Pap Smear

The PAP Smear

by M. Punukollu M.D

What is the purpose of the Pap Smear?

Each year 15,000 women in the United States are diagnosed with cancer of the cervix.
Regular pelvic exams and Pap tests enable most pre cancerous conditions to be detected and treated before cancer develops, preventing more invasive cancers from developing.

Who should have it?

Anyone who is sexually active
If not sexually active then anyone aged 18 years and older
Women who have had a hysterectomy (surgery to remove the uterus, including the cervix) should ask their health care provider's advice about having pelvic exams and Pap tests.

When should I have it?

The best time is between 10 and 20 days after the first day of your menstrual period.
For about 2 days before the Pap test avoid douching, spermicidal foams, creams, jellies or vaginal medicines (except as directed by your health care provider), which may wash away or hide abnormal cells.
Do not have the Pap test at the time of your menstrual period as the blood can obscure the specimen reading.

What happens during the Pap test?

A wooden spatula (scraper) and/or a small brush are used to collect a small sample of cells from the cervix and upper vagina.
The cells are placed on a glass slide and sent to a medical laboratory to be checked for abnormal changes that may appear years before the cancer develops.

THE RESULTS

Negative Tests

A "negative" result means that the sample looked normal. If the results are negative then no further action is usually needed. However, you should:

Contact your health care provider if you experience unusual discharge, bleeding or pain.
Have regular Pap tests as recommended
Take steps to reduce your risk of cancer i.e. avoid smoking, if sexually active then use a latex condom to help protect against certain types of sexually transmitted diseases that could be precancerous.

Positive tests

A "positive" or "abnormal" test result means some changes in the cells were observed.

What does an abnormal Pap test mean?

Infection - even with no symptoms, an infection can cause cell changes. For example:

Yeast infections
Chlamydia
Genital herpes

Irritation - cervical cells may be irritated by:

Birth control devices e.g. Diaphragms or cervical caps.
Vaginal crams, douches or tampons.

Low estrogen levels

If postmenopausal, a decline in the hormone estrogen can cause inflammation.

Dysplasia

This is a condition where some cervical cells show changes that, in time, may turn into cancer.
Many women with dysplasia also show signs of infection with HPV (Human PapillomaVirus). There are many types of HPV, including those that cause genital warts, which are sexually transmitted. Certain types of HPV have been linked to cervical cancer.

Types of dysplasia

Mild dysplasia - a small number of abnormal cells in the top layer of the cervix.
Moderate dysplasia - a larger percentage of abnormal cells than mild dysplasia.
Severe dysplasia - two thirds of the top layer of cells in the cervix show changes. Severe dysplasia can become invasive cancer if not treated.
Carcinoma in situ - the abnormal cells have filled all the top layer of the cervix, but they have not spread deeper yet. Treatment is necessary.

What happens after an abnormal Pap test?

If the suspected cause is:

Infections/irritation or inflammation - treatment can be by medications with a repeat Pap in 3-6 months.

Mild dysplasia - may be handled in 1 of 2 ways:

Colposcopy - a special examination of the cervix.
Pap tests every 3-6 months to monitor the condition, since mild dysplasia may go away on its own but this cannot be predicted without repeat tests.

Other dysplasias, carcinoma in situ, and warts on the cervix - colposcopy is needed and possibly a biopsy.

Colposcopy and biopsy:

A colposcope (a special microscope) lights and magnifies the cervix.
The colposcope helps the examiner see abnormal areas (if any) and take samples for study.
The removal of samples for study is called biopsy.
The samples will be sent to the medical laboratory to be studied and to detect if abnormal cells are truly present.

What to expect:

You will lie down as for a pelvic exam.
A speculum will hold your vagina open.
A mild solution will be brushed onto your cervix. It will turn any abnormal areas white, making them easier to detect.
The colposcope will be focused on your cervix.
You will feel a brief pinch or cramp if a biopsy is taken.

After a biopsy:

You may have spotting and it may be necessary to use a sanitary towel.
You may experience mild cramping pain, use regular over the counter painkillers.
Be sure to follow up with your health care provider for the results of the biopsy and for further recommendations.

If your test results are abnormal and you are worried about cancer of the cervix, in addition to speaking to your health care provider, you can also call the cancer information service (CIS) on 1-800-422-6237 (1-800-4-CANCER) for up to date information on the latest treatments. The staff can talk with you in English or Spanish.

April 22, 2009 — The American College of Obstetricians and Gynecologists (ACOG) has issued a committee opinion on routine pelvic examination and cervical cytology screening that will be published in the May issue of Obstetrics and Gynecology.

The recommendations of ACOG Committee Opinion Number 431 come with the caveat that the document "reflects emerging clinical and scientific advances as of the date issued and is subject to change," writes ACOG's Committee on Gynecologic Practice. "The information should not be construed as dictating an exclusive course of treatment or procedure to be followed."

ACOG decided to issue the guidelines because the advent of the human papillomavirus vaccine has given rise to some confusion about when, and in whom, to perform periodic health assessments in women.

The recommendations on when to start screening, how often to continue screening, and when to stop routine pelvic examination and cervical cytology are based on age.

For women younger than 21 years who have never been sexually active, no routine pelvic examination, cervical cytology, or testing for sexually transmitted disease (STD) is needed. If the women have ever been sexually active, however, ACOG recommends cervical cytology be performed 3 years after the onset of sexual activity, and annually thereafter. Routine pelvic examination should be performed only when indicated by the patient's medical history.

For women aged 21 to 29 years, ACOG recommends an annual pelvic examination and cervical cytology. Sexually active women aged 25 years or younger should be screened for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Urine-based screening without a speculum examination is sufficient for such screening, according to ACOG.

ACOG also says that all adolescents and women aged 19 to 64 years who are sexually active should be screened for HIV.
For women aged 30 to 64 years, the recommendation is for annual pelvic examination plus cervical cytology. However, screening can be decreased to every 2 to 3 years after 3 normal test results if the patient has no history of cervical intraepithelial neoplasia (CIN) 2 or CIN3, is not immunosuppressed, is not HIV-positive, and was not exposed to diethylstilbestrol (DES) in utero.

For women older than 65 years, ACOG recommends an annual pelvic examination. However, cervical cytology may be discontinued if the woman has had 3 or more normal test results in a row, no abnormal test results in 10 years, no history of cervical cancer, no DES exposure in utero, is HIV-negative and immunocompetent, and does not have other risk factors for STDs. The need to begin screening again should be evaluated at each annual examination.

The pelvic examination is not a routine part of the annual health examination in girls aged 13 to 18 years, unless it is medically indicated. It should be performed when it is likely to yield information about amenorrhea, abnormal bleeding, vaginitis, pelvic pain, an STD, a pelvic mass, or other conditions.

It is also reasonable to stop speculum and bimanual pelvic examinations in asymptomatic women who have had a total hysterectomy and bilateral oophorectomy for benign indications, although annual examination of the external genitalia should continue.

It would also be reasonable to stop pelvic examination when a woman's age or other health issues reach a point where the woman would not choose to treat conditions detected during the routine examination. Such a decision should be discussed between the patient and her physician, ACOG recommends.

Obstet Gynecol. 2009;113:1190–1193.

page upated May 12, 2009

"But my daughter, when I told her of our topic [cancer] and my difficulty with it, said, 'Tell them about how you're never really a whole person if you remain silent, because there's always that one little piece inside of you that wants to be spoken out, and if you keep ignoring it, it gets madder and madder, and hotter and hotter, and if you don't speak it out, one day it will just up and punch you in the mouth.'
-Audre Lorde, Cancer Journals

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