PAP SMEAR

AIDA & AINA

This is an outpatient procedure. It is a

screening, not diagnostic, test for
premalignant cervical changes; it allows for
early intervention, thus preventing cervical
Specimens required.
cancer.
Pap smear should
include cytologic
specimens from 2
areas:
1. Stratified squamous
epithelium of
transformation zone
(TZ) of the
ectocervix
2. Columnar epithelium

RECOMMENDATION
Former guidelines recommended starting Pap smear
screening at age 18 or the onset of sexual activity.
2006: initiation 3 years after the onset of sexual
activity or age 21, whichever comes first.
2009: cervical cancer screening begin at age 21,
regardless of sexual history.
This recommendation was confirmed in 2012 and
again in January 2016.[2]

Summary of 2012 Screening Guidelines from the American Cancer

Society, American Society for Colposcopy and Cervical Pathology,
and American Society for Clinical Pathology

TYPES

Parameters

ACS Recommendations

Age to start screening

Begin screening with cytology at 21 years old,

regardless of sexual history

Screening interval age

2129

Screen with cytology alone every 3 years.* HPV

testing should not be used for screening in this
age group

Screening interval age

30-65

Screen with a combination of cytology and HPV

testing every 5 years (preferred) or cytology alone
every 3 years. Screening by HPV testing alone is
generally not recommended.*

Age to stop screening

Age 65, if the woman has adequate negative prior

screening and is not otherwise at high risk for
cervical cancer

Screening after
hysterectomy

Not indicated for women without a cervix and

without a history of a high-grade precancerous
lesion (eg, CIN2 or CIN3) in the past 20 years or
cervical cancer ever

HPV-vaccinated
women

Screen according to the same

recommendations as for unvaccinated

CONTRAINDICATION
Relative Contraindications for Pap
Testing: (Temporary Deferral):
Heavy menstrual bleeding
Women less than 8 weeks postpartum (vaginal delivery) or 8
weeks post-abortion.
Visible cervical mass with
bleedingrefer
PLEASE NOTE: Pap testing should
NOT be deferred if vaginal
discharge or signs and symptoms
of vaginal infection are present

TYPES
Testing for cervical cancer is
performed using either:
I. Liquid-Based Cytology or
II. Conventional (slide) Pap Test
(no difference in screening interval is
recommended).

Devices for
collecting cervical
cellular samples:

a)Aylesbury spatula
(modified Ayres
spatula) for sampling
the cervix and
transformation zone
b)Endocervical brush to
sample the
endocervix.
c)Cervical broom (LBC

PREPARATION
I. The patient should not
menstruating, schedule pap
smear between days 12-16
of menstrual cycle if possible
II. Avoid vaginal intercourse 1-2
days prior to smear
III. No douching or use of
tampons, use of medical
vaginal cream or
Example of Forms:
contraceptive cream for 24- 1)Borang
48 hours prior to cervical
Permohonan Pap
screening

Smear

PROCEDURE
1) Equipment:
Examination table with foot supports
Examination light
Metal or plastic speculum
Examination gloves
Cervical spatula (Aylesbury) and
cytobrush
Liquid-based cytology container or
glass slide and fixative

Different types of spatula

Plastic
speculum

Metal
speculum

2) Positioning of the patient

Supine, in dorsal lithotomy position

3) Technique:

Warm water or alcohol swab use to

lubricate and clean the speculum
and the labia majora
A speculum is inserted into the vagina .
The cervix must be clearly visualized
using a direct light source and the
cervical os should be located.

The sampling device(s) used should be selected

according to the shape and size of the cervix
and the location of the squamocolumnar
junction

The mucus plug is wiped away gently

to make sure the spatula/ brush is in
direct contact with epithelial tissue

An Aylesbury spatula or the extended tip of the

Ayre spatula is suitable for sampling the cervix
of a young or nulliparous woman
The rounded end is used for a parous woman. A
brush may be needed as well as a spatula to
sample the cervix of a post-menopausal woman
where the squamocolumnar junction lies within
the endocervical canal

The broom should be rotated 360 degree

5 times to remove cells from the region of
the transformation zone,
squamocolumnar junction and cervical
canal.

The sample should be transfer immediately to a

glass slide for conventional cytology or liquidbased cytology

For conventional cytology, the glass slide must

be fixed with an appropriate fixative (95%
alcohol) and the slide transported to cytology
laboratory together with the request form with
patients name

Sample taken for LBC : the tip of the

sampling device should be broken off
into transport medium before
transported into the laboratory.

Squamocolumnar
junction

Manageme
nt

Unsatisfact
ory smear

Negative
For
Intraepithel
ial lesion or
malignancy
(NIIM)

Abnormal
pap smear

Abnormal
Pap Smear
and CIN in
Pregnancy

Squamous cell
abnormalities

Atypical

low-grade
Squamous
Intraepithelial
lesion (ISII)

Pap smear
guidelines
after
hysterecto
my

Glandular cell
Abnormalities

High-grade
Squamous
Intraepithelial
lesion (HSII) and
squamous cell
carcinoma

Atypical
glandular cell
and
adenocarcinom
a

Adapted from Guidelines for Pap Smear Screening (Bethesda

Classification) 2001)

1)

Management of
Unsatisfactory Smear

2) Management of
negative for
intraepithelial lesion or
malignancy (NILM)
smear

3) Management of
Abnormal Pap Smear
3.1 Squamous cell
carcinoma
3.1.1 Atypical cell
carcinoma

3.1.2 Low-grade Squamous

Intraepithelial lesion
(LSlL)

3.1.3. High-grade Squamous

Intraepithelial Lesion (HSIL) and
Squamous Cell Carcinoma

3.2 Glandular Cell

Abnormalities

Pap Smear Guidelines After Hysterectomy

Status

Action

Hysterectomyfor benign disease:

In the absence of symptoms, may

not require any further screening.

Normal pap smear history.

Histopathology of cervix known
and is benign with no dysplastic /
neoplastic
changes
Subtotal hysterectomy

Should continue to have pap

smears
According to normal screening
procedure

Hysterectomy where histology is

not known

Should have one baseline vault

smear. If this is normal, further
screening
should be based on clinical
indications.

Women with past history of CIN:

If excision margin was involved or
histological assessment inadequate

Women with past history of CIN:

Follow up should be at the discretion

of
the Gynecologist. In general, vault
smears should be taken at least
yearly.
Vault smears yearly for 5 years
followed by two yearly smear

CIN 1 / 2/ 3 completely
excised at hysterectomy
Women previously treated for
invasive gynecological
malignancy

Should be followed up by a
Gynecologist, preferably a
Gynecological Oncologist.

Management of
Abnormal Pap Smear and
CIN in Pregnancy
Colposcopic examination should be undertaken to
exclude invasive disease by a Colposcopist.
If a high grade lesion is suspected on colposcopy, a
biopsy is indicated to exclude possible invasive
disease. Cervical biopsy is safe in pregnancy.
If CIN 2 or 3 is present, colposcopic review should be
done in the second and third trimester to exclude
any possible progression to invasive disease.
Treatment of CIN should be deferred till at least 6
weeks postpartum, when the lesion should be
reassessed.

References
I. Guidelines for Pap Smear Screening
(Bethesda Classification 2001)
II. Obstetrics by Ten Teachers, 19th
Edition, Philip N. Baker
III. Obstetrics illustrated , 7th edition,
Kevin P.Hanretty
IV. Essentials of Obstetrics and
Gynecology, 5th edition, Hacker &
Moores