What about these endometrial cells in my Pap?

The management of atypical, or malignant endometrial cells in a Pap test is obvious; immediate tissue sampling in the form of biopsy or curettage. However, what is the relevance of normal endometrial cells (NEMCs) in a premenopausal patient? NEMCs are routinely seen on Pap tests, particularly when related to menstrual cycle phase; these may be seen up to 12th day of the cycle. (After this 12th day, NEMCs are considered abnormal.) The updated Bethesda system of 2014 suggests reporting the presence of normal endometrial cells in women age 45 and over. However, while endometrial pathology is much more common in older women, what do patients with endometrial neoplasia look like? Are they all over 45, or even 40? With obesity, polycystic ovarian syndrome, and metabolic syndrome being so common in our pre-menopausal patient population, it is not unusual to see endometrial hyperplasia or neoplasia in younger women. In addition, we do often see non-neoplastic endometrial pathology in younger women which is most commonly manifested by dysfunctional bleeding due to an anovulatory cycle, acute/chronic endometritis, excess progestin effect, benign endometrial polyps or a post-partum condition. The recent changes in the Bethesda system suggest reporting the presence of normal endometrial cells based on age alone (regardless of the date of the last menstrual period/LMP) as age is a simple demographic, unlike clinical history, menopausal status and LMP date which may be incorrect or difficult to quantify. It is for these hard to quantify reasons, however, that at PathAdvantage we report the presence of endometrial cells on all Pap tests. Menstrual history, date of LMP, menopausal status, and current clinical findings are all details best known by the treating clinician, and can help guide the decision making process in determining which patients may need further investigation, regardless of age.

Article Highlights:

Normal Endometrial Cells (NEMCs) are routinely seen on Pap tests up to 12 days after the LMP date.
The Bethesda system now suggests limiting the reporting of NEMCs in women 45 years and older.
Some high risk groups of women <45 years old may develop significant endometrial pathology – therefore, at PA, we report NEMCs in all patients.

BIBLIOGRAPHY ¹ Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287:2114–2119. ² Beal HN, Stone J, Beckmann MJ, et al. Endometrial cells identified in cervical cytology in women > or = 40 years of age: criteria for appropriate endometrial evaluation. Am J Obstet Gynecol. 2007;196:568.e1–5. ³ Gomez-Fernandez CR, Ganjei-Azar P, Capote-Sishaw J, et al. Reporting normal endometrial cells in Pap smears: an outcome appraisal. Gynecol Oncol. 1999;74:381–384. Article written by PathAdvantage pathologist Richard Hopley, MD.