Comparison of Benign-Appearing Endometrial Cells in Papanicolaou Tests Between Patients 45-49 and Patients Over 50 Years of Age

Summary: Introduction: Cervical pap smears, are used for detecting squamous lesions of the ectocervix, but can occasionally detect glandular lesions. Exfoliated endometrial cells in pap smears of patients of reproductive age are normal and common if the specimen is collected around the time of menses. However, considering that some patients with endometrial cancer can be asymptomatic, it is recommended by the Bethesda System that if endometrial cells, even if benign-appearing, are present in a preparation of a patient over 45 years of age, they be reported. It is then up to the clinician's judgment to determine how to proceed i.e., with radiologic imaging, endometrial sampling, or interpret the findings as physiologic. Our aim is to determine if the somewhat arbitrary age of 45 years for reporting benign-appearing endometrial cells results in unnecessary testing and if 50 years of age as a minimum has a significant difference in the predictive value for screening for endometrial neoplasia. Materials and Methods: Cervical pap smear preparations received at our institution from July 2021 to January 2024 in which benign-appearing endometrial cells were detected in patients over 45 years of age were included in this study. Data including patient age; follow-up treatment, such as radiologic imaging and/or endometrial sampling; and the results thereof were collected. Patients were divided into two cohorts, those 45-49 years of age and those 50 years of age and older. Results: 190 patients were identified, with 110 ages of 45-49 and 80 aged 50+. Only 15 patients underwent ultrasound, 10 belonging to the 45-49 cohort and 5 in the 50+ group (n=10/110; 9.1% and n=5/80; 6.3%, respectively). 47 patients had endometrial sampling, 23 were in the 45-49 group and 24 were in the 50+ cohort (n=23/110; 20.9% and n=24/80; 30.0%, respectively). 3 endometrial samples were interpreted as ""benign endometrial hyperplasia"" out of the 47 cases for which endometrial sampling was performed (n=3/47; 6.4%). Only 2 of the 47 cases that had surgical sampling were interpreted as ""atypical hyperplasia"" (n=2/47; 4.3%) with a single case from each cohort represented. The remaining 42 cases with endometrial sampling had no abnormalities (n=42/47; 89.4%). In total, 4 of 5 cases with endometrial sampling which found a diagnostic abnormality, were in patients in the 50+ group (4/5; 80%). The 1 case in the 45-49 cohort with atypical hyperplasia occurred in a patient who was symptomatic. Conclusions: Benign endometrial cells noted in a cervical pap smears in patients over 45 years of age who are not experiencing symptoms, do not infrequently prompt additional work-up by clinicians in the form of radiologic imaging or endometrial sampling. When surgical sampling is performed, most cases have no pathologic findings while few endometrial samples find benign hyperplasia and rarely atypical hyperplasia. The chances of pathologic findings in asymptomatic patients was even less likely in this study. Based on our data, hyperplasia with or without atypia, is far less likely to be found in patients under 50 years of age.