INTRODUCTION The epithelia of the female genital tract are sensitive to estrogen, progesterone, androgens & various additional steroid hormone derivatives.
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INTRODUCTION The epithelia of the female genital tract are
sensitive to estrogen, progesterone, androgens & various
additional steroid hormone derivatives & metabolites. In
general estrogen promotes & progesterone inhibits squamous cell
maturation. Hormones may influence the morphology staining
characteristics of the cervical, endometrial, vaginal, urethral
& bladder mucosa cell.
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Hormonal evaluation is based on the degree of maturation &
glycogen storage of the exfoliated squamous cells. For useful
cytologic evaluation, some information about the age, menstrual
history & previous hormonal, surgical or treatment of the
patient should accompany the smear.
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INDICATIONS FOR CYTOLOGIC HORMONAL EVALUATION 1)Assessment of
ovarian function. During puberty & reproductive, menopausal
& post menopausal years after hysterectomy. During menstrual
disorders. In premature menses (childhood). To determine ovulation
time.
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2)Assessment of abnormal hormonal production (placenta, ovaries
& other endocrine organs). Before, during & after a
pregnancy (fertility study, threatened abortion, retained placenta
). Existence of functioning (hormone producing) tumors. Various
endocrine disorders. Assessment & guidance for hormonal
therapy.
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NORMAL HORMONAL PATTERNS ESTROGEN It increases cellular
maturation & proliferation of all layers of squamous epithelium
mostly Superficial cells and Intermediate cells. DECREASING LEVEL
Deficiency of estrogen increases parabasal cells. The mucosa
becomes thin & superficial layer is absent in deficient
estrogen stimulation.
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INCREASING LEVEL Increase in estrogen level enlarges the
parabasal cells to intermediate.this continue to enlarge &
mature into keratinized superficial cells. Increases the amount of
intra cellular glycogen ( by protein & nucleic acid synthesis )
High estrogenic effect in a vaginal smear is recognized by a clean
background & increased eosinophilic & karyopyknotic
indices.
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PROGESTERONE It produce proliferation of intermediate squamous
epithelium at the time of exfoliation. INCREASING LEVEL Clusters of
intermediate cells dominate the smear. The amount of intracellular
glycogen-increases No. of leukocytes decreases
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ANDROGEN Male sex hormone. Small amount is present in female.
INCREASING LEVEL It increases the no. of exfoliated large parabasal
cells with central, almost pyknotic nuclei & dense, glycogen
containing cytoplasm.
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GUIDELINES FOR SPECIMEN COLLECTION & SUITABLE FOR HORMONAL
ASSESSMENT 1)SPECIMEN COLLECTION GUIDELINES: Smear taken from the
lateral vaginal wall Smear taken from the junction of the middle
& upper 1/3 rd of the vagina. 2)FACTORS THAT MAKE A SMEAR
UNSUITABLE FOR HORMONAL ASSESSMENT: Material not collected
properly. Adequate clinical information not provided (age,
menstrual status, treatment etc) Evidence of an infection.
Inflammation. Air-drying artifact.
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HORMONAL PATTERN AT DIFFERENT STAGES OF LIFE LIFE STAGEHORMONAL
PATTERN Newborn Sterile No inflammation Intermediate cells
superficial cells 1 st - 2 week of life Acquires bacteria
Neutrophils appear Atrophic cells Childhood Maturation & cyclic
alternations occur months (or)years before menarche, due to cycles
that are initially anovulatory Cyclic women, proliferative phase
Increasing squamous cell maturation Cyclic women, post ovulatory
phase Decreasing squamous cell maturation
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PregnancyNavicular cells may be numerous LactationAtrophy
persists but some maturation may appear slowly. Post partumAtrophy
MenopauseAtrophy (or) intermediate cell predominate
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CELLS 1) SUPERFICIAL CELLS Cell flat, delicate &
transparent. Size 35-45 micro meter in diameter. Nuclei small, dark
& pyknotic (nuclear material become condensed & shrunken.
Cytoplasm delicate pink (eosinophilic / acidophilic)
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2) INTERMEDIATE SQAMOUS CELLS Cell flat Size 35-45 micro meter
Nucleus spherical / oval -vesicular Cytoplasm basophilic A variant
of intermediate cells boat shaped navicular cells. Navicular cells
common in early menopause & pregnancy. Oval shaped cells store
glycogen in the form of cytoplasmic deposits stains yellow in PAP
stain
CYTOLOGICAL INDICES The degree of proliferation, maturation
& desquamation of vaginal cells is influenced by various
hormones. The cytological assessment of these hormones is given by
different types of indices. All are based on recognition &
exact typing of the epithelial cells exfoliated from the surface of
the stratified squamous vaginal mucosa.
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If the smear is to inflammatory & a repeat specimen is not
possible after the proper treatment, the exfoliated urethral cells
in the first portion of a voided urine specimen can be examined for
this evaluation. The terminal part of the urethral mucosa is almost
as sensitive to hormonal changes as in the vaginal mucosa but more
difficult to evaluate.
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TYPES OF INDICES Maturation index (MI) It is determined by the
percentage of the basal, intermediate & superficial cells as
presented as 3 part ratio with the basal cells started 1 st,
intermediate cells 2 nd & superficial cells 3 rd. Example : MI
= 80 /20 / 0 Indicates : 80 % - Parabasal cells 20 % - Intermediate
cells 0 % - Superficial cells
RESULT READ AS Shift to left atrophic effect. Shift to right
increased estrogen like effect. Shift to midzone progesterone like
effect
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2)KARYOPYKNOTIC (KPI) / CORNIFICATION INDEX The percentage of
squamous cell with sharp squared cytoplasmic edges with pyknotic
nuclei compared with other mature squamous cells with vesicular
nucleus. Parabasal cells are not counted.
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3)MATURATION VALUE (MV) This method is useful for providing
hormonal evaluation data to a computer. Each parabasal cell is
counted as 0 Intermediate cell as 0.5 superficial cell as - 1.0 The
addition of all the values given to the first 100 epithelial cells
is recorded.
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Example : MI = 0 / 35 / 65 0 x 0 =0 35x 0.5 = 17.5 65x1.0 =
65.0 MV = 82.5 MV of 100 indicates pure population of superficial
squamous cells MV of 0 indicates pure population of parabasal
cells.
4)EOSINOPHILIC INDEX (EI) The no. of mature squamous cells with
eosinophilic (pink) cytoplasm, nuclear appearance is compared with
the no. of other mature squamous cells with basophilic (blue)
cytoplasm. The result is given in ratio. Parabasal cells not
counted. Example : 2:14 2 eosinophilic sq. cell 14 basophilic sq.
cells
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5)FOLDED CELL INDEX (FCI) No. of mature sq. cells with folded
cytoplasmic rims are compared with no. of mature cells with flat
non folded cytoplasm. The folded cells with cytoplasmic glycogen
are considered as less mature than flat cells.
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6)SUPERFICIAL CELLS INDEX (SCI) Superficial sq. cells with any
type of nucleus is compared with any other sq. cell present in the
smear. 7)CROWED CELL INDEX (CCI) The no. of mature sq. cells that
are clustered together in groups of 5 or 6 cells is compared to the
no. of similar cells found singly / less than 3 or 4.
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INDICES USED FOR HORMONAL ASSESSMENT TYPE OF INDEXCELL TYPE
RATIO COMPARED Maturation indexParabasal : intermediate :
superficial Karyopyknotic index Superficial : intermediate
Eosinophilic indexEosinophilic : basophilic Folded cell indexFolded
cytoplasm : non folded cytoplasm Crowed cell indexClusters of more
than 4 cells : single cell
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NORMAL CYTOHORMONAL AVERAGES 1)NEW BORN (UPTO 8 WEEKS) MI =0 /
90 / 10 Intermediate cell increase with glycogen in their
cytoplasm. - this is due to maternal hormones in infants blood. 1
st 4 8 days - Very little cellular debris, bacteria, leucocytes,
lymphocytes (or)mucous can be found. 2 3 weeks increased no. of
leucocytes & micro organism occurs. 3 4 weeks intermediate cell
decreases.
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2 ) INFANCY & NEWBORN (3 WEEKS TO PUBERTY) MI = 80 / 20/ /0
Vaginal pool smears are scanty in cells & contain mainly
parabasal cells. Leucocytes few. These smears are very similar to
the cells found in the late postmenopausal period except for their
smaller size & the absence of inflammatory background.
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3) MENSTRUAL AGE (REPRODUCTIVE PERIOD) MI = 0 / 70 / 30 The
vaginal cellular changes start to appear several months before the
beginning of menstruation. A nucleated eosinophilic sq. cells are
present. Basal cells & polymorphonuclear cells are the main
cells found during the reminder of the cycle. Superficial &
intermediate cells always present. Parabasal cells-few.
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4)DURING PRE OVULATORY TIME. (Proliferative phase, 3-14 day of
the cycle) MI=0/40/60 8 th day of cycle -the cyanophilic
intermediate cells gradually increases in size with progressive
cytoplasmic eosinophilia & nuclear pyknosis. - no. of
leukocytes decreases. mucous decreases.
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5) DURING OVULATION & POST OVULATORY TIME (Secretory phase
15 19th days) MI = 0 / 70 / 30 Super ficial & eosinophilic
cells decreases Intermediate cells increases & the cells show a
tendency to cluster together.
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6) DURING MENSTRUAL FLOW. MI = 0 / 60 / 40 Increase of fresh
& old red blood cells, cyanophilic intermediate cells,
histiocytes, mucous & leukocytes. Grandular & stromal
endometrial cells are seen singly in clusters /in acinic formation.
The evaluation of smears taken at 3 day intervals will indicate if
ovulation has occurred & the level of estrogenic effect.
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7) MENOPAUSE MI = 0 / 80 / 20 Exfoliated superficial &
intermediate sq. cells become smaller & show some decrease in
their staining capacity.
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8) EARLY POST MENOPAUSE 2-6 years cessation of menstruation a
decrease in estrogenic activity occurs. Parabasal &
intermediate cells increases Glycogen is found in some of the
cells.
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9 ) LATE POST MENOPAUSE MI = 100 / 0 / 0 Some smear may become
completely atrophic. Atrophic parabasal cells: size varies shape
oval / round with mild irregularities cytoplasm cyanophilic -show
degenerative changes in the form of vacuolization. No glycogen is
present.