Reappraisal of cytology-histology correlation in cervical cytology based on the recent American Society of Cytopathology guidelines (2017) at a cancer research centre.

OBJECTIVE: To assess the impact of recently published American Society of Cytopathology (ASC) guidelines (2017) on the conduct of cervical cytology-histology correlation (CHC). METHODS: A retrospective review was conducted for cervical biopsies with their corresponding conventional cervical smears over a 7.5-year period (January 2011-June 2018). As per the ASC guidelines, a discrepancy assessment grid was prepared. Major cytology-histology discordance was defined as a diagnosis of high-grade squamous intraepithelial lesion (HSIL) or CIN2+ in one of the tests with negative result in the other. Smears and biopsies of all discordant cases were reviewed for reasons of overcall and undercall. RESULTS: Of the 341 cervical biopsies with corresponding Papanicolaou smear, cytology-histology agreement was noted in 249 (73%) cases. Major discordance was observed in 22 cases (6.4%)-16 undercalls and six overcalls on cytology-while minor discrepancies were noted in 70 cases. Atypical metaplasia and repair changes were the main reasons for overcall while small HSIL cells in atrophic smear and scant HSIL cells were important causes of undercall on cytology review. Using the ASC guidelines, we could improvise upon the existing CHC methodology for categorisation of cyto-histological pairs of cases with a cytological diagnosis of atypical glandular cells. CONCLUSION: The present study demonstrates, for the first time, that the recent ASC guidelines facilitate cervical CHC, especially for categorisation of cases with atypical glandular cells on cytology. Uniform application of these guidelines would standardise the conduct of cervical CHC internationally and provide scope for inter-laboratory comparison of data as well as enhance self-learning and peer learning.

Cervical high-grade squamous intraepithelial lesion on conventional cytology: Cytological patterns, pitfalls, and diagnostic clues.

BACKGROUND: Conventional cervical cytology, which has a relatively low sensitivity in diagnosing high-grade lesions as compared to liquid-based cytology, is still being practiced in low resource settings. This study aimed at elucidating various cytomorphological patterns, pitfalls, and subtle clues to high-grade squamous intraepithelial lesion (HSIL) diagnosis on conventional cervical cytology through cytologic-histologic correlation. METHODS: Cervical biopsies reported as CIN2/3 were correlated with their corresponding Pap smears over a 10-year period to determine the frequency of undercalls. For characterization of overcalls, cervical smears reported as HSIL and their corresponding biopsies during the same period were correlated. The discordant cases in both the groups were reviewed for problematic patterns and pitfalls in cytological diagnosis of HSIL. RESULTS: Of the 142 biopsies with CIN2/3, 29 (20.4%) cases had been undercalled on cytology. Sixteen (16) of these could be reclassified as ASC-H/HSIL on smear review. Smears showing predominant cells of low-grade squamous intraepithelial lesion grade with a few HSIL cells and those with small abnormal cells in an atrophic background formed the main confounders for HSIL underdiagnosis. Thirteen (13) out of 130 (10%) Pap smears called as HSIL, where biopsy diagnosis was less than CIN2, were labeled as overcalls. Atypical metaplasia, hyperchromatic crowded groups, and reparative changes constituted the major diagnostic pitfalls on cytology. A diligent smear review helped to reduce the undercall and overcall rates to 9.1% and 2.3%, respectively. CONCLUSION: Awareness of morphological challenges in interpretation of HSIL among cytopathologists practicing cervical cytology would assist in reducing the diagnostic errors and ensure better patient management.

Cervical Cancer Screening in Resource-Constrained Countries: Current Status and Future Directions

Cervical cancer continues to be a major public health problem affecting large numbers of women in many developing countries. Limitations of various screening modalities and the lack of ready availability of a cost-effective point-of-care screening tool have hindered the efficient implementation of population-based screening programs in these settings. It has not proved possible for many countries to adopt cytology as a screening modality due to inadequate infrastructure and trained manpower. However, recent developments, notably design and testing of a low-cost HPV test kit and initiatives by countries like India in developing and putting into operation a framework for large-scale screening of women, have raised hopes that cervical cancer control may be possible even in resource-constrained locations. With the advent of HPV vaccination, primary prevention of cervical cancer also seems a distinct possibility. However, wide availability and acceptability of vaccination is still an unresolved issue for developing countries. The possible future effects of vaccination on test characteristics of various screening strategies also need to be evaluated. This review gathers information on the current status of cervical cancer screening with a special focus on low resource settings. It revisits the strengths and limitations of the available screening modalities for cervical cancer viz. cytology, visual methods and HPV testing, in the context of their applicability in developing countries. In addition, the role of newer HPV-detection methods, for instance DNA, RNA and protein-based techniques, in triage of screen-positive women is discussed. The contemporary issue of impact of HPV vaccination on cervical cancer screening is also addressed briefly. The main highlight of the review is the reference to 'operational framework guidelines' for population-based cervical cancer screening, which have recently been formulated and are in the process of being implemented in India. The guidelines may serve as a model for other similar low-resource settings where implementation of cancer screening is desired.

Bacterial Vaginosis and Cervical Intraepithelial Neoplasia: Is there an Association or is Co-Existence Incidental?

Objectives: To determine associations, if any, of bacterial vaginosis with cervical pre-neoplastic lesions and evaluate any effects of sub-categorization of smears with bacterial vaginosis. Methods: All cervico-vaginal smears reported as positive for bacterial vaginosis over a five-year period were reviewed and sub-categorized into 'type I (dysbacteriosis)' and 'type II (pure Gardenerella infection)' smears by two cytopathologists (PS, SG). The proportion of smears with healthy flora and pre-neoplastic lesions was compared with those having bacterial vaginosis in conjunction with such changes. In addition, a comparison was also attempted between the frequencies of pre-neoplastic lesions with the two categories of bacterial vaginosis smears. Results: Bacterial vaginosis was diagnosed in 28.6% (7017 of the 24,565) of the 24,565 smears received in the Institute during the study period. Of these 7,017 smears with bacterial vaginosis, 53% (3717) were categorized as type I and 42.7% (3000) as type II by both cytopathologists. Pre-neoplastic lesions were detected in 10.2% of smears with bacterial vaginosis compared to 5.7% of those with healthy flora (P<0.0001). Of the sub-categories of bacterial vaginosis, the risk of detecting precancerous lesion was higher for type II smears (P<0.001). Conclusion: Sub-categorization of bacterial vaginosis, as performed in the Dutch coding system, may be worthwhile due to the strikingly different risk of associated preneoplasia.

Spindle cell lipoma with predominant nerve sheath tumor-like areas: A potential diagnostic pitfall on aspiration cytology.

Spindle cell lipoma (SCL) is an uncommon variant of lipoma that usually is present in subcutaneous fat of adult men. This tumor has a low rate of local recurrence and no risk of malignant behavior. Although histological features of SCL are well documented, cytological descriptions have been few. We present the case of a 41-year man with a right arm swelling, which on fine-needle aspiration cytology showed adipose tissue fragments, spindle cell areas mimicking benign nerve sheath tumor, and bundles of ropy collagen in a myxoid background, suggesting a diagnosis of SCL. SCL with predominant spindle cell component may mimic benign nerve sheath tumor on aspiration cytology. Subtle cytological features like presence of adipose tissue, ropy collagen, and mast cells help in accurate diagnosis.

Glutathione S-transferase M1 and T1 Polymorphisms, Cigarette Smoking and HPV Infection in Precancerous and Cancerous Lesions of the Uterine Cervix.

Glutathione S-transferases (GSTs) play an important role in detoxification of carcinogenic electrophiles. The null genotypes in GSTM1 and GSTT1 have been implicated in carcinogenesis. Present study was planned to evaluate the influence of genetic polymorphisms of GSTM1 and GSTT1 gene loci in cervical carcinogenesis. The study was conducted in Lok Nayak hospital, New Delhi. DNA from clinical scrapes of 482 women with minor gynaecologic complaints attending Gynaecology OPD and tumor biopsies of 135 cervical cancer cases attending the cancer clinic was extracted. HPV DNA was detected by standard polymerase chain reaction (PCR) using L1 consensus primer pair. Polymorphisms of GSTM1 and GSTT1 were analysed by multiplex PCR procedures. Differences in proportions were tested using Pearson's Chi-square test with Odds ratio (OR) and 95% confidence interval (CI). The risk of cervical cancer was almost three times in women with GSTM1 homozygous null genotype (OR-2.62, 95%CI, 1.77-3.88; p<0.0001). No association of GSTM1 or GSTT1 homozygous null genotypes was observed in women with normal, precancerous and cervical cancerous lesions among ≤35 or >35 years of age groups. Smokers with null GSTT1 genotype had a higher risk of cervical cancer as compared to non-smokers (OR-3.01, 95% CI, 1.10-8.23; p=0.03). The results further showed that a significant increased risk of cervical cancer was observed in HPV positive smoker women with GSTT1 (OR-4.36, 95% CI, 1.27-15.03; p=0.02) and GSTM1T1 (OR-3.87, 95% CI, 1.05-14.23; p=0.04) homozygous null genotypes as compared to HPV positive non smokers. The results demonstrate that the GST null genotypes were alone not associated with the development of cervical cancer, but interacted with smoking and HPV to exert effects in our Delhi population.

Performance of a low cost magnifying device, Magnivisualizer, versus colposcope for detection of pre-cancer and cancerous lesions of uterine cervix.

OBJECTIVE: To assess the performance of a low cost magnifying device (Magnivisualizer) compared to a standard optical colposcope for detection of precancerous and cancerous lesions of the uterine cervix. METHODS: A total of 659 consecutive symptomatic women attending a gynecologic outpatient clinic underwent unaided visual inspection followed by cytology, visual inspection of the cervix using 5% acetic acid (VIA), and VIA under magnification (VIAM) with the Magnivisualizer. All women, independently of test results, were referred for colposcopic examination. Colposcopic-directed biopsies were obtained from all positive lesions and compared to positive VIAM cases. RESULTS: The detection rate for VIA positive lesions was 12% (134/659), while it was 29% for VIAM positive lesions (191/659). The sensitivities of detection of cervical intraepithelial neoplasia (CIN) 2 and higher lesions were 61.7% for VIA, 88.3% for VIAM, and 86.7% for colposcopy, with a specificity of 58.5% for VIA, 55.8% for VIAM, and 90.4% for colposcopy. The performance of colposcopy and VIAM was moderate (κ, 0.48; 95% confidence interval [CI], 0.41 to 0.54) for detection of CIN 1 and higher lesions and excellent (κ, 0.87; 95% CI, 0.82 to 0.94) for detection of CIN 2 and higher lesions. CONCLUSION: In low resource settings, where colposcopic facilities are not available at the community level, a simple low-cost, handheld Magnivisualizer can be considered a valid option for detection of cervical precancerous and cancerous lesions. However, it cannot replace traditional colposcopy because it has a low specificity that results in many unnecessary biopsies.

Clinical determinants and smear characteristics of unsatisfactory conventional cervicovaginal smears.

OBJECTIVE: To investigate clinical and cytomorphological determinants of unsatisfactory conventional Papanicolaou (Pap) smears. STUDY DESIGN: Records of 82,108 conventional cervicovaginal smears received over a ten-year period were retrieved. The significance of clinical determinants, viz. age (<45 or ≥45) and history of hysterectomy, radiotherapy (RT) and chemotherapy (CT), with respect to unsatisfactory outcomes was evaluated using univariate and multivariate analysis by logistic regression. Reasons for unsatisfactory results, i.e. cellularity, obscuration by blood or inflammation and drying artifact, were compared in the women managed by hysterectomy/RT/CT with those without these histories, using Chi square/Fischer's exact test. RESULTS: The overall unsatisfactory rate on conventional cervicovaginal cytology was 4.9%. For post-hysterectomy/RT/CT smears it was 12.5% while it was 4.6% for those without these histories. Age ≥45, and history of hysterectomy, RT or CT were all found to be significant for unsatisfactory outcomes (P<0.001), with the highest odds ratio for RT (2.81). Inadequate cellularity was the major reason for unsatisfactory cytology in both the treatment and non-treatment groups. Marked obscuring by blood was significantly more frequently associated with unsatisfactory tests in the treatment group (mainly in the post-radiotherapy smears) as compared to the control group (P<0.05). Multiple reasons were more commonly present in unsatisfactory smears from treatment group as compared to the control group (P<0.001). CONCLUSIONS: Older age and history of hysterectomy, RT or CT have a significant bearing on unsatisfactory outcome of Pap tests. Inadequate cellularity and obscuring blood are the main morphological determinants of unsatisfactory smears.

Role of vault cytology in follow-up of hysterectomized women: results and inferences from a low resource setting.

The study was undertaken to assess the utility of cervico-vaginal/vault cytology in the follow-up of women treated for cervical cancer and benign gynecological conditions. Records of 3,523 cervico-vaginal smears from 2,658 women who underwent hysterectomy and/or radiotherapy or chemotherapy, over a 10-year period were retrieved. Data was collected on type of treatment received, indication for hysterectomy, age of patient, presenting symptoms, stage of tumor, interval since treatment, cytology and biopsy results. The results of cytology versus other parameters were analyzed separately for women treated for cervical cancer and those hysterectomized for benign indications. Malignant cells were detected in 141/1949 (7.2%) follow-up smears from treated cervical cancer cases (140 recurrences and 1 VAIN). Around 92% of recurrences of cervical cancer were detected with in 2 years of follow-up and 75% of these women were symptomatic. Cytology first alerted the clinicians to a recurrence in a quarter of cases. On the other hand, VAIN was detected in 5/1079 (0.46%) vault smears from 997 women hysterectomized for benign gynecologic disease. All these women were asymptomatic and majority (80%) were detected in follow-up smears performed between 3 and 10 years. Vault cytology is an accurate tool to detect local recurrences/VAIN in women treated for cervical cancer or benign gynecological conditions. It may even first alert the clinicians to a possibility of recurrence. However, due to extremely low prevalence of VAIN/vaginal cancer, it seems unwarranted in women hysterectomized for benign indications, especially in resource constrained settings.

Cytomorphological profile of neoplastic effusions: an audit of 10 years with emphasis on uncommonly encountered malignancies.

CONTEXT: The diagnosis of metastatic cancer in fluids is of capital importance as, in most such instances, a rapid fatal outcome of the disease is anticipated. AIM: To determine the spectrum and cytomorphological features of the common and unusual malignancies presenting with effusions. METHODS AND MATERIALS: A total of 11,562 effusion samples received for cytopathological examination over a 10-year period were analyzed retrospectively. Cytomorphological features of neoplastic effusions were studied. Special stains and immunocytochemistry (ICC) were performed to aid the diagnosis in difficult cases. OBSERVATIONS: The effusion samples comprised of pleural (5018), peritoneal (6340) and pericardial (204) fluids. A definitive diagnosis of classifiable malignancy could be given in 836 (7.3%) of these cases (5.7% adenocarcinomas and 1.6% uncommon malignancies). Adenocarcinoma was the most frequent cause of malignant pleural (70%) and peritoneal effusions (86.9%). The most common primary site for pleural metastasis was lung (35.7%), while for peritoneal metastasis, it was the ovary (54.3%). Among the uncommon neoplastic effusions, hematopoeitic malignancies were the most frequent, followed by squamous cell carcinomas. Primary malignant mesotheliomas were the most challenging to diagnose on effusion cytology. ICC was useful to arrive at a definitive diagnosis in difficult cases. CONCLUSIONS: Cytology is a useful tool to detect malignant effusions. However, in uncommon malignancies presenting as effusions, a detailed clinical history and ancillary investigations are often required to make a correct diagnosis.

Reducing "atypical squamous cells" overdiagnosis on cervicovaginal smears by diligent cytology screening.

The frequency of possible reasons for "atypical squamous cells" (ASC) overdiagnosis on Papanicolaou (Pap) smears was analyzed. Pap smears of 199 women with negative biopsy outcome after an ASC diagnosis were reviewed. Special attention was paid to presence of reproductive tract infections (RTIs), perimenopausal cells (PM cells), immature metaplastic cells, hormone-related alterations, and drying artefacts. Comparisons were made using χ(2) test between the two ASC qualifiers and also between premenopausal and peri/postmenopausal women. Possible reasons for ASC overdiagnosis could be assigned on Pap smear review in 88/199 (44.2%) negative biopsies. Overall, PM cells were the most frequent reason for ASC overdiagnosis, being present in 35/199 (17.6%) smears. RTIs were the next most common cause (14.6%). PM cells were the most significant confounding factors for persistent ASC undetermined significance (ASC-US) over interpretation (20.2%) while in none of the cases these were interpreted as ASC-H (P = 0.004). Of these, 32 smears belonged to peri/postmenopausal women while only three to premenopausal women (P < 0.001). Immature metaplastic cells were significantly more frequent cause of ASC-H rather than ASC-US interpretation (P = 0.007). RTIs and drying artefacts were more frequently overcalled as ASC-US (in premenopausal women) while hormonal changes were interpreted as ASC-H. Hormone related changes, immature metaplastic cells and drying artefacts more commonly resulted in ASC interpretation in peri/ postmenopausal smears. The results of this study suggest that diligent screening can substantially reduce ASC overdiagnosis, thereby reducing the referrals/ follow ups.

Clinically unsuspected thyroid involvement in cysticercosis: a case report.

BACKGROUND: Disseminated cysticercosis is rare in humans. This case highlights the utility of fine needle aspiration (FNA) in diagnosis of cysticercosis in an unusual site. CASE: A 28-year-old woman underwent FNA from a midline swelling in the neck, clinically suspected to be a nodular goiter or thyroiditis. Giemsa-stained smears revealed a mixed inflammatory infiltrate, foreign body giant cells, and an occasional epithelioid cell granuloma. Thick colloid and occasional clusters of follicular cells were seen. In addition, a single large hooklet, characteristic of cysticercus, and a few calcospherules were also present. Further workup revealed subcutaneous nodules on both thighs, and cystic lesions were detected in the thyroid, brain, and lungs. FNA from a subcutaneous swelling confirmed cysticercosis. A final diagnosis of disseminated cysticercosis involving the thyroid gland was made. CONCLUSION: FNA is a useful procedure to identify parasitic lesions even in unusual sites and in clinically unsuspected cases.

Utility of imprint cytology for early presumptive diagnosis in clinically suspicious cervical cancer.

OBJECTIVE: To determine the utility of imprint cytology (IC) in providing an early presumptive diagnosis of clinically suspected cervical carcinoma. STUDY DESIGN: A total of 219 clinically suspicious cervical cancer cases underwent Pap test, punch biopsy and IC at the same sitting. Correlations were performed between these diagnostic modalities to determine the sensitivity and specificity of IC in diagnosis of cervical cancer. RESULTS: The overall accuracy of IC in detecting cervical cancers was 96.2%. About 78% of squamous cell carcinomas (SCC), 60% of adenocarcinomas and 100% of small cell carcinoma could be accurately typed on imprints. Twelve malignant lesions were diagnosed on IC among 26 unsatisfactory biopsies. Although there was no false positive result, 3.5% false negative diagnoses were given on IC. The sensitivity and specificity of imprint smear cytology to detect malignancy was 96.2% and 100%. Agreement between imprint cytology and Pap smear diagnosis of malignancy was 95.3%. kappa Statistics revealed excellent agreement between imprints and biopsies and between imprints and Pap smears in diagnosis of malignant lesions. CONCLUSION: IC can be used as an adjunctive technique for an early and reliable preliminary presumptive diagnosis of cancer of the uterine cervix.

Outcome of "Atypical squamous cells" in a cervical cytology screening program: implications for follow up in resource limited settings.

(1) To study the incidence and outcome of "Atypical squamous cells (ASC)" diagnosis in a hospital based cytology screening programme. (2) To work out a feasible strategy for follow up of Atypical squamous cells-undetermined significance (ASC-US) and Atypical squamous cells-cannot exclude high grade squamous intraepithelial lesion (ASC-H) in resource limited settings. A total of 29,475 women were screened cytologically through Pap tests. The epithelial cell abnormalities (ECA) detected on screening were reviewed by the cytopathologists and classified according to Bethesda 2001 system. The women with ASC-US reports were followed up by two repeat cytology tests at 3 and 6 months of the initial visit. The persistent ASC-US cases or the cases which revealed squamous intraepithelial lesion (SIL) on follow up smears; as well as all ASC-H and above cases were referred for coloposcopic evaluation. ASC diagnosis comprised 3.6% of all reports. These were qualified as ASC-US (3.36%) and ASC-H (0.22%). On follow up, only 7 CIN 2 or worse (3.2%) lesions were detected on 218 biopsies in ASC-US category while in ASC-H qualifier 16 CIN 2 and above lesions (30.8%) were picked up on 52 colposcopic biopsies. The difference between ASC-US and ASC-H categories for a CIN 2 or worse outcome was highly significant (P < 0.001). ASC-H qualifier has a high likelihood for an ominous histological outcome and warrants an immediate colposcopic evaluation. On the other hand, ASC-US cases can be managed conservatively by repeat cytology tests at regular intervals without a significant risk of missing a high grade lesion. Diligent screening of cervical smears can judiciously downgrade some cases overcalled as ASC because of inflammatory atypia and thereby reduce referrals in geographic settings with high prevalence of reproductive tract infections. High risk HPV (HR HPV) testing may be a useful adjunct to further reduce referrals by selecting the women who require colposcopic evaluation.

TNFalpha-308G/A polymorphism as a risk factor for HPV associated cervical cancer in Indian population.

BACKGROUND: Investigation of the potential association of single nucleotide polymorphisms (SNPs) at -308 G/A and -238 G/A of Tumor necrosis factor alpha (TNFalpha) with susceptibility to HPV-16 associated cervical cancer in Indian women. METHODS: The study included 165 histologically confirmed cases with 45 precancer and 120 cancer patients and an equal number (165) of healthy controls with normal cervical cytology. PCR-RFLP was employed to analyze TNFalpha promoter polymorphisms, which were confirmed by direct sequencing. Both patients and controls were screened for Human Papillomavirus (HPV) infection. RESULTS: The frequency of -308 A allele in TNFalpha was significantly higher in cases compared with control subjects (21% in cases vs. 9% in controls; p<0.01), with an odds ratio of 2.7 (95% CI = 1.41-5.15). Also, women carrying A allele for this locus presented 3 times increased susceptibility to HPV 16 infection as evident from carrier genotype distribution between HPV positive cases and control subjects (24% in HPV positive cases vs. 9% in controls; p<0.01; OR = 3.1; 95% CI = 1.60-6.03). No such association was found for TNFalpha-238 (G/A) polymorphism with the risk of development of cervical cancer. CONCLUSION: It suggests that SNP at -308 (G/A) of TNFalpha promoter may represent an increased risk for HPV infection and development of cervical cancer in Indian women.

Spectrum of epithelial cell abnormalities of uterine cervix in a cervical cancer screening programme: implications for resource limited settings.

OBJECTIVE: (1) To compute the frequencies and peak age incidences of epithelial cell abnormalities (ECA) of uterine cervix in a cytology-based screening programme and (2) to analyze the comparative frequencies of squamous intraepithelial lesions (SIL) and malignancies in age groups <40 and > or =40 years, in order to assess the implications for screening protocol in resource limited settings. STUDY DESIGN: Pap smears form 29,475 women were cytologically screened over a 4-year period as a part of hospital-based screening programme. The frequencies, peak age incidences and mean age of various ECA detected were computed. The data was further stratified in to age groups <40 (Gp 1) and > or =40 (Gp 2) and comparative profile of the lesions was analyzed. RESULTS: On cytologic screening of the smears 5.6% ECA were detected. Atypical squamous cells-undetermined significance (ASC-US) and low grade SILs (LSIL) were diagnosed more frequently in Gp 1 (p<0.001) while atypical glandular cells (AGC) and malignancies were more significantly more frequent in Gp 2 (p<0.001). The frequency of HSIL was similar in the two groups. The SILs predominated in the fourth decade while the malignant lesions were most frequent in age >50 years. The mean age for LSIL and HSIL was 34.7 and 37.7 years, respectively, while for malignancy it was 51.8 years thus corroborating the hypothesis that a prolonged latent phase exists between the precursor lesions and the onset of invasive cancer. CONCLUSIONS: Since the goal of any screening programme should be to pick up majority of the precursor lesions and not frank cancers, it is desirable to initiate screening before 40 years of age. The WHO recommendation of once in a life time screening between 35 and 40 years of age seems appropriate for resource limited settings like ours.

Cytohormonal and morphological alterations in cervicovaginal smears of postmenopausal women on hormone replacement therapy.

The objective of the study was to study the cytohormonal and morphological alterations in cervicovaginal smears associated with the use of hormone replacement therapy (HRT) and to assess the utility of vaginal cytology in determining the response to HRT. Ninety postmenopausal women (30 on estrogen-progesterone combination (HRT) for 1 to 24 mo (user 1), 30 on estrogen therapy (ERT) for 1 to 44 mo (user 2), and 30 not on any hormones (nonusers)) were included in the cross-sectional study. Their lateral vaginal wall smears and cervical smears were examined for hormonal and morphological assessments, respectively. The smear pattern showed predominance of parabasal cells in 46.6% of nonusers, while none of the users had >70% parabasal cells. A high percentage (>70%) of intermediate cells was found in 46.6% of users and only in 16.6% of nonusers. A high maturation value (MV) was found in more than 75% of users but in only 16.6% of nonusers. The women with high MV (>50) were significantly less symptomatic than did nonusers. Atrophic changes were present in cervical smears of 14/20 (46.6%) nonusers when compared with 1/60 (1.66%) users. Atypical squamous cells of undetermined significance (ASC-US) were diagnosed in seven users and three nonusers. It persisted on follow-up in four users and one nonuser. Histology revealed one mild dysplasia among users. Lactobacilli were more frequently observed in users. The cytohormonal pattern on vaginal smears correlates well with the response to hormonal therapy and clinical symptoms. Awareness of the morphological alterations associated with the use of replacement hormones would enable the cytologists to reduce the false-positive diagnoses while evaluating postmenopausal smears.