hormonal cytology - bsc

1. DR. ANINDITA SAHA & DR. ANKITA PAUL

2. • Hormones influences the morphology and staining characters
of endometrial, endocervical and vaginal cells.
• Non- invasive procedure of epithelium for hormonal status
• Vaginal epithelium is very sensitive to estrogen and
progesterone

3. Indication of cytological hormonal
evaluation
• Assessment of ovarian function
• After hysterectomy
• During menstrual cycle
• In premature menses
• Assessment of abnormal hormonal production
• Pregnancy , Abortion , Retained placenta
• Various endocrine disorders
• Existence of hormone producing ovarian tumors
• Assessment and guidance of hormonal therapy.

4.  For useful interpretation; the following information must
be taken in account:-
 Age of the patient
 Menstrual history (regular or irregular cycles)
 Previous past history:
 Hormonal therapy
 Surgical operations in the genital tract
 Irradiation

5. SAMPLE COLLECTION
 The ideal type for sample collection is by:
 Aspiration of vagino-cervical secretion from the
posterior vaginal fornix OR
 Gentle scraping from the lateral mid-third of
healthy vaginal wall.

7. NORMAL CELLS SEEN
 The normal pap smear shows the following types of
squamous epithelial cells.
1)superficial
2)intermediate
3)parabasal

9. SUPERFICIAL SQUAMOUS CELLS
-
-Most mature cells of ectocervix.
-Most abundant during
proliferating phase of MC
under the influence of estrogen.
-Polygonal with abundant
eosinophilic cytoplasm.
-Small pyknotic nucleus(5-6
micron meter)
-Show cytoplasmic keratohyaline
granules.

10. INTERMEDIATE SQUAMOUS
CELLS
-Polygonal in shape
-Abundant bluish cytoplasm
-Nucleus is larger with granular
chromatin
-Most abundant during
secretory phase of MC under
the influence of progesterone

11. PARABASAL CELLS
• Immature squamous cell
• Round- Oval shape
• Nucleus is relatively
larger. N/C= 1:2
• Nucleus is vesicular with
fine reticular chromatin
•
Cytoplasmic area is
smaller
•
Cytoplasmic texture is
granular and dense

12. BASAL CELLS
• Small (8-10 m),
round to oval
• Dense cyanophilic
cytoplasm
• Nucleus large, fine
reticular chromatin,
small nucleoli

13. ENDOCERVICAL CELLS
-Cells are columnar
-Abundant vaculated
cytoplasm
-Eccentrically placed
vesicular nucleus ,
inconspicuous nucleoli
-Cells arranged in strips
giving a picket fence
appearance or in sheets
resembling honey comb

14. EXFOLIATED ENDOMETRIAL CELLS
• Small cells with dark
nucleus and scant
cytoplasm
• Nucleoli is inconspicuous
• Arranged in tight balls like
3-D clusters
• Seen commonly during 1st
12 days of MC
• Background haemorrhage is
indication.

15. Endometrial cells (Exodus ball)
• Seen between 6 to10 days
of the menstrual cycle.
• Last remnants of
endometrial shedding and
the cells show
degenerative changes

21. Physiology of hormone cycle in
women
• In infancy and childhood:
• Small amount of estrogen without progesterone –
inactive ovary.

23. At puberty:
1. Follicle Stimulating Hormone : from the pituitary
gland --- proliferation of ovarian follicles ----
estrogen secretion
– Maturation of vaginal epithelium
– Proliferative phase of endometrium

24. 2. LH (luteinizing hormone): cause maturation of
ovarian follicles until rupture and release of ova
(ovulation).
 Maintain corpus luteum and progesterone
secretion.
 Stimulate secretory phase of endometrium

25.  If no pregnancy (no implantation of fertilized ova)
--- sudden drop of progesterone and estrogen level ----
menstrual bleeding (shedding of endometrium and
basal blood vessels).

26.  If pregnancy occur (implantation of fertilized
ovum) --- corpus luteum continuous secret
progesterone and gonadotrophic hormones -----
until the third month of gestation.
 Also; placenta secrete progesterone and
gonadotrophic hormones

27. Normal cyto-hormonal patterns in
women
 Throughout life, women under variations in type and
level of hormone, which could be due to some factors
such as:-
 Age
 Pregnancy
 Menopause
 Function of pituitary – ovarian – adrenal axis

28.  The general pattern of the smear depends on the level of
gonads hormones, on the vaginal microbiologic factors
and it varies with age.

29. Hormonal effect
 Estrogen:
 Proliferation and maturation of the vaginal squamous
epithelial cells, including the superficial cells.
 Deposition of glycogen within the vaginal epithelium.
 Progesterone and androgen:
 Rapid desquamation of the upper layer of epithelium.
 Exposed intermediate and parabasal cells to the surface

30. AT BIRTH
 Gonadal hormones are produced in a large amount during
pregnancy and pass through the placenta into the fetal
circulation.
 The squamous epithelium of the cervix and of the vagina
of a newborn girl responds to this strong hormonal
stimulation.
 A smear , obtaining with a thin cotton applicator , contain
a clear predominance of superficial cells

31. IN CHILDHOOD
 After a few days after birth the maternal hormones are
eliminated.
 The smears contain mostly parabasal cells, reflecting
the absence of gonadal hormones

32. AT PUBERTY
 Even before the first menstrual period occur ,the
vaginal smear begins to change;
 intermediate cells replace the parabasal cells and
 a few superficial cells reflect the onset of estrogen
production in the ovaries.

33. DURING THE REPRODUCTIVE
YEAR
 DAY 1 of the cycle is the first day of menstruation.
 DAY 1 – DAY 5(onset of menstruation) smear shows
1) blood
2) desquamated endometrial cells in singles and clusters
3) polymorphonuclear leukocytes.
4) squamous cells predominatly intermediate type.
Such cells form clumps and their cytoplasm is folded and
degenerated.
 On the 4th or 5th day, the squamous cells begin to show
less clumping and a better cytoplasmic preservation.

34.  DAY 6 – DAY 13/14 (proliferative/preovulatory)
increase in estrogen
1)Endometrial cells in clusters
2) squamous cells predominatly intermediate type later
replaced by superficial type(12th to 14th day)
3) thick cervical mucus forms fern-like
crystalline structures that vanish just prior to ovulation
4) Small macrophages
5) small nipple-like nuclear protrusions
may occasionally be seen in the endocervical cells

35. A cluster of endometrial glandular cells observed on
day 7 of menstrual cycle.

36. Day 11 of menstrual cycle. The smear
contains a mixture of intermediate and
superficial cells.

38. Mid cycle - fernlike structure.

39.  DAY 14-DAY 28(secretory/post ovulatory/luteal phase)
increase progesterone
intermediate squamous cells with few superficial
squamous cells with cytoplasmic foldings.
 As the time of menstrual bleeding approaches
1) intermediate cells form clusters or clumps.
2) Marked increase in lactobacilli, resulting in cytolysis of
the intermediate cells. The cytolysis results in ‘‘moth-
eaten’’ cell cytoplasm, nuclei stripped of cytoplasm
(naked nuclei) in a smear with a background of
cytoplasmic debris (‘‘dirty’’ type of smear)
 This appearance of the smear persists until the new cycle
begins with the onset of the menstrual bleeding.

40. Luteal phase intermediate cells

41. Cytolysis by
Doderlein lactobacilli

42. DURING PREGNANCY
 Vaginal smears reflect the balance of hormones during
pregnancy.
 Generally the high level of progesterone (placental) do not
allow the complete maturation of the squamous epithelium.
1)clustering of intermediate squamous cells
2) predominance of navicular cells, defined by yellow
cytoplasmic deposits of glycogen, displacing the nuclei to the
periphery, and sharply defined, accentuated borders (presence
of navicular cells is not diagnostic of pregnancy)
3) In the later stages of pregnancy, extensive cytolysis of
squamous cell cytoplasm by lactobacilli is not uncommon
4)Endocervical cells increase in number.
appearance of significant number of parabasal cells
indicates fetal death.

43. MENOPAUSE
 Early Menopause: Slight Deficiency of Estrogens
1)predominantly of dispersed intermediate cells
occasionally showing cytolysis
2)some large parabasal cells
3) reduction in the proportion of superficial squamous
cells

44.  ‘‘Crowded’’ Menopause: Moderate Deficiency of
Estrogens:
1)thick, crowded clusters of intermediate and large
parabasal cells.
The cytoplasm frequently contains deposits of
glycogen in the form of yellow deposits, similar to
navicular cells observed in pregnancy

45.  Atrophic or Advanced Menopause:
1) relatively few cells
2)dominant squamous cells are of the parabasal type.
3) “Blue blobs” are sometimes noted, these being
interpreted by some as mucin by others as degenerate
cells.
4)granular debris in background.

46. Menopausal smear: parabasal cells and naked nuclei

47. Atrophic smear

48. Maturation Index
 It is the percentage study of the parabasal, intermediate, and
superficial squamous cells100 cells counted from exfoliated
epithelial cells of healthy vaginal smear.
 It is determined by morphology of the nucleus and thickness of
cytoplasm of epithelial cells.

49. Reading of the maturation index
 Shift to the right: indicate an increase number of
superficial cell (maturation) i.e. 00100 under the effect of
increase estrogen like effect
 Shift to the left: indicate an atrophic effect e.g. post
menopause women i.e 10000 with no effect of estrogen.
 Shift to the mid-zone: means progesterone like effect e.g.
secretory phase of endometrium i.e. 01000

50. Effect of extrinsic hormones on
vaginal cytology
• Estrogen: MI=01090
• Increase cell maturation
• Proliferation of all layers of epithelium
• Progesterone: MI= 09010
• Proliferation of intermediate cells
• Decrease superficial cell maturation
• Androgen like H. (testosterone) MI= 20800
• Increase number of parabasal and intermediate cells
• No superficial cells.

51. THANK YOU