Anatomy and Histology of female Genital Tract

The uterus Uterus is lined by simple columnar ciliated cells cervix Fundus of the uterus Body of the uterus cervix Uterus is lined by simple columnar ciliated cells

The cervix Anatomy Histology vagina Stratified squamous non-keratinzed epithelium rich in glycogen Ectocervix Endocervix Pseudo-stratified columnar ciliated epithelium, rich in mucus secretion Cervical canal

The vagina Function: protection of upper genital tract. Thickness: Child: thin (few cells) and atrophy Menopause: thin and atrophy Puberty (reproductive period): thick (more than one layer, 7-10 layers).

Cytology of normal female genital tract 1- Epithelial cells: Stratified squamous epithelium Columnar epithelium Endometrium Glandular endometrial cells Stromal endometrial cells: Superficial cells Deep cells

Squamous Epithelium

Superficial Intermediate Parabasal Basal

Glandular endometrial cells Physiologically: they are present as normal cells in the following conditions, in routine vaginal smear Menstrual flow ( early 2-3 days). Early pregnancy Abortion Post-partum period In case of intra-uterine device at the end of menstrual cycle.

Glandular endometrial cells Pathologically: present in endometrial lesions as: Polyp Endometritis Submucous fibroid Endometrial hyperplasia Adeno-carcinoma

2- Non-epithelial cells Smooth muscle cells: normally not present except in deep traumatic scrapping of ulcerative lesion as in polyp, fibroma, and abortion. RBCs Plasma cells Histocytes (macrophages) Sperms Yeast Trichomanos vaginalis

Inflammatory cells usually posterior fornix or cervical smears Bacterial Vaginosis Polymorphs Diplococci Inflammatory changes in epithelial cells Presence of polymorphs Intra-cellular diplococci

Candida spores-hyphae Dust mites Trichomonas Candida spores-hyphae Presence of micro-organisms Trichomonas Candida Bacteria Mites

Methods of collecting endometrial samples Endometrial aspiration Endometrial lavage Endometrial scraping Endometrial biopsy

Cervical – vaginal smears Several possibilities Cervical scrape taken from the squamo-columnar junction; the level of the SC junction varies with sexual maturity Posterior fornix aspiration Lateral vaginal wall [upper third] scrape

Squamo-Columnar Junction Junction of pink cervical skin and red endocervical canal Inherently unstable Key portion of the cervix to sample Most likely site of dysplasia In obtaining the Pap smear, it is important to sample the "Squamo-columnar Junction." This is the circular area right at the opening of the cervix where the pink, smooth skin of the cervix meets the fiery-red, fragile, mucous-producing lining of the cervical canal. If there is going to be a problem with cancer or precancerous changes, it is this area that is most likely to be effected. This area is also known as the SQJ, or transition zone.

Vaginal Speculum The vaginal speculum consists of two blades. When closed, the speculum is inserted into the vagina. Then the blades are opened, revealing the cervix at the end of the vagina. Thin-bladed Pederson speculums are most comfortable for most women. For women who have had babies, the wider Grave’s speculum may be needed for good visualization of the vagina and cervix.

Ayers Spatula Concave end to fit the cervix Convex end for vaginal wall and vaginal pool scrapings The Ayers spatula is specially designed for obtaining Pap smears. The concave end (curving inward) fits against the cervix, while the convex end (curving outward) is used for scraping vaginal lesions or sampling the "vaginal pool," the collection of vaginal secretions just below the cervix. The spatula is made of either wood or plastic. Both give very satisfactory results.

Cytobrush Insert ~ 2 cm (until brush is fully inside canal) Rotate only 180 degrees (otherwise will cause bleeding) Push the cytobrush into the canal, no deeper than the length of the brush (1.5 cm - 2.0 cm). Rotate the brush 180 degrees (half a circle) and pull the cytobrush straight out. Don't keep spinning the brush round and round or you will cause bleeding. Even the 180 degree rotation may cause a little bleeding but usually it doesn't.

Squamous epithelial cells Keratinized type: skin, valva Non-keratinized: vagina, ectocervix - Basal cells: usually not seen unless there is sever ulceration with destruction of whole thickness of epithelium: deep basophilic - Parabasal cells - Intermediate cells - Superfacial cells - Non-nucleated cells

Differentiating feature of normal squamous cells Parabasal Intermediate Superficial Cell formation Single cells or sheet Single cells or clump Diameter 15 – 25 um 30 -55 um 33 – 55 um Nucleus Vesicular with finely granular chromatin 10 -12um Vesicular with finely granular chromatin 8 – 10 um Pyknotic or absent 4 – 6 um Cytoplasm Oval, thick, and dark basophilic Thin, flat or folded, polyhydral, pale basophilic Polyhydral, thin, flat, eosinophilic

Feature of cell maturation Nucleus Cytoplasm Basal cells Reticular chromatin Greenish blue (basophilic) Parabasal and intermediate cells Granular chromatin Yellow Superficial cells Pyknotic chromatin Red (acidophilic)

Make Pap Smear As thin as possible Properly labeled Label the slide with pencil on the frosted end. Two slides may be made, one for the spatula and one for the brush (“two-slide” technique). Alternatively, a single slide may be used (the “one-slide” technique) in which the brush is spread on one half the slide and the spatula is used on the other half. Both techniques give good results.

Spray with Fixative Within 10-15 seconds Allow to fully dry before packaging Cytologic Fixative Allow the slides to dry completely before placing them in the Pap smear container. Once dry and packaged, it is best to send them out promptly for interpretation. When operational circumstances disallow prompt sending of the slides, they can be held for weeks to months without significant loss of readability. Make sure the slides are properly labeled and that important clinical information is included with the requisition. Telling the cytologist that the patient has had a hysterectomy will save considerable amounts of time in evaluating the smear. For women who have had a hysterectomy, Pap smears are obtained by using the convex end of the Ayers spatula, scraping it horizontally across the top of the vagina. Then the cytobrush is used to reach into the the right and left top corners of the vagina.

Causes of unsatisfactory smear Air drying smear before fixation ---- less differentiation between cytoplasm and nucleus. Inadequate fixation Uncleaned slides Incorrect staining time Dryness during staining procedures

Characters of unsatisfactory smear Thick Poorly spread Blood smear with clotting

Thank you