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Pap Smear (Cervical Smear) Description Reasons For Pap Smear Pap Smear Risk Factors Pap Smear Procedure Description Pap Smear Expected Outcome Pap Smear Complications Pap Test Procedure Preparation Pap Test Procedure Description: Client Patient Information Transformation Zone Traditional Pap Technique Thin Prep Method Specimen Collection Tips Test Results Colposcopy Treatment Options After Cervical Biopsy Medication Activity Recommendations & Restrictions Diet & Nutrition Notify Your Health Care Provider
PAP SMEAR (CERVICAL SMEAR) DESCRIPTION
Cervical cancer screening began in the United States in the late 1940s after Dr. George Papanicolaou developed the Pap smear. A Pap smear (also called a Pap test) is a screening test used to examine cells from the cervix and the vagina. (The cervix is the portion of the uterus that protrudes into the vagina). Cervical and vaginal cells are studied to determine whether there is evidence of cancer or pre-cancerous changes. If abnormal cells are found, they are classified according to their degree of abnormality. Most abnormal Pap smears are caused by cervical infections or inflammation which can usually be successfully treated before leading to cancer.
A Pap smear is used to screen a clinically normal appearing cervix for cancer of the cervix or its precursors. When there is an obvious lesion, especially one that is elevated, ulcerated or covered with necrotic exudate, a biopsy is necessary. Pap smears of the cervix are inappropriate to screen for other malignancies of the female genital tract, (i.e. a patient with post-menopausal bleeding should have an endometrial biopsy if her cervix is normal).
Abnormal Pap smear findings may indicate:
- Infection (including the human papillomavirus, HPV)
- Swelling or inflammation
- Pre-cancerous cell changes
- Cervical cancer
Pap smear is perceived by the medical community as a reliable screening tool to help detect cervical cancer, along with regular pelvic exams. It is a laboratory study used to detect cancerous or precancerous cells on the cervix. Examination of the female external and internal genitalia is performed and the Pap smear (cervical smear) is carried out during the pelvic examination. Annual pelvic examination with a Pap Smear is recommended for most women and more often for those in high-risk categories. However, Pap smears cannot typically detect other types of cancers, such as ovarian or uterine cancers, or sexually-transmitted diseases (STD), with the exception of the human papilloma virus (HPV).
The American Cancer Society recommends that all women begin receiving yearly Pap smears and pelvic examinations at age 18 or when they become sexually active, whichever occurs earlier. If an 18 year old woman has not yet been sexually active, the focus of her visit should be on education about Pap smears and the benefits of being involved in a regular Pap smear once she does become sexually active. Some health care providers will not perform a Pap smear each year if a woman has had three negative Pap smears in the course of three years. However, a yearly pelvic exam should be continued even if Pap smears are not given each year.
Women who have never been sexually active have a low probability of developing cervical cancer. The health care professional should develop a rapport with these clients/patients in order to feel confident that they have, in fact, never been sexually active. If there is any doubt, a Pap smear program should be initiated.
At What age should women stop having Pap smears? Evidence-based medicine does not define an upper age when Pap smears should be stopped. Women who have been screened regularly up to age 69 and have had negative smears will have a low risk of developing cervical cancer. Pap smears can still be obtained, if desired, but the interval can be extended to three years.
If a 69 year old has never been screened, she should have two negative smears, one year apart, before the interval is extended or screening is stopped. An upper age limit may be better determined by co-morbid disease.
Frequency of Pap smear screening - Recommendations for a screening interval vary from country to country, from province to province (in Canada) and between professional organizations. They have also changed over time. The recommendations of the 1989 National Workshop on Screening for Cancer of the Cervix state that all women age 18 years and over who have had sexual intercourse should be screened. Initial screening should include two Pap smears, one year apart. If both smears are within normal limits, then rescreening every three years is advised until age of 69. If there has been no significant abnormality in the past, screening can cease at this time.
The recommendation for a three-year screening interval is based on the presence of an organized system that includes a system for recruitment and recall, proper sampling and handling of smears, high-quality laboratory services and a method of quality assurance. In the absence of an organized system, "annual" cytology screening is recommended. Currently, opportunistic screening depends entirely on the individual women's and/or her health care provider's initiative. Unfortunately, as women mature and no longer present for family planning or antenatal care, smears are less likely to be done or the interval tends to exceed what is recommended.
Regular or more frequent Pap smears may be performed on women who have had hysterectomies (surgery to remove the uterus, including the cervix), especially if the hysterectomy was performed because pre-cancerous and cancerous cells were found in the cervix. In women who have had hysterectomies, the tissues of the vagina are analyzed for changes that may indicate cancer.
In addition, women who have a weakened immune system (from AIDS, chemotherapy or drug treatments, or organ transplants) are considered at higher risk for cervical cancer and may require Pap smears more frequently than once a year.
Approximately 50 million Pap smears are performed each year in the United States. The death rate from cervical cancer has declined dramatically since 1955 (74 percent from 1955 to 1992) largely from the increased use of the Pap smear. When detected early, the five-year survival rate for cervical cancer is approximately 91 percent. If cervical cancer is detected before it has invaded any surrounding tissues, the five-year survival rate is nearly 100 percent.
Even with the increased use of the Pap smear, between 60 and 80 percent of American women who are newly diagnosed with cervical cancer have not had a Pap smear within the last five years, if ever. According to recent studies, elderly, African-American, and low-income women are the least likely to have annual Pap smears.
The American Cancer Society estimates that in 2001, 12,900 new cases of invasive cervical cancer will be diagnosed and approximately 4,400 women will die from the disease. Researchers estimate that non-invasive cervical cancer is nearly four times as likely as invasive cervical cancer.
HELPFUL INFORMATION - Please Note:
The Pap Smear test is the only screening test for cancer, in the world, which has caused a decrease in occurrences and deaths from cancer.
A Pap Smear is a screening tool, not a diagnostic test; further evaluation is required when abnormal changes are detected.
A normal Pap Smear is not a guarantee of no cancer; it does not detect cancers of the uterus, fallopian tubes, or ovaries.
Your health care provider may advise you to continue having regular Pap smears even after a hysterectomy.
Your health care provider will determine when you should have your next Pap smear, though every 6 to 12 months is usually recommended.
Pap Smears can be safely performed during pregnancy.
A new pap test has been developed, the PapNet test.
HPV & CERVICAL CANCER
The human papillomavirus (HPV) is a common sexually transmitted disease that affects both men and women. It is estimated that twenty-four million Americans may have the human papillomavirus (HPV), yet more than 76 percent of women in the United States have never heard of this sexually transmitted virus which causes approximately 93 percent of all cervical cancers.
Scientists have discovered over 80 different types or strains of the human papillomavirus virus and although most of them do not pose any health risks, some of the strains of HPV cause genital warts in men and women and can cause cellular changes that may lead to cervical cancer in women. Visible genital warts occur in only about one percent of sexually active adults infected with the HPV virus, while other types of HPV are subclinical infections. A major risk factor for cervical cancer is the HPV. It is estimated that one million new cases of HPV occur each year, and 20 to 40 percent of sexually active women have HPV.
It is essential that all women over age 18 have annual Pap smears since the test accurately detects approximately 90 percent of all cervical cancers. HPV is most commonly discovered by abnormal Pap smears results and is most likely to spread when genital warts are visible. HPV does not typically interfere with pregnancy or childbirth.
Research has shown that condoms do not always prevent the spread of HPV because the virus can be transmitted by skin contact of any HPV-infected area (such as the genitals). Limiting the number of sexual partners and not having sexual intercourse with a person who has had several sexual partners can help prevent HPV. There is currently no cure for HPV.
According to the American Cancer Society, removing genital warts and abnormal cell growths caused by HPV can help reduce the risk of cervical cancer from HPV. Treatments to remove genital warts include:
- Laser surgery.
- Convention surgery.
- Cold cautery (freezing the tissue).
- Hot cautery (burning the warts off with an electric instrument).
- Directly applying podophyllin or trichloroacetic acid.
In addition, the U.S. Food and Drug Administration (FDA) has recently approved a drug called imiquimod cream to treat genital and perianal warts.
LINKS TO OTHER SEXUALLY TRANSMITTED INFECTIONS
- Vaginal Infections, Sexually Transmitted Diseases (STDs)
- Bacterial Vaginitis
- Genital Herpes
- Genital Warts (HPV)
- Pelvic Inflammatory Disease
- Trichomonas (Trichomoniasis, Trich)
- Candida - Vaginal Yeast Infections
- Cervical Cancer Information
CERVICAL CANCER SCREENING: PAP SMEAR INTERVALS
EXTREMELY LOW RISK PATIENTS
Pap Smear not necessary. These may include women in these categories:
- Virginal patients.
- Hysterectomy for benign disease.
- Recent studies suggest no further Pap Smears needed.
- Age over 65 and over 10 benign Pap Smears.
- At least one benign Pap Smear must be after age 60.
LOW RISK PATIENTS
- Initial screening (until age 30 years).
- Normal yearly conventional Pap Smear for 3 years or Normal thin prep Pap Smear every 2 years.
- Subsequent screening (if initial screening normal).
- Pap Smears every 2 to 3 years.
- Sexual activity onset after age 20 years.
- Start Pap Smears within 3 years of 1st intercourse.
- Even virginal patient should start Pap Smears at 21.
- Under age 21 years: pap 3 years after 1st intercourse.
- Patients with less than 3 lifetime sexual partners.
- Patients who consistently use barrier Contraception.
- No Tobacco abuse.
- Previously normal Pap Smear.
- No Sexually Transmitted Disease history.
HIGH RISK PATIENTS:
- Initially screen twice yearly and then...
- Subsequently yearly Pap Smear.
- Sexual activity onset before age 20 years.
- Start Pap Smears within 3 years of 1st intercourse.
- Screen and prevent Sexually Transmitted Diseases.
- Patients with three or more lifetime sexual partners.
- History of HPV or other Sexually Transmitted Disease.
- Previously abnormal Pap Smear.
- Tobacco abuse.
General Recommendations for vaginal cytology:
- No history of abnormal Pap Smear cytology.
- Consider no further screening after Hysterectomy.
- Some clinicians recommend screening every 10 years.
Prior Pap Smear Abnormalities:
- Initial Vaginal smear 3 years after Hysterectomy.
- Subsequent vaginal smears every 5 years.
Endpoint: See Very low risk patient criteria above.
REASONS FOR PAP SMEAR PROCEDURE
Routine diagnostic check. Investigate the cause of abdominal or pelvic pain. Unexpected vaginal bleeding or discharge. Bladder problems. A general check before prescribing any form of contraception. Pain during intercourse. Suspected sexually transmitted disease. In pregnancy, to assess the position of the baby. As a part of infertile studies. Screening test for cervical cancer.
PAP SMEAR RISK FACTORS
None expected with the Pap smear procedure. Rarely, a possibility of infection may occur.
TYPES OF PAP SMEARS
TRADITIONAL MANUAL PAP SMEAR TESTING
Traditionally, this method involves collecting the cells from the cervix and placing them carefully on a slide. The cells must then be preserved before drying can occur by immersion in 95-percent ethanol or by using a fixative spray. The slides are then packaged in protective carriers and sent to a laboratory for analysis under a microscope. Pap smear testing relies on the human eye to look for abnormal cells under a microscope. It is the only large scale laboratory test that is not automated (however, new methods are developing using automated reading devices to improve reliability). The cells collection must be performed quickly and the smear must be thin enough to read properly, free from blood, mucus and other interfering agents. Since a patient with a serious abnormality can have fewer than a dozen abnormal cells among the 30,000 to 50,000 normal cells on her Pap smear, it can be very difficult to detect all cases of early cancer by this "needle-in-a-haystack" search. Imagine proof-reading 80 books a day, each containing over 300,000 words, to look for a few books each with a dozen spelling errors! Relying on manual inspection alone makes it inevitable that some abnormal Pap smears will be missed, no matter how carefully the laboratory analyzes the slides. In fact, even the best laboratories can miss from 10 to 30 percent abnormal cases.
Recently, new techniques have been developed to further improve cervical cancer cell sample collection and specimen quality. Cytyc Corporation's ThinPrep System and TriPath Imaging, Inc.'s SurePath® (formerly AutoCyte®PREP) System are two such new techniques that have been approved by the U.S. Food and Drug Administration (FDA). While the conventional Pap smear is still an accurate method of detecting abnormalities or cancer, research has shown that these new techniques may be more effective at detecting cervical cancer and pre-cancerous conditions than the conventional Pap smear by:
- Making the client/patient's slide more representative of the their clinical condition.
- Improving the preservation of the sample.
- Standardizing the presentation of cells on the slide.
- Reducing mucus, blood, or other debris that may eclipse pre-cancerous or cancerous cells.
A 1991 study of 600 laboratories found that up to 20 percent of Pap smear slides are unsatisfactory for evaluation and 40 percent are satisfactory but of limited value. Reasons for these classifications include too few cells to evaluate or too much mucus or blood in the sample to make an accurate interpretation.
With the conventional Pap smear technique, cervical cells are collected with a small stick or spatula and smeared on a slide for pathological analysis. However, a 1994 study published in the American Journal of Clinical Pathology found that up to 80 percent of a sample taken from a patient using the conventional Pap smear technique is not smeared on the slide but remains on the collection device. Instead of smearing the cervical cells on a slide after they are removed from the patient, new "direct-to-vial" techniques involve immediately rinsing the collected cells in a vial filled with a special solution. This reduces the likelihood that a patient's cell sample will be damaged by air, clumping, etc.
The vial is then taken to the laboratory for slide preparation and screening. In the laboratory, the vial is inserted in a sample preparation device which breaks up blood, mucus, and other problematic materials. The thin layer of cells in then transferred to a slide and is automatically deposited into a preservative solution. With these newer methods, health care providers are also able to conduct multiple analyses (such as HPV testing) using residual cells collected in the vial instead of having to order an additional Pap smear.
With conventional Pap smear, cells can be obscured by blood, mucus or clumping. With direct-to-vial techniques such as the ThinPrep method, more cells are preserved and there is less overlapping, blood, mucus, etc. (Images courtesy of Cytyc Corporation.
In a clinical trial of 6,747 patients conducted by Cytyc, the maker of the ThinPrep direct-to-vial technique, researchers found a 65 percent improvement in the detection of cervical cancer at three screening centers using this new technique and a 6 percent improvement at three hospitals where the incidence of cervical cancer is historically high. The direct-to-vial technique was also found to be more effective at detecting severe cervical lesions than the conventional Pap smear. In all, more than 30 major studies including more than 300,000 patients in the United States, Europe, Asia, Africa, and Australia have found that "direct to vial" Pap smear techniques have benefits over the conventional cervical cell collection.
While new direct-to-vial methods have been shown to be more effective at detecting cervical cancer than the conventional Pap smear, the cost of these new methods is higher. Some insurance companies do provide coverage for these newer techniques while others do not. Therefore, women should check with their insurance companies prior to choosing these newer techniques. In some cases, women who choose to have the new direct-to-vial sample collection will have to pay out-of-pocket for the additional cost of the test.
Another advance in Pap smear screening is the use of computerized instruments that can recognize abnormal cells in Pap smears (similar to the use of computer-aided detection with mammography). An example of this technology is the SurePrep/AutoPap system made by Tripath Imaging, Inc. Normally, technologists and pathologists evaluate all Pap smear samples. However, with this technology, a computer re-examines the sample and marks areas of the sample that may indicate abnormal cells. The technologist or pathologist then takes a closer look at these areas. The advantage of this technology is that the computer instruments may find pre-cancerous or cancerous cells that a technologist or pathologist may miss. However, some health care providers believe that the technology can lead to a significant number of "false positive" results (the technology falsely indicates that the sample contains abnormal cells). These false positive results can lead to unnecessary repeat Pap smears, colposcopy, or other exams. As with the "direct to vial" techniques, this method may or may not be covered by insurance. Nevertheless, with continued improvements, many health care providers believe this type of technology will eventually lead to more accurate detection of cervical cancer and pre-cancerous conditions.
THIN PREP PAP TEST
In addition to the traditional Pap screening, many health care providers (and midwives) offer the ThinPrep Pap Test. The ThinPrep Pap Test is a far superior test than the conventional Pap Smear. ThinPrep utilizes a liquid-based, thin layer preparation that eliminates obscuring elements that may prevent the true view of the specimen. Thin-layer preparations are proven to be more effective from the conventional Pap Smear in detecting abnormal cells. A thin prep pap smear may reveal cervical dysplasia suggested by a previous ASCUS reading. This type of test is an alternative choice to typical cytology. A slightly increased discovery of cellular anomalies over standard cytology is an advantage, thus, the risk of a false negative result is reduced. In some cases, however, specific abnormalities may be easier to identify with the standard method. A thin prep pap smear may reveal cervical dysplasia suggested by a previous ASCUS reading. More information about ThinPrep can be found below.
SUREPATH LIQUID-BASED PAP TEST
The collection and preservative vials for gynecological applications have been renamed SurePath (formerly called AutoCyte PREP). This method is designed to improve the accuracy of results to patient and health care providers alike. The SurePath test pack includes a vial with our preservative liquid, formerly known as CytoRich, as well as all collection, storage and transportation components. SurePath liquid-based Pap test is a FDA approved thin-layer cell preparation process intended for use in the screening and detection of cervical cancer, pre-cancerous lesions, atypical cells and all other cytologic categories as defined by The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses.
Optimized gynecological application-specific preservatives provide:
- Immediate and complete cell fixation which maintains cell morphology resulting in superior nuclear detail.
- Extended sample stability (4 weeks at room temperature, 15 to 30°C, and 6 months refrigerated, 2 to 10°C).
- Extended shelf life (36 months from date of manufacture).
- Immuno/Probe cytology compatible.
- Less than 24 percent Ethanol, a preferred fixative for cytology specimens.
- Color Coding for ease of identification.
SurePath Website and Information
PAPNET COMPUTER-ASSISTED PAP SMEAR TESTING
PAPNET computer-assisted Pap smear testing uses a recent advance in computer technology known as neural network to assist medical professionals in the examination of network to assist medical professionals in the examination of Pap smears. This system was developed by artificial in the field of Pap smear analysis. PAPNET computers screen and analyse each of the 300,000 to 500,000 cells in a Pap smear and identify 128 most suspicious cells for subsequent rescreening by trained cytotechnologists and cytopathologists on high-resolution video monitors. By eliminating the searching process and thereby 98 percent of the work, PAPNET reduces human fatigue and improves accuracy of diagnosis by as much as 10-fold.
LINKS ABOUT THE PAPNET TEST
Study Shows PapNet Can Improve Diagnosis PapNet Testing Helps Laboratories Detect Cervical Cancer Earlier NCBI: Negative Cervical Smears Before CIN 3/Carcinoma. Reevaluation with the PapNet Testing System PapNet Test Available through 138 U.S. Labs
AFTER THE PAP TEST, SPECIMEN PREP & ANALYSIS
After the examiner obtains the cervical cells, he or she will usually give the specimen to an assistant, or other specially trained medical professional in the exam room who will smear them on glass slides and take them to the lab to be evaluated. A new way of collecting cervical cells involves placing the sampling device (spatula, brush, or broom) directly into a liquid (Thin Prep Method). The cells are then placed on slides in the laboratory.
In the lab, a pathologist or specially trained laboratory technologist will analyze the cells under a microscope to determine whether they are cancerous, pre-cancerous, or benign (non-cancerous).
PAP SMEAR RESULT DESCRIPTION
Pap smear results are usually available to clients/patients within two weeks. The Bethesda System (TBS) is the most commonly used system to describe Pap smear results, though some labs use older system such as the CIN (cervical intraepithelial neoplasia) system or the Class system. The Bethesda system involves using a number of descriptive terms instead of a number system.
First, the technologist or pathologist will determine whether the cell sample is satisfactory for evaluation. If it is, he or she will proceed with the analysis. A common reason why the cells may not be satisfactory for evaluation is that too few cells were removed during the Pap smear. In this case, the Pap smear should be repeated.
If no abnormalities are found, the Pap smear results are called negative. If an abnormality is found, then the results of the test are positive.
The following terms may be used to describe abnormal cervical cells:
- ASCUS: Minor cells changes of unknown cause. The situation will be assessed.
- LSIL: Minor cell changes unlikely to progress to cancer. For example, Certain strains of the human papillomavirus (HPV) may cause genital warts.
- HSIL: Cell changes that may progress to or are in the early stages of cancer.
- SIL: Abnormal cells are present in the cervix. The term CIN is accompanied by a number (1 to 3) to describe how much of the cervix contains abnormal cells.
- CIN I: Mild cellular dysplasia. The term dysplasia is used to describe cells that undergo a series of changes in their appearance. They appear abnormal under a microscope but do not invade nearby healthy tissue.
- CIN II: Moderate cellular dysplasia.
- CIN III: Severe cellular dysplasia.
- CIS: Carcinoma in situ. The term "in situ" literally means "in place." Cancer is present but has not spread into nearby tissue.
- Cervical cancer
- Endometriosis: Cells from the lining of the uterus (endometrial cells) have moved outside of the uterus to the cervix.
- AGUS: Glandular cells are found and the reason for their presence on the cervix is unknown.
- Glandular cancer: Cancer from glandular cells in the cervix.
- Endometrial cancer: Cancer from cells that line the uterus (endometrial cells).
- Other types of cancer: Cancer that has spread to the cervix from other parts of the body.
- Other types of glandular cell cancer: Glandular cell cancer that has spread to the cervix from other parts of the body.
If a client/patient has had her uterus removed (hysterectomy), then cells from the vagina will be tested for abnormalities. In this case, the description of the laboratory analysis is typically as follows:
- Normal findings for the patient's age and medical history.
- Abnormal findings for the patient's age and medical history, followed by specific reason.
- Evaluation not possible, followed by specific reason.
Menstrual blood, vaginal lubricants, douches, or vaginal medications may cause inaccurate results of a Pap smear. Also, failure to apply a preservative to the slide sample immediately after cervical cells are obtained and spread onto the slide may cause the cells to become dried out.
Additional Tests May Be Ordered if the Results of a Pap Smear are Abnormal:
- Colposcopy: The cervix is viewed through a colposcope (an instrument with magnifying lenses) to check for abnormalities.
- Cervical Biopsy: A portion of tissue from the cervix may be removed for further examination and to confirm if cancer is present.
- Cone biopsy: An elaborate cervical biopsy, a cone biopsy involves removing a cone-shaped region of tissue high on the cervical (that would not be seen with a colposcopy).
Additional Resources and References:
- The National Cancer Institute provides information on Pap smears at NCI - Cancer.net.
- The American Cancer Society provides information on Pap smears at Cancer.org
PAP SMEAR PROCEDURE - EXPECTED OUTCOME
There are no after-effects expected from the examination. In routine examinations, the results are usually normal.
PAP SMEAR PROCEDURE - POTENTIAL COMPLICATIONS
None expected from the examination. While there is a very remote chance of infection from a Pap smear, there are generally no risks. The findings may indicate a disorder to be treated or a condition requiring further diagnostic testing.
PAP TEST PROCEDURE PREPARATION
Pap smears are an important screening tool for cervical cancer. All women should have annual Pap smears beginning at age 18, or younger if sexually active.
PREPARATION BEFORE YOUR APPOINTMENT
- Call your health provider, schedule an appointment at a time when you do not expect menstruation. Call your provider if your period starts to reschedule, if necessary. Women should not schedule a Pap Smear while they are menstruating because the presence of blood cells may interfere with the test results. However, if a woman is experiencing abnormal vaginal bleeding, a Pap Smear may help to determine the cause. According to the American cancer Society, the ideal time for a woman to have a Pap Smear is five days after her menstrual period has ended.
- Do not douche for at least 3 days prior to your appointment.
- Do not have sexual intercourse for 48 hours prior to your appointment.
- Do not use tampons, vaginal medications, birth control foams or jellies for 48 hours prior to your appointment.
- Do not take tub baths, instead take showers for the 2 days prior to your appointment.
- Tell your health care provider if you have been exposed to HPV.
- Write down any problems you are having, or any questions you have for your health care provider, and take it to your appointment. If you have had previous abnormal Pap smear results be sure to inform your health care provider.
- Do not forget to inform your health care provider about any infections, discharges, or pain you have experienced since your last examination.
- If you receive abnormal results, get a detailed explanation about the meaning from your provider. If you do not understand, ask questions.
- Follow your health care provider's advice about any further diagnostic/treatment procedures. It is always your right to ask for a second opinion, if you desire.
PAP TEST PROCEDURE DESCRIPTION: CLIENT/PATIENT INFORMATION
The client/patient should not douche before the examination. (See the guidelines about preparing for the pap test located above.)
The examination is usually performed in the examiner's office, but an examination may be performed during a client's home visit by a midwife or other health care provider. A nurse or other health care professional may be present to assist the health care provider or midwife. If your health care provider is a male, a female assistant should be present at the time of the examination.
The client/patient will be asked to remove clothing below the waist and drape a paper cloth (or a sheet if performed in the client's home) around the waist prior to the Pap smear. If the client is wearing a dress, then she will be asked to remove any underclothing from the waist down.
On the examination table, the client/patient will lie on her back with knees bent and legs apart (legs are usually placed in stirrups for support). If the examination is performed in a client's home, the exam may be done on a bed (with the buttocks propped up slightly by pillows or padding if internal visual examination must be made using a speculum) or possibly on a firm surface, such as a table top with pillows and soft padding.
The external genital organs will be examined visually for lumps, sores, skin discoloration, inflammation and qualities suggesting the general hormonal status.
To perform a Pap smear, the health care provider will begin by inserting a metal or plastic instrument (called a speculum) into the vagina to keep it open so that the cervix may be clearly seen. The speculum is an instrument that holds the vaginal walls apart and allows the examiner to see the cervix and vagina and check for inflammation, infection, scars or growths. There may be some feeling of pressure on the bladder or rectum with the speculum in place. Speculum lubrication may or may not contaminate pap smear. There are different thoughts on using lubricant.
Select a speculum of appropriate size, lubricate it and warm it with warm water. (Other lubricants, such as K-Y Jelly, may interfere with cytological or other studies but they may be used if no such tests are planned.) By having the speculum ready during assessment of the vaginal outlet, it can ease speculum insertion and increase the efficiency by proceeding to the next maneuver while the client is still straining down.
Place two fingers just inside or at the introitus and gently press down on the perineal body. With the other hand introduce the closed speculum past the fingers at a 45-degree angle downward. The blades should be held obliquely and the pressure exerted toward the posterior vaginal wall in order to avoid the more sensitive anterior wall and urethra. Be careful not to pull on the pubic hair or to pinch the labia with the speculum.
After the speculum has entered the vagina, remove the fingers from the introitus. Rotate the blades of the speculum into a horizontal position maintaining the pressure posteriorly.
Open the blades after full insertion and maneuver the speculum so that the cervix comes into full view.
When the introitus is retroverted, the cervix points more anteriorly than diagrammed. Position the speculum more anteriorly, i.e., more horizontally, in order to bring the cervix into view.
MoonDragon's Womens Health Information: Uterine Abnormalities
Inspect the cervix and its os. Note the color of the cervix, its position, any ulcerations, nodules, masses, bleeding or discharge.
MoonDragon's Womens Health Information: Cervical Abnormalities
A normal cervix will appear pinkish in color. The cervix will appear as purplish in color if a woman is pregnant.
The nullparous cervical os is small and either round or oval. The cervix is covered by smooth pink epithelium. Nullpara means a woman who has not borne children.
After childbirth, the cervical os presents a slit-like appearance.
The trauma of difficult deliveries may tear the cervix, producing permanent transverse or stellate lacerations.
Secure the speculum with the blades open by tightening the thumb screw.
The effects of estrogen and vaginal pH gradually transform the endocervical epithelium into stratified squamous epithelium by a process of squamous metaplasia. This area is known as the transformation zone. It is the primary target of sampling for the Pap smear. Squamous abnormalities arise in the transformation zone. The junction is close to the external OS of the cervix but varies between patients, and according to age (see below).
Location of the Transformation Zone According to Age
The position of the transformation zone varies according to age. In women during the childbearing age, the transformation zone is either in an exposed position or at the external OS. In post-menopausal women the transformation zone is often located within the endocervical canal.
An adequate Pap smear should provide representative assessment of the entire transformation zone. No single criterion determines adequacy. The presence of endocervical cells is suggestive that the area above the transformation zone has been sampled. However, the presence of metaplastic cells or dysplastic cells suggest that transformation zone has been sampled at least in part.
The visual distinction of the separate zones of the cervical epithelium is impossible with the naked eye. The squamous epithelium of the ectocervix has a smooth, pearly, opaque appearance. The endocervical epithelium is very vascular and has a pinkish to red translucent appearance. The epithelium of the transformation zone is identified by the variegation of the color between the two native epithelia. The squamo columnar junction line will be irregular in outline and the ever changing upper end of the transformation zone will be very irregular and impossible to identify without colposcopy.
TRADITIONAL PAP SMEAR TECHNIQUE
Prior to preparation of smears it is useful to obtain all necessary materials and have them at easy access:
A) Instruments to obtain the smear (extended tip spatula, endocervical brush or saline moistened cotton swab, slides with frosted end and speculum).
B) Clean microscopic glass slide with a frosted end and properly labeled with client/patient's PHIN (Patient's Hospital Identification Number). If the client/patient does not have a PHIN, the slide should be identified with the client/patient's surname.
C) Pencil to identify patient PHIN and site if more than one is being sampled on frosted end of slide.
D) Fixative can be a slide container filled with 95 percent ethanol or a non-aerosol spray fixative.
E) Laboratory requisition with all pertinent demographic information and patient history.
Swabbing the cervix to clean away discharge.
- If there is visible blood or leukorrhea present on the cervix it should be wiped off before proceeding (clean only if there is a large discharge). Before collecting the specimen, gently remove excess mucus with a ring forceps holding a folded gauze pad. Surface exudate can be removed by placing a 2 inch x 2 inch piece of gauze over the cervix and peeling it away after it absorbs the exudate. A dry "proctoswab", "scopette" or other large cotton tipped swap can also be used. Do not rinse the cervix with saline, or a hypocellular smear may result. Do not rinse cervix with saline. Avoid performing pap smear during menstruation.
Extended Tip Spatula
Sampling the Ectocervix
Sampling the Endocervix
Sampling the Endocervix
The most effective technique is a combination of ectocervical and endocervical sampling. A wooden type spatula or other type of cyto-spatula is used to sample the ectocervix (Figure 1) and an endocervical brush (Figure 2) or saline moistened cotton swab (Figure 3) is used to sample the endocervix. Both samples are transferred to one slide and quickly fixed with Cytospray. This combined technique has been shown to reduce the false negative rate to less than 15 percent.
Using the Szalay Cyto-Spatula to obtain a cervical cell sample. This spatula is unique that it comes in various sizes to match the client/patient's cervical type. The spatula is designed to obtain all three types of cervical cells in one swipe of the spatula.
(Images courtesy of Szalay Cyto-Spatula Manufacturer)
For more detailed information about the Szalay Cyto-Spatula, see these links:
Szalay Cyto-Spatula Technique
The Szalay Cyto-Spatula Technique Video Clip
- Next, the examiner will use a small brush, cotton-tipped swab, or a spatula to obtain a sample of cells and mucus from the outer part of the cervix (the ectocervix). Using a swab, a sampling of cells is taken from the cervix and placed on a glass slide for the Pap smear test.
The order in which the sample is taken is critical for less blood. If a culture is needed where blood can be an issue, this should be taken first. Otherwise, you would wait and do infectious specimen collecting until last.
Next step should be the exocervix with a Ayres spatula (or similar, such as the Szalay-Cyto-Spatula).
The last step would be using the endocervix using a brush by rotating it 180 degrees or as given by the specific test protocol.
If in doubt about the order or method of specimen collection, check with your laboratory to verify your procedure method. This will help prevent having to do a repeat pap smear.
To transfer cervical material to the slide from a spatula (a), smear the sample with a single stroke using moderate pressure to thin out clumps of cells and mucus. To transfer material from a brush or moistened swab (b), roll the bristles or cotton swab across the slide. This is all to be placed on one slide.
The wooden spatula has various designs; those with elongated ends should provide better sampling of the endocervical area. When taking a direct scraping of the cervix with a spatula, a 360 degree rotation with firm contact is essential. Starting and stopping at the 3 and 9 o'clock position ensures retention of the sample on the upper surface of the spatula. Wooden spatulas allow good adherence of the sample for transfer to a glass slide. There are various designs of plastic spatulas that look similar to the wooden ones except that they are harder and sharp, which can cause capillary bleeding. Transferring the sample from these plastic spatulas to the glass slide is also difficult.
Data is lacking to suggest that the cytobrush is superior to or inferior to the moistened cotton swab. Both are equally effective in yielding dysplastic smears in combination with the spatula. One quarter turn with the cytobrush is sufficient for an adequate sample because the entire surface of the brush is in contact with the mucosa. Capillary bleeding may result from over manipulation and patients should be warned of possible spotting. If using a moistened cotton swab, a full rotation (360 degrees) is required for good sampling.
When the samples are obtained they should be transferred to the slide immediately. The direct cervical scraping from a spatula should be spread with a single stroke using moderate pressure to thin out clumps of cells and mucus. To transfer material from the endocervical brush or moistened cotton swab simply roll the brush or swab across the slide by twirling the brush handle.
Combined Pap Smear
Transferring both samples to one slide labeled with the patient's PHIN.
Combined Pap Smear
Transferring both samples to one slide labeled with the patient's PHIN.
A uniformly spread sample has many advantages:
a) The sample will be easily and uniformly fixed.
b) The staining of the sample will also be uniform.
c) All cellular components will be visible and not lost in thick ridges.
d) Microscopic screening is much easier and less tiring to the cytotechnologist.
If there is to be any delay between the sampling of the ecto- and endocervix, the first sample should be spread and sprayed with fixative, being careful to protect the unused portion of the slide.
Immediate fixation is essential to retain optimal cellular detail. There are various spray/coating fixatives on the market, each with its own instructions. Generally, most spray fixatives have a dual action in that they fix the cells and when dry provide a thin protective coating over the smear. The container should be held 15 to 25 cm from the slide to prevent dispersal or destruction of the cells by the force of the spray.
Alcohol fixatives may also be used but are not as practical. This method of fixation provides excellent results and may be used for all smears prepared at the side of the patient. Smears fixed in 95 percent alcohol should remain in alcohol for at least 15 minutes prior to staining. Sufficient drying time is necessary to avoid the sample sticking to the slide holder.
REJECTION OF SMEARS
Each specimen received must be acquisitioned with a PHIN referenced with the patient's name, together with the name of the referring health care provider, hospital or clinic, and the type of specimen. The specimen(s) should be easily retrievable according to any of the above data.
A. The laboratory will reject a specimen and the slide will be destroyed under the following circumstances:
- Specimen slide improperly labeled.
- Failure to identify the slide with the patient's name in the situation where the patient is a client/patient or for any other reason, has not been issued a PHIN.
- Discrepancy of information between specimen and requisition form.
- Slide broken beyond repair.
- Slide received without accompanying requisition.
B. The slide and requisition will be returned to the health care provider if the requisition is lacking pertinent information:
- Patients PHIN (if one has been issued).
- Patients name.
- Date of birth.
- Name/address of referring health care provider.
C. The requisition will be returned to the health care provider if it is received without a slide.
THIN PREP METHOD: LIQUID-BASED PREPARATION
ThinPrep is the commercial name for a liquid-based method of laboratory preparation of a Pap smear. This method may be used if a client/patient is anxious and might need to be reassured by a second screening test. It is used for women with evident excessive mucus, discharge or blood present and for women with recurrent "inflammatory" smears or unsatisfactory smears due to a lack of cells. Many women may request this method of testing.
The ThinPrep method costs approximately $36 (prices are subject to change). The lab performing the Thin Prep Pap Test will directly bill the woman. Remember to write her address on the request form, and to ask her to sign to acknowledge that she knows she will be sent an account.
The ThinPrep® Pap Test is significantly more effective than the conventional Pap smear for the detection of low-grade and more severe squamous intraepithelial lesions in a variety of patient populations. The ThinPrep Pap Test improved the detection of precancerous lesions by 65 percent in screening populations and 6 percent in high-risk populations when compared with the conventional Pap smear. Cervical cancer is one of the most common cancers among women but if detected early is almost always curable. Early detection of cervical disease usually means less traumatic intervention and can be expected to improve quality of life, increase life expectancy and reduce overall health care costs.
The ThinPrep Pap Test is the most widely used method for cervical cancer screening in the United States. It was developed to address the limitations of the conventional Pap smear, and after rigorous clinical trials, it was approved in May 1996 by the U.S. Food and Drug Administration (FDA) as a replacement for the conventional Pap smear. The ThinPrep Pap Test is the only liquid-based cytology method approved by the U.S. FDA as "significantly more effective" than the conventional Pap smear for detection of cervical abnormalities. Most importantly, since FDA approval more than 100 studies have been published, in peer-reviewed medical journals, demonstrating a wide range of clinical benefits of the ThinPrep Pap Test including increased disease detection, reduction of equivocal diagnoses, improved specimen adequacy, cost effectiveness and the ability to perform additional tests out of the same vial, such as HPV and Chlamydia/Gonorrhea. The ThinPrep Pap Test is currently the only liquid-based cytology method approved by the FDA for HPV testing.
The ThinPrep method also improves specimen quality by reducing blood, mucus, inflammation and other obscuring artifacts.
ADDITIONAL DIAGNOSTIC TESTING
The ThinPrep Pap Test does not consume the entire fluid-based sample collected in the specimen vial. Additional diagnostic testing of the residual sample can increase the information yielded by the ThinPrep Pap Test. The greatest opportunity is in human papilloma virus (HPV) typing of samples that show possible, but inconclusive morphologic abnormality. The FDA approved HPV and Chlamydia/Gonorrhea testing directly from the PreservCyt® vial used for the ThinPrep Pap Test.
The National Cancer Institute estimates that about 3.5 million Pap smears are found to be inconclusive each year in the U.S., often leading to unnecessary colposcopy, biopsy and office visits. The average cost of the standard management of such cases is about $1,200 per case. The NCI estimates the cost to the US health care system at about $3.6 billion each year. HPV typing of samples diagnosed as ASCUS (atypical squamous cells of undetermined significance), or Low-Grade Squamous Intraepithelial Lesion (LSIL) may help triage women into conservative follow-up, or colposcopy and biopsy.
Cervical cancer is a disease that progresses through pre-cancerous and cancerous stages over a number of years. More importantly, cervical cancer is virtually 100% curable if it is detected and treated appropriately in the earlier stages of progression. Conversely, the cost of treatment increases significantly if cervical disease is discovered at later stages.
SUMMARY OF ADVANTAGES
The increased rate of detection of disease demonstrated by the ThinPrep Pap Test provides a new level of confidence for laboratories, clinicians and patients. At the same time the significant improvement in specimen quality and the ability to do multiple testing using the same sample, will substantially reduce costs and patient anxiety associated with re-screening and unnecessary follow-up testing.
FDA approval of the ThinPrep Pap Test as a replacement for the conventional Pap smear and the claim that the ThinPrep Pap Test is "significantly more effective" was based on extensive data submitted from a multi-site pivotal clinical trial. This study of 6747 women was conducted using a matched-pair, double-blinded protocol. The results of this study indicate that the ThinPrep Pap Test significantly increases the detection of low-grade or more severe lesions by 65 percent in screening populations and 6 percent for high risk populations when compared with the conventional Pap smear. The study also showed that the ThinPrep System significantly improved specimen adequacy compared to the conventional Pap smear.
In August 2001, the FDA approved a Premarket Approval (PMA) Supplement allowing inclusion of data describing the detection of High-Grade Squamous Intraepithelial Lesions (HSIL) with the ThinPrep Pap Test. Following initial FDA approval of the ThinPrep System in May 1996, Cytyc Corporation conducted a multi-site, direct-to-vial (intended use) clinical study to evaluate the ThinPrep System versus the conventional Pap smear for the detection of High-Grade Squamous Intraepithelial and more severe lesions (HSIL+; CIN 2/3). The results from this study showed a detection rate of 399/10,226 for the ThinPrep slides versus 511/20,917 for the conventional Pap smear. For these clinical sites and these study populations, this indicates a 59.7 percent (p<0.001) increase in detection of HSIL+ lesions for the ThinPrep System.
THE THINPREP SYSTEM
The heart of the ThinPrep System is the ThinPrep 2000 Processor, an automated slide preparation unit that produces remarkably uniform thin-layer slides, virtually free of obscuring artifacts such as blood, mucus and inflammation.
Step 1: A gynecologic sample is collected using a broom-type or cytobrush/spatula cervical sampling device. Step 2: Instead of smearing the cells on a slide, the sampling device is rinsed into a ThinPrep vial containing PreservCyt transport medium. The device is then discarded. Swirling the sampling device in the preservation solution helps to dislodge the cervical cells from the sampling device. Step 3: The sample vial is capped, labeled, and sent to the laboratory for slide preparation. Step 4: At the laboratory, utilizing Cytyc's Controlled Membrane Transfer (CMT) technology, the vial is placed into the ThinPrep 2000 Processor. First, a gentle dispersion step breaks up blood, mucus, non-diagnostic debris, and then thoroughly mixes the sample. A negative pressure pulse is generated which draws fluid through a ThinPrep Filter that collects a thin, even layer of diagnostic cellular material. The ThinPrep 2000 Processor constantly monitors the rate of flow through the ThinPrep Filter during the collection process to prevent the cellular presentation from being too scant or too dense. The cellular material is then transferred to a glass slide and fixed.
ThinPrep slides are stained, cover-slipped and evaluated by laboratory personnel using criteria similar to the conventional Pap smear. What is different is the marked improvement in clarity and specimen adequacy achieved with the ThinPrep System.
VARIOUS THINPREP PROTOCOLS
ThinPrep® Pap Test
Quick Reference Guide – Endocervical Brush/Spatula Protocol
Obtain an adequate sampling from the ectocervix using a plastic spatula.
Rinse the spatula as quickly as possible into the PreservCyt® Solution vial by swirling the spatula vigorously in the vial 10 times. Discard the spatula.
Obtain an adequate sampling from the endocervix using an endocervical brush device. Insert the brush into the cervix until only the bottommost fibers are exposed. Slowly rotate 1/4 or 1/2 turn in one direction. DO NOT OVER-ROTATE.
Rinse the brush as quickly as possible in the PreservCyt Solution by rotating the device in the solution 10 times while pushing against the PreservCyt vial wall. Swirl the brush vigorously to further release material. Discard the brush.
Tighten the cap so that the torque line on the cap passes the torque line on the vial.
Record the patient's name and ID number on the vial. …the patient information and medical history on the cytology requisition form.
Place the vial and requisition in a specimen bag for transport to the laboratory.
ThinPrep® Pap Test
Quick Reference Guide – Broom-Like Device Protocol
Obtain an adequate sampling from the cervix using a broom-like device. Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the endocervix. Push gently, and rotate the broom in a clockwise direction five times.
Rinse the broom as quickly as possible into the PreservCyt® Solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl the broom vigorously to further release material in the vial. Discard the collection device.
Tighten the cap so that the torque line on the cap passes the torque line on the vial.
Record the patient's name and ID number on the vial. …the patient information and medical history on the cytology requisition form.
Place the vial and requisition in a specimen bag for transport to the laboratory.
Information and ThinPrep graphics obtained courtesy of www.Cytec.com
One Health Care Provider's Opinion about the ThinPrep Method:
ThinPrep is the first of the liquid-based technologies that have been shown to deliver technically superior preparations devoid of drying and other artifacts. Studies funded by ThinPrep's manufacturer, employing labs with a decade of experience with ThinPrep, have shown a slightly increased sensitivity for both high-grade and low-grade squamous intraepithelial lesions. So far, there is no evidence of any superiority in picking up adenocarcinomas and other glandular lesions (the incidence of which is thought to be increasing). Given this evidence, it is hard not to recommend ThinPrep for all Pap tests.
However, having examined these preparations myself, I prefer to be somewhat more cautious. Low grade squamous lesions (LSIL) are clearly easier to recognize on ThinPrep than on conventional Pap smears, but high-grade lesions (HSIL) are another matter. In conventional Paps, the often inconspicuous, small, round cells of HSIL are typically grouped together, where they can be more readily spotted. In ThinPreps, the cells suspension is homogenized, so that HGSIL cells are scattered apart from each other and are much more difficult to spot.
Further, I am bothered by the ThinPrep training materials, which read more like infomercials and soft-pedal the difficulties inherent in this type of preparation, including distinguishing adenocarcinoma cells from normal endometrial cells. Until ThinPrep has proved its superiority in regular, everyday labs that are not funded by grants from ThinPrep's manufacturer or staffed by former ThinPrep employees, I think it is prudent to not abandon the conventional Pap smear altogether. Therefore, my personal recommendation is for women to have annual testing, employing ThinPrep and conventional smears on alternate years.
If you are using a liquid pap procedure (Thin Prep) then follow the same order using the broom or spatular/brush as above.
For women who have had their uteruses removed, a sample of vaginal cells may also be collected.
If you do not have an assistant available to immediately apply the cell samples to the slide, collect the exo- and endocervix before applying to the slide. This prevents one from drying while collecting the other. The Thin Prep method eliminates the drying risk. Samples may be placed on top of one another on the slide. Spread the spatula material in one smooth stroke. Roll the brush along the slide by twirling handle. Fix the Pap smear sample (except thin prep) immediately to prevent air drying. Air drying is common reason for ASCUS Pap Smear.
After the samples of cells and fluid are smeared on glass slides or put into the Pap solution (Thin Prep), they are taken (or sent) to a lab for examination under a microscope. If you have an infection or there are signs of infection present, a sample of vaginal or cervical discharge may be taken for laboratory analysis also.
After the Pap smear is completed, the speculum is removed. The examiner will usually perform a pelvic exam to check the woman's uterus, vagina, ovaries, and fallopian tubes for any abnormalities in shape or size. Typically, the Pap smear and pelvic exam take only a few minutes to complete. the examiner will place two fingers in the vagina and the other hand on top of the abdomen to check placement of uterus and ovaries and to assess their size, shape, consistency and tenderness. This procedure may cause some discomfort.
Often there is a rectal examination, where the examiner places one finger in the rectum (often, one finger is placed in the vagina at the same time) to check the rectum itself and other nearby structures.
Though most women do feel some discomfort, pressure, or cramping during the exams, neither test should be painful. Women with tender, narrow, or irritated vaginas may experience more discomfort than others. Some women experience slight vaginal bleeding after the Pap smear is completed. It would be wise to use a sanitary pad if this should occur.
Pap smears and pelvic exams may be performed by physicians, physician assistants, nurse practitioners, nurse midwives, direct-entry midwives, or other specially trained medical professionals.
SPECIMEN COLLECTION TIPS
Collection technique of the Pap smear sample is critical for accurate sampling, adequate preservation, complete evaluation and meaningful interpretation. Improper sample collection, poor sampling, and/or cell preservation can render a Pap smear unsatisfactory for evaluation, requiring a repeat smear collection. If the Pap smear does not contain appropriate representative cells from the transformation zone and endocervical canal, the ability of the test to detect disease is very low. Likewise, if the preservation of the sample is compromised, the screener's ability to recognize abnormal cell is greatly diminished.
In order to prepare an adequate Pap test smear, the cells must be:
- Accurately labeled.
- Spread in a thin layer over the slide, without any thick areas or mechanical distortion.
- Distributed over the central area of the slide, sparing the ends and sides.
- Prepared rapidly and fixed quickly, to avoid air-drying.
Before beginning the procedure, the slide should be labeled with the client/patient's first and last names. The person collecting the Pap smear is responsible for ensuring the slide is correctly labeled before applying the cell sample to the slide. If the laboratory receives an unlabeled or incorrectly labeled slide or if the identity of the slide is questionable, the slide will not be processed and the Pap smear will have to be recollected.
If active purulent cervicitis is present, the client/patient should be evaluated using various tests available to the examiner such as cervical cultures, a wet mount using handing drop for Trichomonas and yeast, and a gram stain. DNA probes for Chlamydia, herpes, HPV or other organisms may also be considered. It is not recommended that the Pap smear be collected while purulent cervicitis is present, as it may adversely affect the reliability of the Pap test results. Instead, the client/patient should be treated with antibiotics, and a smear collected following successful therapy for infection and inflammation.
The cervical sample should be harvested by a two-stage technique, which includes sampling of the endocervical canal with a cytobrush, as well as obtaining a sample from the transformation zone with the spatula. The use of either the cytobrush or the spatula alone may be adequate but not as effective as the two-stage technique. A cotton-tip applicator should not be used as a collection device as endocervical cells frequently smudge or stick tightly to the cotton. Endocervical sampling is not recommended in pregnant patients since this may interfere with or disturb the cervical "mucous plug" that seals the uterus from the outside vaginal area during pregnancy. Some examiners prefer to use a cotton-tip applicator for the collection of Pap smears during pregnancy. Other examiners prefer to delay a pap smear until after the sixth week postpartum (after the baby is delivered). Often times the pap smear will be taken at the final postpartum visit.
Both the Cervex Brush ® (Unimar, Inc.) and the Accellon Combi ® (Medscand AB) are two collection devices which combine the action of the cytobrush and spatula, thus permitting broader sampling with a one-stage technique. When transferring cervical cells from the collection device to the slide, it's important to distribute the cells centrally onto the slide, and avoid spreading the cells closer than one-fourth inch from the edges or frosted region of the slide. Apply the cells in a thin layer, with light pressure. Thick areas are difficult to screen, and excessive mechanical pressure used in the preparation of the slide can destroy the cells.
Fix the sample quickly as drying artifact begins to appear if the sample is not fixed within 10 seconds, making it difficult to evaluate.
Proper fixation is critical to Pap smear adequacy. Optimally, smears should be fixed within a few seconds of preparation, particularly if the sample is not very moist, or if it possesses little endocervical mucus. The best strategy is to collect samples with the cytobrush and spatula first. Following that, the examiner should apply both samplings to the slide quickly and simultaneously, then follow with rapid fixation.
Fixation of the slide is best accomplished by immediate immersion in fresh fixative (95 percent ethanol). Alternatively, the slide may be fixed by spraying with a cytology fixative (Safetex®). After the slide has been fixed, place the labeled slide into a Pap smear folder. Both the slide and the folder should be labeled with the client/patient's name.
If the slide is not correctly labeled, or the identity of the preparation is doubtful, the slide cannot and will not be processed - and the Pap smear will have to re-collected.
TIPS FOR MAKING GOOD PAP SMEARS
Ed Uthman, MD
Diplomate, American Board of Pathology
Last updated 13 Jan 2001
First Print LAB MED/09-96
Revision MANQAP LAB MED-CYTO/06-01
The challenge we face in interpreting Pap smears is to facilitate the assignment of smears into either a low-risk category (including "within normal limits" and "benign cellular changes") or a high-risk category (including "squamous intraepithelial lesion" and higher-grade categories). We pathologists, with our partners the cytotechnologists, strive to minimize the number of cases classified as "atypical squamous (or glandular) cells of undetermined significance," as these "ASCUS" or "AGCUS" reports place the patient, clinician, and pathologist into a limbo of uncertainty regarding what should be done for the patient.
It has been my experience that the most frequent preventable cause of "the unnecessary ASCUS" is the suboptimal smear. Accordingly, I have put together a few problems with suggestions for solving them.
Problem: Air-drying. This is Pap smear enemy number one. If a cell is dried before it is spray-fixed, the cell enlarges, and nuclear detail is lost. If the pathologist cannot determine if a dried cell is atypical or not, he/she may tend to class the smear as an ASCUS.
Solution: Spray-fix the smear immediately. If you use a two-step technique (brush and spatula both), spray the first part of the smear before collecting the second part of the specimen. When spraying the first part, it is best to use a card or similar object to mask the part of the slide to be used for the second part of the specimen. If this taxes one's dexterity too much, it may be best in the long run to use a two-slide technique.
Problem: Blood, mucus, and pus. This unholy triad serves to obscure and distort the epithelial cells, making it difficult to determine if they are atypical.
Solution: Before collecting the specimen, gently remove excess mucus with a ring forceps holding a folded gauze pad. Surface exudate can be removed by placing a 2 inch x 2 inch piece of gauze over the cervix and peeling it away after it absorbs the exudate. A dry "proctoswab" or "scopette" can also be used. Do not rinse the cervix with saline, or a hypocellular smear may result. To reduce the amount of blood on the smear, use the spatula first, then the brush (the brush is more likely to induce bleeding). Finally, routine Pap smears should not be taken while the patient is menstruating.
Problem: Traumatized cells. These result from excessive manipulation of the delicate epithelial cells, either while being scraped from the cervix or spread on the slide. Traumatized normal cells may impersonate atypical cells.
Solution: When using the spatula, scrape in one continuous motion for a rotation of no more than 360 degrees. Spread the material collected on the spatula in a single, smooth, continuous stroke, as if buttering a saltine. Use moderate pressure against the slide to avoid producing thick clumps of material.
When using the brush, insert it into the os with gentle pressure and rotate it only 90 to 180 degrees. Roll (do not smear) the brush across the glass slide by twirling the handle.
Problem: Incomplete clinical information. To gain the greatest amount of useful information from a Pap smear, we need clinical information about the patient.
Solution: Fill out the requisitions completely. Age, date of last menstrual period, pregnancy status, and the history of previous abnormal Pap smears are absolute musts. Any other pertinent information concerning the reproductive system is welcome. Although much of our time is spent in the laboratory, we pathologists are physicians first. We are interested in the whole patient, not just the cells on the slide. You may be surprised at how helpful our reports can be if we have a little more background information.
Problem: Dueling laboratories. The Pap report from lab A says "atypical squamous cells of undetermined significance", but the biopsy report from lab B says "chronic cervicitis and squamous metaplasia". Who's right? What do I do now?
Solution: The abnormal Pap and follow-up biopsy MUST be examined simultaneously by the same pathologist. Cytopathological correlation is the cornerstone of cervical pathology. Without it, the clinician cannot determine if the abnormal Pap was significant or not. Did the biopsy recover the abnormal area sampled by the Pap, or was a high-grade dysplasia missed by the biopsy? One never knows unless the Pap and biopsy have been correlated. Remember, studies have shown that a very significant proportion of "ASCUS" Paps are ultimately revealed to be high-grade lesions. Correlation is the key to ferreting out some of these very difficult-to-diagnose cases.
The easiest way around this problem is to send the biopsy to the same lab that did the Pap smear. All reputable labs perform Pap/biopsy correlations routinely. If for some reason it is not possible to use the same lab, then call the Pap lab and ask that the patient's slide be sent to the lab charged with examining the biopsy.
If you are a provider, you should ALWAYS insist that the lab issue a correlation statement with the biopsy report. If you are a patient, you should NEVER accept a "negative" or "reactive" cervical biopsy report from a lab that has not also seen your abnormal Pap smear.
It has come to my attention that some labs are now refusing to send out Pap smears to other labs for cytopathological correlation. The reason given is that Pap slides are one-of-a-kind and are irreplaceable. Loss of such a smear in transit, say risk managers, may subject the lab to liability. While this is certainly true, the potential medical benefit to the patient far outweighs any financial liability to the lab. Accordingly, both clinicians and patients should not accept this no-send policy and should demand that direct visual correlation between Pap and biopsy be carried out in some fashion.
Problem: Management. Now that we have a good smear, it still comes back abnormal. Now what?
Solution: Asking how to manage an abnormal Pap is like asking for the correct recipe for potato salad. You will get a variety of answers, all reasonably defendable.
The colposcopist will be able to give you some information while you are still in the office. Results of biopsies or other tests usually take 2 to 3 weeks. You will be contacted by phone or letter when the results are ready.
Please remember that it is important to have your next Pap smear approximately 6 months after your colposcopy.
CLASSIFICATION OF SQUAMOUS CELLS ON THE PAP TEST
Several different classification schemes have evolved over the years for characterizing Pap test results. Unfortunately, this is a continuing source of confusion. The outdated Class system originally developed by Dr. Papanicolaou has been replaced by the CIN grading system and the Bethesda System. CIN stands for cervical intraepithelial neoplasia and implies an underlying aberration in proliferation of cells. In most cases, this is a precancerous lesion that may be easily treated with nearly 100 percent cure. Both the CIN grading system and the Bethesda System are in widespread use today. The table below compares the various nomenclature used to classify squamous cell abnormalities seen on Pap test:
Classification of Squamous Cell Abnormalities Description CIN Grading Bethesda System (1) (See 4 Below) Class (outdated) Normal Normal Normal Class I Atypia Reactive or Neoplastic Atypia ASCUS (2) Class II HPV HPV Low-Grade SIL (3) Class II Atypia with HPV Atypia, "condylomatous atypia" and "koilocytic atypia" Low-Grade SIL Class II Mild Dysplasia CIN I Low-Grade SIL Class III Moderate Dysplasia CIN II High-Grade SIL Class III Severe Dysplasia CIN III High-Grade SIL Class III Carcinoma in-situ CIS High-Grade SIL Class IV Invasive Cancer Invasive Cancer Invasive Cancer Class V
- Kurman, R.J., Solomon D. The Bethesda System for reporting cervical/vaginal cytologic diagnoses, Springer-Verlag, New York, 1994
- ASCUS: Atypical squamous or glandular cells of undetermined significance should be qualified further, if possible, as to whether a reactive or neoplastic process is favored.
- SIL: Squamous intraepithelial lesion.
- There will be a Bethesda III conference May, 2001 to further review and modify The Bethesda System (TBS).
NCI Bethesda System Web Atlas: Cytopathology Histology Images
CLASSIFICATION OF GLANDULAR CELLS ON THE PAP TEST
Glandular abnormalities are more difficult to classify. Glandular cells that are seen on the Pap test most commonly come from the endocervix. However, other glandular epithelial surfaces in the female reproductive tract may shed cells that are visible on the Pap test. Endometrial cells may appear on Pap tests and reveal underlying abnormalities. Because the female reproductive tract is open to the abdominal cavity via the Fallopian tubes, occasionally, cells from the ovary, Fallopian tubes, peritoneum or other interabdominal organs may be seen on the Pap smear. Glandular cells on the Pap test are classified as follows:
- Endometrial cells, cytologically benign, in a post-menopausal woman.
- Atypical glandular cells of undetermined significance (AGUS) that should be qualified further, if possible, as to whether a reactive or neoplastic process is favored.
- Endocervical Adenocarcinoma.
- Endometrial Adenocarcinoma
- Extrauterine Adenocarcinoma (e.g. ovarian, Fallopian tube, pancreas, etc.)
- Adenocarcinoma, not otherwise specified (i.e. unknown primary site)
PROCESS OF CERVICAL CHANGES
The cervix is the part of the uterus that extends into the vagina. There are two types of cells which line the cervix, one lines the outer cervix (portio) and another lines the inner cervix (endocervix). There is a distinct junction between the two cell types called the transformation zone. The Pap test is taken from this area because this where dysplasia (pre-cancer) and cancer most often arise.
Two common changes in cells are metaplasia and dysplasia.
Metaplasia - Metaplasia is generally described as a process of cell growth or cell repair which is benign (not cancerous). This process normally occurs in unborn babies, during adolescence, and with the first pregnancy. Studies have shown that metaplasia is present in more than one half of all women at some point in their development.
Dysplasia - In dysplasia, there is an increase in the number of cells formed, which do not mature as expected. This changes the inside of the cell. The higher the grade of dysplasia found on the cervix, the more likely that it will progress to invasive cancer. For this reason, dysplasia is thought as a "pre-cancerous" condition. Dysplasias are nearly 100 percent curable if managed appropriately. A small proportion of mild dysplasias (CIN I or low-grade SIL) will regress without treatment. However, it is not possible distinguish between dysplastic areas of the cervix that will return to normal and dysplastic areas which will progress and ultimately become cancer.
CAUSES OF CERVICAL CELL CHANGES
Inflammation often results in mildly abnormal Pap tests. These may result in the diagnosis of CIN I in the CIN grading system, ASCUS in the Bethesda System or changes consistent with Human Papilloma Virus (HPV) infection. An inflamed cervix may appear red, irritated, or eroded. Some of the common causes of cervical inflammation are:
- Bacteria (from an infection).
- Viruses, especially herpes infections and condyloma cuminata (warts).
- Yeast or monilia infections.
- Trichomonas infections.
- Pregnancy, miscarriage, or abortion.
- Chemicals (for example, medications).
- Hormonal changes.
When the inflammation is treated and cleared, repair through metaplasia usually will follow. In several months, a repeat Pap test will often then be normal.
Colposcopy: The next diagnostic step - All abnormal Pap smears require further evaluation. If the abnormality is minor (i.e. inflammation, or HPV changes) your health care provider may choose to repeat the Pap test in a few months. If the abnormalities have persisted or worsened, colposcopy is indicated. Colposcopy will enable your health care provider to make a more accurate diagnosis. Management is individual and should be discussed with your health care provider.
PREPARATION FOR A COLPOSCOPY
- Schedule the exam when you are not menstruating.
- Avoid douching, sexual intercourse, vaginal medications, and tampons for 24 hours prior to the exam.
- Eat regularly and consider taking 400 mg of ibuprofen (e.g. 2 Advil) one hour prior to a colposcopy visit and 800 mg of ibuprofen one hour prior to a cryotherapy session.
Colposcopy - A colposcope is a lighted microscope that is used to magnify the cervical tissue during a pelvic examination. The colposcope is used to visualize abnormal areas of the cervix and vagina which are too small to see with the naked eye. The entire transformation zone must be seen. The colposcopic examination is an office procedure and is no more uncomfortable than a routine pelvic examination. It takes 5 to 10 minutes to perform. During the examination, the examiner may take small samples of cervical tissue (biopsies). Another specialist, a pathologist, will examine the tissue samples and cells. These diagnostic biopsies will guide further management.
Colposcopy is considered a very safe office procedure. Risks include bleeding, infection, and pelvic or abdominal pain. If you are pregnant, colposcopy may cause complications with the pregnancy including early labor.
You will be asked to remove your undergarments and then lie down on an examination table with your legs placed in stirrups (the same procedure as for a Pap smear). A speculum will be inserted (the same as in a Pap smear) to open the vaginal walls and allow the cervix to be seen. The speculum will remain in place for the duration of the exam - which may take up to 30 minutes. Next a magnifying lens is used. A small amount of saline (salt water) may be placed into the vagina to moisten the surface. The saline may feel cool.
Then an acetic acid preparation (vinegar) may be applied to your cervix. This may also feel cool, and there may be a slight stinging sensation.
Sometimes additional special stains may be required to better check for abnormalities. An iodine based solution is most commonly used, which again, may feel cool but will not burn.
If any abnormalities are seen or suspected, a biopsy will be taken. You may feel a pinch and some discomfort for several seconds. It is also possible that a gentle scraping (curettage) of the cervical canal may be done that can cause a cramping sensation.
Small amounts of bleeding may occur for 3 to 5 days following the procedure. It is recommended that you wear a sanitary pad during this period.
It is important to drink lots of fluids while the discharge is present, especially water, and fluids and solids containing generous amounts of potassium, such as citrus fruits and juices, bananas, and raisins. Cut back on beverages containing caffeine.
When your health care provider calls and says your Pap smear contains abnormal results you may feel frightened and think the worse. However, you should remember that most abnormal Pap smears are not cancer, and your abnormal results are likely caused by an inflammation or infection.
TREATMENT OPTIONS AFTER CERVICAL BIOPSY
After the biopsy results are reviewed and coordinated with other clinical information, a decision is made about treatment. Options may include:
- "Watchful waiting" - This used when the results are mildly abnormal and it is likely that over a period of months to years your immune system may cure the HPV infection and heal the damage. If used, you must stay in medical care (best with us) and get 2-3 Pap smears within the year. If indicated, repeat colposcopy may be needed.
- Cryotherapy - This is a freezing technique which is applied to the surface of the cervix to remove the abnormal areas. The procedure itself takes about 15 minutes and may be accompanied by some cramping. A rather profuse watery vaginal discharge starts within an hour after the treatment. It may be slightly yellow in color. It gradually thickens and becomes darker as it slows, and should stop completely in 2-4 weeks. For the first two weeks, use a sanitary pad and avoid intercourse. Discharge persisting after four weeks is not normal and, if it does persist, you should be examined promptly by the colposcopist at Hurtado, to determine what further treatment, if any, is required. The discharge should never be bloody, contain pus, or be foul smelling.
- Loop Electro Excision Procedure (LEEP) - This is a procedure done by an outside specialist whereby part of the cervix is sliced away. It is used when cryotherapy is not an appropriate treatment. If necessary, your health care provider will refer you to the specialist.
Medication is usually not necessary.
ACTIVITY RECOMMENDATIONS & RESTRICTIONS
DIET & NUTRITION
No special diet. However, you should continue following a nutritious dietary plan for a strong immune system and fast recovery from surgery.
MoonDragon's Nutrition Information: Adult Regular Diet
MoonDragon's Nutrition Information, Guidelines, Dietary Recommendations
NOTIFY YOUR HEALTH CARE PROVIDER
There may be some slight vaginal discharge following the examination. Use a tissue to wipe or place one in the underpants temporarily. If there is bleeding (rare), a sanitary pad may be necessary. If you have heavier bleeding, contact your health care provider. Any findings from the physical examination or further diagnostic testing recommendations will be discussed with you by the examiner. The results of the Pap smear testing may take several days or more. They will be reported to you by phone or mail. Be sure you and the midwife or health care provider follow up on any abnormalities that are detected. You or your family member have not had a routine pelvic examination as recommended. If you show signs of infection, you need to be evaluated. Medication may be required to take care of infection. If you are pregnant and begin cramping, bleeding, or other signs of possible labor after a pap smear (very rarely), contact your midwife or health care provider.
AROMATHERAPY: ESSENTIAL OILS DESCRIPTIONS & USES
Allspice Leaf Oil Angelica Oil Anise Oil Baobab Oil Basil Oil Bay Laurel Oil Bay Oil Benzoin Oil Bergamot Oil Black Pepper Oil Chamomile (German) Oil Cajuput Oil Calamus Oil Camphor (White) Oil Caraway Oil Cardamom Oil Carrot Seed Oil Catnip Oil Cedarwood Oil Chamomile Oil Cinnamon Oil Citronella Oil Clary-Sage Oil Clove Oil Coriander Oil Cypress Oil Dill Oil Eucalyptus Oil Fennel Oil Fir Needle Oil Frankincense Oil Geranium Oil German Chamomile Oil Ginger Oil Grapefruit Oil Helichrysum Oil Hyssop Oil Iris-Root Oil Jasmine Oil Juniper Oil Labdanum Oil Lavender Oil Lemon-Balm Oil Lemongrass Oil Lemon Oil Lime Oil Longleaf-Pine Oil Mandarin Oil Marjoram Oil Mimosa Oil Myrrh Oil Myrtle Oil Neroli Oil Niaouli Oil Nutmeg Oil Orange Oil Oregano Oil Palmarosa Oil Patchouli Oil Peppermint Oil Peru-Balsam Oil Petitgrain Oil Pine-Long Leaf Oil Pine-Needle Oil Pine-Swiss Oil Rosemary Oil Rose Oil Rosewood Oil Sage Oil Sandalwood Oil Savory Oil Spearmint Oil Spikenard Oil Swiss-Pine Oil Tangerine Oil Tea-Tree Oil Thyme Oil Vanilla Oil Verbena Oil Vetiver Oil Violet Oil White-Camphor Oil Yarrow Oil Ylang-Ylang Oil Aromatherapy
Healing Baths For Colds
Using Essential Oils
AROMATHERAPY: HERBAL & CARRIER OILS DESCRIPTIONS & USES
Almond, Sweet Oil Apricot Kernel Oil Argan Oil Arnica Oil Avocado Oil Baobab Oil Black Cumin Oil Black Currant Oil Black Seed Oil Borage Seed Oil Calendula Oil Camelina Oil Castor Oil Coconut Oil Comfrey Oil Evening Primrose Oil Flaxseed Oil Grapeseed Oil Hazelnut Oil Hemp Seed Oil Jojoba Oil Kukui Nut Oil Macadamia Nut Oil Meadowfoam Seed Oil Mullein Oil Neem Oil Olive Oil Palm Oil Plantain Oil Plum Kernel Oil Poke Root Oil Pomegranate Seed Oil Pumpkin Seed Oil Rosehip Seed Oil Safflower Oil Sea Buckthorn Oil Sesame Seed Oil Shea Nut Oil Soybean Oil St. Johns Wort Oil Sunflower Oil Tamanu Oil Vitamin E Oil Wheat Germ Oil
HELPFUL RELATED MOONDRAGON NUTRITION BASICS LINKS
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NUTRITION BASICS ARTICLES
MoonDragon's Nutrition Basics: 4 Basic Nutrients MoonDragon's Nutrition Basics: Avoid Foods That Contain Additives & Artificial Ingredients MoonDragon's Nutrition Basics: Is Aspartame A Safe Sugar Substitute? MoonDragon's Nutrition Basics: Guidelines For Selecting & Preparing Foods MoonDragon's Nutrition Basics: Foods That Destroy MoonDragon's Nutrition Basics: Foods That Heal MoonDragon's Nutrition Basics: The Micronutrients: Vitamins & Minerals MoonDragon's Nutrition Basics: Avoid Overcooking Your Foods MoonDragon's Nutrition Basics: Phytochemicals MoonDragon's Nutrition Basics: Increase Your Consumption of Raw Produce MoonDragon's Nutrition Basics: Limit Your Use of Salt MoonDragon's Nutrition Basics: Use Proper Cooking Utensils MoonDragon's Nutrition Basics: Choosing The Best Water & Types of Water
RELATED MOONDRAGON HEALTH LINKS & INFORMATION
MoonDragon's Nutrition Information Index MoonDragon's Nutritional Therapy Index MoonDragon's Nutritional Analysis Index MoonDragon's Nutritional Diet Index MoonDragon's Nutritional Recipe Index MoonDragon's Nutrition Therapy: Preparing Produce for Juicing MoonDragon's Nutrition Information: Food Additives Index MoonDragon's Nutrition Information: Food Safety Links MoonDragon's Aromatherapy Index MoonDragon's Aromatherapy Articles MoonDragon's Aromatherapy For Back Pain MoonDragon's Aromatherapy For Labor & Birth MoonDragon's Aromatherapy Blending Chart MoonDragon's Aromatherapy Essential Oil Details MoonDragon's Aromatherapy Links MoonDragon's Aromatherapy For Miscarriage MoonDragon's Aromatherapy For Post Partum MoonDragon's Aromatherapy For Childbearing MoonDragon's Aromatherapy For Problems in Pregnancy & Birthing MoonDragon's Aromatherapy Chart of Essential Oils #1 MoonDragon's Aromatherapy Chart of Essential Oils #2 MoonDragon's Aromatherapy Tips MoonDragon's Aromatherapy Uses MoonDragon's Alternative Health Index MoonDragon's Alternative Health Information Overview MoonDragon's Alternative Health Therapy Index MoonDragon's Alternative Health: Touch & Movement Therapies Index MoonDragon's Alternative Health Therapy: Touch & Movement: Aromatherapy MoonDragon's Alternative Therapy: Touch & Movement - Massage Therapy MoonDragon's Alternative Health: Therapeutic Massage MoonDragon's Holistic Health Links Page 1 MoonDragon's Holistic Health Links Page 2 MoonDragon's Health & Wellness: Nutrition Basics Index MoonDragon's Health & Wellness: Therapy Index MoonDragon's Health & Wellness: Massage Therapy MoonDragon's Health & Wellness: Hydrotherapy MoonDragon's Health & Wellness: Pain Control Therapy MoonDragon's Health & Wellness: Relaxation Therapy MoonDragon's Health & Wellness: Steam Inhalation Therapy MoonDragon's Health & Wellness: Therapy - Herbal Oils Index
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