PART TWO
Diagnostic Cytology
Table 7.1
Common microbial organisms in the vaginal flora
Lactobacilli
Bacteroides
species
Diphtheroids
Peptococcus
species
Staphylococcus
species
Peptostreptococcus
species
Streptococcus
species
Fusobacterium
species
Enterobacter
(not group A)
C lostridium
species
G ardnerella vaginalis
Bifidobacterium
Table 7.2
Common factors influencing vaginal microbial flora
Physiologic
Diseases and drugs
Local factors
Parturition
Hepatic disorders
Infections
Pregnancy
Hormonal imbalance
IUD
Menstruation
Metabolic diseases
Pessary
Menopause
Erosion and infections
Diaphragm
Oral contraceptives
Vaginal douche
Hormonal mimic drugs
Surgery
Antibodies
Trauma
Abortion
Sexual exposure
state physiologically and in health. It contains a large number
of organisms that, under poorly understood conditions, may
become pathogenic and cause disease.
General Features
A number of general cytological features represent the various
effects of infective processes. These include the changes listed
in Table 7.3. Specific cytological changes frequently are associ-
ated with certain infections and are described in their respective
areas. Only some of these responses may occur under specific
inflammatory conditions.
Background Changes
Inflammation and Cellular Obscuring
Overgrowth of microbes in the vaginal milieu may result in
obscuring of morphologic details in the smear (Fig. 7.1). In such
smears, numerous polymorphonuclear leukocytes occur, often
interspersed with a large number of histiocytes. Excessive bacte-
rial growth may also contribute to cellular obscuring. It must be
realized that no meaningful evaluation of cellular change may
be possible on such smears. In all such cases, it is almost man-
datory that appropriate therapy be initiated and a repeat smear
examined before an opinion is rendered. Atrophic epithelium of
the vagina is particularly prone to inflammatory changes (Fig.
7.2) that may mimic atypia. In such cases local hormonal appli-
cation generally helps in proper interpretation of cells. In speci-
mens with overwhelming inflammatory exudates, it may not be
possible to differentiate vaginitis from cervicitis and endocervici-
tis. Inflammatory exudates and vaginal microbial flora is consid-
erably altered in the liquid-based gynecological slides (LBGS).4
Table 7.3
Cytologic features of vaginopancervical smears in infective
processes
General
Cellular
degenerative
changes
Cellular reactive
Background
changes
Nuclear
Hyperplasia and
repair
Acute and chronic
inflammation and
cellular obscuring
Cytoplasmic
Degenerative
Fresh and old blood
Metaplasia
Cytolysis
Parakeratosis
Cell distribution
changes
Hyperkeratosis
Pseudoparakeratosis
Multinucleation
Histiocytic
proliferation
Dysplasia
Postmenopausal atrophy and atypia:
• Important to treat with local estrogens;
• Repeat cytologic examination after 6 weeks; and
• Immediate colposcopy not recommended.
Cellular specimens from specific areas, e.g. the vaginal, cervi-
cal, and endocervical smear,5 or vulvar or lateral vaginal wall
scrapings, may reveal inflammatory response in one or more
preparations that can help localize the infective process within
the lower genital tract. A specific cervical inflammation with
predominant lymphohistiocytic reaction may occur in follicular
cervicitis (discussed later). Granulomatous reaction may occur
in the presence of foreign bodies (e.g. suture material, surgical
clips, IUD) or specific infections such as tuberculosis.
Bleeding
In infectious processes, both fresh and old blood may be
observed. Postmenopausal women with atrophic, thin vaginal
mucosa may bleed more easily. Similar changes may occur in
Trichomonas vaginalis
infection, which produces the typical
"strawberry" cervical lesion. Whereas the fresh bleeding is
recognizable without much difficulty, old bleeding, observed
as fibrin, should be differentiated from mucus. In direct smear
preparations, fibrin threads are uniformly thick and reveal nodal
formations at the points of intersections of interlacing threads.
Sometimes, hemosiderin pigment may be observed within the
macrophages and extracellularly. Sometimes, old hemorrhage
may contain hematoidin crystals that appear as "cockleburs," as
described by Hollander and Gupta6 (Fig. 7.3).
Cytolysis, the process of cellular degeneration due to bacte-
rial overgrowth, commonly affects the intermediate squamous
epithelial cells. The process is believed to be glycogen depend-
ent. Late menstrual cycle and pregnancy as well as hormonal
contraceptives often cause lactobacilli overgrowth. Pale staining,
vesicular nuclei with little or no cytoplasm of the intermedi-
ate cells predominate in such smears. Numerous lactobacilli
may occur interspersed with the remaining cellular remnants
(Fig. 7.4).
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