clinicopathologic correlation of the unsatisfactory papanicolaou smear

the 1991 bethesda system for cervical/vaginal cytology reporting has defined adequacy criteria, including unsatisfactory designation. most laboratories in usa and a few laboratories in iran have implemented these criteria, but only few studies about clinical implications have been performed. all unsatisfactory papanicolaou (pap) smears taken between august 2000 and march 2002 were retrieved from the file of cytologic reports of mirza koochak khan hospital's department of pathology. of 4,598 total pap smears 204 (4.4%) were unsatisfactory (corresponding atypical rate of 2.5% and a sil/carcinoma rate of 0.97%). about 20.2% of unsatisfactory pap smears were from patients with a history of epithelial abnormalities. the majority (71 of 204 specimens; 35%) of follow-up pap smears or biopsies occurred within 6 months,12% within 6-12 months,1% within 12-18 months and 1% after 18 months. approximately 59% had no follow-up. the first repeat pap smear or histologic specimen in 83 patients with follow-up was negative in 71 (85%), unsatisfactory in 2(2.4%), epithelial cell abnormality in 11 (13.2%) and atypical squamous cells of undetermined significance in 4(4.8%). nonmalignant conditions contributing to the unsatisfactory smears on histologic specimens (23%) included cervicitis, endocervical polyp and endometritis. majority of patients with unsatisfactory pap smears were followed up within 6 months. a significant number(13.2%) of those with follow-up had eventual diagnosis of epithelial cell abnormality. benign pathologic conditions also contributed to unsatisfactory smears. these patients were more likely to have a history of abnormalities. unsatisfactory specimens are associated with benign as well as preneoplastic/neoplastic conditions. clinical correlation should be the first step in delineating the cause of the unsatisfactory diagnosis.