CYTOLOGIC INDICES The cytologic assessment of hormonal effects is given by different types of indices. All of these are based on recognition and exact typing of the epithelial cells exfoliated from the surface of stratified squamous vaginal mucosa.

MATURATION INDEX (MI) To determine this, percentages of Basal, Intermediate and Superficial cells are presented as a three part ratio with basal cells stated first, intermediate cells second and superficial cells third.

Shift to left - more basal cells - atrophic effects. For ex. MI = 80/20/0 Shift to left - more basal cells - atrophic effects. Shift to right - more superficial cells - estrogen like effect Shift to midzone - more intermediate cells – progesterone like effect.

2.KARYOPYKNOTIC INDEX (KPI) Also known as Cornification Index (CI) The percentage of squamous epithelial cells with sharp,squared off cytoplasmic edges and with pyknotic nuclei is given in relation to all other mature squamous epithelial cells that possess vesicular nuclei. Normally, peak of KPI (50%-85%) coincide with time of ovulation.

3.EOSINOPHILIC INDEX (EI) Number of mature squamous cells with pink eosinophilic cytoplasm regardless of their nuclear appearance is compared to number of other mature squamous cells with blue cytoplasm and result is given as ratio. Normally,peak of EI coincides with KPI, maximum at ovulation.

4. FOLDED CELL INDEX (FCI) Here the number of mature squamous cells with folded cytoplasmic rims is compared with number of mature cells with a flat,nonfolded cytoplasm,regardless of nuclear features.

5. SUPERFICIAL CELL INDEX (SCI) Here the intact superficial squamous cells with any type of nuclei regardless of staining quality of their cytoplasm are evaluated and given in relation to all other squamous cells.

6. CROWDED CELL INDEX (CCI) The number of mature squamous cells that are clustered together in groups of 5 or 6 cells is compared to number of similar cells found singly or in groups of fewer.

7. MATURATION VALUE (MV) Each parabasal cell is counted as 0, Each intermediate cell is counted as 0.5 and Each superficial cell as 1. MV is expressed by multiplying the percentage in each cell category by its assigned value. MV of 100 shows pure population of superficial squamous cells. MV of 0 shows pure population of parabasal cells.

PITFALLS IN CYTOLOGIC HORMONAL EVALUATION INFLAMMATION : - Genital inflammation may produce variable increased maturation of vaginal mucosa. - Also a large number of inflammatory cells may mask the epithelial cells or produce severe degenerative cellular changes. - So,in presence of inflammation,hormonal evaluation should not be attempted.

2. EROSION : Repair parabasal cells 3. FAULTY FIXATION AND STAINING DEFECTS: - Too thick smear - Improper staining 4. CYTOLYSIS : - More than 50% of cells show degenerative changes. - Large number of stripped nuclei are present.

NORMAL CYTOHORMONAL AVERAGES NEWBORN….MI = 0/90/10 (+/- 10) There are increased number of intermediate cells often with glycogen in their cytoplasm…. In a mature newborn, some basal cells begin to appear after 1st week because of progressive decrease of maternal hormones. In premature newborns….

INFANCY AND CHILDHOOD…. MI = 80/20/0 (+/- 20) Here vaginal pool smears are scanty in cells and contain mainly parabasal cells.

3. MENSTRUAL AGE MI = 0/40/60 (+/-10) - During preovulatory time (proliferative phase)…. MI = 0/40/60 (+/-10) The cyanophilic intermediate cells gradually increase in size with progressive cytoplasmic eosinophilia and nuclear pyknosis. Also,there is progressive decrease in number of leucocytes and amount of mucus.

- During ovulation & postovulatory time (secretory phase)... MI = 0/70/30 (+/-15) At the time of ovulation mature, flat eosinophilic superficial cells with pyknotic nuclei are seen. After ovulation intermediate squamous cells gradually increase indicative of reduced level of maturation under impact of progesterone. During menstrual flow….MI = 0/60/40 (+/-20) There is marked increase of fresh and old RBC’s,cyanophilic intermediate cells become progressively smaller.