Utilization of the Maturation Index from a Pap Smear

The body manufactures three main kinds of estrogen: estradiol, estrone, and estriol. Estrogens are promoters of tissue
growth, stimulating the proliferation of cells in the reproductive organs of women, particularly in the endometrium, the
blood-rich lining of the uterus that is shed during menstruation. The collective effect of estrogen (the ³estrogen effect´) in
a woman¶s body can be estimated through evaluation of the squamous cell layer that lines the vagina in a test known as a
maturation index.

The relationship between hormone cycles and the maturation of vaginal squamous cells were initially noted by Rameriz
and then later by Papanicolaou in the 1920¶s. Papanicolaou¶s research focused on the hormonal cycles of the female
genitalia, and the efficacy of exfoliative cytology in the detection of cervical cancer was an incidental finding. A
Maturation Index (MI) is based on the assumption that the sex hormones estrogen, progesterone and androgens
(testosterone) bring about maturation in squamous cells that can be detected by cytological examination. The higher the
number of mature cells (those designated µsuperficial¶ and µintermediate¶, the higher the maturation index or estrogen
effect in the body. This provides doctors with information regarding levels of estrogen and hormonal influence in their
female patients.1

An MI is a ratio obtained through performing a random count of three major cell types (parabasal cells, intermediate cells
and superficial cells) that are shed from the squamous epithelium. The cell count is expressed as a percentage that reads as
follows: MI= % parabasal cells, % intermediate cells, % superficial cells. Parabasal cells are the least mature cells having
not been affected by estrogen or progesterone. Intermediate cells display mild maturation, having been affected by
progesterone, and superficial cells display the most maturity, having been affected by estrogen. A patient¶s MI can vary on
a daily basis, and of course MIs vary from patient to patient. There are only two absolutes when it comes to cellular
patterns in an MI: the first is that a predominance of parabasal cells indicates an absence of estrogen stimulation, and
second is that a predominance of superficial cells indicates estrogen stimulation. Intermediate cells have little clinical
usefulness. The maturation index is useful for the evaluation of therapies designed to treat vaginal hormonal symptoms.2

The Maturation Index provides practitioners with a simply obtained (samples are taken during the course of obtaining a
pap smear) sample that is easily analyzed to detect hormonal changes in the vagina that are age-appropriate or an early sign
of possible hormonal related disease processes. The best samples for an MI should be taken with a gentle scrape along the
lateral wall of the upper vagina at the level of the cervix. Cellular tissue from this area accurately reflects the hormonal
status at the time of collection. Samples obtained must be free from signs of inflammation (white blood cells) and
endocervical cells, both of which may falsely elevate the MI. MIs are useful for evaluating hormonal function, evaluating
cellular composition of the surface layers of vaginal tissue which reflects the balance of estrogen and progesterones effects
on this tissue, and diagnosing conditions that produce abnormal hormonal balance (pituitary gland dysfunction, ovarian
dysfunction, and hormone secreting tumors). Additionally, MIs can detect the beginnings of endometrial cancer in
menopausal women, and have been used to screen for other cancerous process such as vaginal adenosis and clear cell
carcinoma in women who were exposed in utero to diethylstilbestrol (DES), a synthetic estrogen. The sensitivity of using a
smear to determine a maturation index in the diagnosis of vaginal intraepithelial neoplasia was estimated to be at 83%
percent in one recent study.3

Taking the following table into account, practitioners can decide on a course of treatment for the patient that presents with
clinical symptoms once this hormonal µcross check¶ has been measured. The maturation index is most useful for detecting
hormonal effects in menopausal and post-menopausal women, who may be experiencing symptoms with and without
treatment.4 Additionally, practitioners may find the use of an MI in post-menopausal woman to be a good screening tool
for as-of-yet undetected vaginal cancers. Cellular cytology is useful in this process, detecting cellular changes prior to
organ dysfunction, when the disease is in an advanced state.

Various treatments for female hormonal health and normalization exist, from standard hormone replacement therapies
(HRT) and dietary and botanical medicines. Botanical medicines such as phytoestrogens have been shown to increase the
MI in women consuming soy-rich diets over a 6-month period.5 Because of these effects, soy and other phytoestrogens
should be considered as part of a preventative intervention in treating menopausal symptoms related to estrogen
deficiency. However, the use of the maturation index should be correlated with clinical/symptomatic findings in order to
accurately treat the patient¶s symptoms and take steps to prevent worsening of symptoms or disease processes.
 `
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MI=% Parabasal Cells: % Intermediate Cells: MI =
Indicates mostly estrogen stimulation.
% Superficial Cells 0:40:60
Day 14 - Ovulation

MI =
Day 28 - Premenstrual Indicates mostly progesterone stimulation.
0:70:30

MI =
Menopausal Progesterone only, no estrogen.
0:100:0

MI =
Atrophic No progesterone or estrogen.
100:0:0

MI =
Child No progesterone or estrogen.
100:0:0

MI = Mostly progesterone stimulation, minimal

MI =
Pregnancy Progesterone only, no estrogen.
0:100:0

MI = Minimal hormonal stimulation. Ovarian

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maturation index

An index indicating the degree of maturation attained by the vaginal epithelium as adjudged by the cell types being exfoliated; serves
as an objective means of evaluating hormonal secretion or response; represents the percentage of parabasal cells/intermediate
cells/superficials, in that order; i
  indicates more immature cells on the surface (atrophy), while i
 
 indicates
more mature epithelium.