Significance of benign endometrial cells in Pap smears from postmenopausal women

OBJECTIVE: To assess the significance of benign exfoliated endometrial epithelial or stromal cells on cervicovaginal Pap smears obtained from postmenopausal women not receiving exogenous hormones. STUDY DESIGN: A computerized search of the cytology database at two institutions was performed for a five-year period, and all cervical cytology cases from postmenopausal patients diagnosed with benign endometrial cells were identified. Those cases with histologic follow-up within 12 months of the original cytologic evaluation were selected for analysis, and their cytology and surgical pathology slides were reviewed. RESULTS: A total of 227 postmenopausal women with benign endometrial cells were identified. Of the 61 patients with histologic follow-up, 25 (41%) had significant endometrial diseases, including hyperplasia without atypia (11), atypical endometrial hyperplasia (5), well-differentiated adenocarcinoma (8) and high grade serous carcinoma (1). Benign diagnoses, including atrophy (15), weakly proliferative endometrium (9) and proliferative endometrium (6), were noted in 30 patients (49%). Endometrial polyp was identified in three patients (5%). There were three cases of nondiagnostic histologic specimens that lacked endometrial tissue (5%). Two of nine women (22%) with proven carcinoma were asymptomatic. CONCLUSION: The diagnosis of endometrial cells, cytologically benign, in a postmenopausal woman not receiving hormone on Pap smears is associated with a significant number of cases of endometrial hyperplasia, atypical hyperplasia and carcinoma.     

Endometrial hyperplasia: a review

Endometrial hyperplasia is a precursor to the most common gynecologic cancer diagnosed in women: endometrial cancer of endometrioid histology. It is most often diagnosed in postmenopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Hyperplasia with cytologic atypia represents the greatest risk for progression to endometrial carcinoma and the presence of concomitant carcinoma in women with endometrial hyperplasia. Abnormal uterine bleeding is the most common presenting symptom of endometrial hyperplasia. Specific Pap smear findings and endometrial thickness per ultrasound could also suggest the diagnosis. Unopposed estrogen in women taking hormone replacement therapy increases the risk of endometrial hyperplasia. Tamoxifen has demonstrated its efficacy in treating women at risk for breast cancer, but it increases the risk of endometrial hyperplasia. The choice of treatment for endometrial hyperplasia is dependent on patient age, the presence of cytologic atypia, the desire for future childbearing, and surgical risk. Endometrial hyperplasia without atypia responds well to progestins. However, women with atypical hyperplasia should be treated with hysterectomy unless other factors preclude surgery. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the definition and classification of endometrial hyperplasia, to outline the clinical features of a patient with endometrial hyperplasia, to point out the natural history of endometrial hyperplasia, and to summarize the diagnostic options for patients with endometrial hyperplasia.     

Significance of normal endometrial cells detected by cervical cytology

A retrospective study was conducted to assess and confirm the significance of normal-appearing endometrial cells detected in cervical cytologic smears in the second half of the menstrual cycle or in the postmenopausal period. Of 440 women with normal endometrial cells identified on routine Papanicolaou smears, 179 underwent further endometrial evaluation. Endometrial disease was identified in 64 (35.7%) of those patients having endometrial sampling and/or hysterectomy within 12 months of the cytologic evaluations. These lesions included 21 cases (11.7%) of endometrial polyps, 23 cases (12.9%) of endometrial hyperplasia, and 20 cases (11.2%) of adenocarcinoma. The frequency of endometrial cancer was positively associated with age (P less than .01). Five of 20 women with endometrial cancer were asymptomatic.     

Cytologically benign endometrial cells in the papanicolaou smears of postmenopausal women

OBJECTIVE: The objective of this study was to determine the clinical significance of the presence of benign endometrial cells in the Pap smears of postmenopausal women. METHODS: A retrospective analysis of the clinical outcome of 297 postmenopausal women containing benign endometrial cells in their Pap smears was performed. All patients had subsequent endometrial biopsies or routine follow-up for 1-5 years. In addition, Pap smears of 253 of the patients were reviewed with particular reference to the morphology and type of the endometrial cells. Immunohistochemical staining with CD68 was performed in 15 selected cases to determine the origin of the stromal cells. RESULTS: One hundred thirty-two (44%) women had endometrial biopsies while the remaining 165 (56%) were followed up by routine gynecologic examinations and repeat Pap smears. Endometrial lesions were detected in 14 patients of whom only 3 had significant lesions (2 atypical hyperplasias and 1 adenocarcinoma). Review of the Pap smears revealed benign superficial endometrial stromal cells in most cases (73%). Stromal cells showed CD68 positivity indicating a histiocytic origin. Glandular cells were present in 27%, either alone or in association with stromal cells. Statistical analysis revealed that the presence of endometrial glandular cells in Pap smears was associated with five times the likelihood of significant endometrial disease than found in women with normal Pap smears, although sensitivity and positive predictive value were very low (7.14 and 2.94%, respectively). Superficial endometrial stromal cells were not useful in predicting endometrial pathology. CONCLUSION: Significant endometrial lesions were present in 1% of postmenopausal women containing morphologically benign endometrial cells in the Pap smears. In the majority, the endometrial cells were of the superficial stromal type, which were demonstrated immunohistochemically to be histiocytes. The presence of endometrial glandular cells correlated significantly with endometrial pathology. Such an association was not observed in cases with stromal cells only.     

Significant increase of benign endometrial cells on Papanicolaou smears in women using hormone replacement therapy

OBJECTIVE: To determine the prevalence of benign endometrial cells on Papanicolaou smears from postmenopausal women and to compare the prevalence and histologic diagnosis in women who use hormone replacement therapy (HRT) with those who do not. METHODS: Papanicolaou smear diagnoses from postmenopausal women and women over age 50 between April 1995 and December 1998 were retrieved and linked with follow-up smears and biopsies. Hormone status of women with benign endometrial cells smears was obtained from requisition forms or phone conversation with primary care providers. All surgical pathology material as well as Papanicolaou smears from women subsequently diagnosed with endometrial adenocarcinoma were reviewed. Relative prevalence with 95% confidence intervals was determined. RESULTS: A total of 589 of 52,662 Papanicolaou smears from postmenopausal women were diagnosed with benign endometrial cells, a prevalence of 1.1%. Also, HRT was reported in 16,073 (31%), no HRT was reported in 33,170 (63%), and hormone status was unknown in 3379 (6%). Smears from 245 HRT users, 324 nonusers, and 20 with unknown hormone status were diagnosed with benign endometrial cells. There was a significant increased prevalence of benign endometrial cells in women on HRT compared with nonusers (relative prevalence 1.56, 95% confidence interval 1.32, 1.84, P <.001). Among 436 women with known hormonal status and follow-up, 12 (2.7%) had endometrial carcinoma, three (1.5%) in HRT users and nine (3.7%) in nonusers (P =.175). In addition, HRT users had significantly less abnormal endometrial histology than non-HRT users (2.6% versus 7.4%, P =.025). CONCLUSION: We found that HRT is significantly associated with an increased prevalence of benign endometrial cells on Papanicolaou smears. Women on HRT who have benign endometrial cells on their Papanicolaou smears, however, have less abnormal endometrial histology compared with women not using HRT who have benign endometrial cells on their Papanicolaou smears.     

Endometrial patterns and endocrinologic characteristics of asymptomatic menopausal women

The endometrial histology and endocrinologic and demographic characteristics of 556 asymptomatic postmenopausal women ,who attended the menopause outpatient clinic at Ankara Numune Education and Research Hospital were studied before initiating estrogen replacement therapy. Of these women ,486 (87.4%) had atrophic endometrium ,37 (6.65%) had proliferative endometrium ,27 (4.86%) had endometrial hyperplasia without atypia ,three (0.54%) had endometrial hyperplasia with atypia and three (0.54%) had endometrial adenocarcinoma on their biopsy specimens. When demographic characteristics of the patients were considered, we found that the patients with endometrial adenocarcinoma and endometrial hyperplasia with atypia had potential risk factors for endometrial pathology such as chronic anovulation ,diabetes or hypertension. This study confirms that routine endometrial sampling in asymptomatic postmenopausal women is not warranted ,but patients with associated risk factors should be screened for endometrial pathology before starting estrogen replacement therapy.     

Endometrial patterns and endocrinologic characteristics of asymptomatic menopausal women.

The endometrial histology and endocrinologic and demographic characteristics of 556 asymptomatic postmenopausal women, who attended the menopause outpatient clinic at Ankara Numune Education and Research Hospital were studied before initiating estrogen replacement therapy. Of these women, 486 (87.4%) had atrophic endometrium, 37 (6.65%) had proliferative endometrium, 27 (4.86%) had endometrial hyperplasia without atypia, three (0.54%) had endometrial hyperplasia with atypia and three (0.54%) had endometrial adenocarcinoma on their biopsy specimens. When demographic characteristics of the patients were considered, we found that the patients with endometrial adenocarcinoma and endometrial hyperplasia with atypia had potential risk factors for endometrial pathology such as chronic anovulation, diabetes or hypertension. This study confirms that routine endometrial sampling in asymptomatic postmenopausal women is not warranted, but patients with associated risk factors should be screened for endometrial pathology before starting estrogen replacement therapy.     

Interpreting epithelial cell abnormalities detected during cervical smear screening--a cytohistologic approach

PURPOSE: To determine the underlying pathology and clinical significance of epithelial cell abnormalities (ECA) identified during cervical Papanicolaou (Pap) smear screening. MATERIAL AND METHODS: A total of 19,215 Pap smears stained by Papanicolaou stain were screened during a 36-month period. They were classified according to The Bethesda System (TBS) for cervical cytology screening and the results of ECA were compared with histology. The chi square test was applied to determine the significance and validity of high-grade lesions on cytology diagnosis. RESULT: 360 cases of ECA were identified. Mean age at presentation was 50.58 years. Cytohistologic correlation of ECA was possible in n = 249 (69.17%) of cases. Out of these, 18 cases were negative, six were inflammatory, three were benign, and 222 cases showed pathology ranging from mild dysplasia to invasive carcinoma. The chi square test showed a highly significant predictive value (p < 0.001) for high-grade lesions detected on Pap smears. CONCLUSION: Pap smear results of high-grade squamous intraepithelial lesions (HSIL) or invasive malignancy are highly reliable and the patient may be considered directly for therapeutic intervention. Of cytologically detected ASCUS cases 38.89% were diagnosed as CIN (1-3) on histology. Thus the management of these patients needs to be re-evaluated. Atypical glandular cells of undetermined significance (AGUS) detected in postmenopausal women signify an underlying pathology. These patients should be further investigated and followed to biopsy if necessary.     

Proliferation in "atypical" atrophic pap smears

OBJECTIVE: Atrophic cervical epithelium of postmenopausal women may mimic high-grade cervical intraepithelial neoplasia (CIN2-3) in Papanicolaou-stained cervical smears (Pap smears). Women with such an "atypical" Pap smear need a repeated Pap smear after a course of estrogens before a definite diagnosis can be made. The aim of this study was to determine whether measurement of proliferative activity in Pap smears of postmenopausal patients that were difficult to interpret is a reliable test for differentiating between cervical atrophy and high-grade CIN. METHODS: Pap smears obtained before and after estrogen treatment of 30 postmenopausal women with an atypical Pap smear were restained with the monoclonal antibody MIB1 to visualize proliferating cells. The proliferative activity index (PAI) was subsequently measured in order to explore the feasibility of a recently proposed PAI-based diagnostic decision tree to reduce the number of estrogen courses and follow-up Pap smears in postmenopausal women. RESULTS: The PAI-based test to discriminate between cervical atrophy and high-grade CIN resulted in 100 and 96% correct diagnoses in women with high-grade CIN and cervical atrophy, respectively. Only 2 of the 30 women would have needed a repeated Pap smear after estrogen treatment for definite diagnosis if the PAI-based diagnostic decision had been used. CONCLUSIONS: Measurement of PAI in MIB1 restained Pap smears is a simple, reliable, safe, and probably also cost-effective method to obtain a substantial reduction of diagnostic estrogen courses and subsequent Pap smears in postmenopausal women with an atypical Pap smear.     

Reporting Normal Endometrial Cells in Pap Smears: An Outcome Appraisal

OBJECTIVE: The purpose of this study was to determine the clinical relevance of reporting the presence of normal endometrial cells in the Pap smears of women over the age of 35 years and the significance of this practice as it relates to patient management. METHODS: From January 1992 to December 1995, normal endometrial cells were reported in 206 consecutive Pap smears of women over the age of 35 years. Clinical follow-up was available for all patients, including the results of diagnostic procedures whenever performed. RESULTS: Of the 206 women with normal endometrial cells in their Pap smears, 162 presented with the chief complaint of abnormal vaginal bleeding. They were all evaluated by direct endometrial sampling, resulting in detection of 10 endometrial hyperplasias and 7 endometrial carcinomas. The remaining 44 women who were clinically asymptomatic were followed up with only routine annual gynecologic examinations for a minimum of 3 years. All had negative clinical courses. CONCLUSION: Reporting the presence of normal endometrial cells in Pap smears has little, if any, impact on subsequent patient management. Women who present with abnormal uterine bleeding are worked up for endometrial disease regardless of their Pap smear findings. In clinically asymptomatic patients, practitioners may, and in our experience often do, choose to disregard normal endometrial cells in Pap smear reports. The negative follow-up for the asymptomatic women in our study supports this practice. Therefore, reporting the presence of normal endometrial cells in Pap smears is of no clinical relevance and may, in fact, create a management dilemma for clinicians.     

Aromatase inhibitor anastrozole for treating endometrial hyperplasia in obese postmenopausal women

This is a preliminary study investigating the efficacy of aromatase inhibitor anastrozole in treating endometrial hyperplasia in obese postmenopausal women. We administered anastrozole for 12 months to 11 obese postmenopausal women with high operative risk, in order to treat endometrial hyperplasia (four simple, five complex and two atypical). Endometrial thickness in all cases and histology too in the two cases with atypia, revealed atrophical endometrium during treatment and additional mean follow-up of 10.2 months. The safety and tolerance profile was satisfactory. Anastrozole appears to be an interesting new modality for the treatment of endometrial hyperplasia in obese postmenopausal women.     

Specialist life--Hans-Konrad Selbmann

This is a preliminary study investigating the efficacy of aromatase inhibitor anastrozole in treating endometrial hyperplasia in obese postmenopausal women. We administered anastrozole for 12 months to 11 obese postmenopausal women with high operative risk, in order to treat endometrial hyperplasia (four simple, five complex and two atypical). Endometrial thickness in all cases and histology too in the two cases with atypia, revealed atrophical endometrium during treatment and additional mean follow-up of 10.2 months. The safety and tolerance profile was satisfactory. Anastrozole appears to be an interesting new modality for the treatment of endometrial hyperplasia in obese postmenopausal women.     

Liquid-based endometrial cytology: its possible value in postmenopausal asymptomatic women

The incidence of endometrial adenocarcinoma in asymptomatic women is low. Nevertheless, some of these women might require endometrial surveillance. In this study, we evaluated the accuracy of liquid-based endometrial cytology compared to biopsy in asymptomatic postmenopausal women. Three hundred twenty women scheduled for hysteroscopy were enrolled for this study. After hysteroscopy, patients were submitted to endometrial cytology and to biopsy. Two hundred ninety-three (92%) women had sonographically thickened endometrium (>5 mm), 53 (17%) were on tamoxifen, and 16 (5%) were on hormonal substitutive treatment. The evaluation of the biopsies determined that six (2%) women had adenocarcinoma, one (<1%) had adenomatous atypical hyperplasia, and eight (3%) had simple nonatypical hyperplasia. Endometrial cytology evidenced 5 (2%) neoplastic cases, 2 (<1%) hyperplastic with atypia cases, and 25 (8%) hyperplastic without atypia cases. Two hundred twenty-two biopsies (69%) and 17 (5%) cytologies were inadequate. One adenocarcinoma and one simple nonatypical hyperplasia were underrated by cytology resulting, respectively, as atypical hyperplasia and as negative. Four cases were false positive (simple nonatypical hyperplasias on cytology, negative on biopsy). The sensitivity and specificity were estimated, respectively, at 94% and 95%; the positive and negative predictive value were estimated, respectively, at 80% and 99%. Endometrial cytology provided sufficient material more often than biopsy (P < 0.01). We suggest to introduce liquid-based endometrial cytology in the management of some subpopulations of asymptomatic postmenopausal women. Particularly, the combination of liquid-based endometrial cytology and transvaginal sonography may improve their diagnostic accuracy and reduce unnecessary more invasive and expensive procedures.     

A comparison of the human papillomavirus test and Papanicolaou smear as a second screening method for women with minor cytological abnormalities

BACKGROUND: Of the estimated one million Papanicolaou (pap) smears performed annually in Sweden, about 4% show any degree of abnormality. Approximately, 1% of these cases contain moderate or severe atypia (high-grade squamous intraepithelial lesions) and the rest contain low-grade atypia. Recommendations for the management of minor abnormalities vary in various parts of Sweden. Generally, a second Pap smear is obtained 4-6 months after the first one showing low-grade atypia. The aim of this study is to compare the sensitivity of human papilloma virus (HPV)-DNA testing for the detection of cervical intraepithelial neoplasia (CIN) 2-3 with that of a second Pap smear in women, who had low-grade atypia in their first Pap smear. METHODS: Women with low-grade atypia in the Stockholm area, detected at a population-based cytology screening, were enrolled. A repeat Pap smear, HPV test, and colposcopically directed biopsies were obtained. For the detection of HPV, Hybrid Capture II (HC II) was used. RESULTS: The HPV-DNA test was positive in 66% of the 177 participating women. The sensitivity of the second Pap smear and HPV-DNA test to detect CIN 2-3 was 61 (95% CI = 45-74) and 82% (95% CI = 67-91), respectively. The positive and negative predictive values of HPV testing were 27 (95% CI = 18-35) and 89% (95% CI = 80-97), respectively. CONCLUSIONS: In Sweden, a second Pap smear is often obtained for the follow-up of women with low-grade atypia. The results of our study show that compared to the second Pap smear, HPV testing with HC II is a more sensitive method for detecting high-grade lesions.     

Clinical evaluation of follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears.

OBJECTIVES: The aim of this study was to evaluate the efficacy of the follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears. METHODS: From May 1991 to December 1996, we have performed 407, 451 cervicovaginal Pap smears, of which 326 patients were identified as AGUS. Of the 326 patients, 268 patients were followed by repeat Pap smears, colposcopy, cone biopsy, or endometrial curettage. RESULTS: The incidence of AGUS on Pap smears is approximately 0.08%. The mean age of the patients was 43 years (range 22-79 years). The most common complaint was abnormal vaginal bleeding. The gross findings of the cervix were normal to mild erosion. The following past histories of patients could affect the AGUS results on Pap smear: 30 had cone biopsy, 21 had Pap smears on pregnancy and within 8 weeks after delivery or evacuation, 3 were on hormonal replacement therapy, 2 had intrauterine devices for contraception, and 5 were undergoing follow-up after treatment of cervical cancer. The benign lesions detected during follow-up periods were 6 microglandular hyperplasia of the cervix, 5 atypical squamous metaplasia of the cervix, 2 cervical endometriosis, 2 tubal metaplasia, 10 cervical myoma, 11 cervical polyps, 9 endometrial polyps, 3 uterine myoma, 1 pelvic endometriosis, 1 ovarian endometriosis, and 4 uterine adenomyosis. The premalignant or malignant lesions of the cervix were 4 low-grade squamous intraepithelial lesions, 24 high-grade squamous intraepithelial lesions, 8 glandular atypia/dysplasia, 5 adenocarcinoma in situ, 3 microinvasive adenocarcinoma, and 4 invasive adenocarcinoma. The neoplastic lesions of the uterus were 6 endometrial hyperplasia, 11 endometrial adenocarcinoma, 1 malignant mixed Müllerian tumor, and 1 metastatic endometrial adenocarcinoma. Sixty-seven (25%) of 268 patients followed up were identified as having clinically significant lesions of the cervix or uterus. The detection rates of abnormal lesions were 3.1% with repeated Pap smears (3/98), 28.4% with colposcopic-directed biopsy (31/109), 63.6% with cone biopsy (35/55), and 29.7% with endometrial curettage (19/64). CONCLUSION: AGUS on Pap smears showed various benign and malignant lesions of the cervix or uterus. The clinicians must communicate with the pathologists regarding the patient's clinical information as well as the origin of the atypical glandular cells in Pap smears. We recommend that patients with AGUS on Pap smear should undergo immediate intensive diagnostic studies, including colposcopic-directed biopsy with endocervical curettage or cone biopsy, to detect cervical lesions and endometrial curettage to detect endometrial lesions.     

Significance of atypical endometrial cells detected by cervical cytology

A retrospective study was conducted to assess the histologic significance of atypical endometrial cells identified on routine cervical cytology. One hundred seventy-seven women had Papanicolaou smears demonstrating atypical endometrial cells. The histology of the endometrium was available from endometrial sampling and/or hysterectomy in 134 of the patients within 12 months of their abnormal cytologic evaluation. Fifty-six women (42%) had endometrial disease, including 14 cases (10%) of endometrial polyp, 15 cases (11%) of endometrial hyperplasia, and 27 cases (20%) of adenocarcinoma. The frequency and nature of the endometrial changes depended on the age of the patient (P less than .001) and the degree of cytologic atypia (P less than .05). In 21 women over 59 years who had atypical endometrial cells suspicious for adenocarcinoma, 12 (57%) had adenocarcinoma. Using this information, we have estimated the risk of adenocarcinoma in various groups of women with atypical endometrial cells.     

Transvaginal ultrasonography and endometrial histology in peri- and postmenopausal women on hormone replacement therapy.

OBJECTIVE: To determine the association between endometrial thickness and endometrial histology in a large sample of women using HRT. DESIGN: Results from three multi-centre studies were combined. PARTICIPANTS: Five hundred and sixty-four climacteric women were treated with either sequential, continuous combined or long-cycle therapy. MAIN OUTCOME MEASURES: The women underwent 717 examinations with both transvaginal ultrasonography and histological examination of the endometrium. Endometrial thickness was measured and associated with the histological findings. RESULTS: Eight cases of endometrial hyperplasia were diagnosed. All the hyperplasias were simple without atypia. Two cases had an endometrial thickness < 4 mm and two a thickness > 8 mm. The > 4 mm threshold for abnormal endometrium had a sensitivity of 75%, a specificity of 47%, a positive predictive value of 2% and a negative predictive value of 99%. CONCLUSION: No association could be found between the endometrial thickness measured by transvaginal ultrasonography and endometrial pathology. In six out of eight women with simple hyperplasia the endometrium measured > 4 mm.     

Loss to follow-up of cervical smears without endocervical columnar cells is not disturbing

OBJECTIVE: To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme. METHODS: Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation. RESULTS: The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001). CONCLUSIONS: Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.     

Normal appearing endometrial cells in cervical smears of asymptomatic postmenopausal women have predictive value for significant endometrial pathology

The objective of this study was to determine whether postmenopausal asymptomatic women with normal endometrial cells in their smear are at higher risk for endometrial pathology compared with women without these cells. Histologic follow-up outcome and otherwise cytologic follow-up of 29,144 asymptomatic postmenopausal women was determined. Presence of normal endometrial cells, age, use of hormones, and reported elevated maturation index were assessed. The effect of each variable on outcome as well as the combined effect were evaluated. Prevalence rate of (pre)malignant uterine disease was significantly higher when normal endometrial cells were found in the cervical smear (6.5%) as compared to smears without these cells (0.2%), resulting in a relative risk of 40.2 (95% CI 9.4-172.2). Neither age nor hormone use or elevated maturation index showed significant impact on the outcome. Asymptomatic postmenopausal women with normal endometrial cells in their smear are at significant higher risk for (pre)cancerous endometrial lesion than women without these cells. These cases should be reported to the physician with an explicit comment that normal endometrial cells in a smear of a postmenopausal woman is an abnormal finding, possibly associated with significant endometrial pathology. It raises the question whether further gynecological examination would be more appropriate.     

The abnormal glandular smear: cytologic prediction, colposcopic correlation and clinical management.

We reviewed recent cytological reporting of abnormal glandular cells on cervical smears in order to assess the predictive value of these reports and the contribution of colposcopy in the assessment of these abnormalities. The study consisted of a 5-year retrospective review of the clinical management of 80 women with abnormal glandular cells on a cervical smear, with clinical and histopathological data available for review in the interval 1992-1996. There were two groups of women: (i) those referred with gynaecological symptoms and (ii) those with screen detected abnormalities who were asymptomatic and significantly younger than the first group. The predictive value of a glandular smear for malignancy was 42.5% and for premalignancy 28.8%. The most common lesions detected were cervical intraepithelial neoplasia (CIN) (13), endometrial cancer (13), cervical adenocarcinoma (10) and cervical intraepithelial glandular neoplasia (CIGN) (8). Four cases of endometrial carcinoma presented through screening. In the remainder a variety of benign conditions were identified as responsible for the abnormal smear. Failure to find an explanation for the abnormal smear only occurred in 8.8%. In developing a protocol for abnormal glandular smears, our observations indicate that: (a) those with abnormal bleeding require endometrial sampling; (b) for those with screen detected abnormality, colposcopy is valuable as it is a sensitive predictor of early invasion and can predict glandular abnormality; (c)diseases of the entire genital tract, non-gynaecological viscera and metastatic cancer can generate cytological abnormality; (d) screen detected borderline abnormality in endocervical cells is associated with CIN III.