MoonDragon's Women's Health Procedures Information
CERVIX ABNORMALITIES & VARIATIONS
For "Informational Use Only".
For more detailed information, contact your health care provider
about options that may be available for your specific situation.
CERVIX EXAMINATION DESCRIPTION
Examination of the cervix is an integral and important part of every gynecological examination. The appearance of the vulva, vagina and cervix varies normally in relation to age and hormone status and changes must take into account the expected texture of the epithelium for any given age.
MoonDragon's Womens Health Procedures Information: Pelvic Exam
MoonDragon's Womens Health Procedures Information: Rectal Exam
MoonDragon's Womens Health Procedures Information: Uterine Abnormalities Exam
MoonDragon's Womens Health Procedures Information: Vaginal Inflammations Exam
MoonDragon's Womens Health Procedures Information: Vulval Lesions Exam
NORMAL NULLIPAROUS CERVIX
Nulliparous means a woman who has never had gone through childbirth. The normal nulliparous cervical os is small and either round or oval. The cervix is covered by smooth pink epithelium.
NORMAL PAROUS CERVIX
After childbirth, the cervical os presents a slit-like appearance.
LACERATIONS OF THE CERVIX
The trauma of difficult childbirth deliveries may tear the cervix, producing permanent transverse or stellate lacerations.
ECTROPION (CERVICAL EROSION)
The mucosa around the central os is at times a plush red rather than the usual shiny pink. It may bleed easily when touched. This appearance is usually due to ectropion, i.e., the presence of columnar epithelium like that lining the cervical canal. An ectropion is not abnormal but may be difficult to distinguish from early carcinoma without further study, e.g., by cytology, colposcopy or biopsy. The term erosion is also used for this condition but is misleading since the mucosa has not actually been eroded away.
NABOTHIAN OR RETENTION CYSTS
Retention or Nabothian cysts may accompany or follow chronic cervicitis. variable in size, single or multiple, they appear as translucent nodules on the cervical surface.
Cervical polyps usually arise from the endocervical canal, becoming visible when they protrude through the cervical os. They are bright red, soft, and rather fragile. When only the tips are seen they cannot be clinically differentiated from polyps originating in the endometrium.
CARCINOMA OF THE CERVIX
Carcinoma of the cervix usually begins at or near the cervical os. it presents a hard granular surface which bleeds easily, proceeding later to an extensive irregular cauliflower type of growth. Early carcinomas are clinically indistinguishable from ectropions and may even be present in a cervix that appears normal.
FEMALE REPRODUCTIVE CANCER LINKS FROM MOONDRAGON
MoonDragon's Womens Health Disorders Information: Cervical Cancer
MoonDragon's Womens Health Disorders Information: Ovary Cancer
MoonDragon's Womens Health Disorders Information: Uterine Cancer
MoonDragon's Womens Health Disorders Information: Vaginal Cancer
DESCRIPTION OF PAP SMEAR PROCEDURE: CLIENT/PATIENT INFORMATION
The client/patient should not douche before the examination. (See the guidelines about preparing for the pap test located below.)
MoonDragon's Procedures: Pap Smear
The examination is usually performed in the examiner's office, but an examination may be performed during a client's home visit by a midwife or other health care provider. A nurse or other health care professional may be present to assist the health care provider or midwife. If your health care provider is a male, a female assistant should be present at the time of the examination.
The client/patient will be asked to remove clothing below the waist and drape a paper cloth (or a sheet if performed in the client's home) around the waist prior to the Pap smear. If the client is wearing a dress, then she will be asked to remove any underclothing from the waist down.
On the examination table, the client/patient will lie on her back with knees bent and legs apart (legs are usually placed in stirrups for support). If the examination is performed in a client's home, the exam may be done on a bed (with the buttocks propped up slightly by pillows or padding if internal visual examination must be made using a speculum) or possibly on a firm surface, such as a table top with pillows and soft padding.
The external genital organs will be examined visually for lumps, sores, skin discoloration, inflammation and qualities suggesting the general hormonal status.
To perform a Pap smear, the health care provider will begin by inserting a metal or plastic instrument (called a speculum) into the vagina to keep it open so that the cervix may be clearly seen. The speculum is an instrument that holds the vaginal walls apart and allows the examiner to see the cervix and vagina and check for inflammation, infection, scars or growths. There may be some feeling of pressure on the bladder or rectum with the speculum in place. Speculum lubrication may or may not contaminate pap smear. There are different thoughts on using lubricant.
Select a speculum of appropriate size, lubricate it and warm it with warm water. (Other lubricants, such as K-Y Jelly, may interfere with cytological or other studies but they may be used if no such tests are planned.) By having the speculum ready during assessment of the vaginal outlet, it can ease speculum insertion and increase the efficiency by proceeding to the next maneuver while the client is still straining down.
Place two fingers just inside or at the introitus and gently press down on the perineal body. With the other hand introduce the closed speculum past the fingers at a 45-degree angle downward. The blades should be held obliquely and the pressure exerted toward the posterior vaginal wall in order to avoid the more sensitive anterior wall and urethra. Be careful not to pull on the pubic hair or to pinch the labia with the speculum.
After the speculum has entered the vagina, remove the fingers from the introitus. Rotate the blades of the speculum into a horizontal position maintaining the pressure posteriorly.
Open the blades after full insertion and maneuver the speculum so that the cervix comes into full view.
When the introitus is retroverted, the cervix points more anteriorly than diagrammed. Position the speculum more anteriorly, i.e., more horizontally, in order to bring the cervix into view.
MoonDragon's Procedures: Uterine Abnormalities
Inspect the cervix and its os. Note the color of the cervix, its position, any ulcerations, nodules, masses, bleeding or discharge.
A normal cervix will appear pinkish in color. The cervix will appear as purplish in color if a woman is pregnant.
Secure the speculum with the blades open by tightening the thumb screw.
The effects of estrogen and vaginal pH gradually transform the endocervical epithelium into stratified squamous epithelium by a process of squamous metaplasia. This area is known as the transformation zone. It is the primary target of sampling for the Pap smear. Squamous abnormalities arise in the transformation zone. The junction is close to the external OS of the cervix but varies between patients, and according to age (see below).
Location of the Transformation Zone According to Age
The position of the transformation zone varies according to age. In women during the childbearing age, the transformation zone is either in an exposed position or at the external OS. In post-menopausal women the transformation zone is often located within the endocervical canal.
An adequate Pap smear should provide representative assessment of the entire transformation zone. No single criterion determines adequacy. The presence of endocervical cells is suggestive that the area above the transformation zone has been sampled. However, the presence of metaplastic cells or dysplastic cells suggest that transformation zone has been sampled at least in part.
The visual distinction of the separate zones of the cervical epithelium is impossible with the naked eye. The squamous epithelium of the ectocervix has a smooth, pearly, opaque appearance. The endocervical epithelium is very vascular and has a pinkish to red translucent appearance. The epithelium of the transformation zone is identified by the variegation of the color between the two native epithelia. The squamo columnar junction line will be irregular in outline and the ever changing upper end of the transformation zone will be very irregular and impossible to identify without colposcopy.
TRADITIONAL PAP SMEAR TECHNIQUE
Prior to preparation of smears it is useful to obtain all necessary materials and have them at easy access:
A) Instruments to obtain the smear (extended tip spatula, endocervical brush or saline moistened cotton swab, slides with frosted end and speculum).
B) Clean microscopic glass slide with a frosted end and properly labeled with client/patient's PHIN (Patient's Hospital Identification Number). If the client/patient does not have a PHIN, the slide should be identified with the client/patient's surname.
C) Pencil to identify patient PHIN and site if more than one is being sampled on frosted end of slide.
D) Fixative can be a slide container filled with 95 percent ethanol or a non-aerosol spray fixative.
E) Laboratory requisition with all pertinent demographic information and patient history.
Swabbing the cervix to clean away discharge.
- If there is visible blood or leukorrhea present on the cervix it should be wiped off before proceeding (clean only if there is a large discharge). Before collecting the specimen, gently remove excess mucus with a ring forceps holding a folded gauze pad. Surface exudate can be removed by placing a 2 inch x 2 inch piece of gauze over the cervix and peeling it away after it absorbs the exudate. A dry "proctoswab", "scopette" or other large cotton tipped swap can also be used. Do not rinse the cervix with saline, or a hypocellular smear may result. Do not rinse cervix with saline. Avoid performing pap smear during menstruation.
Figure 1: Extended Tip Spatula - Sampling the Ectocervix Figure 2: Endocervical Brush - Sampling the Endocervix Figure 3: Saline Moistened Cotton Swab - Sampling the Endocervix
The most effective technique is a combination of ectocervical and endocervical sampling. A wooden type spatula or other type of cyto-spatula is used to sample the ectocervix (Figure 1) and an endocervical brush (Figure 2) or saline moistened cotton swab (Figure 3) is used to sample the endocervix. Both samples are transferred to one slide and quickly fixed with Cytospray. This combined technique has been shown to reduce the false negative rate to less than 15 percent.
Using the Szalay Cyto-Spatula to obtain a cervical cell sample. This spatula is unique that it comes in various sizes to match the client/patient's cervical type. The spatula is designed to obtain all three types of cervical cells in one swipe of the spatula.
(Images courtesy of Szalay Cyto-Spatula Manufacturer)
For more detailed information about the Szalay Cyto-Spatula, see these links:
Szalay Cyto-Spatula Technique
The Szalay Cyto-Spatula Technique Video Clip
- Next, the examiner will use a small brush, cotton-tipped swab, or a spatula to obtain a sample of cells and mucus from the outer part of the cervix (the ectocervix). Using a swab, a sampling of cells is taken from the cervix and placed on a glass slide for the Pap smear test.
The order in which the sample is taken is critical for less blood. If a culture is needed where blood can be an issue, this should be taken first. Otherwise, you would wait and do infectious specimen collecting until last.
Next step should be the exocervix with a Ayres spatula (or similar, such as the Szalay-Cyto-Spatula).
The last step would be using the endocervix using a brush by rotating it 180 degrees or as given by the specific test protocol.
If in doubt about the order or method of specimen collection, check with your laboratory to verify your procedure method. This will help prevent having to do a repeat pap smear.
To transfer cervical material to the slide from a spatula (a), smear the sample with a single stroke using moderate pressure to thin out clumps of cells and mucus. To transfer material from a brush or moistened swab (b), roll the bristles or cotton swab across the slide. This is all to be placed on one slide.
The wooden spatula has various designs; those with elongated ends should provide better sampling of the endocervical area. When taking a direct scraping of the cervix with a spatula, a 360 degree rotation with firm contact is essential. Starting and stopping at the 3 and 9 o'clock position ensures retention of the sample on the upper surface of the spatula. Wooden spatulas allow good adherence of the sample for transfer to a glass slide. There are various designs of plastic spatulas that look similar to the wooden ones except that they are harder and sharp, which can cause capillary bleeding. Transferring the sample from these plastic spatulas to the glass slide is also difficult.
Data is lacking to suggest that the cytobrush is superior to or inferior to the moistened cotton swab. Both are equally effective in yielding dysplastic smears in combination with the spatula. One quarter turn with the cytobrush is sufficient for an adequate sample because the entire surface of the brush is in contact with the mucosa. Capillary bleeding may result from over manipulation and patients should be warned of possible spotting. If using a moistened cotton swab, a full rotation (360 degrees) is required for good sampling.
When the samples are obtained they should be transferred to the slide immediately. The direct cervical scraping from a spatula should be spread with a single stroke using moderate pressure to thin out clumps of cells and mucus. To transfer material from the endocervical brush or moistened cotton swab simply roll the brush or swab across the slide by twirling the brush handle.
Combined Pap Smear
Transferring both samples to one slide labeled with the patient's PHIN.
Combined Pap Smear
Transferring both samples to one slide labeled with the patient's PHIN.
A uniformly spread sample has many advantages:
a) The sample will be easily and uniformly fixed.
b) The staining of the sample will also be uniform.
c) All cellular components will be visible and not lost in thick ridges.
d) Microscopic screening is much easier and less tiring to the cytotechnologist.
If there is to be any delay between the sampling of the ecto- and endocervix, the first sample should be spread and sprayed with fixative, being careful to protect the unused portion of the slide.
Immediate fixation is essential to retain optimal cellular detail. There are various spray/coating fixatives on the market, each with its own instructions. Generally, most spray fixatives have a dual action in that they fix the cells and when dry provide a thin protective coating over the smear. The container should be held 15 to 25 cm from the slide to prevent dispersal or destruction of the cells by the force of the spray.
Alcohol fixatives may also be used but are not as practical. This method of fixation provides excellent results and may be used for all smears prepared at the side of the patient. Smears fixed in 95 percent alcohol should remain in alcohol for at least 15 minutes prior to staining. Sufficient drying time is necessary to avoid the sample sticking to the slide holder.
REJECTION OF SMEARS
Each specimen received must be acquisitioned with a PHIN referenced with the patient's name, together with the name of the referring health care provider, hospital or clinic, and the type of specimen. The specimen(s) should be easily retrievable according to any of the above data.
A. The laboratory will reject a specimen and the slide will be destroyed under the following circumstances:
- Specimen slide improperly labeled.
- Failure to identify the slide with the patient's name in the situation where the patient is a client/patient or for any other reason, has not been issued a PHIN.
- Discrepancy of information between specimen and requisition form.
- Slide broken beyond repair.
- Slide received without accompanying requisition.
B. The slide and requisition will be returned to the health care provider if the requisition is lacking pertinent information:
- Patients PHIN (if one has been issued).
- Patients name.
- Date of birth.
- Name/address of referring health care provider.
C. The requisition will be returned to the health care provider if it is received without a slide.
THIN PREP METHOD: LIQUID-BASED PREPARATION
ThinPrep is the commercial name for a liquid-based method of laboratory preparation of a Pap smear. This method may be used if a client/patient is anxious and might need to be reassured by a second screening test. It is used for women with evident excessive mucus, discharge or blood present and for women with recurrent "inflammatory" smears or unsatisfactory smears due to a lack of cells. Many women may request this method of testing.
The ThinPrep method costs approximately $36 (prices are subject to change). The lab performing the Thin Prep Pap Test will directly bill the woman. Remember to write her address on the request form, and to ask her to sign to acknowledge that she knows she will be sent an account.
The ThinPrep® Pap Test is significantly more effective than the conventional Pap smear for the detection of low-grade and more severe squamous intraepithelial lesions in a variety of patient populations. The ThinPrep Pap Test improved the detection of precancerous lesions by 65 percent in screening populations and 6 percent in high-risk populations when compared with the conventional Pap smear. Cervical cancer is one of the most common cancers among women but if detected early is almost always curable. Early detection of cervical disease usually means less traumatic intervention and can be expected to improve quality of life, increase life expectancy and reduce overall health care costs.
The ThinPrep® Pap Test is the most widely used method for cervical cancer screening in the United States. It was developed to address the limitations of the conventional Pap smear, and after rigorous clinical trials, it was approved in May 1996 by the U.S. Food and Drug Administration (FDA) as a replacement for the conventional Pap smear. The ThinPrep Pap Test is the only liquid-based cytology method approved by the U.S. FDA as "significantly more effective" than the conventional Pap smear for detection of cervical abnormalities. Most importantly, since FDA approval more than 100 studies have been published, in peer-reviewed medical journals, demonstrating a wide range of clinical benefits of the ThinPrep Pap Test including increased disease detection, reduction of equivocal diagnoses, improved specimen adequacy, cost effectiveness and the ability to perform additional tests out of the same vial, such as HPV and Chlamydia/Gonorrhea. The ThinPrep Pap Test is currently the only liquid-based cytology method approved by the FDA for HPV testing.
The ThinPrep method also improves specimen quality by reducing blood, mucus, inflammation and other obscuring artifacts.
Additional Diagnostic Testing
The ThinPrep Pap Test does not consume the entire fluid-based sample collected in the specimen vial. Additional diagnostic testing of the residual sample can increase the information yielded by the ThinPrep Pap Test. The greatest opportunity is in human papilloma virus (HPV) typing of samples that show possible, but inconclusive morphologic abnormality. The FDA approved HPV and Chlamydia/Gonorrhea testing directly from the PreservCyt® vial used for the ThinPrep Pap Test.
The National Cancer Institute estimates that about 3.5 million Pap smears are found to be inconclusive each year in the U.S., often leading to unnecessary colposcopy, biopsy and office visits. The average cost of the standard management of such cases is about $1,200 per case. The NCI estimates the cost to the US health care system at about $3.6 billion each year. HPV typing of samples diagnosed as ASCUS (atypical squamous cells of undetermined significance), or Low-Grade Squamous Intraepithelial Lesion (LSIL) may help triage women into conservative follow-up, or colposcopy and biopsy.
Cervical cancer is a disease that progresses through pre-cancerous and cancerous stages over a number of years. More importantly, cervical cancer is virtually 100% curable if it is detected and treated appropriately in the earlier stages of progression. Conversely, the cost of treatment increases significantly if cervical disease is discovered at later stages.
Summary of Advantages
The increased rate of detection of disease demonstrated by the ThinPrep Pap Test provides a new level of confidence for laboratories, clinicians and patients. At the same time the significant improvement in specimen quality and the ability to do multiple testing using the same sample, will substantially reduce costs and patient anxiety associated with re-screening and unnecessary follow-up testing.
FDA approval of the ThinPrep Pap Test as a replacement for the conventional Pap smear and the claim that the ThinPrep Pap Test is "significantly more effective" was based on extensive data submitted from a multi-site pivotal clinical trial. This study of 6747 women was conducted using a matched-pair, double-blinded protocol. The results of this study indicate that the ThinPrep Pap Test significantly increases the detection of low-grade or more severe lesions by 65 percent in screening populations and 6 percent for high risk populations when compared with the conventional Pap smear. The study also showed that the ThinPrep System significantly improved specimen adequacy compared to the conventional Pap smear.
In August 2001, the FDA approved a Premarket Approval (PMA) Supplement allowing inclusion of data describing the detection of High-Grade Squamous Intraepithelial Lesions (HSIL) with the ThinPrep Pap Test. Following initial FDA approval of the ThinPrep System in May 1996, Cytyc Corporation conducted a multi-site, direct-to-vial (intended use) clinical study to evaluate the ThinPrep System versus the conventional Pap smear for the detection of High-Grade Squamous Intraepithelial and more severe lesions (HSIL+; CIN 2/3). The results from this study showed a detection rate of 399/10,226 for the ThinPrep slides versus 511/20,917 for the conventional Pap smear. For these clinical sites and these study populations, this indicates a 59.7 percent (p<0.001) increase in detection of HSIL+ lesions for the ThinPrep System.
The ThinPrep® System
The heart of the ThinPrep System is the ThinPrep® 2000 Processor, an automated slide preparation unit that produces remarkably uniform thin-layer slides, virtually free of obscuring artifacts such as blood, mucus and inflammation.
Step 1: A gynecologic sample is collected using a broom-type or cytobrush/spatula cervical sampling device. Step 2: Instead of smearing the cells on a slide, the sampling device is rinsed into a ThinPrep vial containing PreservCyt® transport medium. The device is then discarded. Swirling the sampling device in the preservation solution helps to dislodge the cervical cells from the sampling device. Step 3: The sample vial is capped, labeled, and sent to the laboratory for slide preparation. Step 4: At the laboratory, utilizing Cytyc's Controlled Membrane Transfer (CMT) technology, the vial is placed into the ThinPrep 2000 Processor. First, a gentle dispersion step breaks up blood, mucus, non-diagnostic debris, and then thoroughly mixes the sample. A negative pressure pulse is generated which draws fluid through a ThinPrep Filter that collects a thin, even layer of diagnostic cellular material. The ThinPrep 2000 Processor constantly monitors the rate of flow through the ThinPrep Filter during the collection process to prevent the cellular presentation from being too scant or too dense. The cellular material is then transferred to a glass slide and fixed.
ThinPrep slides are stained, cover-slipped and evaluated by laboratory personnel using criteria similar to the conventional Pap smear. What is different is the marked improvement in clarity and specimen adequacy achieved with the ThinPrep System.
VARIOUS THINPREP PROTOCOLS
ThinPrep® Pap Test
Quick Reference Guide – Endocervical Brush/Spatula Protocol
Obtain an adequate sampling from the ectocervix using a plastic spatula. Rinse the spatula as quickly as possible into the PreservCyt® Solution vial by swirling the spatula vigorously in the vial 10 times. Discard the spatula.
Obtain an adequate sampling from the endocervix using an endocervical brush device. Insert the brush into the cervix until only the bottom-most fibers are exposed. Slowly rotate 1/4 or 1/2 turn in one direction. DO NOT OVER-ROTATE.
Rinse the brush as quickly as possible in the PreservCyt Solution by rotating the device in the solution 10 times while pushing against the PreservCyt vial wall. Swirl the brush vigorously to further release material. Discard the brush. Tighten the cap so that the torque line on the cap passes the torque line on the vial. Record the patient's name and ID number on the vial. …the patient information and medical history on the cytology requisition form. Place the vial and requisition in a specimen bag for transport to the laboratory.
ThinPrep® Pap Test
Quick Reference Guide – Broom-Like Device Protocol
Obtain an adequate sampling from the cervix using a broom-like device. Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the endocervix. Push gently, and rotate the broom in a clockwise direction five times. Rinse the broom as quickly as possible into the PreservCyt® Solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl the broom vigorously to further release material in the vial. Discard the collection device. Tighten the cap so that the torque line on the cap passes the torque line on the vial. Record the patient's name and ID number on the vial. …the patient information and medical history on the cytology requisition form. Place the vial and requisition in a specimen bag for transport to the laboratory.
Information and ThinPrep graphics obtained courtesy of www.Cytec.com
One Health Care Provider's Opinion about the ThinPrep Method:
ThinPrep is the first of the liquid-based technologies that have been shown to deliver technically superior preparations devoid of drying and other artifacts. Studies funded by ThinPrep's manufacturer, employing labs with a decade of experience with ThinPrep, have shown a slightly increased sensitivity for both high-grade and low-grade squamous intraepithelial lesions. So far, there is no evidence of any superiority in picking up adenocarcinomas and other glandular lesions (the incidence of which is thought to be increasing). Given this evidence, it is hard not to recommend ThinPrep for all Pap tests.
However, having examined these preparations myself, I prefer to be somewhat more cautious. Low grade squamous lesions (LSIL) are clearly easier to recognize on ThinPrep than on conventional Pap smears, but high-grade lesions (HSIL) are another matter. In conventional Paps, the often inconspicuous, small, round cells of HSIL are typically grouped together, where they can be more readily spotted. In ThinPreps, the cells suspension is homogenized, so that HGSIL cells are scattered apart from each other and are much more difficult to spot.
Further, I am bothered by the ThinPrep training materials, which read more like infomercials and soft-pedal the difficulties inherent in this type of preparation, including distinguishing adenocarcinoma cells from normal endometrial cells. Until ThinPrep has proved its superiority in regular, everyday labs that are not funded by grants from ThinPrep's manufacturer or staffed by former ThinPrep employees, I think it is prudent to not abandon the conventional Pap smear altogether. Therefore, my personal recommendation is for women to have annual testing, employing ThinPrep and conventional smears on alternate years.
If you are using a liquid pap procedure (Thin Prep) then follow the same order using the broom or spatular/brush as above.
For women who have had their uteruses removed, a sample of vaginal cells may also be collected.
If you do not have an assistant available to immediately apply the cell samples to the slide, collect the exo- and endocervix before applying to the slide. This prevents one from drying while collecting the other. The Thin Prep method eliminates the drying risk. Samples may be placed on top of one another on the slide. Spread the spatula material in one smooth stroke. Roll the brush along the slide by twirling handle. Fix the Pap smear sample (except thin prep) immediately to prevent air drying. Air drying is common reason for ASCUS Pap Smear.
After the samples of cells and fluid are smeared on glass slides or put into the Pap solution (Thin Prep), they are taken (or sent) to a lab for examination under a microscope. If you have an infection or there are signs of infection present, a sample of vaginal or cervical discharge may be taken for laboratory analysis also.
After the Pap smear is completed, the speculum is removed. The examiner will usually perform a pelvic exam to check the woman's uterus, vagina, ovaries, and fallopian tubes for any abnormalities in shape or size. Typically, the Pap smear and pelvic exam take only a few minutes to complete. the examiner will place two fingers in the vagina and the other hand on top of the abdomen to check placement of uterus and ovaries and to assess their size, shape, consistency and tenderness. This procedure may cause some discomfort.
Often there is a rectal examination, where the examiner places one finger in the rectum (often, one finger is placed in the vagina at the same time) to check the rectum itself and other nearby structures.
Though most women do feel some discomfort, pressure, or cramping during the exams, neither test should be painful. Women with tender, narrow, or irritated vaginas may experience more discomfort than others. Some women experience slight vaginal bleeding after the Pap smear is completed. It would be wise to use a sanitary pad if this should occur.
Pap smears and pelvic exams may be performed by physicians, physician assistants, nurse practitioners, nurse midwives, direct-entry midwives, or other specially trained medical professionals.
PAP SMEAR SPECIMEN COLLECTION TIPS
Collection technique of the Pap smear sample is critical for accurate sampling, adequate preservation, complete evaluation and meaningful interpretation. Improper sample collection, poor sampling, and/or cell preservation can render a Pap smear unsatisfactory for evaluation, requiring a repeat smear collection. If the Pap smear does not contain appropriate representative cells from the transformation zone and endocervical canal, the ability of the test to detect disease is very low. Likewise, if the preservation of the sample is compromised, the screener's ability to recognize abnormal cell is greatly diminished.
In order to prepare an adequate Pap test smear, the cells must be:
- Accurately labeled.
- Spread in a thin layer over the slide, without any thick areas or mechanical distortion.
- Distributed over the central area of the slide, sparing the ends and sides.
- Prepared rapidly and fixed quickly, to avoid air-drying.
Before beginning the procedure, the slide should be labeled with the client/patient's first and last names. The person collecting the Pap smear is responsible for ensuring the slide is correctly labeled before applying the cell sample to the slide. If the laboratory receives an unlabeled or incorrectly labeled slide or if the identity of the slide is questionable, the slide will not be processed and the Pap smear will have to be recollected.
If active purulent cervicitis is present, the client/patient should be evaluated using various tests available to the examiner such as cervical cultures, a wet mount using handing drop for Trichomonas and yeast, and a gram stain. DNA probes for Chlamydia, herpes, HPV or other organisms may also be considered. It is not recommended that the Pap smear be collected while purulent cervicitis is present, as it may adversely affect the reliability of the Pap test results. Instead, the client/patient should be treated with antibiotics, and a smear collected following successful therapy for infection and inflammation.
The cervical sample should be harvested by a two-stage technique, which includes sampling of the endocervical canal with a cytobrush, as well as obtaining a sample from the transformation zone with the spatula. The use of either the cytobrush or the spatula alone may be adequate but not as effective as the two-stage technique. A cotton-tip applicator should not be used as a collection device as endocervical cells frequently smudge or stick tightly to the cotton. Endocervical sampling is not recommended in pregnant patients since this may interfere with or disturb the cervical "mucous plug" that seals the uterus from the outside vaginal area during pregnancy. Some examiners prefer to use a cotton-tip applicator for the collection of Pap smears during pregnancy. Other examiners prefer to delay a pap smear until after the sixth week postpartum (after the baby is delivered). Often times the pap smear will be taken at the final postpartum visit.
Both the Cervex Brush ® (Unimar, Inc.) and the Accellon Combi ® (Medscand AB) are two collection devices which combine the action of the cytobrush and spatula, thus permitting broader sampling with a one-stage technique. When transferring cervical cells from the collection device to the slide, it's important to distribute the cells centrally onto the slide, and avoid spreading the cells closer than one-fourth inch from the edges or frosted region of the slide. Apply the cells in a thin layer, with light pressure. Thick areas are difficult to screen, and excessive mechanical pressure used in the preparation of the slide can destroy the cells.
Fix the sample quickly as drying artifact begins to appear if the sample is not fixed within 10 seconds, making it difficult to evaluate.
Proper fixation is critical to Pap smear adequacy. Optimally, smears should be fixed within a few seconds of preparation, particularly if the sample is not very moist, or if it possesses little endocervical mucus. The best strategy is to collect samples with the cytobrush and spatula first. Following that, the examiner should apply both samplings to the slide quickly and simultaneously, then follow with rapid fixation.
Fixation of the slide is best accomplished by immediate immersion in fresh fixative (95 percent ethanol). Alternatively, the slide may be fixed by spraying with a cytology fixative (Safetex®). After the slide has been fixed, place the labeled slide into a Pap smear folder. Both the slide and the folder should be labeled with the client/patient's name.
If the slide is not correctly labeled, or the identity of the preparation is doubtful, the slide cannot and will not be processed - and the Pap smear will have to re-collected.
TIPS FOR MAKING GOOD PAP SMEARS
Ed Uthman, MD
Diplomate, American Board of Pathology
Last updated 13 Jan 2001
First Print LAB MED/09-96
Revision MANQAP LAB MED-CYTO/06-01
The challenge we face in interpreting Pap smears is to facilitate the assignment of smears into either a low-risk category (including "within normal limits" and "benign cellular changes") or a high-risk category (including "squamous intraepithelial lesion" and higher-grade categories). We pathologists, with our partners the cytotechnologists, strive to minimize the number of cases classified as "atypical squamous (or glandular) cells of undetermined significance," as these "ASCUS" or "AGCUS" reports place the patient, clinician, and pathologist into a limbo of uncertainty regarding what should be done for the patient.
It has been my experience that the most frequent preventable cause of "the unnecessary ASCUS" is the suboptimal smear. Accordingly, I have put together a few problems with suggestions for solving them.
Problem: Air-drying. This is Pap smear enemy number one. If a cell is dried before it is spray-fixed, the cell enlarges, and nuclear detail is lost. If the pathologist cannot determine if a dried cell is atypical or not, he/she may tend to class the smear as an ASCUS.
Solution: Spray-fix the smear immediately. If you use a two-step technique (brush and spatula both), spray the first part of the smear before collecting the second part of the specimen. When spraying the first part, it is best to use a card or similar object to mask the part of the slide to be used for the second part of the specimen. If this taxes one's dexterity too much, it may be best in the long run to use a two-slide technique.
Problem: Blood, mucus, and pus. This unholy triad serves to obscure and distort the epithelial cells, making it difficult to determine if they are atypical.
Solution: Before collecting the specimen, gently remove excess mucus with a ring forceps holding a folded gauze pad. Surface exudate can be removed by placing a 2 inch x 2 inch piece of gauze over the cervix and peeling it away after it absorbs the exudate. A dry "proctoswab" or "scopette" can also be used. Do not rinse the cervix with saline, or a hypocellular smear may result. To reduce the amount of blood on the smear, use the spatula first, then the brush (the brush is more likely to induce bleeding). Finally, routine Pap smears should not be taken while the patient is menstruating.
Problem: Traumatized cells. These result from excessive manipulation of the delicate epithelial cells, either while being scraped from the cervix or spread on the slide. Traumatized normal cells may impersonate atypical cells.
Solution: When using the spatula, scrape in one continuous motion for a rotation of no more than 360 degrees. Spread the material collected on the spatula in a single, smooth, continuous stroke, as if buttering a saltine. Use moderate pressure against the slide to avoid producing thick clumps of material.
When using the brush, insert it into the os with gentle pressure and rotate it only 90 to 180 degrees. Roll (do not smear) the brush across the glass slide by twirling the handle.
Problem: Incomplete clinical information. To gain the greatest amount of useful information from a Pap smear, we need clinical information about the patient.
Solution: Fill out the requisitions completely. Age, date of last menstrual period, pregnancy status, and the history of previous abnormal Pap smears are absolute musts. Any other pertinent information concerning the reproductive system is welcome. Although much of our time is spent in the laboratory, we pathologists are physicians first. We are interested in the whole patient, not just the cells on the slide. You may be surprised at how helpful our reports can be if we have a little more background information.
Problem: Dueling laboratories. The Pap report from lab A says "atypical squamous cells of undetermined significance", but the biopsy report from lab B says "chronic cervicitis and squamous metaplasia". Who's right? What do I do now?
Solution: The abnormal Pap and follow-up biopsy MUST be examined simultaneously by the same pathologist. Cytopathological correlation is the cornerstone of cervical pathology. Without it, the clinician cannot determine if the abnormal Pap was significant or not. Did the biopsy recover the abnormal area sampled by the Pap, or was a high-grade dysplasia missed by the biopsy? One never knows unless the Pap and biopsy have been correlated. Remember, studies have shown that a very significant proportion of "ASCUS" Paps are ultimately revealed to be high-grade lesions. Correlation is the key to ferreting out some of these very difficult-to-diagnose cases.
The easiest way around this problem is to send the biopsy to the same lab that did the Pap smear. All reputable labs perform Pap/biopsy correlations routinely. If for some reason it is not possible to use the same lab, then call the Pap lab and ask that the patient's slide be sent to the lab charged with examining the biopsy.
If you are a provider, you should ALWAYS insist that the lab issue a correlation statement with the biopsy report. If you are a patient, you should NEVER accept a "negative" or "reactive" cervical biopsy report from a lab that has not also seen your abnormal Pap smear.
It has come to my attention that some labs are now refusing to send out Pap smears to other labs for cytopathological correlation. The reason given is that Pap slides are one-of-a-kind and are irreplaceable. Loss of such a smear in transit, say risk managers, may subject the lab to liability. While this is certainly true, the potential medical benefit to the patient far outweighs any financial liability to the lab. Accordingly, both clinicians and patients should not accept this no-send policy and should demand that direct visual correlation between Pap and biopsy be carried out in some fashion.
Problem: Management. Now that we have a good smear, it still comes back abnormal. Now what?
Solution: Asking how to manage an abnormal Pap is like asking for the correct recipe for potato salad. You will get a variety of answers, all reasonably defendable.
The colposcopist will be able to give you some information while you are still in the office. Results of biopsies or other tests usually take 2-3 weeks. You will be contacted by phone or letter when the results are ready.
Please remember that it is important to have your next Pap smear approximately 6 months after your colposcopy.
Classification of Squamous Cells on the Pap Test
Several different classification schemes have evolved over the years for characterizing Pap test results. Unfortunately, this is a continuing source of confusion. The outdated Class system originally developed by Dr. Papanicolaou has been replaced by the CIN grading system and the Bethesda System. CIN stands for cervical intraepithelial neoplasia and implies an underlying aberration in proliferation of cells. In most cases, this is a precancerous lesion that may be easily treated with nearly 100% cure. Both the CIN grading system and the Bethesda System are in widespread use today. The table below compares the various nomenclature used to classify squamous cell abnormalities seen on Pap test:
Classification of Squamous Cell Abnormalities Description CIN Grading Bethesda System (1) (See 4 Below) Class (Outdated) Normal Normal Normal Class I Atypia Reactive or Neoplastic Atypia ASCUS (2) Class II HPV HPV Low-Grade SIL (3) Class II Atypia with HPV Atypia, "condylomatous atypia" and "koilocytic atypia" Low-Grade SIL Class II Mild Dysplasia CIN I Low-Grade SIL Class III Moderate Dysplasia CIN II High-Grade SIL Class III Severe Dysplasia CIN III High-Grade SIL Class III Carcinoma in-situ CIS High-Grade SIL Class IV Invasive Cancer Invasive Cancer Invasive Cancer Class V
- Kurman, R.J., Solomon D. The Bethesda System for reporting cervical/vaginal cytologic diagnoses, Springer-Verlag, New York, 1994
- ASCUS: Atypical squamous or glandular cells of undetermined significance should be qualified further, if possible, as to whether a reactive or neoplastic process is favored.
- SIL: Squamous intraepithelial lesion.
- There will be a Bethesda III conference May, 2001 to further review and modify The Bethesda System (TBS).
NCI Bethesda System Web Atlas: Cytopathology Histology Images
Classification of Glandular Cells on the Pap Test
Glandular abnormalities are more difficult to classify. Glandular cells that are seen on the Pap test most commonly come from the endocervix. However, other glandular epithelial surfaces in the female reproductive tract may shed cells that are visible on the Pap test. Endometrial cells may appear on Pap tests and reveal underlying abnormalities. Because the female reproductive tract is open to the abdominal cavity via the Fallopian tubes, occasionally, cells from the ovary, Fallopian tubes, peritoneum or other interabdominal organs may be seen on the Pap smear. Glandular cells on the Pap test are classified as follows:
- Endometrial cells, cytologically benign, in a post-menopausal woman.
- Atypical glandular cells of undetermined significance (AGUS) that should be qualified further, if possible, as to whether a reactive or neoplastic process is favored.
- Endocervical Adenocarcinoma.
- Endometrial Adenocarcinoma
- Extrauterine Adenocarcinoma (e.g. ovarian, Fallopian tube, pancreas, etc.)
- Adenocarcinoma, not otherwise specified (i.e. unknown primary site)
Process of Cervical Changes
The cervix is the part of the uterus that extends into the vagina. There are two types of cells which line the cervix, one lines the outer cervix (portio) and another lines the inner cervix (endocervix). There is a distinct junction between the two cell types called the transformation zone. The Pap test is taken from this area because this where dysplasia (pre-cancer) and cancer most often arise.
Two common changes in cells are metaplasia and dysplasia.
Metaplasia - Metaplasia is generally described as a process of cell growth or cell repair which is benign (not cancerous). This process normally occurs in unborn babies, during adolescence, and with the first pregnancy. Studies have shown that metaplasia is present in more than one half of all women at some point in their development.
Dysplasia - In dysplasia, there is an increase in the number of cells formed, which do not mature as expected. This changes the inside of the cell. The higher the grade of dysplasia found on the cervix, the more likely that it will progress to invasive cancer. For this reason, dysplasia is thought as a "pre-cancerous" condition. Dysplasias are nearly 100 percent curable if managed appropriately. A small proportion of mild dysplasias (CIN I or low-grade SIL) will regress without treatment. However, it is not possible distinguish between dysplastic areas of the cervix that will return to normal and dysplastic areas which will progress and ultimately become cancer.
Causes of Cervical Cell Changes
Inflammation often results in mildly abnormal Pap tests. These may result in the diagnosis of CIN I in the CIN grading system, ASCUS in the Bethesda System or changes consistent with Human Papilloma Virus (HPV) infection. An inflamed cervix may appear red, irritated, or eroded. Some of the common causes of cervical inflammation are:
- Bacteria (from an infection).
- Viruses, especially herpes infections and condyloma cuminata (warts).
- Yeast or monilia infections.
- Trichomonas infections.
- Pregnancy, miscarriage, or abortion.
- Chemicals (for example, medications).
- Hormonal changes.
When the inflammation is treated and cleared, repair through metaplasia usually will follow. In several months, a repeat Pap test will often then be normal.
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