Vegetable matter in a cervical smear: Complementary medicine complicates smear interpretation

A 27-year-old female presented for follow-up after a cone biopsy (performed 3 months prior) showed high grade dysplasia extending to the endocervical margin. During the gynecologic examination, foreign material was identified in the vaginal vault. The liquid-based cervical smear showed single cells and clusters with features of low grade squamous intraepithelial lesion, but also showed additional clusters which, at low power, appeared to be hyperchromatic crowded groups. On higher power, some of these groups showed cells with a thick cytoplasmic border and perinuclear cytoplasmic transparency, reminiscent of koilocytes (Fig. C-1). Other clusters appeared to be cells with much high nuclear to cytoplasmic ratios (Fig. C-2). Further investigation into the patient’s history revealed that she was using a homeopathic vaginal suppository containing vitamin E, fish oil, and green tea. The material seen on the Pap smear represented vegetable matter, likely a residual of the suppository. Herbal escharotic treatment is a form of ablative therapy used in complementary and alternative medicine as a way to treat cervical dysplasia. Either through direct application during pelvic examination or through the use of vaginal suppositories, a variety of plant-based materials are applied to the cervix, including Calendula (marigold) succus, Sanguinaria (bloodroot) tincture, and Camellia (green tea). A variety of extrinsic materials have been observed in cervical smears, including pollen grains and fungal elements. The presence of vegetable cells in these specimens is uncommon, however, and usually attributed to post-collection extrinsic contamination; in this case, the presence of these cells within the same plane of focus as the human cells suggests that this material was present at the time of cervical sampling. Rivasi et al. performed a thorough investigation tracing the presence of vegetable matter to pessary use. In our case, the history of vaginal suppository use as well as the presence of foreign material in the vaginal vault on examination is consistent with the contamination occurring during the time of sampling. While the majority of the extraneous material seen on the slide was easily recognizable as that of plant origin, rare fragments showed features that could be mistaken for low grade or even high grade dysplasia, atypical glandular cells, or a parasite. In this situation, communication from clinicians regarding the use of pessaries, vaginal suppositories, and other possible pollutants is important to ensure accurate identification.