Cervical Exam & Smear Guide

Cervical speculum examination
and taking a smear.
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Title page
Speculum examination
Inspection of vagina
Inspection of cervix
Cervical smear
methods
devices
Slide method
Liquid-based cytology
Swabs
Cusco
Removing the speculum

Ending the procedure
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Sims
Learning Outcomes
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Able assemble the speculum

correctly
Able to inspect vagina and cervix
using a speculum
Perform a cervical smear
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Title page
Cervical smear
methods
devices
Slide method
Swabs
1. Designed for the inspection of the

cervix and vaginal walls.
Bivalve (cusco) speculum is the instrument
most commonly used to inspect the
vagina

Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
2. Access to the cervix and fornices

for bacteriological swabs and
cervical smears.
Examination
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
GRIP
Greet, rapport, introduce and identify, explain
procedure
Tell the patient the procedure is not

painful, but may be a bit uncomfortable.
Make sure:
not menstruating
no spermicide, lubricant, sexual intercourse
in the previous 48 hours.
Position
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Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Lie on the couch, put your heels together, draw them up to

your bottom and let your knees flop apart
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Warm blades under a stream of tepid
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
water.
Wear gloves, prepare the slide/bottle
Write name of the patient, date and time
of taking the specimen with pencil not
pen if using slide
Hold the speculum with dominant hand,
separate the labia and expose introitus
with non-dominant hand
Tell the patient you are about to
introduce the speculum and reassure
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Cervical smear
methods
Slide the closed blades obliquely over

the fingers into the introitus , introduce
the instrument into the vagina
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
While inserting the instrument rotate it to

a clockwise direction until the anterior
and posterior blades run along the
anterior and posterior vaginal walls with
the handles pointing towards the anus or
clitoris.
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Maintain a downward pressure, on

the speculum and press on the
thumb piece to hinge the blades
open to expose the vaginal vault
and cervix.
Adjust the light source to illuminate
the vagina.
Inspect vagina and cervix.
Inspection of the vagina

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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
Discharge:
Normal clear / milky, odourless
Increased during ovulation, pregnancy, breastfeeding, sexual arousal
Cottage cheese / curd-like: candida (assoc.

with pain, itching, swelling and erythema of
the vulva)
Frothy, fishy odour: Trichomoniasis
Asymptomatic discharge: gonorrhoea
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Ulcers
Foreign body
Inspection of the cervix

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Title page
Cervix normally points posteriorly

and inferiorly
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Look for:
Discharge
Cysts
Polyps
Ulceration or fungating growth
Normal
Normal with
ectropion
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
cervicitis
cancer
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Nabothian cyst mucus filled cervical cyst due to blockage of

a mucus gland
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Cervical polyp (appears to be descending through the os)
Cervical smear
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Cervical smear performed after

inspecting the cervix.
The aim is to
sample cells
from the
transformation
zone (where the
epithelium
changes from
columnar to
squamous)
Cervical smear - methods

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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Newer method = LBC ( Liquidbased

cytology )
Use cervex brush (see next slide)

Dip brush into bottle of liquid fixative
Fewer inadequate samples. Being rolled out
across the UK
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Older method = slides

Use Aylesbury spatula (see next slide)
Spray or dip in fixative
Cervical smear - devices

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Title page
Cervical smear
methods
devices
LBC
A cervex brush is
commonly used
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Slide-based
A wooden spatula
is used with a bifid
end (Aylesbury
spatula) .
Liquid Based Cytology method

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Title page
Use a cervex brush
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Place the tip of the brush in the os

Twirl 10 times
Place brush in fixative bottle and dip
/ stir / squish vigorously to wash the
cells off the brush into the bottle
Slide method
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
The bifid end is used to harvest the

cervical cells.
Introduce the spatula through the
speculum and position the bifid end
at the os.
Rotate through 360
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
The desquamating cells are

collected by rotating the spatula
around the circumference of the
os and the lips of the cervix.
Slide method
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Title page
Send sample to the lab
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Spread the cervical material onto the

labelled glass slide by stroking each
side of the bifid end of the spatula
along the glass
Slide method
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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
The cervical cells and some mucus

should cling to the glass.
Immediately spray the slides with
fixative or fix them by immersion in
95% alcohol
Do not allow the sample to dry.
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Some examples of cells processed with the Papanicolau stain
Swabs
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Title page
If any ulcers, take swab from base of

ulcer.
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
If infection suspected, take swab from

cervix or high vaginal.

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Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Undo the thumb screw

Simultaneously withdraw the speculum
and rotate the open blades to ensure that
the anterior and posterior walls of vagina
can be inspected.
Near the introitus, allow the blades to
close
Taking care not to pinch the labia or any
hairs while withdrawing the speculum.

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Title page
Cervical smear
methods
devices
Tell the patient that you have

finished , give a towel to the patient
to wipe herself.
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Send samples to lab
Summary
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Cusco
Cuscos speculum
Cervix brush
Specimen bottle
Microbiology swabs
Water based lubricant
Tissues
Introduce yourself
Identify patient (full name and DOB)
Procedure
Explain what you are going to do and
what she may experience
Permission
Obtain informed consent
Privacy
Position
age
risk factors

Necessary equipment
Heels together, draw heels towards

bottom, let knees flop apart
Light
Exposure
Remove clothing from the waist

down, cover with blanket
Wash hands, don gloves

Label bottle and open the lid
Assemble speculum
If not in warmer, warm under tap
Use fingers to keep blades shut
Warn patient
Separate labia
Insert with rotating motion
Avoid touching clitoris
Under direct vision open the blades
and angle the speculum accordingly
so that cervix comes into view
Inspect cervix and lateral vaginal
walls
Insert tip of cervex brush into os
Rotate 10X, sample whole cervix
Remove brush and dip vigorously into
bottle
Remove the speculum gently, rotate
to inspect anterior and posterior
vaginal walls
Let the blades close carefully
Offer patient some tissues to wipe
herself, cover her with blanket and
leave the curtained area
Further Reading
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Why screen regularly with smear

test
What is CIN ?
What are the stages ?
How do we treat ?
How does CIN differ from invasive
cancer
Further reading
Jump menu
Title page
Cervical smear
methods
devices
http://www.cancerscreening.nhs.uk/
cervical/publications/cervicalpocket2
004.pdf
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
http://www.gfmer.ch/Books/Cervical
_cancer_modules/Aided_visual_ins
pection_atlas.htm
Cervical Screening
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Title page
General screening criteria
Cervical smear
methods
The disease should be responsible for
devices
Slide method
Swabs

Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
significant morbidity or mortality in the target

population
The natural history of the disease should be
known
Intervention at an early stage should be
effective in preventing the condition
A screening programme should be cost effective
Treatment should cause low morbidity
Cervical Screening
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Title page
Almost four million women are

screened each year
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
42% fall in incidence of cervical

cancer between 1988 and 1997
attributable to screening
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Mortality rates in 2000 were 60%

lower than 30 years earlier
Cervical Screening
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Title page
The screening programme in England and
Wales invites all women between 25 and 64

years for three- or five-yearly screening.
Cervical smear
methods
devices
Slide method
Swabs
It is recommended that women 25 to 49 are
screened three-yearly and 50 to 64 five yearly.

Summary
Further reading
Cervical Cancer
incidence
age
Women over 65 are only called if they have not
had a smear since age 50, or have had a recent

abnormality.
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
In Scotland the programme is slightly different, with women
between the ages of 20 and 60 being invited for screening every

three years.
Cervical Intraepithelial
Neoplasia
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Title page
CIN I- Dysplasia in the basal 1/3
Cervical smear
methods
devices
Slide method
Swabs
CIN 2- Dysplasia extending to middles

1/3

Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
CIN 3- Dysplasia involving the whole

epithelium but the basal membrane is
intact.
pathology macro
presentation
investigation
Cervical Screening
Dysplasia
basal hyperplasia - multi-layering of basal cells

nuclear pleiomorphism
increased mitotic activity
Cervical Cancer
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Title page
Incidence
Cervical smear
methods
devices
Slide method
Swabs
2400 new cases per year in England and

Wales

Summary
Further reading
Cervical Cancer
<1000 deaths annually
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
of women who present with late stage

disease have never had a smear
Cervical Cancer
Jump menu
Title page
Age
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Rare under 20yrs

Peak 45-55yrs
Peaks earlier in pts from lower
socioeconomic groups
Cervical Cancer
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Risk factors
Age
Lower social class
HPV infection (types 16 and 18 mainly)
Large numbers of sexual partners
Partner with many previous partners
Smoking
Immunosuppression
Early age of 1st intercourse and 1st pregnancy
Abnormal smear
Oral contraceptive use rather than barrier
Cervical Cancer
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Title page
Pathology - micro
Cervical smear
methods
devices
Slide method
Swabs
80% squamous carcinoma of

transformation zone

Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Rest are adenocarcinoma
Cervical Cancer
Jump menu
Title page
Pathology macro
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Ulceration or mass on cervix that

bleeds easily
Cervical Cancer
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Title page
Common Presentations
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
During routine smear

Postcoital bleeding
Intermenstrual bleeding
Postmenopausal bleeding
Offensive vaginal discharge
Pain
Cervical Cancer
Jump menu
Title page
Investigations
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Urgent referral for colposcopy
Direct visualisation
Green light abnormal blood vessels
Acetic acid causes coagulation of nuclear
proteins, hence areas of high nuclear density
appear white
Iodine Schillers test abnormal immature
epithelium doesnt contain glycogen and
therefore doesnt stain with iodine
Other test
Jump menu
Title page
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
FBC
U&E
LFT
Serum Ca
Chest X-ray
CT scan
In advanced disease consider
cystoscopy / sigmoidoscopy
Treatment
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Title page
Depend on the stage of the disease
Cervical smear
methods
devices
Slide method
Swabs
Summary
Further reading
Cervical Cancer
incidence
age
risk factors
pathology micro
pathology macro
presentation
investigation
Cervical Screening
Cone biopsy
Radical
Hysterectomy
Radiotherapy Stage I-IV

Chemotherapy for some cases

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Cervical speculum examination

and taking a smear.

Removing the speculum

Able assemble the speculum

1. Designed for the inspection of the

Removing the speculum

2. Access to the cervix and fornices

Tell the patient the procedure is not

Lie on the couch, put your heels together, draw them up to

Warm blades under a stream of tepid

Slide the closed blades obliquely over

While inserting the instrument rotate it to

Maintain a downward pressure, on

Inspection of the vagina

Cottage cheese / curd-like: candida (assoc.

Inspection of the cervix

Cervix normally points posteriorly

Nabothian cyst mucus filled cervical cyst due to blockage of

Cervical polyp (appears to be descending through the os)

Cervical smear performed after

Cervical smear - methods

Newer method = LBC ( Liquidbased

Use cervex brush (see next slide)

Older method = slides

Cervical smear - devices

Liquid Based Cytology method

Use a cervex brush

Place the tip of the brush in the os

The bifid end is used to harvest the

The desquamating cells are

Send sample to the lab

Spread the cervical material onto the

The cervical cells and some mucus

Some examples of cells processed with the Papanicolau stain

If any ulcers, take swab from base of

If infection suspected, take swab from

Removing the speculum

Undo the thumb screw

Ending the procedure

Tell the patient that you have

Send samples to lab

Obtain informed consent

Removing the speculum

Heels together, draw heels towards

Remove clothing from the waist

Wash hands, don gloves

Why screen regularly with smear

General screening criteria

The disease should be responsible for

Ending the procedure

significant morbidity or mortality in the target

Almost four million women are

42% fall in incidence of cervical

Mortality rates in 2000 were 60%

The screening programme in England and

Wales invites all women between 25 and 64

It is recommended that women 25 to 49 are

screened three-yearly and 50 to 64 five yearly.

Removing the speculum

Women over 65 are only called if they have not

had a smear since age 50, or have had a recent

In Scotland the programme is slightly different, with women

between the ages of 20 and 60 being invited for screening every