Hormonal cytology

hormonal cytology - bsc

1. HORMONAL CYTOLOGY STUDY 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.

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

7. 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.

8. 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

9. 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

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

11. 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

12. 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 1 st 12 days of MC Background haemorrhage is indication.

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

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

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

16. 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

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

18. 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

19. 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

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

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. 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 (12 th to 14 th 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

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

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

29. Mid cycle - fernlike structure .

30. 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 intermediate cells form clusters or clumps. 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.

31. Luteal phase intermediate cells

32. Cytolysis by Doderlein lactobacilli

33. 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.

34. 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

35. ‘‘ 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

36. 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.

37. Menopausal smear: parabasal cells and naked nuclei

38. Atrophic smear

39. Maturation Index It is the percentage study of the parabasal, intermediate, and superficial squamous cells\100 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.

40. Reading of the maturation index Shift to the right: indicate an increase number of superficial cell (maturation) i.e. 0\0\100 under the effect of increase estrogen like effect Shift to the left: indicate an atrophic effect e.g. post menopause women i.e 100\0\0 with no effect of estrogen. Shift to the mid-zone: means progesterone like effect e.g. secretory phase of endometrium i.e. 0\100\0

41. Effect of extrinsic hormones on vaginal cytology Estrogen: MI=0\10\90 Increase cell maturation Proliferation of all layers of epithelium Progesterone: MI= 0\90\10 Proliferation of intermediate cells Decrease superficial cell maturation Androgen like H. (testosterone) MI= 20\80\0 Increase number of parabasal and intermediate cells No superficial cells.

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