limited value
KARYOPYKNOTIC INDEX
• Most widely used
• Determined by
– Ratio of superficial cells to intermediate cells in a smear
(SC:IC)
– Minimum of 300 cells counted
• Not easy to critically differentiate pyknotic nuclei
from vesicular nuclei so differences can occur
between interpreters
KARYOPYKNOTIC INDEX
MATURATION INDEX
• Measures the relationship of parabasal cells to
intermediate to superficial cells (PBC/IC/SC)
• Determined by counting 100 squamous cells
• With rare exceptions, only one or two cell types
occur
• If all three cell types occur then either smear was
taken from ectocervix or an inflammatory process is
present – either case the result is valueless
MATURATION INDEX
EOSINOPHILIC INDEX
• Expresses the ratio of mature eosinophilic squames
to mature cyanophilic squames, regardless of
nuclear appearance
• Most often altered by artefacts –
pseodoeosinophilia due to poor fixation, poor
staining technique or changes due to the influence
of vaginal pH – most unreliable of the indices
• Of limited value without KPI or MI
EOSINOPHILIC INDEX
FOLDED CELL INDEX
• Assess tendency of cells towards folding
• Measures ratio of mature cells with folded cellular
borders to mature cells without cytoplasmic folding
• Mature squames that are folded are usually less
mature than are flat cells with no folding
• Usually when FCI is high KPI is low and vice versa
FOLDED CELL INDEX
CROWDED CELL INDEX
• Assesses tendency of cells towards cluster formation
• Measures the ratio of mature squames occurring in
cell clusters of 4 or more to mature squames lying in
clusters of 3 or less
• Relatively difficult index to assess as cell clusters
often contain so many cells that they do not lend
themselves to accurate counting
• Usually parallels the FCI
REPORTING CYTOLOGIC FINDINGS
• Indices are of no value for diagnostic evaluation of
the individual case on a single specimen
CROWDED CELL INDEX
• Of some value when assessment is made on
repeated or serial smears from the same patient
• Different women respond differently to steroid
hormones and so indices are not directly related to
actual amount of oestrogen present
• Descriptive report taking clinical and menstrual
history into consideration more meaningful than
quoting indices
• Only two definite diagnostic patterns:
– Pattern with mature, flat, single-lying cells, most of
which are SC with some IC unequivocally imply
oestrogenic activity
– Predominantly PC indicate lack of oestrogenic
stimulation
 CYTOPHYSIOLOGIC PATTERNS
NEWBORN
• Exfoliated cells are predominantly intermediate
cells usually in clusters and exhibit folded cytoplasm
• Occasional superficial cells, also cytoplasmic folding
and tend to part of the cell clusters
• Some superficial cells
• No parabasal cells
• No leucocytes, no bacteria – clean background
NEW BORN – 4 DAYS OLD
EARLY CHILDHOOD
• Pattern of newborn changes during the first few
weeks – up to 10 weeks
• Mature squamous cells gradually disappear
• Parabasal cells increase and become the
predominant cell type; persists until 3-4 years
before menarche.
• Leucocytes appear and become numerous
• Usually coccoid bacteria accompany this pattern
CHILD – 3.5 YEARS OLD
PREMENARCHE
• Cellular pattern of early childhood persists up to 3
to 4 years before onset of menstruation depending
on ovarian maturation
• Parabasal cells gradually replaced by mature cells
mainly intermediate cells
CHILD – 11 YEARS OLD
MENSTRUAL CYCLE
• Increased maturation of the vaginal epithelium
during proliferative phase with increasing number
of superficial cells up to time of ovulation, tendency
of cells to be flat lying and eosinophilic – superficial
cells predominate
• Decrease in maturation after ovulation with
increased number of intermediate cells, tendency
towards cyanophilia, folding and cellular crowding
• In late secretory phase, premenstrual phase, smear
usually is free of leucocytes and cytolysis may be
marked
MENSTRUAL CYCLE – DAY 2
MENSTRUAL CYCLE – DAY 9
MENSTRUAL CYCLE - DAY 13
MENSTRUAL CYCLE – DAY 16
MENSTRUAL CYCLE – DAY 20
MENSTRUAL CYCLE – DAY 25
PREGNANCY
• After conception gradual change to exclusively
cyanophilic intermediate cells with marked
tendency toward folding and crowding
• In some cases the classic pattern is not seen and
many superficial cells may be seen – in such cases
the pattern does not fluctuate from intermediate
cells only to a more mature cell type
• Cytolysis may be marked
• Presence of parabasal cells indicate either foetus is
dead or has been expelled
• Presence of extremely marked cellular maturity
indicates progesterone deficiency
PREGNANCY – 14 WEEKS
PREGNANCY – MONTH 5
 POSTPARTUM
• Characterised by presence of parabasal or intermediate
cells in smear
• During lactation parabasal cells predominate; persists as
long as lactation lasts – prolactin inhibits secretion of
oestrogen; in some intermediate cells
• Superficial cells may be seen but very few
• Not all lactating women exhibit parabasal cell
predominance
• Occasionally, intermediate cell predominance is seen
• Other samples may contain intermediate and superficial
cells
– Almost any cell pattern containing combinations of above cell
types may be observed during the postpartum period
POSTPARTUM – 6 WEEKS
Postpartum – 6 weeks
MENOPAUSE
• Early menopause may be mixed pattern with
superficial and intermediate cells in varying
numbers
• Intermediate cell pattern later
• Followed by atrophic pattern – parabasal cells
– May occur within a few months after cessation of
menstruation
– May never occur – intermediate cell pattern persists
POSTMENOPAUSAL – 4 YEARS
POSTMENOPAUSAL – 4 YEARS
POSTMENOPAUSAL – 10 YEARS
POSTMENOPAUSAL – 15 YEARS
OESTROGEN ADMINISTRATION
• Oral, parenteral or topical oestrogen induces
epithelial proliferation practically in all physiologic
conditions except in pregnancy
ADMINISTRATION OF PROGESTERONE
• Effect depends on initial cell type before
administration
• If the initial pattern is that of oestrogen primed
epithelium, result is decreased cellular maturity
with increased number of intermediate cells
• If atrophic pattern, some epithelial growth may be
induced with reduced parabasal cells and increased
intermediate cells or no proliferative effect with
persistence of parabasal cell only pattern
EFFECT OF OESTROGEN ADMIN DURING
PREGNANCY
LMP 10 YRS ON OESTROGEN – 0.2 MG DLY
3X WEEK X 10 YRS
LMP 13 YRS ON OESTROGEN – 0.5 MG DLY
X21 DAYS
• If intermediate cell pattern, no changes.
PRIMARY AMERRHOEA
• Atrophic pattern
SECONDARY AMENORRHOEA
• E.g. bilateral oophorectomy during reproductive
years
• Intermediate cell pattern
• Apparently the adrenals play a role in the
maintenance of this intermediate cell pattern.
BILATERAL OOPHORECTOMY – 12 YEARS AGO