The Bethesda System is a standardized reporting system used for Pap test results. It provides a structured format for reporting cervical and vaginal cytology diagnoses. The system includes sections for specimen type, adequacy, interpretation/result, and optional notes. Interpretation/result categories include negative for intraepithelial lesion or malignancy, epithelial cell abnormalities (such as atypical squamous cells, low-grade squamous intraepithelial lesion, or high-grade squamous intraepithelial lesion), and other malignant neoplasms. Specific cytological features are described for each category. The system aims to improve consistency and communication of Pap test results.

1. THE BETHESDA SYSTEM
DR.ABHINAV GOLLA
MEDICURE DIAGNOSTICS AND RESEARCH CENTER
VIJAYANAGAR COLONY
HYDERABAD , TELANGANA

2. INTRODUCTION
• The Bethesda system (TBS) :
• It is a system of reporting cervical or vaginal cytologic diagnoses
,used for reporting Pap smear results
• Introduced in 1988 , revised in 1991 , 2001 , 2014.

3. THE BETHESDA SYSTEM (TBS)
• SPECIMEN TYPE
• SPECIMEN ADEQUACY
• GENERAL CATEGORIZATION (optional)
• INTERPRETATION / RESULT
• ANCILLARY TESTING
• AUTOMATED REVIEW
• EDUCATIONAL NOTES AND SUGGESTIONS (optional)

4. • The Bethesda system
• SPECIMEN TYPE
Indicate conventional smear (Pap smear)
vs. liquid-based preparation
vs. other.

5. • Conventional Pap
In a conventional Pap smear , samples are smeared directly onto a
microscope slide after collection.
• Liquid based cytology
 The sample of (epithelial) cells is taken from the Transitional Zone
 Liquid-based cytology uses an arrow-shaped brush
 The cells taken are suspended in a bottle of preservative &
transported to the laboratory .

7. SPECIMEN ADEQUACY
• Satisfactory for evaluation
• Unsatisfactory for evaluation …(specify reason)
• Specimen rejected/not processed (specify reason)
• Specimen processed and examined, but unsatisfactory for evaluation of
epithelial abnormality because of (specify reason)

8. • Satisfactory :
 Presence / absence of Endocervical / transformation zone
component .
 Appropriate labeling & identifying information .
 Relevant clinical information .
• Unsatisfactory :
Rejected specimen
Fully evaluated , unsatisfactory

9. • Minimum squamous cellularity criteria :
5000 well visualized / well preserved squamous cells in liquid based
preparation .
8000 – 12000 cells in conventional preparation .
• Endocervical / Transformation Zone component :
10 well preserved endocervical / squamous metaplastic cells singly / in
clusters .

11. GENERAL CATEGORIZATION (optional)
• Negative for Intraepithelial Lesion or Malignancy
• Other: See Interpretation/result (e.g., endometrial cells in a woman >= 40
years of age)
• Epithelial Cell Abnormality: See Interpretation/result (specify ‘squamous’ or
‘glandular’ as appropriate)

12. INTERPRETATION / RESULT
Negative For Intraepithelial Lesion Or Malignancy,
( when there is no cellular evidence of neoplasia , state this in
the General Categorization above and / or in the
Interpretation / Result section of the report , whether or not
there are organisms or other non-neoplastic findings ).

13. INTERPRETATION / RESULT
NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY
Normal Study :
Non neoplastic findings
Non Neoplastic cellular variations :
Reactive cellular changes :
Glandular cell changes post hysterectomy
Organisms :
Trichomonas , Candida , Bacterial vaginosis ,
Actinomyces ,HSV ,CMV

14. NORMAL
• Squamous cell
• Endocervical cells
• Endometrial cells

15. • Superficial squamous cell : Mature ,polygonal
cytoplasm – mostly Eosinophilic
nucleus - pyknotic
cells show relatively prominent cellular outline .

16. • Intermediate squamous cell : Mature
cytoplasm - Cyanophilic
nucleus - non pyknotic ,vesicular nucleus
large oval / rounded nuclei with groove
granular chromatin

17. • Parabasal / Basal squamous cells :
small , oval , round
immature
cytoplasm - cyanophilic / eosinophilic
nucleus – oval, fine chromatin

19. • Endocervical cells :
 Columnar in shape & contain mucin
 In cervical smears endocervical cells arranged singly in
layers & in sheets forming a palisade .
 Honey comb / picket fence appearance .
 nucleus is large ,rounded, placed at basal portion
nucleus is granular evenly distributed chromatin
 cytoplasm - eosinophilic / basophilic

21. Endometrial cells :
 in smears appear as rounded clusters
 central core of connective tissue with elongated cells
(stromal)surrounded by round- oval cells(glandular) - Exodus
 cytoplasm - scanty , vacuolated
 nucleus - size similar to intermediate cells
- karyorrhexis
 cell border - ill defined
 histiocytes

22. • In liquid based preparation , exfoliated endometrial
cells may be slightly larger , with more easily
visible nucleoli and enhanced chromatin details
compared to conventional smear preparations .
EXODUS

23. NILM- NON NEOPLASTIC
FINDINGS
• Non neoplastic cellular variations
• Squamous Metaplasia :
 nucleus - round to oval
 evenly distributed chromatin
 in conventional smears – spider cells

25. NILM- NON NEOPLASTIC
FINDINGS
• Non neoplastic cellular variations
Keratotic cellular changes
 Keratosis
 Hyperkeratosis
 Parakeratosis
 Dyskeratosis

26. KERATOHYALINE GRANULES

27. PARAKERATOSIS
• Squamous cells with dense orangeophilic or
eosinophilic cytoplasm .
• Cells- isolated ,in sheets, in whorls
• Cell shape – round / polygonal / spindle shaped
• Nucleus - pyknotic

28. HYPERKERATOSIS
• Anucleate squamous cells with ghost like nuclear
holes .

29. NILM- NON NEOPLASTIC
FINDINGS
• Non neoplastic cellular changes :
• TUBAL METAPLASIA :
 columnar ciliated / pseudo stratified
 nucleus - round-oval , enlarged , pleomorphic ,
hyperchromatic &
 N:C ratio – high
 Cytoplasm - vacuoles / goblet cell change

30. NILM- NON NEOPLASTIC
FINDINGS
• Non neoplastic cellular changes :
ATROPHY
 flat monolayer sheets of parabasal like cells
 nucleus enlargement , N:C ratio, regular contour
 abundant inflammatory exudate,
 basophilic granular backgroud
 blue blobs – conventional preparations

31. NILM- NON NEOPLASTIC
FINDINGS• Non neoplastic cellular changes :
Pregnancy related cellular changes
 navicular cells- boat shaped intermediate cells
- abundant basophilic clear cytoplasm
- nucleus- vesicular , delicate chromatin
 decidua
 cytotrophoblast & syncytiotrophoblast
 Arias – Stella reaction

33. NILM- NON NEOPLASTIC
FINDINGS• Reactive cellular changes :
• 1. Inflammation :
 reactive squamous cells- mild nuclear enlargement without
significant chromatin abnormality .
 reactive endocervical cells – variation in nuclear size, prominent
nucleoli , fine chromatin, intra cytoplasmic PML’s
 perinuclear halos

34. NILM- NON NEOPLASTIC
FINDINGS• Reactive cellular changes :
• 2. Lymphocytic (Follicular) cervicitis:

35. NILM- NON NEOPLASTIC
FINDINGS• Reactive cellular changes :
• 3. Radiation :
cell size ,bizarre shape
nucleus size / N , Binucleation / Multinucleation
cytoplasm - vacuolated polychromatic , intra cytoplasmic
PML’s

36. NILM- NON NEOPLASTIC
FINDINGS• Reactive cellular changes :
• 4. IUCD :
Glandular cells - singly / clusters in clean background
signet ring appearance

37. NILM- NON NEOPLASTIC
FINDINGS
Glandular cell changes Post hysterectomy :
benign appearing glandular cells

38. NILM- ORGANISMS
1. Trichomonas vaginalis :
Pear shaped cyanophilic
nucleus – pale , vesicular , eccintrically
cytoplasm – eosinophilic granules
flagella
leptothrix
squamous cell TRICH change , polyballs

39. NILM- ORGANISMS
2. Candida :
budding yeast &/ pseudo hyphae
in liquid based preparation : spearing of epithelial cells/ shish
kebab effect

40. NILM- ORGANISMS
3. Bacterial vaginosis
clue cells
LACTOBACILLI

41. NILM- ORGANISMS
4. Actinomyces :
cotton ball clusters

42. NILM- ORGANISMS
5. HSV :
nucleus – ground glass appearance
- dense eosinophilic intranuclear inclusions
( Cowdry ) surrounded by a halo
large multinucleated / mononucleate squamous cells

43. NILM- ORGANISMS
6. CMV :
Endocervical glandular cells affected
cells & nucleus – enlarged
large eosinophilic intranuclear viral inclusions with
halo

44. INTERPRETATION / RESULT
OTHERS :
Endometrial cells (in a woman >= 40 years of
age)
(Specify if ‘negative for squamous intraepithelial
lesion’)

45. INTERPRETATION / RESULT
EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL
 Atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
 Low grade squamous intraepithelial lesion (LSIL)
(encompassing: HPV/mild dysplasia/CIN 1)
 High grade squamous intraepithelial lesion (HSIL)
(encompassing: moderate and severe dysplasia, CIS,
CIN 2 and CIN 3)
- with features suspicious for invasion (if invasion is

46. INTERPRETATION / RESULT
EPITHELIAL CELL ABNORMALITIES
GLANDULAR CELL
ATYPICAL
 endocervical cells (not otherwise specified (NOS) or specify in comments),
 endometrial cells (NOS or specify in comments),
 glandular cells (NOS or specify in comments)
ATYPICAL
 endocervical cells, favor neoplastic
glandular cells, favor neoplastic
ENDOCERVICAL ADENOCARCINOMA IN SITU
ADENOCARCINOMA:
 Endocervical
 Endometrial
 extrauterine
 not otherwise specified (NOS)

47. INTERPRETATION / RESULT
• OTHER MALIGNANT NEOPLASMS: (specify)
1. Uncommon primary tumors of cervix & uterine corpus:
 Carcinomas ( spindle SCC, Poorly diff SCC ,)
 Neuroendocrine ( small cell ,large cell, carcinoid ,glassy
,mucinous , MMMT ,Clear cell, Sarcoma, )
2. secondary / metastatic tumors :
 Extra uterine carcinomas (Breast , Stomach, Ovary ,Colon
, Kidney ,Bladder)

48. INTERPRETATION / RESULT
• ASC
• ASC-US:
changes that are suggestive of LSIL but are
insufficient for a definitive interpretation
ASC – 1. Squamous differentiation
2. N:C ratio
3. nucleus – size enlarged hyperchromasia ,
clumped chromatin ,irregular , multinucleated
Seen in atypical parakeratosis , atypical repair , atypia
in postmenopausal woman

49. ATYPICAL
PARAKERATOSIS

50. INTERPRETATION / RESULT
• ASC
• ASC-H:
Atypical immature metaplasia
Crowded sheet pattern

51. INTERPRETATION / RESULT
• LSIL :
cells - singles/ clusters / sheets
nucleus - enlarged , hyperchromatic , anisonucleosis
- chromatin is coarsely granular to smudgy
- binucleated / multinucleated
koilocytes & increased keratinization

52. INTERPRETATION / RESULT
• HSIL :
cells - smaller than LSIL
- singly / sheets / syncytial aggregates
- hyperchromatic crowded group
nucleus – enlarged , high N:C ratio than LSIL
- irregular nuclear membrane

53. INTERPRETATION / RESULT
• HSIL with invasion

54. INTERPRETATION / RESULT
SCC - Keratinizing SCC
- Non keratinizing SCC
Keratinizing SCC :
cells- variable sizes & shapes ,
- keratinized tadpole cells
nucleus – vesicular to pyknotic
cytoplasm – deeply eosinophilic /cyanophilic
back ground - tumor diathesis

55. INTERPRETATION / RESULT
SCC - Keratinizing SCC
- Non keratinizing SCC
Non Keratinizing SCC :
cells- singly / syncytial aggregates
nucleus – irregular coarsely clumped chromatin
- nucleoli prominent
- features of HSIL
back ground - tumor diathesis

56. INTERPRETATION / RESULT
• Atypical Endocervical cells: NOS
cells - sheets , cell crowding
nucleus - overlapping , enlarged ,pleomorphism
- nucleoli
- increased N:C ratio

57. INTERPRETATION / RESULT
• Atypical Endocervical cells , favour Neoplastic
cells - sheets , strips ,rosettes / feathering
- ill-defined border
nucleus - crowding ,overlap, pseudostratification
- enlarged
- coarse chromatin , increased N:C ratio

58. INTERPRETATION / RESULT
• Atypical Endometrial cells :
cells - small groups (5-10 cells)
- ill-defined border
nucleus – enlarged
mild hyperchromasia , chromatin heterogenecity
nucleoli
cytoplasm - vacuolated & scanty

59. INTERPRETATION / RESULT
• AIS :
cells - sheets , clusters , rosettes ,nuclear crowding &
Overlap , feathering
nucleus - enlarged, hyperchromatic, increased N:C ratio
coarsely granular chromatin
mitoses , apoptotic bodies
cytoplasm – less
background – clean

61. INTERPRETATION / RESULT
• Adenocarcinoma :
Endocervical Adenocarcinoma
Endometrial Adenocarcinoma
Extrauterine Adenocarcinoma

62. INTERPRETATION / RESULT
• Adenocarcinoma :
Endocervical Adenocarcinoma :
cells – singles, sheets , clusters ,syncytial aggregates
- oval / columnar
nucleus - enlarged , pleomorphic, irregular
chromatin
macronucleoli
cytoplasm – vacuolated , mucin
background – necrotic tumor diathesis

63. INTERPRETATION / RESULT
• Adenocarcinoma :
Endometrial Adenocarcinoma :
cells – singles, clusters ,
- round in shape
nucleus - enlarged , hyperchromasia, irregular
chromatin
prominent nucleoli
cytoplasm – vacuolated , scanty , cyanophilic
background – watery tumor diathesis

64. INTERPRETATION / RESULT
• Adenocarcinoma :
Extrauterine Adenocarcinoma :
cells – few , variable shape
nucleus - variable
cytoplasm – variable
background – no diathesis

65. Spindle SCC MMMT / CARCINOSARCOMA
MALIGNANT MALANOMA MALIGNANT LYMPHOMA (NHL)

66. ANCILLARY TESTING
• Provide a brief description of the test method(s) and report the result so
that it is easily understood by the clinician.
AUTOMATED REVIEW
If case examined by automated device, specify device and result.
EDUCATIONAL NOTES AND SUGGESTIONS
(optional)
Suggestions should be concise and consistent with clinical follow-up guidelines
published by professional organizations (references to relevant publications may
be included).

67. MANAGEMENT GUIDELINES RELATED TO ADEQUACY:
2/4
2/4

68. • Colposcopy is recommended (if LSIL)
• Loop electrosurgical excision or colposcopy for HSIL.
• ASCUS….. (HPV testing/ Repeat cytology in 1 year
If HPV negative - cotesting - cotesting at 3 years.
If HPV positive - colposcopy.
If 1 year cytology is negative - routine screening
• NILM – Repeat cotesting in 3 years is preferred.
• NILM – after 65 years – No further screening is required if
prior negative screening.

69. TAKE HOME MESSAGE
The 2014 BETHESDA SYSTEM FOR REPORTING CERVICAL
CYTOLOGY
SPECIMEN TYPE:
Indicate conventional smear (Pap smear) vs. liquid-based preparation vs. other
SPECIMEN ADEQUACY :
• Satisfactory for evaluation ( describe presence or absence of endocervical/transformation
zone component and any other quality indicators, e.g., partially
obscuring blood, infl ammation, etc. )
• Unsatisfactory for evaluation . . . ( specify reason )
– Specimen rejected/not processed (s pecify reason )
– Specimen processed and examined, but unsatisfactory for evaluation of epithelial
- abnormality because of ( specify reason )

70. GENERAL CATEGORIZATION ( optional )
• Negative for Intraepithelial Lesion or Malignancy
• Other: See Interpretation/Result ( e.g., endometrial cells in a woman ≥45 years of
age )
• Epithelial Cell Abnormality: See Interpretation/Result ( specify ‘squamous’ or
‘glandular’ as appropriate )
INTERPRETATION/RESULT
NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY
(When there is no cellular evidence of neoplasia, state this in the General
Categorization above and/or in the Interpretation/Result section of the report --
whether or not there are organisms or other non-neoplastic findings )
NON-NEOPLASTIC FINDINGS ( optional to report optional to report; list not
inclusive )
• Non-neoplastic cellular variations
– Squamous metaplasia
– Keratotic changes
– Tubal metaplasia
– Atrophy
– Pregnancy-associated changes

71. Reactive cellular changes associated with:
– Infl ammation (includes typical repair)
• Lymphocytic (follicular) cervicitis
– Radiation
– Intrauterine contraceptive device (IUD)
• Glandular cells status post hysterectomy
ORGANISMS
• Trichomonas vaginalis
• Fungal organisms morphologically consistent with Candida spp.
• Shift in flora suggestive of bacterial vaginosis
• Bacteria morphologically consistent with Actinomyces spp.
• Cellular changes consistent with herpes simplex virus
• Cellular changes consistent with cytomegalovirus
OTHER
• Endometrial cells ( in a woman ≥45 years of age )
( Specify if “negative for squamous intraepithelial lesion” )

72. EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL
• Atypical squamous cells
– of undetermined signifi cance (ASC-US)
– cannot exclude HSIL (ASC-H)
• Low-grade squamous intraepithelial lesion (LSIL)
( encompassing: HPV/mild dysplasia/CIN 1 )
• High-grade squamous intraepithelial lesion (HSIL)
( encompassing: moderate and severe dysplasia, CIS; CIN 2 and CIN 3 )
– with features suspicious for invasion (i f invasion is suspected )
• Squamous cell carcinoma
GLANDULAR CELL
• Atypical
– endocervical cells (NOS o r specify in comments )
– endometrial cells (NOS o r specify in comments )
– glandular cells (NOS o r specify in comments )
• Atypical– endocervical cells, favor neoplastic
– glandular cells, favor neoplastic
• Endocervical adenocarcinoma in situ
• Adenocarcinoma– endocervical– endometrial– extrauterine– not otherwise specifi
ed (NOS)

73. OTHER MALIGNANT NEOPLASMS: (specify)
ADJUNCTIVE TESTING
Provide a brief description of the test method(s) and report the result so that it is
easily understood by the clinician.
COMPUTER-ASSISTED INTERPRETATION OF CERVICAL CYTOLOGY
If case examined by an automated device, specify device and result.
EDUCATIONAL NOTES AND COMMENTS APPENDED TO CYTOLOGY
REPORTS ( optional )
Suggestions should be concise and consistent with clinical follow-up guidelines
published by professional organizations (references to relevant publications may be
included).

74. REFERRENCES
• The Bethesda System for Reporting Cervical Cytology
– 3 rd edition – Ritu Nayar , David C.Wilbur
• Gynecological Cytopathology Cervix- 2 nd edition –
Suresh Bhambhani
• Comprehensive Cytopathology – 2 nd edition –
Marluce Bibbo
THANK YOU