Pap Smear Findings in Postmenopausal Women: Correlation with Atrophic Changes and Malignancy Risk

Background: Cervical cancer is a major health problem worldwide, particularly in developing countries such as India, which contributes nearly one-fifth of the global burden. Postmenopausal women present unique challenges in cytological screening due to estrogen deficiency–related atrophic changes that can mimic epithelial abnormalities, leading to potential diagnostic errors. Objective: To assess Pap smear findings in postmenopausal women, evaluate the prevalence of atrophic smears, and correlate atypical epithelial abnormalities with the risk of premalignant and malignant lesions. Materials and Methods: This cross-sectional observational study was conducted in the Departments of Obstetrics & Gynecology and Pathology at a tertiary care hospital in Central India over one year (January–December 2024). A total of 520 postmenopausal women underwent Pap smear examination using conventional Papanicolaou staining. Smears were reported as per the Bethesda System 2014. Cases with epithelial abnormalities underwent colposcopic-guided biopsy, and histopathological correlation was obtained in 42 cases. Results: The majority of women were in the 51–60 years age group (46.2%), with a mean age of 58.4 years. Atrophic smears were the most frequent finding (60%), followed by inflammatory smears (23.8%). Epithelial cell abnormalities were detected in 11.7% of cases, with ASC-US (4.6%) being the most common, followed by HSIL (2.9%), LSIL (2.3%), and invasive carcinoma (2.5%). Histopathological correlation revealed that 59.5% of abnormal cytology cases were confirmed premalignant or malignant, while 40.5% were benign/reactive. Notably, all cases of LSIL, squamous cell carcinoma, and adenocarcinoma were confirmed malignant, whereas most ASC-US and some HSIL cases were benign on biopsy. Conclusion: Atrophy is the predominant cytological finding in postmenopausal Pap smears and often mimics atypical or premalignant changes, posing interpretation challenges. Despite these pitfalls, Pap smear remains an essential screening tool, with nearly 5.4% of women in this study harboring HSIL or invasive carcinoma. Continued screening in postmenopausal women, supplemented by adjunctive methods such as HPV testing, can improve diagnostic accuracy and reduce unnecessary interventions, thereby strengthening cervical cancer prevention strategies in resource-limited settings.