Cytophysiologic changes in female genital tract

Menstrual phase
 • 1st- 5th day

• Erythrocyte

• Leukocytes

• Endometrial cells

• Superficial and intermediate cells

Proliferative phase
• 6th-10th day

• mainly large and small basophilic (blue)

• Intermediate cells

• Leukocytes

• Histiocytes

• Endometrial cells

• Towards the end of follicular phase, number of superficial squamous cells

increase
Ovulation phase

• Numerouus of superficial epithelial cells

• Cells lie flat and obviously discrete

• Pattern is clean without leukocytes

• Very few bacteria

• appear due to high estrogen levels

• Some smear, a fern pattern of the endocervical mucus can be discerned.

Secretory phase

• Day 15-22

• folded or with curled edges

• Appear immediately after ovulation due to increase in progesterone.

• Leukocytes (small black cells) becoming more numerous.

Late secretory phase

• Day 23rd -28th

• Intermediate cells predominate

• Clustering and folding of cells occurs at this stage and both leukocytes
(neutrophil)and bacteria (Doderlin bacilli) are prevalent
 Physiological changes of the female genital tract

There are a few phases in a women’s life which can influence the
surroundings of the cervical area and more importantly the cells which
predominates during those stages. The changes commonly occur during
phases as below:-

i) Pregnancy

ii) Post-delivery and post-partum

iii) Menopause

iv) Exogenous sex steroid

The aforementioned cytohormonal changes can be evaluated using

hormonal evaluation. Hormonal evaluation is used in evaluating the
hormonal status for monitoring pregnancy, determining timing of ovulation
for fertility workup, and artificial insemination. Sequential smears are
obtained to assess variability in pattern. A minimum of 100 cells are counted
and the number of parabasal (P), intermediate(I), and a superficial(S) clls are
expressed as a ration (P:I:S).

Pregnancy

Pregnancy constitutes a major physiologic upheaval in the life of

a woman. This brief summary will stress those morphologic changes that
may have an impact on cytology of the female genital tract. Cytologic
manifestations of pregnancy:

i) Squamous cells:

a. The effects on the squamous cell epithelium are frequently but

not always reflected in vaginal smears after the 2nd month.

b. These changes are characterized by clustering of intermediate

cells and the predominance of intermediate squamous cells, the
latter defined by yellow cytoplasmic deposits of glycogen,
displacing the nuclei to the periphery, and sharply defined,
accentuated borders.
 c. In the later stages of pregnancy, extensive cytolysis of squamous
cell cytoplasm by lactobacilli is not uncommon.

d. Majority of women show pattern of navicular cells but isn’t

always diagnostic of pregnancy.

ii) Endocervical cells:

a. May appear in somewhat increased number in cervical smears

and may be larger than normal

b. Cytoplasm is often mucoid, and the nuclei are prominent,

granular, and may show small nucleoli.

iii) Decidual cells:

a. Large mononucleated cells, occurring singly or in clusters, with

abundant eosinophilic or basophilic faintly vacuolated cytoplasm
and prominent, centrally-located vesicular nuclei containing
identifiable nucleoli.

b. Occasionally, nuclei of decidual cells may be dense and

hyperchromatic, particularly when derived from degenerating
decidual tissue.

iv) Arias-Stella Phenomenon

a. Large cells with large, hyperchromatic nuclei located within the

endometrial gland lining in the presence of products of
conception or in ectopic pregnancy.

b. Appear following curettage for interruption of pregnancy.

c. Protruding large cells stand out among normal endometrial cells.

d. Great variability of nuclear morphology.

Postpartum period
 During the postpartum period, there is often no evidence of estrogen
activity.

a) Many women display atrophic smear pattern with predominance of

parabasal squamous cells.

b) During lactation, intermediate and large parabasal cells of navicular

type, with large cytoplasmic glycogen deposits may be observed.

c) The return to cyclic patterns varies from patient. In the great

majority of patients, whether lactating or not, the cyclic pattern will
be evident 6 months after delivery.

d) Persistence of atrophic smear pattern, beyond 1 year after delivery,

may indicate a serious endocrine disorder.

Abortion

The interruption of pregnancy prior to 20 weeks of gestation is

referred to as abortion and it may be spontaneous or induced. Spontaneous
abortion is classified as threatened, inevitable, incomplete and complete.
Cytologic assessment of these conditions should only be used an adjuvant to
the more critical and reliable clinical and chemical evaluations.

i) Threatened abortion:

a. Certain changes in the cytohormonal pattern may suggest that

the patient is at risk of aborting.

b. The superficial cells increase in number >10% and the navicular

cells gradually disappear.

c. This may reflect the relative dominance of estrogen and risk to

the fetus.

d. The development of postpartum pattern and the dominance of

parabasal cells may be associated with fetal demise.

ii) Incomplete abortion:

a. Residual villi or deciduas can cause bleeding and infection

b. The smears contain blood, leukocytes, trophoblastic cells, and

rarely, smooth muscle cells.
 c. Isolated or clustered decidual cells with cobblestone squamoid
appearance may be present. If well preserved, these decidual
cells have abundant eosinophilic or cynophilic cytoplasm.

d. Their nuclei have vesicular, finely granular, and uniformly

distributed chromatin, and unlike squamous cells, they possess
nucleoli. The thin but well-defined nuclear membrane may be
wrinkled.

e. Exfoliated decidual cells, however, are usually degenerated with

poor delineation of cytoplasmic borders and nuclear details.

iii) Spontaneous abortion

a. Occur at about 12th week of gestation.

b. The risk of abortion increases with age, parity, and the number of
previous abortions.

c. Causes of spontaneous abortions are many and in a given case

it’s difficult to state the exact cause as several factors may be
involved:

i. Defective germ plasm: due to defective embryos. Closer

examination of the conceptus may reveal several
developmental or structural anomalies in the embryo,
defects in the placenta or in the cord.

ii. Maternal causes: infections such as rubella, CMV disease or

toxoplasmosis. Syphilis is seldom responsible for the
abortions in the first trimester.

iii. Endocrine deficiency of the thyroid or corpus luteum.

iv. Anatomical defects: congenital uterine anomalies such as a

bicornuate or septate uterus, internal os insufficiency due
to congenital or acquired causes.

v. Uterine myomata

vi. Trauma, chemicals, radiation

vii. Immunological factors

 viii. Maternal diseases like diabetes, systemic lupus
erythematosus.

ix. Paternal cause: defective spermatozoa, however, there is

not enough evidence in support.

Menopause

The menopause is caused by the cessation of cyclic ovarian

function, resulting in the arrest of menstrual bleeding. The onset of the
menopause is rarely sudden, the changes are usually gradual and may
stretch over a period of several years, with gradual reduction in duration and
frequency of the menstrual flow. The age at which complete menopause
occurs varies. Clinical and cytologic menopause doesn’t necessarily coincide.
The most important manifestation of the menopause is associated with
reduced production of estrogen, although other complex changes in the
endocrine balance are known to occur. The ovaries, the principal source of
estrogen, become scarred and hyalinized without remaining evidence of
ovogenic activity. Because of estrogenic deficiency, there is a cessation of
endometrial proliferation with resulting endometrial atrophy. Gradual
estrogen depletion will also result in gradual loss of superficial cell layers. In
final stages of atrophy, the surface of squamous epithelium is composed of
parabasal cells. Endocervical epithelium also shows evidence of atrophy; the
columnar endocervical cells are often more cuboidal in shape, and their
cytoplasm becomes opaque. Vaginal dryness is common in menopausal
women; hence it causes a number of artifacts, similar to air drying of the
smear. Dryness also offers little resistance to bacterial invasion, resulting in
vaginitis and cervicitis.

There are 3 basic cytologic patterns of menopause which may be

differentiated – early menopause, “crowded” menopause and advanced or
atrophic menopause. A sharp separation of the 3 post-menopausal smear
patterns isn’t always possible in practice, since one pattern may emerge into
another.

i) Early menopause: slight deficiency of estrogens

a. The smears are essentially those of childbearing age, except for

a reduction in the proportion of superficial squamous cells.
 b. Cells are composed predominantly of dispersed intermediate
cells, occasionally showing cytolysis, and some large parabasal
cells. These cells contain vesicular nuclei of normal size, about 8
microns in diameter.

c. Nuclei may appear to be diffusely enlarged.

d. Women who lead an active sexual life after the menopause

appear to be less likely to develop post-menopausal atrophy than
sexually inactive women.

ii) “Crowded” menopause: moderate deficiency of estrogens

a. This type of smear usually follows the smear of early menopause

and characterized by thick, crowded clusters of intermediate and
large parabsal cells

b. Cells are well-preserved and there’s little dryness

c. Small-sized-cells; thus nuclei may appear to be relatively large

but are of normal sizes.

d. The cytoplasm frequently contains deposits of glycogen in the

form of yellow deposits, similar to navicular cells observed in
pregnancy.

iii) Atrophic or advanced menopause

a. May be invariably preceded by early or crowded menopause or

both. There’s always a stage of transition between normal cycle
and the advanced menopause.

Exogenous sex steroid

The vaginal epithelium can be influenced by the administration of exogenous

hormones and drugs. The effects of these substances depend on the drug
dosage, receptivity of the end organ, age of patient, and the initial hormonal
status.

i) Estrogen

a) Administration of exogenous estrogen has no effect on the

cytohormonal pattern of a normal pregnancy.
b) In post-menopausal women, exogenous estrogenic stimulation
results in progressive maturation of epithelium.

c) Parabasal cell type atrophy changes into intermediate cell type,

while the intermediate cell type atrophy matures to superficial cells
if the hormone was given for a short period of 3-6 months.
Administration for longer periods results in marked predominance of
intermediate cells. Estrogen may be administered to clarify the
nature of questionable or suspicious cells showing post-menopausal
nuclear enlargement, or atypical immature cells.

d) It can also improve the cellularity and adequacy of sampling in

some cases. A conjugated estrogen such as premarin or
diethylstilbestrol is given orally, divided over 5 days, and a smear is
obtained on day 7.

e) Alternatively, a single topical application of estrogen ointment or

suppositories can be used, to be followed by smears in 3 days.
Following this “estrogen test”, a normal smear is usually clean, with
more superficial and intermediate cells.

ii) Exogenous progesterone, androgen

a. Has no effect on normal pregnancy, but can induce increased

exfoliation of intermediate cells.

b. After menopause, the administration of progesterone may alter the

parabasal cell pattern may alter the parabasal cell pattern to an
intermediate cell pattern in some patients, while in others no change
may occur.

c. The administration of androgens to postmenopausal patients doesn’t

result in characteristic pattern. This effect may be similar to that of
progesterone and may or may not alter the atrophic pattern.

d. In large doses, however, androgens can induce maturation to

superficial cells. In younger patients, endogenous or exogenous
androgens induce an atrophic pattern, with glycogen-rich parabasal
cells.

e. Corticosteroids induce maturation of the cells to the intermediate cell

level, followed by shedding of epithelium. This results in intermediate
cell predominance or a spread effect. However, the intermediate cells
don’t cluster or exhibit the folding of their edges that characterize
progesterone effect.
iii) Oral contraceptives

These are the most commonly administered exogenous hormones

and consist of a combination of estrogen and progesterone in various
ratios. They are usually given in day 5 to 25 of the menstrual cycle
and they are discontinued until the 5th day of the next cycle. 3 types
of combinations are used: a fixed combination of estrogen and
progesterone, a biphasic one with more progesterone 3 types from
day 11, and a triphasic combination, with a gradually increasing
dosage of progesterone.