Pap Smear

Danil Hammoudi.MD

HTTP://PATHOLOGYLECTURES.HOMESTEAD.COM

BEFORE SIGNING OUT UNDERSTAND THE PRINCIPLES

Pap smears have contributed greatly to the prevention of invasive cancers.

However, patients forget to get an annual check or refuse follow-up diagnostic tests, most often.

Physicians may not do a pelvic examination or fail to follow-up abnormalities.

Laboratories may occasionally make diagnostic errors.

The pap smear should be combined with a pelvic and, breast examination, and a general health check. About 75% of women aged 18 and older have had a Pap smear in the preceding 3 years in the U.S. Ten to 25% of elderly women have never been screened.

They have cancer three times more often than those regularly screened.

About a third of women who have had a hysterectomy still have a uterine cervix and should also be screened.

Done properly Pap smears are the most effective cancer screening test known today and save many lives.

A Pap test finds cancer while it is still easy to cure. When a test is positive a repeat cervical examination is required with a microscope guided biopsy.

Protection in women aged 35 to 64 years is estimated at 94% if done yearly, 84% if every 5th year and 64% if every 10th.

With high participation in Iceland the cancer death rate has been reduced by 73%.

Women at high risk are those beginning sexual activity at an early age and those with many previous sexual partners.

The cancer is related to sexual exposure to human papilloma or wart virus.

Who Should Have a Pap Smear?

· Pap smears of the cervix are recommended every year as soon as a woman is sexually active; otherwise, every year starting from ages 18-21.

· If a woman has had her uterus removed, Pap smears of the vagina should be done regularly as recommended by her doctor.

What Does a Pap Smear Tell Us?

A Pap smear gives us information about the cells of the cervix or vagina. An abnormal Pap smear means that changes in the cells have been found. These changes can be referred to as "warning cells" (cells that can later become cancer cells.) This is why it is important to have regular Pap smears and to treat any abnormalities at an early stage.

Some abnormal Pap smears are due to infections of the cervix or vagina. Many abnormal Pap smears caused by infection will return to normal once the infection is treated.

It is not possible to remove every cell of the cervix with a Pap smear. Therefore, cells that are taken for the Pap smear can be normal and the cells remaining on the cervix may be abnormal. This does not happen often, but it is possible . This is another reason to have Pap smears regularly.

· A common myth is that women should not have a Pap smear until after they have had intercourse.

· The exam does not in any way harm or alter the female organs

Who is At Greater Risk for Abnormal Paps?

Women

who have had sexual contact before age 18.
with a history of many sexual partners.
whose mothers took DES (Di-Ethyl-Stilbestrol) - a medication which used to be taken for certain pregnancy complications from the 1940s to the 1960s.
with frequent infection which may be spread by sexual contact.
who smoke.
who become pregnant before age 18.

What are the Warning Signs of Cancer?

Bleeding between periods
Any unusual vaginal discharge or pain
Bleeding after intercourse
Bleeding after menopause

Remember that these are just warning signs which may or may not indicate cancer. If you notice any of the symptoms listed above, it is important for you to see your doctor to find out the cause and to receive treatment.

It is also important to realize that often there are no warning signs. Because of this, it is important to have regular Pap smears.

Most women with abnormal Pap results can look forward to a normal Pap smear in the future with appropriate treatment and follow-up.

Planning for Pap Smear

You can help your doctor do the very best exam by having the following information available:

Date of last period
Current medications such as birth control pills or other hormone pills or creams (the name and dose)
Any bleeding at times other than your period and when it occurred
Any discharge (white, thick, or watery liquid)
Any history of abnormal Pap smears or surgery such as a hysterectomy (having the uterus removed)

These facts help the doctor and the specialist looking at the cells to decide if the Pap smear is normal or not.

If the patient is having her period at the time of the exam, it is best not to have a Pap done that day.

should also avoid douching or using vaginal cream for at least 24 hours before having a Pap smear.

In summary, there are many good reasons to make the choice to have a Pap smear:

It's a simple procedure
A Pap costs little
It's a source of valuable information
It can help prevent further health problems
You're doing something for yourself
You can also get a general physical at the same time
It can be a time to ask questions about other health topics
It can leave you with the positive feeling of knowing you made a "smart choice" and a "good investment for your health."

Factors that adversely affect smear quality

Menstruation, blood loss or breakthrough bleeding
Vaginal inflammation/infection
Severe genital atrophy (menopause)
Pregnancy (and lactation)
Foregoing digital examination
Disinfectant cream or fluid, lubricating jelly
Vaginal medication (less than 48 hours before)
Vaginal douche (less than 24 hours before)
Foregoing colposcopy with acetic acid (less than 24 hours before)
Previous smear (less than 3 months before)
Cervical surgery (less than 3 months before)
Radiotherapy

Effect of menstrual cycle on smear quality

The best time for a smear to be taken is between the seventh and fifteenth day of the menstrual cycle
At this time, there is no longer menstrual blood or cell debris and there is virtually no cytolysis of squamous cells.
However, this does not mean that a doctor should propose a woman to come back if she presents at a different time in her cycle.
The presence of a small amount of blood does not necessarily have any adverse effect on the quality of the smear, but smears should not be taken during menstruation itself or when there is significant blood loss or breakthrough bleeding, as the presence of excess blood obscures a clear view of the epithelial cells causing reduction of the sensitivity of the screening test.

Anatomy histology review

The exocervix or portio protrudes into the vagina and is generally covered with multilayer squamous epithelium.
Via the external os, the exocervix internally becomes the narrow endocervical canal.
This canal branches into the endocervical crypts and is lined with monolayer columnar mucus-producing epithelium.
The transition between the two epithelia is called the squamocolumnar junction (SCJ). In prepuberty, this SCJ is usually situated inside the endocervical canal, close to the ostium externum.
After puberty, as a consequence of a change in shape of the uterine cervix, with use of the contraceptive pill and still under the influence of the first pregnancy, the endocervical columnar epithelium everts.
This cervical ectopy or ectropion is perfectly physiological during the reproductive period.
It is visible as a red zone (erroneously termed cervical erosion) contrasting with the pinker squamous portio.
The extent of the ectropion varies from person to person [Ferenczy, 1994].
Gradually, this exocervical columnar epithelium is replaced by metaplastic squamous epithelium.
Two junctions can be distinguished: the distal transition between squamous and metaplastic epithelium (the primary SCJ) and the more proximal junction between metaplastic squamous and columnar epithelium
(the secondary or physiological squamocolumnar junction [Boon, 1993; Ferenczy, 1994].
This area between the original and the current junction is called the transformation zone (TZ) or transition zone.
The shape of the TZ is often irregular and at first comprises multifocal islands, which gradually go on to coalesce.
Sometimes, there are still residual gland openings visible. Later, the metaplastic squamous epithelium may mature into fully mature multilayer squamous epithelium.
The functional SCJ migrates inwards with increasing age.
In post-menopausal women, this junction is almost always inside the endocervical canal.

COMBINED SPATULA-CYTOBRUSH TECHNIQUE (CONVENTIONAL SMEAR)

Fill in the appropriate request form with patient details. An adequate clinical history is essential.

	Label frosted end of slide with full patients name and date of birth or unit record number
	Rotate spatula 360 degrees
	Smear ectocervical material on the slide, ensuring a thin uniform smear
	Spray fix immediately
	Rotate brush in endocervical canal
	Roll brush onto unused area of slide. Do not overlap frosted area
	Spray fix immediately. Allow slide to dry prior to placing in slide mailer holder

Endocervical Sampling
Separate sampling of the endocervical canal is advisable for patients over the age of 40 years and in those instances where the smear taker is unable to confidently visualise the squamocolumnar junction.

NOTE: USE OF THE CYTOBRUSH IS NOT RECOMMENDED FOR PREGNANT PATIENTS.

I. Approach Based on Pap Smear

·
ASCUS = atypical squamous cells of undertermined significance.

·
AGCUS = atypical glandular cells of undetermined significance.

·
LSIL = low-grade squamous intraepithelial lesion (same as CIN I, or cervical intraepithelial neoplasia, grade 1).

A. Normal. Repeat every year from 18 to 65 years of age. If low risk, may change to every 3 years after 2 consecutive normals. After 65 years may discontinue after 2 consecutive normals.

B. No endocervical cells present. Pap test is considered inadequate and should be repeated.

C. ASCUS secondary to reactive/reparative changes or inflammatory changes. Look for causative agent on wet mount or cultures and treat. If no agent identified, treat with doxycycline 100 mg BID x 7 days. Repeat Pap test in 3 months. If resolved, repeat Pap in 6 months and then yearly. If abnormal at 3 months, do colposcopy.

D. ASCUS.

Repeat Pap smear in 3 months and then every 6 months for 2 years reverting to yearly after having 3 consecutive normals.
Colposcopy indicated if follow-up smear indicates ASCUS, or patient not able to comply with every 6 month follow-up exam.

E. LSIL or CIN I: Proceed to colposcopy.

F. ASCUS with dysplasia. Colposcopy indicated.

G. AGCUS. Colposcopy with endocervical curettage.

H. Other indications for colposcopy.

Dysplasia (mild, moderate, severe),
squamous cell carcinoma,
adenocarcinoma,
human papillomavirus infection (cervical or external genitalia),
persistent inflammation.

II. Methods for Treating Cervical Dysplasia

. Ectocervical.

Cryotherapy.
Laser therapy.
Topical 5-fluorouracil.
Local excision (biopsy forceps) if entire lesion well visualized.

A. Endocervical.

Surgical or laser conization.
Loop electrosurgical excision procedure

What is a colposcopy?
A colposcopy is a test in which the doctor uses an instrument called a colposcope to look at the vagina and cervix and possibly take a sample of tissue. A colposcope has a series of lenses that magnify the tissue in the vagina and cervix so that the doctor can directly examine the organs.

LEEP PROCEDURE

What is it?
Cervical LEEP is a procedure used to treat cervical dysplasia. Dysplasia is a precancerous change in the skin on the cervix. Many patients with abnormal PAP smears have an underlying dysplasia. The treatment for dysplasia is to remove or destroy the abnormal skin. There are several options that can be used to do this including—

Each of these are options for the treatment of dysplasia. Your provider will discuss the risks and benefits of these different options with you.

How will I know I need treatment at all for my abnormal PAP?
If you have an abnormal PAP smear, your doctor will usually perform a procedure called colposcopy on you. Colposcopy involves looking at your cervix with a microscope in the office. Sometimes, if an abnormality is seen, small biopsies of the skin of the cervix will be obtained at the time of the colposcopy. The biopsies will be sent to a pathologist to determine if there is any dysplasia present. If there is dysplasia present, then you may be a candidate for treatment.

How is a LEEP procedure performed?
A speculum is placed in the vagina just like for a PAP smear. The doctor will then place a numbing medicine in the cervix (similar to what the dentists use to numb your teeth before filling.) After the cervix is numb, a special wire loop is used to remove the abnormal area. The wire loop is hooked up to a special electrical machine and a sticky pad is placed on your leg in order to complete the electrical circuit. The procedure itself is usually painless, although some mild cramping may occur afterward. The whole procedure typically takes about 5 minutes to perform.

What happens to the tissue that is removed?
The tissue that is removed is sent to the pathologist to make sure that all the dysplasia was removed.

What kind of follow-up do I need?
Typically you will be seen back in 2-4 weeks to make sure the cervix has healed. You then should have a follow-up PAP smear every 3 months for 2 years to make sure that there is no recurrence of the dysplasia.

What are the risks?
Most women do not have any problems afterward. The most common problem is abnormal bleeding from the cervix which can occur even several days after the procedure. Infections are very rare. There is also some theoretical risks of damage to or weakening of the cervix which can result either in fertility problems in the future, or complicate pregnancy. These risks increase with the amount of tissue that needs to be removed in order to cure the dysplasia.

Will I be cured afterward?
Most women will be "cured" afterward, however a small percentage may have a recurrence or persistence of the dysplasia afterward. It is, therefore, important to have regular follow-up visits for PAP smears afterward.

Cryosurgery
Cryosurgery involves freezing the abnormal tissue on the cervix with a special probe in the office. It does cause some mild cramping during the procedure, however this usually resolves in several minutes afterward. The biggest complaint afterward is a bad malodorous discharge from the vagina that may take a few weeks to resolve. Cryosurgery is very effective in treating dysplasia, however about 10% of women may have a recurrent lesion in the future. Certain types of dysplasia can not be treated with this technique.

Laser Ablation of the Cervix
The abnormal skin on the cervix can also be removed using a laser. The laser has the advantage of removing the abnormal skin very precisely. Healing is more rapid than with cryosurgery and there is not a bad discharge afterward. The most common problem is bleeding that can occur even several days afterward. These procedures are done as an outpatient at the hospital. Local anesthesia, similar to the LEEP procedure is used for these procedures. Laser treatment of dysplasia is very effective, however about 10% of women may have a recurrence in the future as with the other methods. Certain types of dysplasia can not be treated with this technique

Cone Biopsies
Cone biopsy of the cervix is an old operation that is still very effective in the treatment of advanced cervical dysplasia. An alternative is the LEEP procedure that can usually be performed in the same types of patients. The procedure is performed under anesthesia as an outpatient at the hospital. A large biopsy of the cervix (shaped in a conical fashion, hence the name) is obtained. The tissue is sent to the pathologist to make sure all the dysplasia was removed and that there was no real cancer present. Cone biopsy is the most invasive treatment for cervical dysplasia and because of the amount of tissue removed has the greatest potential for causing fertility and pregnancy problems in the future.

Hysteroscopy

Hysteroscopy involves looking into the cavity of the uterus with a small "scope" as pictured above. Hysteroscopy can be performed as either an office procedure or an outpatient hospital procedure. In the office it is mainly used as a diagnostic tool to help evaluate patients that have infertility, recurrent miscarriage, or abnormal bleeding.

How is hysteroscopy done in the office?
Office hysteroscopy is a relatively painless procedure. Usually an appointment will be made in advance for this procedure. Upon arrival you will be given a mild pain medicine (Motrin or Anaprox) to help with cramping during the procedure. You will be place in a special chair that tilts back. The doctor will then wash the vagina and cervix off with a "prep" solution. Next a local anesthetic, like the dentists use (lidocaine), will be placed in the cervix. This usually provides excellent relief of any discomfort during the procedure. The doctor with then carefully dilate the cervix to allow the "scope" to be placed into the uterus. Usually carbon dioxide gas or water is attached to the scope to allow the walls of the uterus to expand. A bright light is also attached to the scope to illuminate the cavity of the uterus. The doctor with then carefully look at the inside of the uterus and make sure it is normal. The places where the fallopian tubes enter into the uterus can usually be seen. Any abnormalities are usually discussed afterward. In most cases a small sample of the lining of the uterus is removed for examination.. This is especially true if there is any abnormal bleeding.

What kind of problems are found with this technique?
If you are an infertility patient or a patient that has had multiple miscarriages, a common finding is a "septum" in the middle of the uterus. These can cause the cavity to be "split in two" and are usually totally asymptomatic. Other common finding include uterine fibroids and polyps. Fibroids and polyps commonly cause abnormal bleeding. Sometimes cancerous or precancerous growths are found. Sometimes there are no abnormal findings, but even this information can be very useful and reassuring.

What are the risks?
Most patients do not have any problems and can even go back to work the same day. Some patients may feel weak and have cramps that last several hours afterward. It is suggested that someone come with you that can drive you home afterward if you normally get a lot of cramps with your periods. Spotting and light bleeding like a period can occur for several days afterward and are considered normal. Serious risks are very rare but can include--

Bleeding
Infection
Perforation of the uterus with the hysteroscope
Allergic reaction to the anesthetic
Allergic reaction to the "prep" solution

When should I call the doctor afterward?
You should call the doctor is you develop--

A fever above 101
Severe lower abdominal pain
Abnormal discharge
Heavy bleeding

What can be done if I have a "septum"?
A septum is an extra fold of tissue down the middle of the uterus. It usually is a congenital condition that has been there your whole life. If there is no other associated abnormality of the uterus, these septum can be cut and removed using a larger "operative" hysteroscope in the operating room. These outpatient procedures are done under general or spinal anesthesia and usually you go home the same day. The septum is cut using a "wire electrode" which the doctor passes through the operating hysteroscope.

What if I have a fibroid?
Some fibroids can be removed by passing a "wire loop electrode" through a operative hysteroscope. The loop is used to shave away the fibroid and the pieces removed from the uterus. Only fibroids that extend into the cavity of the uterus can be removed with this technique.

What if I have a polyp?
Polyps are extra growths of tissue from the lining of the uterus. They are usually benign, however can cause excessive bleeding. They are usually easy to remove through the operative hysteroscope as an outpatient.

What if I just have heavy bleeding and no abnormality?
Many women develop excessive bleeding with their periods as they get older. Previously, if the bleeding could not be controlled with medication or hormones, a hysterectomy was needed. Recently a procedure has been developed in which the lining of the uterus is destroyed or removed using the operative hysteroscope. This procedure is called an endometrial ablation. Under anesthesia, the operative hysteroscope is placed in the uterus and a electric "roller-ball" is used to destroy the lining of the uterus. This outpatient technique can save many women from having a hysterectomy. Women can typically resume their normal activity in just a few days.

Cryosurgery

What is cryosurgery?
Cryosurgery is a procedure in which abnormal body tissues (sometimes referred to as lesions) are destroyed by exposure to extremely cold temperatures.

When is it used?
Cryosurgery is used to treat skin lesions such as freckles (for cosmetic reasons), hemorrhoids, warts, and some skin cancers.

It is also used to treat skin changes from genital wart virus and precancerous changes on the surface of a woman's cervix. These precancerous abnormalities are usually found from a Pap smear. (The lesions are also called "dysplasia", CIN, or cervical intraepithelial neoplasia.) Sometimes freezing is not an option if the abnormalities are too large.

How do I prepare for cryosurgery?
Most likely you will not have to do anything to prepare for cryosurgery. It is a simple procedure and it is done in a short time in your health care provider's office.

What happens during the procedure?
Your health care provider will use a probe-like tool to treat the affected areas. A very cold gas, usually nitrous oxide, is pumped through the probe. The gas makes the tip of the probe very cold.

Your provider will touch the tip of the probe to the affected area. When the cervix is treated you probably won't feel the cold sensation. Most women tolerate this procedure well, and leave the office with no discomfort.

How long your provider keeps the probe touching the skin or cervix depends on the size and type of the lesion and what type of gas is being used. For some abnormal tissue, such as genital warts, the procedure works best if the tissue is frozen quickly, allowed to thaw for a few minutes, and then frozen again.

What happen. after the procedure?
For skin lesions such as warts, a small blister will form. The blister will later become a scab or a crust. Your health care provider will tell you how to care for the wound.

There are usually no complications from this procedure. However, occasionally women who are having cervical cryosurgery have hot flushes or faint. If you have cryosurgery of the cervix, you will be asked to stay in the health care providers office for at least 10 minutes after the procedure. Although it is rare, sometimes women faint more than 10 minutes after the procedure, so it is a good idea to have someone take you home. Many women have mild abdominal cramping after cervical cryosurgery. Many women also have a watery discharge from the vagina after the procedure.

Some abnormal tissues may need to be treated more than once. Your health care provider will tell you how often you need to be checked for recurrence or retreatment. You will need a follow-up visit to check healing and to see if any abnormal tissue still remains.

If you have cervical cryosurgery for an abnormal Pap smear, your health care provider will tell when you should have your next Pap smear.

Follow your health care provider's instructions for checking back for problems, questions, and your next visit.

What are the benefits of cryosurgery?
Cryosurgery is very effective and is less expensive than other treatments. It can be done in your health care provider's office and anesthesia is not necessary.

What are the risks associated with cryosurgery?
If you are being treated for a cervical lesion, during or after cryosurgery you may experience: - fainting - hot flushes - lower abdominal cramping.

If you are being treated for a skin lesion, you may have: - discoloration of the treated area - damaged hair and sweat glands in the treated area - minor scarring.