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CYT 2113 Cytology I

Lesson 7:
Introduction to Pap Smear Test

Pap Smear
An examination under the microscope of cells
scraped from the tip of the cervix
(Cervix the lower part of the uterus that
opens at the top of vagina)
Done as part of a gynecological exam

How Pap Smear Test is Performed


The patient will lie and position pelvis for
examination
The health care provider will insert speculum
into vagina and open it slightly to see inside
the vaginal canal

A cotton swab is sometimes used to clear away


mucus that might interfere with an optimal
sample
A sample of cells is taken from the outside and
just inside the opening of the cervix (cervical
canal) by gently scrapping the outside of the
cervix with a wooden or plastic spatula, then
inserting a small brush into the canal

The cells are placed on a glass slide, or put in a


bottle containing a preservative and then sent
to the lab for examination
The cells are examined under a microscope in
order to look for pre-malignant or malignant
changes

Pap Smear

Pap Smears
Conventional smears are often obtained using
the combination of a spatula and brush
The spatula is used first
Although a wooden or plastic spatula is
acceptable, the plastic spatula is
recommended because wooden fibers trap
diagnostic material
The spatula is rotated 360 degrees

The sample can be smeared on one half of a


slide and spray fixed (the other half should be
covered to avoid coating it with fixative before
the endocervical sample is applied)
Alternatively, one may set aside the spatula
sample momentarily while the endocervical
brush sample is obtained

After the brush is inserted in the endocervical


canal, some bristles should still be visible
If inserted too far, there may be inadvertent
sampling of the lower uterine segment (LUS),
which causes diagnostic difficulties because its
epithelium resembles a high-grade squamous
intraepithelial lesion (HSIL) and
adenocarcinoma in situ (AIS)

The brush should be rotated gently only one


quarter turn
A larger rotation is unnecessary because the
circumferential bristles are in contact with the
entire surface the moment the brush is
inserted
The spatula sample, if not already applied and
fixed, should be applied to the slide, then the
brush sample rolled over the slide, followed
by immediate fixation

The two samples can be placed in quick


succession on two separate halves of the slide,
or the endocervical sample can be rolled
directly over the spatula sample, both
covering the entire slide
Immediate fixation (within seconds) is critical
to prevent air-drying artifact, which distorts
the cells and hinders interpretation

The broomlike brush (broom) has a flat


array of plastic strips contoured to conform to
the cervix, with longer strips in the middle
This design allows simultaneous sampling of
the endocervix and ectocervix
The long middle strips are inserted into the os
until the shorter outer strips bend against the
ectocervix

The broomlike brush

The broom is rotated three to five times


To transfer the material, each side of the
broom is stroked once across the slide in a
painting motion
The cotton swab moistened with saline is no
longer recommended because its fiber trap
cells, reducing the efficiency of cell transfer
onto slides

Cervex brush

Cytobrush

Spatula

There are two options for smear fixation


Coating fixatives contain alcohol and
polyethylene glycol and applied by pump
sprays, by droppers from dropper bottles, or
by pouring from an individual envelope
included as part of a slide preparation kit
Alternatively, the smear can be immersed
directly into a container filled with 95%
ethanol

Samples for liquid-based cytology (LBC) are


obtained as described except that, instead of
smearing the cells on a slide, the collection
device is rinsed in a vial containing liquid
fixative

How to Prepare for the Test


Tell the health care provider if you:
 Are taking any medications or birth control pills
 Have had an abnormal Pap smear
 Might be pregnant
Within 24 hours of the test, avoid:
 Douching
 Having intercourse
 Taking a tub bath
 Using tampons

Avoid scheduling Pap smear while


menstruating because blood and cells from
the uterus may affect the accuracy of the Pap
smear
Empty the bladder just before the test

Pap Smear
A simple, quick and relatively painless screening
test
Specificity (its ability to avoid classifying a normal
smear as abnormal) is very good but not perfect
Sensitivity (its ability to detect every single
abnormality) is good but also not perfect
Some false negative results (in which
abnormalities are present but not detected by
the test) will occur

Thus, a few women develop cervical cancer


despite having regular Pap screening
In the vast majority of cases, a Pap test does
identify minor cellular abnormalities before they
have had a chance to become malignant and at a
point when the condition is most easily treatable
The Pap smear is not intended to detect other
forms of cancer such as those of the ovary, vagina
or uterus

Cancer of these organs may be discovered


during the course of the gynecologic (pelvic)
exam, which usually is done at the same time
as the Pap smear

Why the Test is Performed


The Pap smear can detect cancerous or
precancerous conditions of the cervix
Most invasive cancers of the cervix can be
detected early if women have Pap tests and
pelvic examinations
Screening should start within 3 years after first
having vaginal intercourse or by age 21

After the first test:


Woman should have a Pap smear every 2
years to check for cervical cancer
If the woman is over age 30 or the Pap smears
have been negative for 3 times in a row, the
doctor may recommend Pap smear to be done
every 3 years
If the woman or her sexual partner have other
new partners, then she should have a Pap
smear every 2 years

After age 65-70, most women can stop having


Pap smears as long as they have had three
negative tests within the past 10 years
If the woman has a new sexual partner after
age 65, she should begin having Pap smear
screening

Who Should Have a Pap Smear


Women who have had a total hysterectomy
(uterus and cervix removed) and have not had
any previous history of cervical dysplasia
(abnormal cells), cervical cancer or any other kind
of pelvic cancer, may not need to have Pap
smears
Pregnancy does not prevent a woman from
having a Pap smear
Pap smears can be safely done during pregnancy

The screening guidelines of American Cancer


Society 2004:
 When to start Pap smear testing 3 years after
vaginal intercourse, no later than age 21
 Frequency of Pap smear testing yearly with
exceptions: every 2 years if liquid-based kit; every
2-3 years if three normal tests in a row in women
30 years old
 Age to stop having Pap smears total
hysterectomy of benign disease 70 years old
with at least three normal Pap smear results in
the last 10 years

The screening guidelines of United States


Preventative Services Task Force 2003:
When to start Pap smear testing within 3
years of onset of sexual activity or age 21,
whichever comes first
Frequency of Pap smear testing at least
every 3 years (no evidence that every year is
better than every 3 years)

Age to stop having Pap smears


-recommend against doing Pap smears in
women older than 65 years of age, if adequate
screening with normal results
- recommend against doing Pap smears in
women who have had a total hysterectomy for
benign disease

The screening guidelines of American College of


Obstetrics and Gynecology:
 When to start Pap smear testing 3 years after
first sexual intercourse or age 21, whichever
comes first
 Frequency of Pap smear testing yearly until age
30 years. Beginning at age 30, if three normal
annual Pap results, can do a Pap alone every 2-3
years
 Age to stop having Pap smears difficult to set an
upper age limit- postmenopausal women
screened within the prior 2-3 years have a very
low risk of developing abnormal Pap smears

It has been seen that women who do not


participate in screening programs, and women
whose interval between smears is more than 3
years, are at highest risk for developing cervical
carcinoma
In Malaysia, all women who are, or who have
been sexually active, between the ages of 20 and
65 years, are recommended to undergo Pap
smear testing
If the first two consecutive Pap results are
negative, screening every three years is
recommended.

Women with a history of cervical cancer, in


utero diethylstilbestrol (DES) exposure, and
who are immunocompromised (organ
transplantation, chemotherapy, chronic
corticosteroid treatment, or positive for
human immunodeficiency virus) may benefit
from more frequent screening

Normal results
A normal value is negative, meaning there are no
abnormal cells present
Abnormal results
Atypical cells of uncertain significance (ASCUS)
these changes may be due to infection with HPV
but may also mean there are precancerous
changes present
Low-grade dysplasia or high-grade dysplasia: this
means precancer changes are likely to be present;
the risk of cancer is greater if the result is highgrade dysplasia

Carcinoma in situ (CIS) this usually means


the abnormal changes are likely to progress to
cancer
Atypical squamous cells (ASC-H) this means
abnormal changes have been found and may
be high-grade squamous intraepithelial lesion
Atypical glandular cells (AGC) cell changes
are seen that suggest precancer of the upper
part of the cervical canal or inside the uterus

When a Pap smear shows abnormalities, further


testing or follow-up is needed
The next step depends on the results of the Pap
smear, previous history of Pap smears and risk
factors for cervical cancer
This may include
- colposcopy-directed biopsy
- An HPV test to check for the presence of the HPV
virus types most likely to cause cancer
For minor cell changes, doctors usually
recommend having a repeat Pap smear in 3-6
months

(colposcopy a procedure to closely examine


cervix, vagina and vulva for signs of disease)

Which women are at increased risk for having an


abnormal Pap smear?
A number of risk factors have been identified for
the development of cervical cancer and
precancerous changes in the cervix.
 HPV: The principal risk factor is infection with the
human papillomavirus (HPV), although most
women with HPV infection do not get cervical
cancer

 Smoking: Smoking increased the risk of cervical


cancer about two to four fold.
 Weakened immune system: Women whose
immune systems are weakened by medications (for
example, those taken after an organ transplant)
also have a higher risk of precancerous changes in
the cervix.
 Medications: Women whose mothers took the
drug diethylstilbestrol (DES) during pregnancy also
are at increased risk.
 Other risk factors: having multiple sexual partners
and becoming sexually active at a young age.

Strengths of Cytology Screening

The decades of experience in its use


High specificity
Its adaptability to computer-assisted reading
The lesions identified are easy to treat
Relatively low cost

Limitations of Cytology Screening


The test is difficult to comprehend in many
cultures
Invasive and potentially embarrassing
Trained personnel are required
Smear adequacy is not intrinsically obvious
It is necessary to recall women for further
tests if the results are not clearly negative
The test has only moderate sensitivity

Unable to distinguish progressive disease from


that destined to regress
It is impossible by screening to eliminate all
cervical cancer mortality

Essential Elements for a Successful


Cytology Screening Programme
Training of the relevant health care professionals,
including smear takers, smear readers
(cytotechnologists), cytopathologists,
colposcopists and programme managers
An agreed decision on the priority age group to
be screened
Adequately taken and fixed smears
Efficient and high quality laboratory services, that
should preferably be centralized, quality control
of cytology reading

A means to rapidly transport smears to the


laboratory
A mechanism to inform the women screened
of the results of the test in an understandable
form
A mechanism to ensure that women with an
abnormal test result attend for management
and treatment

An accepted definition of an abnormality to


be treated, i.e. high grade lesions
A mechanism to follow up treated women
A decision on the frequency of subsequent
screens
A mechanism to invite women with negative
smears for subsequent smears

Elements that Interfere with the


development of Successful Cervical
Screening Programmes
Over-reliance on maternal and child health
services for screening, especially for defining
the target group
Opportunistic (spontaneous) screening, often
focusing on frequent screening of low risk
women

Low compliance with screening of the target


group (evaluation by counting smears, rather
than counting women screened)
Setting too low a threshold for referral for
colposcopy (over-treating non-progressive
disease)