Significance of benign endometrial cells in papanicolaou tests from women aged ≥ 40 years

Long-term clinical significance of benign endometrial cells identified on routine cervical cytology in women aged more or equal to 45 years

INTRODUCTION

Within the Bethesda System, the recommendation of describing benign-appearing endometrial cells (BECs) has changed over recent years. Since the 2014 revision, their presence in cervical cytology reports has been deemed essential, beginning with age 45. Recent studies have suggested rising the reporting age to 50 years. Does the presence of these cells necessitate further assessment?

MATERIALS AND METHODS

This retrospective cohort study included patients aged between 45 and 65 years in whom BECs were present on cervical cytology between January 2001 and December 2010, with a follow-up at 5 and 10 years. Women who had abnormal cervical cells or atypical endometrial cells on cervical cytology were excluded, as well as women with a history of cervical or endometrial cancer, or a history of hysterectomy and incomplete follow-up data.

RESULTS

One hundred seventy-six women were included. Of these, 31% were postmenopausal of which 65% used hormonal substitution therapy. Twenty-eight percent presented with abnormal uterine bleeding at inclusion. During the follow-up period of 10 years, 87.5% had a normal gynecological follow-up and 11.4% underwent a hysterectomy for benign pathology. One percent (2 patients) had been diagnosed with endometrial malignancy, both presenting with postmenopausal bleeding and aged over 60 years.

CONCLUSIONS

Our study confirmed that the presence of BECs is not a reason for concern when no additional clinical indicator is recognized, especially with normal ultrasonographic examination. Further invasive exploration may be controversial. If reporting BECs in cervical cytology continues, we strongly agree on rising the reporting age to 50 years or postmenopausal state.

Change of Practice Patterns Following an Educational Comment on Reports of Benign-Appearing Endometrial Cells in Papanicolaou Tests

OBJECTIVES

Since the publication of our study demonstrating high negative predictive values (>99% for women in their 40s) of benign-appearing endometrial cells (nEMCs), we have begun to include an educational comment in Papanicolaou (Pap) test reports with nEMCs that recommends routine periodic screening for asymptomatic premenopausal women (APW). The current study evaluated how the inclusion of this comment has affected clinical practice patterns at our institution.

METHODS

The 2017 to 2019 database identified 175 reports containing the educational comment in women aged 45 to 54 years with a follow-up time of 11 to 37 months. Data, including age, menopause status, symptoms, imaging, and outcome, were collected. The procedure rate and the impact of clinical modifiers were assessed.

RESULTS

Thirty-seven (20.6%) patients had biopsies within 6 months, which decreased from 48.1% as we previously reported. All nine (5%) APW with biopsies triggered only by nEMCs had benign histopathology. The remaining 28 biopsied patients had abnormal bleeding or a thickened endometrium, or they were postmenopausal, including a 53-year-old patient with complex atypical hyperplasia. None of the 138 patients with conservative follow-up developed atypical/malignant lesions.

CONCLUSIONS

A qualifying educational note included in Pap reports significantly reduced follow-up biopsies in APW. Optimal follow-up of nEMCs should be based on relevant clinical modifiers.

Diagnostic Role of Papanicolaou Smear, Hemoglobin, Blood Group, and Other Clinical Symptoms in Detecting Endometrial Carcinoma: A Clinicopathological Study of 175 Iranian Women with Endometrial Carcinoma

Objectives:

Endometrial carcinoma (EC) is a common gynecologic malignancy in the female genital tract, especially in postmenopausal women. The current study aimed to analyze Papanicolaou (Pap) smear in patients with EC to assess the relationship between EC and abnormal cells in Pap smear, ABO blood group, and hemoglobin anemia.

Materials and Methods:

A retrospective study was conducted on 175 patients with EC in Imam Hossein Hospital, Tehran, Iran, during the period from 2013 to 2019. The histology information of cases was extracted from the hospital database, and Pap smear slides were taken from pathological archives. The acquired information and slides were then reviewed by an expert pathologist in the hospital. The data were analyzed in SPSS (version 18) by the Chi-square test, Fisher's exact test, and independent-samples t-test. P < 0.05 was assigned as significant.

Results:

The mean age of patients was 54.47 ± 11.34, ranging from 32 to 85 years, and 31.4% of the patients were premenopausal women. Grade III, invasion ≥ 50% of myometrial, and advanced stage (III and IV) were diagnosed in 30%, 7.4%, and 22.86% of the patients, respectively. The most common histological types of EC were endometrioid (66.9%), papillary (10.3%), and malignant mixed Mullerian tumor (5.7%). The abnormal Pap smear was achieved only in 37 EC patients (21.1%). Endometrial cells, atypical squamous cells of undetermined significance, and atypical glandular cells were observed in 56.8%, 29.7%, and 13.5% of the patients > 40 years of age with abnormal Pap smears, respectively. In patients with normal Pap smears, the most common results were inflammation in 75.1% and atrophy in 14.6% of the patients. Abnormal uterine bleeding was the most important problem observed in patients with EC.

Conclusion:

The efficacy of Pap smear in detecting EC is limited. Therefore, women with EC, >40 years of age, with heavy bleeding, anemia, O blood group, inflammation, and atrophy in Pap smear in the past 3 years need to be precisely checked up for EC. These items can be added as new criteria for EC screening procedures.

Age cutoff for reporting of benign-appearing endometrial cells in Papanicolaou specimens; should it be raised? A 10-year retrospective study from a large county hospital

INTRODUCTION

The recommendation for reporting benign-appearing endometrial cells in Papanicolaou specimens was increased from 40 to 45 years in the 2014 edition of The Bethesda System. Recent studies suggest that increasing the reporting age to 50 years would have no significant negative impact. Reporting of benign endometrial cells may trigger unnecessary procedures and increase the cost of patient care. The goal of our study was to perform cytohistologic correlations and determine an optimal age cutoff for reporting endometrial cells in cervical cytology specimens.

MATERIALS AND METHODS

The pathology database was searched between 2006 and 2015 for Papanicolaou tests with benign-appearing endometrial cells that were followed by endometrial sampling within 1 year of the cytology result in women ≥45 years. In cases where more than one follow-up surgical specimen was available, only the most significant result was included. Endometrial carcinoma or atypical hyperplasia was considered a significant histologic result. The data were organized into 4 age groups, 45 to 49, 50 to 54, 55 to 59, and ≥60 years.

RESULTS

Among 453,420 Papanicolaou specimens, 1121 cases reported endometrial cells in women ≥45 years. Of these, 588 (52%) had an endometrial biopsy/curettage or hysterectomy. Benign diagnosis was reported for 558 (95%) and 12 (2%) samples were insufficient for diagnosis. Significant histologic findings were present in 18 (3%) of cases, of which all were endometrial carcinoma. The difference was statistically significant between the age groups 45 to 54 and ≥55 (1.5% versus 17% of cases had significant endometrial pathology, P < 0.05).

CONCLUSIONS

Increasing the current reporting age appears safe and may improve efficiency and cost savings.

The effects of the Bethesda System 2014 on endometrial cell reporting and follow-up endometrial biopsies in women 45 years of age and over

INTRODUCTION

The Bethesda System (TBS) guidelines for reporting the presence of endometrial cells on Papanicolaou tests increased the reporting age from 40 (TBS 2001) to 45 (TBS 2014) years. Exfoliated endometrial cells (EMC) are usually a normal finding. Nevertheless, benign-appearing EMC occasionally correspond to endometrial hyperplasia or malignancy, especially in older, postmenopausal women. This study assesses the impact of this age cutoff change.

MATERIALS AND METHODS

This retrospective review compares endometrial biopsies following TBS 2001 and TBS 2014. Papanicolaou tests with EMC reported in women older than age 40 or 45 years were correlated with follow-up endometrial biopsies performed between May 25, 2014, to May 26, 2015, and May 27, 2015, to May 26, 2016, respectively.

RESULTS

The number of reported EMC declined from 770 to 492 (a 36.1% decrease). The follow-up endometrial biopsy rate for Papanicolaou tests reporting EMC using TBS 2001 was 13.6% (105 of 770) versus TBS 2014 at 13.8% (68 of 492; P = 0.92). For TBS 2001, 15% of women aged 45 and older had follow-up biopsies (65 of 434; P = 0.62). Most follow-up biopsies showed benign endometrium. In the TBS 2001 group, 1 biopsy showed malignancy and another showed complex hyperplasia with atypia. Both patients were older than 45 years. The TBS 2014 group contained 1 biopsy of malignancy and 1 with simple hyperplasia with focal atypia.

CONCLUSIONS

The implementation of TBS 2014 reduced the frequency of reporting benign-appearing endometrial cells. The follow-up biopsy rate has remained essentially the same, but the total number of biopsies performed decreased, with a similar low yield of significant abnormalities.

Significance of finding benign endometrial cells in women 40-45 versus 46 years or older on Papanicolaou tests and histologic follow-up

BACKGROUND

The 2014 Bethesda System recommends reporting the finding of benign-appearing, exfoliated endometrial cells on Papanicolaou (Pap) tests in women aged 45 years and older. We aimed to determine the significance of normal endometrial cells on liquid-based Pap tests in women aged 40 years and older and to correlate this finding with clinical factors and cytologic/histologic follow-up.

MATERIALS AND METHODS

We retrospectively identified all women aged 40 years and older who had benign endometrial cells (BECs) on Pap tests at our institution during a 6-year period. Histologic follow-up and outcomes were evaluated.

RESULTS

Among 18,850 Pap tests during the study period, 255 (1.4%) had findings of BECs and 159 (62.4%) of these women had follow-up Pap tests or subsequent tissue sampling by surgical procedures. Of the 159 cases, only 4 (2.5%) had significant endometrial pathologic processes, all endometrial endometrioid adenocarcinoma (three women had postmenopausal bleeding and 1 was perimenopausal with menorrhagia). No women between ages 40 and 45 years had significant pathologic findings and only one woman between 46 and 50 years (47 years) had an endometrial endometrioid carcinoma (1.5%). Women older than 47 years have higher odds (5.38) of having a significant endometrial lesion (P = 0.029) than those who are ≤47.

CONCLUSION

Clinically significant endometrial lesions occurred predominantly in women older than 50 years (4.6%) and in only one woman between ages 46 and 50 years (1.5%). Therefore, endometrial sampling should be performed in women aged 47 years and older with BECs, especially when additional clinical indicators (e.g., postmenopausal bleeding) are recognized.

Negative Predictive Value and Significance of Benign-Appearing Endometrial Cells in Papanicolaou Tests

OBJECTIVES

Reporting benign-appearing endometrial cells (nEMCs) in Papanicolaou (Pap) smears of women 40 years and older, introduced in The Bethesda System 2001, may be interpreted as an abnormal finding and lead to unnecessary endometrial biopsies. To our knowledge, this is the first study on the negative predictive value (NPV) of this cytology finding.

METHODS

An 11-year database with 1,036,629 Pap test reports and 121,079 surgical pathology reports identified reports of nEMCs in women 40 years and older with follow-up endometrial histopathology within 6 months. Endometrial carcinoma and atypical endometrial hyperplasia were chosen as relevant outcomes. NPVs were calculated. Bayesian modeling assessed the impact of age, bleeding, and postmenopausal status on risk.

RESULTS

NPVs for patients aged 40 to 44 years and 45 to 49 years (99.5% and 99.3%, respectively) were not significantly different. NPVs for patients aged 50 to 54 years, 55 to 59 years, and 60 years and older (97.1%, 95.3%, and 94.5%, respectively) were lower than the NPV for patients aged 40 to 49 years. Bayesian modeling indicated that asymptomatic patients in all age groups 40 years and older have very low risk. Bleeding history increased risk in all age groups, especially in women 50 years and older.

CONCLUSIONS

nEMCs in Pap test reports of women 40 years and older are a normal cytology finding in premenopausal women, which may result in unnecessary endometrial biopsies. The NPV associated with this finding for women aged 40 to 49 years exceeded 99%.

Pap Smears in Endometrial Adenocarcinoma: Does It Have a Role?

Background: Historically the conventional Pap smear has been an effective screening tool for Carcinoma cervix. However the reporting of benign and malignant endometrial cells on Pap smear has remained controversial. There are very few studies addressing the utility of Pap smears in diagnosing endometrial carcinomas. Objective: To rescreen the Pap smears of patients with endometrial adenocarcinoma for the detection of normal/ atypical endometrial cells and to correlate with clinico-pathological parameters. Methods: The present study was carried out at SDM College of Medical Sciences, Dharwad, Karnataka, India for a period of 7 years. Of the 89 endometrial cancers diagnosed, Pap smear slides were available in 32 patients, which were reviewed and classified as normal cells/ atypical cells. Corresponding biopsy slides were reviewed for tumour type, nuclear grade, myometrial invasion and stage. Statistical tests of independence were applied for selected clinico-pathological parameters. Results: Cervical cytology was normal in nine patients (28.1%) and atypical in 23 patients ( 71.2%). The most common histological type was endometrioid carcinoma in 27 cases (84%). 13 cases(40.5%) had nuclear grade 1 whereas 9 cases(28%) and 10 cases(31.2%) had grades 2 and 3, respectively. Of the 22 cases assessed for invasion and stage, 12 cases had <1/2 of invasion (41.2%) and remaining 10 cases had >1/2 of invasion (58.8%). Early stages (I and II) had 17 cases (77.27%) and advanced stage (III and IV )had 5 cases (23.5 %). Significant correlation was found between post-menopausal status and higher nuclear grades (p<0.05).Conclusion: Pap smear is primarily a screening test for squamous cell carcinoma cervix. If atypical glandular cells are seen, further investigations are required to rule out neoplasia. All women with atypical endometrial cells on Pap tests need endometrial sampling irrespective of age/menstrual status.

Significance of endometrial cells in cervical cytology

This study evaluated the clinical significance of endometrial cells in Papanicolaou test (Pap test). A retrospective study was performed from the cytological database of Seoul National University Hospital. The results of Pap tests of women aged 40 years or older between January 1998 and December 2007 were sorted. Medical records were reviewed to identify the presence of endometrial cells from cytology, and cytologic and histologic follow-ups were performed to determine the clinical significance of the lesions. Among 75,673 Pap cases, 832 cases presenting normal endometrial cells (nEMCs) were included in this study. Their follow-up data are as follows: 800 with nEMCs, 5 with atypical EMCs (aEMCs), and 27 with endometrial cancer cells (EMCCs) on cytologic and histologic follow-ups. Significant endometrial or cervical diseases were found in 0.5%, 40%, and 100% of the cases on the following-up the pathologic examination of the women with nEMCs, aEMCs, and EMCCs, respectively. Unlike aEMCs and EMCCs, nEMCs on Pap tests did not increase the risk of developing endometrial hyperplasia or endometrial cancer in women aged 40 years or older. There is no clinical benefit to perform routine endometrial work-up in women with nEMCs, as recommended in the 2001 Bethesda System. However, symptomatic women with nEMCs on Pap test should perform endometrial work-up regardless of menopausal status.

Morphometric analysis of endometrial cells in liquid-based cervical cytology samples

BACKGROUND

Exfoliated endometrial cells can be seen in cervical smears in association with a wide variety of conditions ranging from normal proliferative endometrium to endometrial malignancies. It is often difficult to differentiate between benign, atypical and malignant endometrial cells using cytomorphology alone. This study was conducted to evaluate if morphometric analysis of endometrial nuclei on liquid-based cervical samples could be of help in differentiating between these endometrial cells.

MATERIALS AND METHODS

Three groups of cervical samples with histopathological correlation were selected: Group A: showing benign endometrial cells; Group B: showing atypical endometrial cells and Group C: showing malignant endometrial cells. There were 30 cases each in Group A and B and 39 cases in Group C. Image J, NIH, USA was used for selecting the endometrial nuclei and performing the morphometric measurements. MANOVA was used for statistical analysis.

RESULTS

The mean nuclear area and nuclear perimeter were significantly different between the three groups of endometrial cells with a P-value <0.05. However, the mean standard deviation of the nuclear area (SDNA) was not significantly different between atypical and malignant endometrial cells (P = 0.765) and the mean nuclear diameter was not statistically different between benign and atypical cells (P = 0.112). Also, the difference in the mean integrated gray density amongst all three groups was not statistically significant (P = 0.397, 0.844, 0.732).

CONCLUSION

We conclude that the morphometric parameters of the nuclear area and nuclear perimeter are helpful in differentiating between benign, atypical and malignant endometrial nuclei even in liquid-based cervical cytology samples.

Normal-Appearing Endometrial Cells in Pap Tests of Women Aged Forty Years or Older and Cytohistological Correlates

OBJECTIVE

The Bethesda System 2001 for reporting cervical cytology recommends reporting benign-appearing, exfoliated endometrial cells in women aged 40 years or older. The objective of this study was to determine the significance of normal endometrial cells in conventional Papanicolaou (Pap) tests of women aged 40 years and older and to correlate this finding with histological follow-up.

STUDY DESIGN

Over a period of 5 years, all Pap tests showing endometrial cells in women aged ≥ 40 years were identified. Histological follow-up and outcome were evaluated.

RESULTS

Out of 17,275 Pap tests, 199 (1.15%) showed benign endometrial cells. Forty-seven of these 199 patients had subsequent tissue sampling by surgical procedures including endometrial curettage (n = 31), lower genital tract biopsy (n = 30) and hysterectomy (n = 2). Overall, out of 47 cases, 3 (6.4%) had significant endometrial pathology including 2 simple hyperplasias without atypia and 1 complex hyperplasia with atypia.

CONCLUSION

The incidence of clinically significant endometrial lesions associated with the presence of endometrial cells in Pap tests of women aged 40 years and older was very low. Considering this finding, women aged between 40 and 50 years with benign endometrial cells in a Pap test should undertake endometrial sampling only when additional clinical indicators are recognized.

Histologic follow-up in patients with Papanicolaou test findings of endometrial cells: results from a large academic women's hospital laboratory

We studied 1,183 Papanicolaou (Pap) cytology cases (739 with normal endometrial cells [nEMCs], 423 with atypical EMCs [aEMCs], and 21 with endometrial cancer cells [EMCCs] in women 40 years or older) with histologic follow-up. Significant endometrial lesions were found in 2.7%, 18.4%, and 100% of cases with nEMCs, aEMCs, and EMCCs, respectively. Significant lesions were present in women 50 years or older with nEMCs found after day 12 of the menstrual cycle or who were postmenopausal (5.2%), but not in women with nEMCs before day 12 (0.5%) or women younger than 50 years with nEMCs after day 12 (1.6%). Our data indicate that endometrial sampling provides no clinical benefit in women (regardless of age) with nEMCs before day 12 of the menstrual cycle or women younger than 50 years with nEMCs after day 12. Endometrial sampling should be routinely performed in women with aEMCs and in women 50 years or older with nEMCs after day 12 of the menstrual cycle or who are postmenopausal.

In Papanicolaou smears, benign appearing endometrial cells bear no significance in predicting uterine endometrial adenocarcinomas

Reporting of benign appearing endometrial cells (BECs) in the Papanicolaou smears of women aging 40 years or older was mandated in the Bethesda System 2001 aiming at predicting the uterine pathology. The purpose of this study was to determine the clinical significance of the BECs in patients in our Medical Center. A two-arm study was designed in ≥40-years-old women with BECs and without BECs in their Pap smears from January 2002 to December 2004. Of 21,965 patients, 882 had BECs in their Pap smears and the rest did not. Among the patients with BECs, 186 (study group) and among those without BECs, 2,064 (control group) had histopathologic follow-ups. There were 4 patients in the study and 47 in the control groups who had uterine adenocarcinoma. The Chi-square P-value for adenocarcinoma between the two groups was 0.91; indicating insignificant differences between the two groups. We conclude that presence of BECs in the Pap smears of ≥40-years-old women signal no significance as a harbinger of endometrial adenocarcinoma.

Normal endometrial cells in cervical cytology: systematic review of prevalence and relation to significant endometrial pathology

OBJECTIVES

To estimate the prevalence of normal endometrial cells (NECs) and the proportion of NECs associated with significant endometrial pathology in conventional and liquid-based cytology (LBC) cervical smears; and to assess the association between NECs and clinical symptoms in women with endometrial hyperplasia or carcinoma.

METHODS

Systematic review of the literature and meta-analysis of prevalence and proportion data. The review was confined to studies reporting on NECs in smears from postmenopausal women or women aged 40+.

RESULTS

A total of 22 relevant primary studies were identified from 1970 to 2007. The overall summary estimate for the prevalence of NECs in smears from postmenopausal women or women aged 40+ in all screening smears was 0.4% (95% CI 0.2-0.7%); this was 0.3% (95% CI 0.1-0.5%) and 0.9% (95% CI 0.5-1.4%) for conventional and LBC smears, respectively; P = 0.003 for difference. The overall estimate for the proportion of NECs associated with significant endometrial pathology was 7% (95% CI 4-10%); this was 11% (95% CI 8-14%) and 2% (95% CI 1-2%) for conventional and LBC smears, respectively; P < 0.001 for difference. In women with significant endometrial pathology, the presence of NECs in followed-up women was associated with abnormal uterine bleeding in 79% (95% CI 68-87%) of cases.

CONCLUSION

Compared with conventional cytology, LBC may be associated with a higher prevalence of NECs but these are less likely to be associated with endometrial pathology. This finding might be explained by more consistent use of sampling instruments for LBC with better access to the endocervical canal or alternatively by changes over time, broadly coincident with the introduction of LBC, in the population in which NECs are reported. In followed-up women with NECs, most endometrial pathology is accompanied by symptoms, implying that a relatively smaller number of additional cases are identified through follow-up of asymptomatic women.

Normal endometrial cells in liquid-based cervical cytology specimens in women aged 40 or older

OBJECTIVE

The 2001 Bethesda System consensus statement directs the reporting of endometrial cells on cervical cytologic preparations in women aged 40 years or older. Our objective was to assess the significance of endometrial cells on cervical liquid-based cytology (LBC) specimens in this population.

METHODS

The population included women aged 40 years or older in whom endometrial cells were identified in otherwise normal LBC specimens from December 2001 through June 2005, and who subsequently underwent endometrial sampling within a 12-month period. Patient age, menopausal status, hormonal use, the presence or absence of co-incident symptoms and endometrial sampling results were recorded.

RESULTS

Endometrial cells were identified on LBC specimens in 2494 women during the study period, for an incidence of 0.4%. Of these, 370 women underwent endometrial sampling within 12 months of the incident LBC preparation and met inclusion criteria. In asymptomatic premenopausal women, sampled solely due to the presence of endometrial cells, 2.1% were identified with significant endometrial pathology, compared to 2.6% of symptomatic premenopausal women. In menopausal women, only those with symptoms (mainly bleeding) had significant pathology on subsequent sampling (25%); none of the asymptomatic menopausal women were found to have hyperplasia or carcinoma. No significant differences were identified in premenopausal women according to the time of sampling during the menstrual cycle or use of oral contraceptives.

CONCLUSION

Endometrial cells on LBC preparations, even in the absence of symptoms in premenopausal women aged 40 years or older, are associated with significant uterine pathology.

Endometrial cells identified in cervical cytology in women > or = 40 years of age: criteria for appropriate endometrial evaluation

OBJECTIVE

No consensus exists regarding evaluation of asymptomatic premenopausal women with benign endometrial cells (BECs) identified on cervical cytology. We determined the frequency of uterine pathology in asymptomatic women, > or = 40 years of age, positive for BECs on cervical cytology.

STUDY DESIGN

Cervical cytopathology records from a Midwestern US teaching hospital from April 2002 through December 2005 were reviewed and cases with BECs identified. Patient age, symptomatology, and endometrial sampling results were obtained.

RESULTS

Of 194,717 records examined, 1784 (0.9%) of women > or = 40 years had BECs present and 440 had follow-up endometrial pathology. There were 4 cases of complex hyperplasia with atypia, 2 from patients < or = 50 years, 1 was asymptomatic; 4 cases of adenocarcinoma were identified, all from women > 50 years.

CONCLUSION

To date, the present study is among the largest follow-up studies of women with BECs on cervical cytology. Follow-up endometrial sampling may not be indicated in asymptomatic patients < or = 50 years.

Routine endometrial sampling of asymptomatic premenopausal women shedding normal endometrial cells in papanicolaou tests is not cost effective

BACKGROUND

Following The Bethesda System 2001 (TBS 2001) recommendation to report normal endometrial cells (nEMC) in women ages >or=40 years, studies have shown that endometrial (EM) sampling has increased, but detection of significant EM pathology has not increased. The cost implications of this increased EM sampling have not been specifically addressed. The aim of this study was to assess the cost effectiveness of EM sampling in women ages >or=40 years with nEMC in their Papanicolaou tests.

METHODS

The authors reviewed 499 cases at a large academic women's hospital where nEMC had been reported in Papanicolaou tests followed by EM tissue sampling. Relevant clinical information was obtained from cytopathology and surgical pathology reports. Data on costs of EM sampling were obtained from business offices.

RESULTS

Of 1049 women ages >or=40 years who were shedding nEMC, 499 (48%) had follow-up EM sampling. In follow-up EM sampling, 6 cases of significant pathology (atypical complex EM hyperplasia or adenocarcinoma) were detected. Asymptomatic women totaled 350, and the total cost for EM sampling of asymptomatic patients shedding nEMC was estimated at 107,272 dollars. Three of the asymptomatic patients had significant EM pathology, but all 3 were postmenopausal. Three additional premenopausal patients with significant pathology were symptomatic with vaginal bleeding.

CONCLUSIONS

No asymptomatic premenopausal patients shedding nEMC either before or after Day 12 of their menstrual cycle were found to have significant EM pathology in this large study of almost 500 women with nEMC in their Papanicolaou tests. The total costs, when projected nationally, for EM sampling in asymptomatic premenopausal women were highly significant. Educational discussions with clinicians in this community are underway to reduce the number of women who undergo EM sampling after Papanicolaou test findings of nEMC. Routine EM sampling of asymptomatic premenopausal women with nEMC in Papanicolaou tests is not cost-effective.

Endometrial Cells in Cervical Cytology: Review of Cytological Features and Clinical Assessment

The 2001 Bethesda System for Reporting Cervical Cytology recommends reporting benign exfoliated endometrial cells in women age 40 and older, and a review of the literature supports this recommendation. Stromal cells and histiocytes do not need to be reported. The effect of hormonal therapy on endometrial shedding is reviewed. Clinical information should be provided to the laboratory so that appropriate educational notes can be appended to the cytology report. Benign endometrial cells in premenopausal women in the first half of the cycle are not associated with significant pathology and such women do not need additional evaluation. Significant pathology is also unlikely in the second half of the cycle and evaluation may not be required unless clinically indicated. Initial evaluation of other women with benign endometrial cells may include either endometrial sampling or transvaginal ultrasound. Atypical endometrial cells are associated with a higher rate of significant pathology and should lead to additional evaluation. Additional prospective studies on the management of patients with endometrial cells on Pap tests are needed.

The significance of benign endometrial cells in cervicovaginal smears

The success of the routine Papanicolaou (pap) smear in reducing the incidence and mortality of cervical cancer has been chronicled extensively. Unfortunately, endometrial cancer, the most common malignancy of the gynecologic tract, continues to lack a screening modality of comparable efficacy. It is generally accepted that the Papanicolau test has a low sensitivity for detecting endometrial disease. Nonetheless, it remains true that endometrial cells are not uncommonly identified on routine cervicovaginal smears and along with each case comes an associated responsibility for pathologists to assess cytologic features, assign a potential clinical significance, and make a decision on reporting this finding. When endometrial cells with an entirely normal cytologic appearance are identified on an otherwise unremarkable cervicovaginal smear, the central question raised is whether such cells are exfoliating physiologically or whether their exfoliation is pathologic in response to an underlying endometrial disease. Additionally, in the former scenario, could subsets of patients be defined in which the reporting of this finding is deemed unnecessary in the cytologic report? In this contribution, we explore the clinical significance of finding normal endometrial cells in cervicovaginal smears based on a review of the medical literature of the last half-century. The historical and evidentiary basis for the Bethesda 2001 recommendations, which calls for the reporting of cytologically benign endometrial cells only in patients 40 years and older, is reviewed in detail.