Type of test Microscopic examination

Normal findings

No abnormal or atypical cells

Test explanation and related physiology

 A Pap test can detect neoplastic cells in cervical and vaginal secretions. This test is based on the fact that normal cells and abnormal cervical and endometrial neoplastic cells are shed into the cervical and vaginal secretions. By examining these secretions microscopically, one can detect early cellular changes associated with premalignant conditions or an existing malignant condition. The Pap test is 95% accurate in detecting cervical carcinoma; however, its accuracy in the detection of endometrial carcinoma is only approximately 40%.

The Bethesda System includes evaluation of the following:

 • Adequacy of specimen

• General categorization (optional)

• Interpretation or result

• Automated review and ancillary testing

 • Educational notes (optional)

❍ Negative for intraepithelial lesion or malignancy

❍ Epithelial cell abnormalities

A common method of Pap test specimen collection is liquid based cervical cytology (LBCC). With this technique, the specimen obtained from the cervix is placed into a preservative solution instead of smearing it onto a slide as is done during conventional Pap smear testing (CPT). Any blood cells and debris are then isolated by centrifuge, leaving only cervical cells. A thin film of the residuum is then placed on a slide to be evaluated. The specimen can be split into two parts. The first is evaluated for cytopathology. In the event that cytologic abnormalities of undetermined significance are found that could be better elucidated with further testing, the cells in the second split specimen are used for that testing. For example, if cellular changes are found that may be related to HPV, the second split specimen is tested by real time polymerase chain reaction (PCR) for HPV DNA (p. 522). A slightly different technique called the PapSpin uses a special brush placed in a collection device and centrifuged to provide a cellular concentrate for microscopic examination.

U.S. Preventive Services Task Force (USPSTF) recommended that

• Women aged 21 to 65 years should get Pap tests no more than every 3 years.

• Women aged 30 to 65 years may extend the interval between screens to 5 years if they use HPV tests in conjunction with the Pap test.

• Women younger than 21 years should not be screened for cervical cancer, regardless of sexual history.

• Women older than 65 years should not be screened as long as they have had consistently normal Pap test results and are not at high risk for cervical cancer.

 The guidelines apply to healthy women who do not have abnormal Pap test results or history of cervical cancer.

Contraindications

• Patients currently having routine, normal menses because this can alter test interpretation

• Patients with vaginal infections: Cellular changes that may be misinterpreted as dysplastic may transiently occur.

Interfering factors

• A delay in fixing a specimen allows the cells to dry, destroys the effectiveness of the stain, and makes interpretation difficult.

• Using lubricating jelly on the speculum can alter the specimen.

• Douching and tub bathing may wash away cellular deposits.

• Menstrual flow may alter test results.

• Infections may interfere with hormonal cytology. Such drugs as digitalis and tetracycline may alter the test results by affecting the squamous epithelium.

Procedure and patient care

 Before

* Explain the procedure to the patient.

* Instruct the patient not to douche or tub bathe during the 24 hours before the Pap test. (Some physicians prefer that patients refrain from sexual intercourse for 24-48 hours.)

* Instruct the patient to empty her bladder.

* Tell the patient that no fasting or sedation is required.

During

 • Note the following procedural steps:

 1. The patient is placed in the lithotomy position.

2. A vaginal speculum is inserted to expose the cervix.

 3. Material is collected from the cervical canal by rotating a moist saline cotton swab or spatula within the cervical canal and in the squamocolumnar junction (Figure 1).

4. The cells are immediately wiped across a clean glass slide and fixed either by immersing the slide in equal parts of 95% alcohol and ether or by using a commercial spray (e.g., Aqua Net hair spray). The secretions must be fixed before drying because drying will distort the cells.

5. If liquid-based cervical cytology is performed, the cervical specimen is placed in the fixative preservative solution. After being placed in this solution, cells can be evaluated any time within the next 3 weeks if kept frozen.

6. The slide is labeled with the patient’s name, age, and parity and with the date of her last menstrual period.

• Note that a Pap smear is obtained by a nurse or a physician in approximately 10 minutes.

* Tell the patient that no discomfort, except for insertion of the speculum, is associated with this procedure.

 After

* Inform the patient that usually she will not be notified unless further evaluation is necessary.

Fig1. Papanicolaou (Pap) smear. A, The vaginal speculum is shown in position to allow direct visualization of the cervix. B, The cervix is scraped with the bifid end of a wooden spatula.

Abnormal findings

- Cancer

- Infertility

- Sexually transmitted disease

- HPV infection

- Reactive inflammatory changes

- Fungal infection

- Parasitic infection

- Herpes infection

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