Pap Smear

Also known as: PAP Test Formal name: Papanicolaou Smear; Cervical Smear; Cervical/vaginal Cytology Related tests: HPV; Trichomonas

How is it used?
A doctor or health provider performs a Pap smear primarily to look for cervical and/or vaginal cells that are cancerous or that may be pre-cancerous. A sample of cervical cells or cell suspension is placed on a glass slide, stained with a special dye (Pap stain), and viewed under a microscope by a cytotechnologist or pathologist. The Pap test can also be used to detect vaginal or uterine infections. Abnormal cells and infections can be present without causing any noticeable symptoms. In some cases, further testing and/or treatment may be required while in other cases, the doctor may choose to monitor the person over time to see if the situation resolves on its own. Some strains of human papillomavirus (HPV), a very common sexually transmitted viral infection, can be associated with an increased risk of cervical cancer. A doctor may also order an HPV DNA test along with or following a Pap smear, especially for women age 30 to 65. ^ Back to top

When is it ordered?
The appropriate frequency of Pap testing is dependent on age, concurrent use of the HPV DNA test, and risk factors (see Screening: Cervical Cancer (ages 19-29), (ages 30-49), (ages 50 and Up)). The American Congress of Obstetricians and Gynecologists (ACOG) revised their guidelines in 2009 to recommend that screening with Pap smears begin no earlier than age 21 and then be performed every two years until age 29. For women age 30 and older, ACOG recommends screening with both the Pap and HPV DNA tests, with a longer screening intervalat least three yearsif results from both

are negative. Women older than 64 can forgo screening if they have had no abnormal Pap smears for 3 years and no other abnormal test results for 10 years. The U.S. Preventive Services Task Force (USPSTF) and American Cancer Society both released new guidelines in 2012 recommending a longer screening interval. These organizations suggest that women between the ages of 21 and 65 be screened with a Pap test every 3 years. Between ages 30 and 65, having both a Pap smear and an HPV test every 5 years is preferable, although a Pap test alone every 3 years is also acceptable. After age 65, no screening is necessary if women have had adequate prior screening. USPSTF defines adequate prior screening as 3 consecutive negative Pap smears or 2 negative HPV DNA tests within the last 10 years, with the most recent within the last 5 years.

Both sets of guidelines say that some women may need more frequent screening. Women with the following conditions and circumstances should discuss shorter screening intervals with their doctors:

HIV infection Suppressed immune system for other reasons, such as organ transplant Exposure to DES (diethylstilbestrol) during their mothers' pregnancy Previous treatment for cervical cancer or a condition called cervical intraepithelial neoplasia-2 or 3 (CIN 2, CIN 3)

A doctor may also order a Pap smear when a woman has frequent sexual partners, is pregnant, or has abnormal vaginal bleeding, pain, sores, discharge, or itching. ^ Back to top

What does the test result mean?

A "negative" Pap smear means the cells obtained appear normal or there is no identifiable infection. In some instances, the conventional Pap smear may be reported as "unsatisfactory" for evaluation. This may mean that cell collection was inadequate or that cells could not be clearly identified. A summary of other reported results follows. [See also Pap Smear Terminology on the 2001 Bethesda System for classification of Pap smear results.]

Unsatisfactory: inadequate sampling or other interfering substance Benign: non-cancerous cells, but smear shows infection, irritation, or normal cell repair

Atypical cells of uncertain significance: abnormal changes in the cells that cover most of the external part of the cervix (squamous cells-ASCUS) or in the cells that cover the lining of the uterus opening and canal (glandular cellsAGCUS) for which the cause is undetermined; an ASCUS test result is frequently followed up with DNA testing to identify the presence of a high-risk infection with HPV.

Low-Grade changes: frequently due to infection with HPV, which in some instances can be a risk for cervical cancer; this test result may be followed up with DNA testing to identify the presence of a high-risk HPV infection [see HPV DNA].

High-Grade changes: very atypical cells that may result in cancer Squamous cell carcinoma or adenocarcinoma: terms used to identify certain types of cancer; in these cases, cancer is evident and requires immediate attention. ^ Back to top

Is there anything else I should know?

The Pap smear is generally used as a screening test. A certain percentage of abnormalities in women may go undetected with a single Pap smear, which is why it is important to have Pap smears done regularly. A significant limitation of the test has to do with sample collection. The Pap smear represents a very small sample of cells present

on the cervix and in the vaginal area. Even for the most experienced physician, sample collection can be occasionally inadequate and a repeat Pap may be required.

If a woman douches, tub bathes, or uses vaginal creams 48 to 72 hours prior to the examination, the test results might be "unsatisfactory." Other factors that may alter results include menstrual bleeding, infection, drugs (such as digitalis and tetracycline), or having sexual relations within 24 hours prior to examination. In these cases, a repeat Pap smear may be necessary, but it does not necessarily mean there is a significant problem. In some instances, the use of the liquid-based techniques may eliminate obscuring materials such as blood and mucus that may prevent a clear and uncluttered presentation of cervical cells. A second advantage is that the same sample may be used to perform additional testing for HPV, if appropriate.