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Pap Smear
Aka: Pap Smear, Cervical Cytology, Cervical Smear, Papanicolaou Smear, Cervical Dysplasia
- See Also
- Pap Smear Intervals
- Cervical Cancer Screening
- Cervix Anatomy
- Colposcopy
- Colposcopy Findings
- Colposcopy Protocol
- Cervical Intraepithelial Neoplasia Procedures
- Atypical Squamous Cells of Undetermined Significance (ASCUS)
- Low Grade Squamous Intraepithelial Lesion (LSIL)
- High Grade Squamous Intraepithelial Lesion (HSIL)
- Atypical Glandular Cells of Undetermined Significance (AGUS Pap Smear)
- Human Papillomavirus (HPV)
- Cervical Cancer
- Efficacy: Pap Smear
- Specificity of Pap Smear: 70%
- Sensitivity of Pap Smear: 80%
- Thin Prep Pap Smear
- Liquid based Pap Smear improves sensitivity
- Can be used for HPV DNA testing
- Will allow Gonorrhea and Chlamydia testing
- Reduces sampling error (e.g. drying artifact)
- Use spatula and cytobrush (instead of broom)
- Improves endocervical sampling
- Repeating Pap Smear improves sensitivity
- Repeated in short interval, sensitivity: 96%
- Third repeated in short interval: 99.2%
- Short interval is approximately 1 year
- Precautions
- Abnormal visible cervical lesions indicate diagnostic Colposcopy (regardless of Pap Smear)
- Despite negative Pap Smears, HPV positive status confers higher risk at older ages
- Kjaer (2006) Cancer Res 66(21): 10630-6 [PubMed]
- Prognosis: Reassuring findings
- Negative HPV test with a negative Pap Smear after age 30
- High longterm Negative Predictive Value
- Bigras (2005) Br J Cancer 93(5): 575-81 [PubMed]
- Technique
- Preparation: Water-based Speculum lubrication
- Does not contaminate conventional Pap Smear slide
- Amies (2002) Obstet Gynecol 100:889-92 [PubMed]
- Harer (2002) Obstet Gynecol 100:887-8 [PubMed]
- Does not affect thin prep Pap Smear
- Note that thin-prep manufacturer recommends water
- Hathaway (2006) Obstet Gynecol 107:66-70 [PubMed]
- Tips to prevent unsatisfactory Pap Smears
- Avoid Pap Smear during time of Menses
- Avoid tampons and intercourse within 48 hours
- Blot Cervix prior to Pap Smear
- Focus on endocervical canal in postmenopausal women
- Step 1: Clean Cervix (clean only if large discharge)
- Gently wipe excess Cervical Mucus from os
- Use large cotton tipped swab
- Do not rinse Cervix with Saline
- Avoid performing Pap Smear during menstruation
- Step 2: Sample the Cervix
- Order is critical for less blood
- First: Chlamydia cultures (if needed)
- Option 1: Conventional Pap Smear
- Second: Exocervix with Ayres spatula (or similar)
- Last: Endocervix with Brush (rotate 180 degrees)
- Option 2: Thin prep
- Liquid pap (with broom or spatula/brush as above)
- Reflex to HPV testing (do not HPV test under age 20 due to low predictive value)
- Conventional Pap Smear pointers
- Get exo- and endocervix before applying to slide
- Prevents one from drying while collecting other
- Thin prep eliminates drying risk
- Samples may be placed on top of one another
- Spread spatula material in one smooth stroke
- Roll the brush along slide by twirling handle
- Pregnancy
- Place brush only 50% into canal and sample sides
- Step 3: Fix Pap Smear Sample (except thin prep)
- Fix sample immediately to prevent air drying
- Air drying is common reason for ASCUS Pap Smear
- Labs
- HPV DNA
- Tested at age 30 regardless of Pap Smear results
- Directs further management of Cervical Cytology in age over 25-30 years old
- Not typically useful prior to age 25-30 years old
- Do not obtain more often than every 3 years
- Identify HPV Genotype if HPV positive result
- Findings
- Normal
- Bethesda: Normal
- World Health Organization (WHO): Normal
- Inadequate Pap Smear
- Negative Pap Smear Cytology but Missing Transformation Zone
- Benign Pap Smear Changes
- Vaginal Infection
- Reactive changes (Inflammation)
- ASCUS Pap Smear
- Atypical Squamous Cells of Undetermined Significance
- AGUS Pap Smear
- Atypical Glandular Cells of Undetermined Significance
- Cervical Intraepithelial Neoplasia (Dysplasia)
- Mild Dysplasia
- Bethesda: Low Grade SIL
- WHO: CIN I
- Risk of progression
- Regresses spontaneously in 60% of cases
- Persists in 30% of cases
- Progresses to CIN III in 10% of cases
- Progresses to invasive cancer 1% of cases
- Moderate Dysplasia
- WHO: CIN II
- Risk of progression
- Regresses spontaneously in 40% of cases
- Persists in 40% of cases
- Progresses to CIN III in 15% of cases
- Progresses to invasive cancer 5% of cases
- Severe dysplasia
- Bethesda: High Grade SIL
- WHO: CIN III
- Risk of progression
- Regresses spontaneously in 33% of cases
- Persists in 55% of cases
- Progresses to invasive cancer >12% of cases
- Cervical Adenocarcinoma In-Situ (Pre-invasive Cervical Cancer)
- Cervical Cancer
- References
- Ostor (1993) Int J Gynecol Pathol 12(2): 186-92 [PubMed]
- Management: Primary HPV Screening Protocol
- See Pap Smear Intervals
- HPV DNA negative
- Routine screening
- HPV DNA high risk type 16 or 18
- Colposcopy
- HPV DNA other high risk type (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
- Negative Cervical Cytology
- Repeat Cervical Cytology in one year
- Positive Cervical Cytology for ASCUS or higher
- Colposcopy
- References
- Huh (2015) Gynecol Oncol 136(2): 178-82 [PubMed]
- Management: Benign or Mild Pap Smear Changes
- See Inadequate Pap Smear
- See Negative Pap Smear Cytology but Missing Transformation Zone
- See Benign Pap Smear Changes
- Management: Abnormal Pap Smear
- See ASCUS Pap Smear (Pap Smear Atypia)
- ASC-H should be managed as abnormal with Colposcopy
- See AGUS Pap Smear
- See Low Grade Squamous Intraepithelial Lesion (LSIL)
- See High Grade Squamous Intraepithelial Lesion (HSIL)
- See Cervical Cancer
- Resources
- American Society for Colposcopy and Cervical Pathology
- http://www.asccp.org
- (2014) ASCCP Guidelines
- http://www.asccp.org/Guidelines-2/Management-Guidelines-2
- (2019) ASCCP Guidelines
- https://www.asccp.org/management-guidelines
- References
- Boon (1989) Acta Cytol 33(6):843-8 [PubMed]
- Brotzman (1996) Am Fam Physician 53(4):1154-62 [PubMed]
- Fowler (1993) Postgrad Med 93(2):57-70 [PubMed]
- Kurman (1994) JAMA 271(23):1866-9 [PubMed]
- Koss (1989) JAMA 261(5):737-43 [PubMed]
- Miller (1992) Am Fam Physician 45(1):143-50 [PubMed]
- Orr (1992) Gynecol Oncol 44:260-2 [PubMed]
- Rerucha (2018) Am Fam Physician 97(7): 441-8 [PubMed]
- Shepherd (1995) Am Fam Physician 51(2):434-40 [PubMed]
- Stack (1997) Postgrad Med 101(4):207-4 [PubMed]