Pap Smear

Introduction

Cancer of the cervix (cervical cancer) is the second most common cause of cancer-related disease and death among women worldwide. The best way to detect cervical cancer is by having regular Papanicolaou tests, or Pap smears. (Pap is a shortened version of the name of the doctor who developed the screening test.) A Pap smear is a microscopic examination of cells taken from the cervix.

A Pap smear can detect certain viral infections (such as human papillomavirus [HPV]) and other cancer-causing conditions. Early treatment of these conditions can stop cervical cancer before it fully develops. A woman may have cervical cancer and not know it because she may not have any symptoms.

The incidence of cancer and deaths from cervical cancer can significantly decline because of prevention, screening, and early detection by the Pap smear.

  • Risks factors for cancer of the cervix include the following:
  • Multiple sexual partners (or sexual partners who have had multiple partners)
  • Starting sexual intercourse at an early age
  • Viral infection, such as HPV, human immunodeficiency virus (HIV), or herpes simplex virus (HSV)
  • Weakened immune system
  • Previous cancer of the lower genital tract
  • Smoking

Frequency of Pap Smears

Recommendations (American Cancer Society) :

  • Screening should begin no later than age 21.
  • Screening should begin earlier than age 21 if the patient is sexually active. In this case, it should start 3 years after initiation of vaginal intercourse.
  • Once initiated, screening should be performed annually if a traditional, glass-slide-based technique is used. If liquid medium is used, Pap smear screening may be performed every other year.
  • After age 30, for women who have had 3 consecutive, normal Pap smears, screening frequency may be reduced to every two to three years.
  • Women who are HIV positive, immunocompromised due to disease or medication, or are DES daughters, should continue annual screening.
  • Screening may stop following a total hysterectomy (including the cervix), if the the patient is at low risk, and has had three consecutive normal Pap smears within the last 10 years.
  • High risk patients, including those with a history of cervical cancer, DES exposure in-utero, HIV positive, immunocompromised from medication, and those tested positive for HPV, should continue to be screened indefinitely.
  • Screening may stop after age 70, if the patient is low risk, and has had three normal Pap smears over the last 10 years.
  • Screening may be omitted in the case of women with life-threatening or other serious illness.

Preparation

The best time to have a Pap smear is when the woman isnot menstruating. For 2 days before the test, avoid the following because these might hide any abnormal cells:

  • Intercourse
  • Douches
  • Vaginal medications
  • Vaginal contraceptives such as birth control foams, creams, or jellies

Procedure

A Pap smear is usually part of a pelvic exam and accompanied by a breast exam . It only takes about 1 minute to perform a Pap smear during this overall exam.

  • Position : dorsal/lithotomy
  • Insert cusco’s/sims speculum to open the vagina so that the walls of the vagina and cervix can be seen clearly.
  • A sample of mucus and cells will be obtained from the cervix (transitional zone) and endocervix using Ayre’s spatula-rotated 360 deg & endobrush.
  • The sample of cells is evenly applied to a glass slide and sprayed with a fixative. This sample is sent to the lab for close and careful examination under a microscope. If the doctor is using a new kind of Pap smear called a ThinPrep test, the sample is rinsed into a vial and sent to a lab for slide preparation and examination.
  • A cytologist reviews both types of tests.

After the Procedure

  • An abnormal Pap smear result does not always indicate cancer. Cells sometimes appear abnormal but are not cancerous.
  • If the Pap smear result is positive because of an infection, the underlying cause should be treated. The test should then be repeated in 2-3 months, because cancer of the cervix can be hidden by an infection.
  • Although the Pap smear is the best method of detecting cervical cancer early, it is not perfect. Because even the best labs can miss some cell changes, a woman should have the test performed yearly, as the American Cancer Society recommends.
  • Recently, 2 computerized systems (PAPNET and AutoPap) have been approved by the US Food and Drug Administration to detect abnormal cells from a Pap smear. To ensure accuracy of the test, they use computer technology to recheck Pap smears for abnormal cells the technician may have missed.

Organizational Listing (Bethesda 2001 System)

SPECIMEN ADEQUACY

  • Satisfactory for evaluation
  • Unsatisfactory for evaluation
  • Specimen rejected/not processed

GENERAL CATEGORIZATION

  • Negative for intraepithelial lesion or malignancy
  • Epithelial cell abnormality
  • Other

Negative for Intraepithelial Lesion or Malignancy

  • Atrophy
  • Trichomonas vaginalis
  • Fungal oganisms morphologically consistent with Candida species
  • Shift in flora suggestive of bacterial vaginosis
  • Bacteria morphologically consistent with Actinomyces species
  • Cellular changes consistent with herpes simplex virus

Reactive cellular changes associated with:

  • Inflammation (includes typical repair)
  • Radiation
  • Intrauterine contraceptive device
  • Glandular cells status posthysterectomy
  • Atrophy

Epithelial Cell Abnormalities

Squamous cell

  • Atypical squamous cells (ASC) of undetermined significance (ASC-US)
  • cannot exclude HSIL (ASC-H)
  • Low-grade squamous intraepithelial lesion (LSIL) encompassing: human papillomavirus/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1
  • High-grade squamous intraepithelial lesion (HSIL) encompassing: moderate and severe dysplasia, carcinoma in situ; CIN 2 and CIN 3
  • Squamous cell carcinoma

Glandular cell

  • Atypical glandular cells (AGC) (specify endocervical, endometrial, or not otherwise specified)
  • Atypical glandular cells, favor neoplastic (specify endocervical or not otherwise specified)
  • Endocervical adenocarcinoma in situ (AIS)
  • Adenocarcinoma

Follow-up

  • Under the Bethesda System, Pap smear samples that have no cell abnormalities are reported as "negative for intraepithelial lesion or malignancy"
  • If a woman's Pap smear result is normal, she will continue routine screening.
  • If her Pap smear result is atypical (not able to be categorized as normal or abnormal), the test is repeated in 4 months.
  • If the repeat test is abnormal, the doctor will do a COLPOSCOPY.
  • If colposcopy is abnormal, BIOPSY is recommended.
  • If a woman's smear result is abnormal and suggestive of cancer, she will have colposcopy and biopsy tests performed.
  • In a biopsy, the doctor will take a small sample of the tissue of the woman's cervix to see if cancer cells are present. A biopsy is the only way to determine if she has precancer, true cancer, or neither.
  • To treat precancer tissue or a very early cancer, the abnormal tissue may be removed entirely during the biopsy or later by conisation,LEEP,laser excision,cryosurgery as per needed.
  • If both the biopsy and the Pap smear findings are normal, the Pap smear will be performed again in 4 months.
  • If the biopsy finding is normal but a Pap smear finding is abnormal, the doctor will repeat the colposcopy and biopsy.
  • If the biopsy finding is abnormal and suggestive of cervical intraepithelial neoplasia (CIN) or cancer, treatment will begin for cervical cancer.

Dr. Mona Shroff 1