Papanicolaou Test (Pap Smear)

Last updated 20.09.12

 

Definition

-  Screening cytological assessment of endocervical epithelium to detect early changes predisposing to cervical cancer

 

Features

-  National cervical cancer screening program

-  Detects early endocervical cell changes associated with Human Papilloma Virus (HPV)

-  Recommend every 2yrs for all Australian women 18-70yrs OR 2yrs after sexually active (which ever later)

-  Even if vaccinated (not 100% protected)

-  70yrs+

-  If normal for last 5yrs: nil more required

-  Screen if never had

-  Hysterectomies

-  Not required in women with hysterectomies (Total) who have never had an abnormal pap smear

-  Required if never had a pap smear prior to hysterectomy or still have a cervix (subtotoal)

-  Required if previous changes noted then vault smear is performed every 2nd year

-  Pregnancy

-  Should be part of normal antenatal care

-  If post partum should wait 12 weeks

-  Can be safely performed up to 24 weeks of pregnancy (not associated with increased miscarriage)

-  Avoid use of cytobrush

-  Cytology from smear = LSIL or HSIL

-  Histology from biopsy = CIN

-  Transformation zone (squamocolumnar junction) is site of SCC

 

Indication

-  Detection of early endocervical cell changes associated with Human Papilloma Virus (HPV) as screening tool for cervical cancer

 

Equipment

-  Gloves

-  +/- Lubricant (water based)

-  Speculum

-  Light source

-  Glass slide

-  Pap Smear kit

-  Broom & cytobrush

-  OR Spatula & cytobrush

-  Fixative

 

Procedure

-  Consent & explanation

-  Label slide in pencil with 3 patient identifiers

-  +/- preceded by Bimanual Palpation

-  If metal speculum warm first

-  Lubricate with water

-  +/- Small volume lubricant (water based) if needed

-  Perform Speculum Exam & identify cervix

-  Insert at 45o

-  Elevate pelvis with pillow as needed

-  If difficult to identify remove speculum & perform PV

-  Insert cervix brush into external os of cervix rotate 1/4 turn

-  Not required if premenopausal & transformation zone easily identifiable

-  Sample transformation zone (squamocolumnar junction)

-  Rotate broom 3-5 times clockwise

-  OR Rotate spatula 1-2 times

-  Insert brush 7/8 of length & rotate 1/4 rotation

-   Required to sample transformation zone which may be deeper

-   May not be required if premenopausal & transformation zone readily visible

-  Apply brush to slide immediately

-  Wipe one side down long axis of slide

-  Wipe other side parallel to first

-  Spray fixative immediately over slide

-  Must be applied within 5 seconds of being on slide

-  Hold 10-15cm from slide

-  +/- Rinse cervical brush into solution for liquid cytology

-  Stab bristle onto botton of container

-  Should use plastic instruments

-  Brush vigourously

-  Label & send solution + slides to pathology

-  +/- Digene test for HPV +/- Chlamydia

 

Results

-  Unsatisfactory results

-  Repeat between 6-12/52

-  Not necessarily progressive from CIN1 to 3

-  Squamous Changes

-  Low Grade (Low-grade Squamous Intraepithelial Lesion)

-   Very common, may be transient abnormality

-   Possible LSIL

-   Non-specific minor squamous cell changes

-   +/- suggestive of HPV changes or CIN1

-  Definite LSIL

-   Acute HPV infection, CIN1

-  High Grade (High-grade Squamous Intraepitheleal Lesion)

-  0-3% chance of invasive cervical cancer

-  Possible HSIL

-   +/- suggestive CIN2, CIN3 or SCC

-  Definite HSIL

-   CIN2 or CIN3

-  Squamous Cell Ca (SCC): cervical cancer

-  Glandular Changes

-  Atypical Endocervical Cells of Undetermied Significance

-   Nonspecific minor changes in endocervical cells

-  Atypical Glandular Cells of Undetermined Significance

-  Possible High-grade Glandular Lesion

-   +/- suggestive AIS or adenocarcinoma

-  Adenocarcinoma: cervical cancer

 

Mx

-  Cervical Screening Register (in each State)

-  Victorian Cervicall Cytology Register (03) 9250 0399

-  LSIL (defininte or possible)

-  Repeat Pap in 12/12

-   If NAD F/U Pap in 12/12 & if NAD go to routine testing

-   If persistant LSIL or HSIL: colposcopy

-  If >30yrs & abnormal Pap in last 3yrs

-   Offer immediate colposcopy

-  OR repeat Pap in 6/12

-  If x2 LSIL within 3yrs: colposcopy

-  If symptomatic or clinical concern re cervical appearance: colposcopy

-  HSIL (definite or possible): referral + colposcopy + Bx

-  If HSIL + invasive features or SCC: Gynae onc R/V within 2 wks

-   Confirmation by histology required before treatment

-  If colposcopy CIN2, CIN3: excision or ablation treatment to prevent cervical Ca (LLETZ..)

-  Atypical glandular cells: colposcopy (requires exp to Dx)

 

LSIL

 

 

HSIL

 

Contraindications/Precautions

-  Hysterectomy (total) if no cervix not required

-  Bleeding (menstrual or other) may confuse results

-  When used for screening wait for after period

-  When used as Dx test not contraindicated

 

 

 

References

 

Dorevitch Pathology: Thin Prep Cervical Cytology Instructions

Screening to Prevent Cervical Cancer: NH&MRC, June 2005

Victorian Cervical Cytology Registry