1. Body Mass Index and Outcome of
ASC-H-Interpreted Cervical Smears
in Postmenopausal Women
Ahn S., Lee Y., Sung J., Lee J., Oh Y., Sung C., Song S.
Presented by
Phetnamnueng Yimthet
53080092

2. Introduction
Pap Smear or Cervical pap smear is a method
to investigate a disorder of the cervical cells lining
in the precancerous stage and the early stages of
cervical cancer.
,
,
PAP SMEAR.

3. Introduction (cont.)
General Categorization
Negative for
intraepithelial
lesion or
malignancy
Epithelial Cells
Abnormality
Squamous cell
lesion
Other
Malignant
Neoplasms
Glandular cell
lesion

4. General Categorization of Squamous cell lesion
Atypical squamous
: ASC-US, ASC-H
ASC-US
ASC-H
LSIL
(Low-grade squamous
intraepithelial lesion)
CIN 1
CIN 1; HPV
CIN 2-3
Keratinizing
HSIL
(High-grade squamous
intraepithelial lesion)
Squamous cell carcinoma
(ASC-US : atypical squamous cells of undetermined significance ;
ASC-H : atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion)

5. Background of Study
Cytryn et al (2009), Selvaggi et al (2003)
•
ASC-H is associated with a significantly higher
incidence of HSIL during the follow-up compared
with ASC-US.
•
The reporting of ASC-H does lead to the detection
of HSIL in average of 68% of the ASC-H positive
patients.

6. Background of study (Cont.)
Louro et al (2003), Sung et al (2011)
• Patient age is an important factor to be
considered when evaluating the risk of ASC-H
smears.
• A follow-up study of the ASC-H positive has
been reported that patients younger than 40
years has a higher rate of HSIL than the age 40
or older.
• The study suggests the positive ASC-H in older
patients may be associated with secondary
changes (atrophy or metaplastic changes).

7. Background of study (Cont.)
Repse- Fokter et al (2008)
Postmenopausal vaginal atrophy is
correlated with decreased estradiol and
body mass index (BMI)

8. • ASC-H can be difficult to distinguish from secondary
changes which occur more frequently at older ages.
Secondary
atrophic
changes
hypoestrogenic status
• Body fat tissue is an important source of estrogen in
postmenopausal women.
Body fat
body mass index (BMI)

9. Body mass index (BMI) could affect ASC-H
interpretation and the outcome of ASC-H
smears in postmenopausal women.

10. Study design
• Cross-sectional study of retrospective data between
July 2002 and August 2008
( The Samsung Seoul Hospital, Korea )
• 154 postmenopausal women with ASC-H positive ,
age ≥ 55 years, without hormonal contraceptive or
Hormonal therapy

11. Patients and Methods (Cont.)
154 patients
Colposcopy
Normal colposcopy
( 79 patients )
Follow-up Pap test
for 6-12 months
Colposcopic abnormalities
( 75 patients )
Follow-up tissue
sampling

12. Patients and Methods (Cont.)
Classification of the follow-up results
Negative
LSIL : CIN 1
HSIL : CIN 2 , CIN 3
Carcinoma

13. Patients and Methods (Cont.)
154 smears
Conventional Pap
smear (107)
ThinPrep test
Smear (47)

14. Patients and Methods (Cont.)
Patient data collection
Body weight and height were obtained from
medical chart
BMI was calculated
BW
BMI = ---------------(height)2
Serum estradiol levels were measured in 46
patients using a Coat-A-Count estradiol kit.
HPV DNA testing were performed in 41
patients (Hybrid Capture II or the HPV DNA
microchip)

15. Characteristics of the 154 postmenopausal women
Characteristics
Median age, years
Range
Preparation
Conventional
ThinPrep
HPV test (n= 41)
Negative
Positive
Outcome (n=154)
Negative
LSIL
HSIL
Carcinoma
Patients, n (%)
62
55-85
107 (69.5)
47 (30.5)
19 (46.3)
22 (53.7)
103 (66.9)
13 (8.4)
28 (18.2)
10 (6.5)

16. Patients and Methods (Cont.)
Pearson’s 2 : test correlation between SIL and
BMI, SIL and HPV
Mann-Whitney U test : test correlation between
serum estradiol and BMI
*P < 0.05 was considered as statistic significance

17. Results

18. Classification of patient BMI
BMI (n = 154)
Patients, n (%)
< 18.5 (underweight)
6 (3.9)
18.5-22.9 (normal)
64 (41.6)
23-24.9 (overweight)
34 (22.1)
25-29.9 (obese 1)
47 (30.5)
≥30 (obese 2)
3 (1.9)

19. Outcome of the
postmenopausal women
with ASC-H smears stratified by BMI
BMI with cutoffs of 23
%
BMI with cutoffs of 25
42%
29.8%
30%
%
*P = 0.014 vs BMI < 23
%
28.8%
22.1%

20. Representative figures of ASC-H
BMI  23
BMI  23
BMI < 23
CIN3
Carcinoma
NILM
CIN3
Carcinoma
NILM
( NILM : Negative for intraepithelial lesion or malignancy )

21. Conventional vs. Liquid-based preparation
BMI with cutoffs of 25
BMI with cutoffs of 23
Prevalence (%)
LSIL or LSIL+
HSIL or HSIL+
Prevalence (%)
LSIL or LSIL+
HSIL or HSIL+
BMI<23
BMI≥23
BMI<23
Conventional
P <
vs BMI 23
BMI≥23
LBP
BMI<25
BMI≥25
Conventional
BMI<25
BMI≥25
LBP

22. Correlation of BMI and serum estradiol levels
Serum estradiol (pg /ml)
BMI<23
P
BMI with cutoffs of 25
Serum estradiol (pg /ml)
BMI with cutoffs of 23
BMI≥23
vs BMI<25
BMI<25
BMI≥25

23. *P
80
70
60
50
72.7%
40
30
20
36.8%
10
0
HPVvs HPV-
HPV+
Prevalence of HSIL or HSIL+ (%)
Prevalence of LSIL or LSIL+ (%)
Association of HPV and the presence of SIL
70
60
50
59.1%
40
30
20
10
15.8%
0
HPV-
HPV+

24. Discussion
The present findings
In patients with higher BMI, an underlying
squamous intraepithelial lesion (SIL) was more
frequent than in patients with lower BMI, and a
higher BMI was also associated with increased
serum estradiol levels and HPV positive.

25. Discussion (cont.)
Hormonal alteration and ASC-H interpretation
Patton et al (2008)
The diagnosis of ASC-H in postmenopausal Pap
smears has a low predictive value in the subsequent
diagnosis of HSIL in contrast to the pregnant,
postpartum, and contraceptive-use categories.
The finding supports the idea that
hormonal alterations are associated with the
risk level of ASC-H smear.

26. Discussion (cont.)
Vaginal atrophic changes associated
with estradiol and BMI
Repse-Fokter A. et al (2008)
• Estradiol and BMI are associated with vaginal
cell maturation and atrophy in
postmenopausal women.
• Increased BMI was associated with increased
serum estradiol levels.

27. Discussion (cont.)

28. Conclusions
• Postmenopausal women with an ASC-H smear
who are higher BMI are more likely to have
underlying SIL on follow-up
• Therefore, patient BMI should be considered
when evaluating the risk level of ASC-H smears
in postmenopausal women

29. Acknowledgements
•
•
•
•
•
Asst. Prof. Petcharat Trongtorsak
Atchareeya Nudchawong (Hu-So, English major)
Hattaya Chanasit (Education, English major)
Isara Techakijwaroros (Medical)
Tippawan Kasaratikool (Allied Health Science)

30. Thank you