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Pap Smear / Pap test

Our goal is  to provide accurate laboratory testing, with a reasonable turnaround time, in a cost-effective manner. 

Pap Smears: Pap smear results are generally reported within2 working days after receipt in the laboratory. 

All specimens must be properly labeled with the patient's name and accompanied by a completed requisition form. The requisition should include the source of the specimen and any pertinent clinical history or history of carcinoma. For Pap smears an LMP is required and any other information (i.e. PMP, surgery, exogenous hormones, hysterectomy, radiation, chemotherapy, abnormal bleeding and previous abnormal Pap smears) is essential to interpretation and should be included on the requisition. Unlabeled specimens will be rejected. 

To ensure maximum cellular preservation, please refer to the specific test's Collection comment to be sure the specimen is collected in the correct transport media.  

Traditional (Conventional) Papanicolaou Smear Technique:

  1. Use the following for one-slide – 2 spatula, 1 cytobrush, and cytology spray fixative.
  2. Label the frosted end of the glass slide in pencil with the patient’s name.
  3. Scrape the upper lateral vaginal wall lightly with a wooden spatula and have a nurse or assistant hold this spatula.
  4. With a second spatula, lightly scrape the entire ectocervix, especially the borders of erosions and have a nurse or assistant hold this spatula.
  5. Insert a cytobrush into the endocervix through the device, immediately roll the endocervical specimen contained on the cytobrush on the section of the slide farthest from the frosted end; quickly take the ectocervical specimen (second spatula) and spread the cervical material in the middle section of the slide; and finally take the vaginal specimen (first spatula) and smear it on the section of the slide closest to the frosted end.
  6. Spray immediately with cytology spray fixative (caution – flammable)

The patient should be instructed not to douche for 24-48 hours prior to the examination. Please collect cytology specimens before manual examination, introduction of chemicals, biopsy, or before another procedure is performed. Lubricant should not be used on the speculum as it interferes with the staining reactions.

On the cytopathology requisition form, fill in the patient's name, age, and address, as well as the physician's name and location. Be sure date of specimen is indicated.  Adequate clinical information is essential for proper interpretation of the specimen. Be sure to include complete relevant history, including date of last menstrual period, history of cancer or dysplasia, therapy history, gyne surgery, laser treatment, DES exposure, etc.

Sampling:

Cervical smears: Gently remove excessive secretion or blood at cervical os with cotton swab. Scrape cervix circumferentially at squamocolumnar junction. Spread material evenly onto one half of labeled slide. Then gently insert brush into cervical os. Rotate it. Retrieve brush and spread material evenly onto the other half of the slide. (It does not matter if the two samples mix together.) Fix with spray or alcohol IMMEDIATELY before any drying occurs. Vaginal and vulval smears: Fix and label.

Processing:

Allow fixative to dry before enclosing in the cardboard mailer. Label cardboard mailer with patient's name. Close mailer and secure with tape or rubber bands. Send with completed cytopathology requisition to specimen receiving/Cytopathology Laboratory.

Cause for Rejection:

Improper labeling of the slide or the requisition, fixation in formalin, drying of smear before fixation, incomplete requisition, failure to provide AGE, LMP, and history on requisition will result in rejection.

Health Tips 

Why should I have a Pap smear?

Pap smears look for changes in the cells of the cervix, located at the neck of the uterus (or womb). These cell changes are almost always caused by the Human Papillomavirus (HPV), and can be treated to prevent cervical cancer from developing. The cervix has millions of tiny cells, and changes can happen to some of these cells without you knowing.

What causes cervical cancer?

Changes to the cells of the cervix that can lead to cancer are caused by long-term infection with the Human Papillomavirus (HPV). HPV is a common outcome of being sexually active, with 4 out of 5 people having HPV at some stage in their life. Most people with HPV have no symptoms. Usually your body will clear HPV naturally in 1 to 2 years, however in a small number of cases, it can stay for longer and lead to cervical cancer. For more information on HPV see HPV vaccine frequently asked questions.

Who needs to have a Pap smear?

Guidelines have been developed for cervical cancer screening that address the frequency with which women should have Pap smears. The US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) both recommend that all women receive cervical cancer screening every 3 years between the ages of 21 and 65. A Pap smear is the typical screening procedure, but when a Pap smear is combined with a test for human papillomavirus (HPV, the known cause of cervical cancers), screening every 5 years is acceptable for women aged 30 and above.

Pregnancy does not prevent a woman from having a Pap smear, therefore, Pap smears can be safely done during pregnancy.

Pap smear testing is not indicated for women who have had a hysterectomy (with removal of the cervix) for benign conditions. Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy.

All women who have ever been sexually active need to have a regular Pap smear, even if:

• you are well and have no symptoms
• you have received the HPV vaccine (also known as the cervical cancer vaccine)
• you are pregnant
• you have only had one sexual partner
• same sex attracted/lesbian women
• you no longer have periods
• you no longer sexually active
• you have had a hysterectomy (your doctor can advise you)

When should I have a Pap smear?

All women over the age of 18 who have ever been sexually active should have Pap smears every two years, or two years after first sexual activity (which ever is later) and continue until age 70.
If you are older than 70 and have had two normal tests in the past 5 year, your doctor will advise you whether you still need to have Pap smears.

If I have a disability, do I still need a Pap smear?

Yes. Women with disabilities need Pap smears too. If you have a disability and require special needs to assist in having a Pap smear, there are places with adjustable beds. Please contact your local health service provider to discuss if they can cater to your needs.

Do I have to pay for a Pap smear?

Yes. When you make an appointment for a Pap smear, ask your health service provider if you will be required to pay for a doctor’s consultation fee and the Pap smear test.
If your doctor ‘bulk bills’ then they will claim the cost direct from Medicare and you will not have to pay anything or
You will need to pay the fee but you will be able to claim most of this back by going to your local Medicare office.

What happens during a Pap smear?

A Pap smear is a simple test that takes a few minutes to carry out a doctor or nurse will take you to a private room where you will be asked to remove your underwear and to lie on your back on an examination bed
you will be given a sheet to cover yourself from the waist down, and if this has not been provided, you can ask for one
a speculum (an instrument which may be made of stainless steel or hard plastic) is gently placed in the entrance to the vagina so that the cervix can be seen
a small spatula and a tiny brush are used to rub some cells from the cervix
it should not hurt but it might feel uncomfortable. You can ask to have a pillow under you to help put your cervix in the right position.
the cells are wiped onto a glass slide and sent to a laboratory to be tested.
Remember, if you are nervous, you can take a support person (such as your worker, friend or family member) with you.

What if my Pap smear is abnormal?

An abnormal result doesn't usually mean you have cancer. Almost all abnormal results are caused by HPV. Sometimes these go away on their own, and sometimes you may need treatment to stop them from developing into cancer.

What is the difference between a Pap smear and an HPV test?

Cervical cancer screening includes two types of tests: a Pap smear and an HPV test. While the Pap test detects cell abnormalities, the HPV test detects high-risk HPV strains in cervical cells. Many doctors perform both tests at the same time, even using the same sample in a procedure called Pap and HPV costesting.

Will it hurt?

A Pap shouldn’t hurt, according to The Office on Women’s Health. Some women experience light bleeding afterward that is similar to spotting. Still, the worst part of a Pap is the sheer discomfort of it all—and I’m not talking physical discomfort. Let’s face it, this is not what any woman has in mind when it comes to playing doctor. The gels, the speculum... none of them are my idea of a hot date. Meanwhile, paper “gowns” leave more than a little something to be desired. Couldn’t someone at least invest in two-ply?

Should I do anything to prepare for the test?

It’s best to have a Pap and/or HPV test between 10 and 20 days after the first day of your last period, according to the National Cancer Institute. If you’re in the middle of perimenopause and have irregular periods, this can be difficult to time. But OB-GYNs understand. So if you wake up on the day of your Pap with a period, give the office a call and ask if you should postpone. The institute also stresses that for two days before testing, you should not to use douches, tampons, vaginal creams, or have sex. Basically, don’t put anything up there! By washing away or hiding abnormal cells of the cervix, insertion of any foreign objects can cause incorrect test results.

How long will it take to get the results?

The waiting game is largely in the examining laboratory’s court. While some labs need as few as three days to process the results, most doctors tell patients it’ll take about three weeks, according to The Office on Women’s Health. Don’t use the waiting time to worry. Even if you have an abnormal test result, it does not necessarily mean you have cervical cancer.

What happens if the Pap finds something?

If your doctor says your Pap results are “positive,” it means it presented abnormal cells. In this case, your doctor may follow up with an HPV test if one was not performed as a part of your original screening. The doctor may also repeat the Pap to determine if follow-up tests or interventions are needed. Many times, cell changes in the cervix go away without treatment, especially if the HPV test shows no infection, according to the National Cancer Institute. If you are near or past menopause and have abnormal cervical cells—but no signs of HPV—your doctor may prescribe estrogen cream. According to the institute, low estrogen levels can cause cervical cell changes that can be remedied by applying an estrogen cream to the cervix for a few weeks.

How often should I have a Pap?

Current guidelines recommend that you have a Pap test every three years starting at age 21. These guidelines also say that women ages 30 to 65 should have HPV and Pap cotesting every five years or a Pap test alone every three years. Women with certain risk factors may need more frequent screening or to continue cervical cancer screenings beyond age 65, according to the National Cancer Institute. Talk to your doctor to determine if you are at higher risk for cervical cancer.

I had a hysterectomy. Do I need a Pap?

It depends on the type of hysterectomy you had as well as your health history. If you had a total hysterectomy—in which the cervix is removed along with the uterus—for reasons other than cancer, you may not need regular Pap tests, according to The Office on Women’s Health. However, if the hysterectomy was due to abnormal cells or cancer, you should be tested yearly for vaginal cancer until you score three normal test results. Meanwhile, women who have had only their uterus, not cervix, removed during hysterectomy should still have regular Paps. Either way, you should talk with your doctor about your individual needs.
When it comes to matters of health, a good offense is always the best defense. So treat your cervix to regular screenings. Tell your daughters to do the same. It only takes minutes—but it can gain you years of health and happiness.

What are the risks of having a Pap smear?

There are absolutely no known medical risks associated with Pap smear screening. (However, there are medical risks from not having a Pap smear.) A woman may experience a small amount of spotting (light vaginal bleeding) immediately after a Pap smear, but heavy or excessive bleeding is not normal.

What kind of doctor performs a Pap test?

Pap testing is performed by obstetrician-gynecologists (OB-GYNs) or by primary care physicians including family practitioners, internal medicine specialists, or pediatricians. Pap smears can also be performed by other specially trained health-care professionals including physician assistants, nurse practitioners, or nurse midwives.

How is a Pap smear done?

With the woman positioned on her back, the health-care professional will often first examine the outside of the patient's genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal.

A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.)
A small brush or swab is inserted into the opening of the cervix and twirled around to collect a sample of cells.
A second sample is also collected on the surface of the cervix as part of the Pap smear
The samples are placed in a solution from which cells are isolated and used to produce slides for laboratory evaluation.
A bimanual (both hands) pelvic exam usually follows the collection of the two samples for the Pap smear. The bimanual examination involves the physician or health-care professional inserting two fingers of one hand inside the vaginal canal while feeling the ovaries and uterus with the other hand on top of the abdomen (belly).

How will I find out the results of my Pap smear?

The results of the Pap smear are usually available within one to two weeks. At the end of Pap smear testing, each woman should ask how she should expect to be informed about the results of her Pap smear. If a woman has not learned of her results after a month, she should contact her health-care professional's office.

What is an abnormal Pap smear?

An abnormal Pap smear shows cancer or precancerous changes in the cells of the cervix. It is especially important to identify abnormal cells in the early stages, because treatment can be carried out to remove the abnormal cells. The section below entitled "How is a Pap smear read and analyzed" contains the specific terminology used in the report for an abnormal Pap smear.

How is a Pap smear read (analyzed)?

Pap smear analysis and reports are all based on a medical terminology system called The Bethesda System. The system was developed (at the National Institutes of Health (NIH) in Bethesda, Maryland) to encourage all medical professionals analyzing Pap smears to use the same reporting system. Standardization reduces the possibility that different laboratories might report different results for the same smear.

The Bethesda System was the outcome of a National Cancer Institute workshop that was held in 1988 in an effort to standardize Pap smear reports. In 2001, the guidelines were revised and improved. Acceptance of the Bethesda reporting system in the United States is virtually universal.

The major categories for abnormal Pap smears reported in the Bethesda Systems are as follows (described in further detail in the "What are the possible recommendations for follow-up after a Pap smear?" section):

ASC-US: This abbreviation stands for atypical squamous cells of undetermined significance.
LSIL: This abbreviation stands for low-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade I.
HSIL: This abbreviation stands for high-grade squamous intraepithelial lesion. Under the old system of classification, this category was called CIN grade II, CIN grade III, or CIS.
ASC-H: This means atypical cells are present and HSIL cannot be excluded.
The word "squamous" describes the thin, flat cells that lie on the surface of the cervix. "Intraepithelial" indicates that the surface layer of cells is affected. A "lesion" means that abnormal tissue is present.

An abnormal or inadequate Pap smear report may contain the following diagnoses.

Absence of endocervical cells on the Pap smear
There is a particular area inside the opening of the cervix where the cells lining the vagina change to the cells that characterize the inside of the cervix (endocervical cells). This is called the "transition zone". The Pap smear sample from the cervical opening attempts to sample these cells. However, this area may be so far up inside the cervix that the Pap smear sampling instrument simply cannot reach that high. Sometimes, the transition zone may be less accessible to the Pap brush or the cervical opening cannot be seen well enough to obtain an adequate sample.

Unreliable Pap smear due to inflammation
If severe inflammation is present, its cause(s) are investigated. The physician's goals are to identify the cause of inflammation and to treat and resolve the condition, if possible. Untreated inflammation can have consequences for the woman as well as her sexual partner(s).

The vaginal irritation may be caused by a lack of estrogen, such as occurs after menopause when the ovaries stop producing this hormone. This lack of estrogen tends to make the vaginal walls irritated and red. If a woman has this condition and it is related to an estrogen deficiency (called "atrophic vaginitis" and usually described on the Pap smear report as "atrophic changes"), her physician may recommend a trial of topical (locally- applied) vaginal estrogen (cream, vaginal estrogen tablets, vaginal estrogen ring) to heal the inflammation. The Pap smear is then repeated.

Atypical squamous cells of undetermined significance (ASC-US)
Sometimes, atypical squamous cells of undetermined significance (also called "ASC-US"), is the Pap report. This is the mildest form of cellular abnormality on the spectrum of cells ranging from normal to cancerous. ASC-US means that the cells appear abnormal, but are not malignant.

"Of undetermined significance" means that the atypical-appearing cells may be the end result of a number of different types of injuries to the cervix. For example, the human papilloma virus (HPV) could be the cause of ASC-US. Most instances of ASC-US (80%-90%) resolve spontaneously (by themselves without specific medical intervention or treatment).

Low-grade squamous intraepithelial lesion (LSIL)
A reading of LSIL is a reason for immediate further investigation because it is more abnormal than ASC-US. Fifteen to 30% of women who have this abnormality on Pap testing will have a more serious abnormality on biopsy of the cervix. Thus, all women with LSIL are recommended to undergo colposcopy (an examination of the cervix using a special visualizing scope, often accompanied by a cervical biopsy, see below). Even LSIL spontaneously returns to normal without therapy in many women within several months.

High-grade squamous intraepithelial lesion (HSIL)
The most severe cellular abnormality that is not actually cancer is high-grade squamous intraepithelial lesion (HSIL). A finding of HSIL unquestionably requires prompt evaluation and treatment.

What information is included on a Pap smear report?

The first items on a Pap smear report are for purposes of identification. The report is expected to have the name of the woman, the name of the pathologist and/or the cytotechnologist who read the smear, the source of the specimen (in this case, the cervix), and the date of the last menstrual period of the woman.

The Pap smear report should also include the following:

A description of the woman's menstrual status (for example, "menopausal" (no longer menstruating) or "regular menstrual periods")
The woman's relevant medical history (example, "history of genital warts")
The number of slides (either one or two, depending on the health care professional's routine practice)
A description of the specimen adequacy (whether the sample is satisfactory for interpretation)
The final diagnosis (for example, "within normal limits")
The recommendation for follow-up (for example, "recommend routine follow-up" or "recommend repeat smear")

Why is a woman's menstrual status important for the Pap smear?

A woman who is menstruating sheds cells from the lining of her uterus called endometrial cells. If these cells are seen on the Pap smear of a menstruating woman, the report may note that these cells are present. This is normal if the Pap test was done around the time of the woman's menstrual period. The comment that these cells are "cytologically benign" means that they do not appear to be malignant (cancerous) cells.

However, if a woman is menopausal (no longer menstruating) she would not be expected to be shedding cells from the uterine lining. Therefore, endometrial cells on a Pap report might be indicative of an abnormal thickening of the endometrium, the lining of the uterus. The Pap smear is not specifically designed to detect such an abnormality. Nonetheless, if these cells are noted in a non-menstruating woman, her doctor should attempt to determine the cause of the shedding of the endometrial cells.

Sometimes, the cause is endometrial hyperplasia, a precancerous condition of the uterine lining, which can be detected by a relatively simple office procedure called an endometrial biopsy. Sometimes, menopausal hormone therapy can cause shedding of endometrial cells that appear on a Pap smear. The pattern of bleeding, the exact type of hormone therapy, and the individual woman's health history are the three components that guide the physician to know whether and what type of further evaluation is necessary.

What are risk factors for cervical cancer and precancer?

A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.

HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. Almost all cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women.
Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increases the risk of cervical cancer about two to four fold.
Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.
Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk.
Other risk factors: Other risk factors for precancerous changes in the cervix, having an abnormal Pap test, having multiple sexual partners, and becoming sexually active at a young age.

Why is a woman's past Pap smear history pertinent?

If a woman has had a history of a cellular abnormality on a previous Pap smear, it is important for her to inform the health-care professional performing the current Pap smear. The woman should provide the details of any previous problems and treatments so that this information can be noted on the lab form. The past history of the woman helps the person who is reading (interpreting) the current Pap smear, because a particular abnormality on previous screening alerts the health-care professional to look more carefully for specific findings on the current Pap smear.

When might a Pap smear not be adequate for interpretation?

It is a requirement that the report comment on the adequacy of the smear sample for Pap analysis. If the sample is inadequate, the report details the reason. Examples of problems that might be listed under "sample adequacy" include "drying artifact" or "excessive blood." These comments refer to factors that the person analyzing the smear feels may have interfered with his or her ability to interpret the sample.

Sometimes, a Pap smear report will read "unsatisfactory due to excessive inflammation." Inflammation that is present in the woman's cervical area may make it difficult to interpret the Pap smear. Examples of causes of inflammation might include infections or irritation. Inflammation is a common finding on pap smears. If it is severe, your doctor may want to try to determine the cause of the inflammation. In many cases, a repeat pap smear is recommended to determine if the inflammation has resolved and to obtain a sample that is adequate for interpretation.

How is the final Pap smear diagnosis made?

The final Pap smear diagnosis is based on three determining factors:

The patient's history: The reader (the person reading the smear) takes into account the woman's history as noted on the lab request by the clinician performing the smear.
Sample adequacy: The reader then decides whether the sample was adequate for interpretation.
The presence or absence of cellular abnormalities: The reader then notes whether cellular abnormalities were seen on the slides. If the appearance of the Pap smear does not seem to coincide with the woman's clinical history, a comment may also be made to that effect.
The final diagnosis is a short statement that summarizes what the reader has found.

What are the possible recommendations for follow-up after a Pap smear?

Once the final diagnosis has been made, the follow-up recommendation informs you what the appropriate next step(s) might be. For example, if the final diagnosis states that the smear was "within normal limits," the appropriate follow-up might be "recommend routine follow-up."

An abnormal Pap smear is one in which the laboratory interprets the cellular changes to be different from those normally seen on a healthy cervix. There are a number of possible follow-up scenarios for an abnormal Pap smear.

What treatments are available if a Pap smear is abnormal?

If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, and large-loop excision of the transformation zone.

All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in a number of other respects and so will be discussed separately.

Colposcopy
Colposcopy is a procedure that allows the doctor to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.

During colposcopy, the cervix is cleaned and soaked with 3% acetic acid (vinegar). This mild acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).

If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist, and the biopsy results determine the next step in the treatment.

The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.

Conization
Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a small cone-shaped specimen of tissue is taken from around the endocervical canal.

Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching, and using tampons and refrain from sexual intercourse.

Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.

With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had severe changes on biopsy, have adenocarcinoma in situ (a diagnosis of cancer in the inner portion of the cervix), or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.

Large-loop excision (LEEP) of the transformation zone
Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.

Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. This is now the most commonly used treatment for Pap smear abnormalities.

Hysterectomy
A hysterectomy for the treatment of abnormal Pap smears is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments.

What is the current status of human papilloma virus (HPV) testing?

HPV is a sexually transmitted virus that may be spread from one person to another even when the genital sores are not visible. Many sexually active people are carriers of HPV, very often without even knowing they are carriers. It is estimated that up to 60% of sexually active women harbor this virus on their cervix or in their vaginal area. It is not unusual for a woman to be unaware that she has HPV - only to find out that her Pap smear shows evidence of HPV.

HPV is not curable, although the cellular damage it causes is generally treatable and vaccines against the most commonly found HPV types are available.

The main use of HPV testing in screening for cervical cancer is for determination of treatment and follow-up recommendations for women with Pap smears interpreted as atypical squamous cells of undetermined significance (ASC-US).

With Pap smears so available, why are women still dying of cervical cancer?

It is critically important to recognize that the women who are at highest risk for abnormal Pap smear testing are those who are not getting regular Pap testing. Therefore, it follows that in order to improve overall cervical cancer screening, women who are not getting regular Pap smears should be educated about and offered Pap testing. These under-served women should be the most heavily targeted for Pap screening.

Between 60% and 80% of American women who are newly diagnosed with invasive cervical cancer have not had a Pap smear in the past five years and may never have had one. Women who have not had Pap smear screening tend to be concentrated in certain population groups including:

Older women;
The uninsured;
Ethnic minorities, especially Latino, African American, and Asian American women;
Poor women; and
Women in rural areas.
Many doctors feel that the emphasis should be on universal access to proper Pap screening as opposed to the comparatively small benefit that would come from utilizing the newer technologies in women already undergoing screening. Cervical cancer is one of the most common causes of cancer worldwide. It is also one of the most preventable and treatable cancers.

Making your Pap tests more accurate

You can do several things to make your Pap test as accurate as possible:

Try not to schedule an appointment for a time during your menstrual period. The best time is at least 5 days after your menstrual period stops.
Don't use tampons, birth-control foams or jellies, other vaginal creams, moisturizers, or lubricants, or vaginal medicines for 2 to 3 days before the Pap test.
Don't douche for 2 to 3 days before the Pap test.
Don’t have vaginal sex for 2 days before the Pap test.

A pelvic exam is not the same as a Pap test

Many people confuse pelvic exams with Pap tests. The pelvic exam is part of a woman’s routine health care. During a pelvic exam, the doctor looks at and feels the reproductive organs, including the uterus and the ovaries and may do tests for sexually transmitted disease. Pelvic exams may help find other types of cancers and reproductive problems. Pap tests are often done during pelvic exams after the speculum is placed. Sometimes a pelvic exam is done without having a Pap test, but a Pap test is needed to find early cervical cancer or pre-cancers. Ask your doctor if you had a Pap test with your pelvic exam.

How Pap test results are reported

he most widely used system for describing Pap test results is the Bethesda System (TBS). There are 3 main categories, some of which have sub-categories:

Negative for intraepithelial lesion or malignancy
Epithelial cell abnormalities
Other malignant neoplasms.
You may need further testing if your Pap test showed any of the abnormalities below.

Negative for intraepithelial lesion or malignancy

This category means that no signs of cancer, pre-cancer, or other significant abnormalities were found. There may be findings that are unrelated to cervical cancer, such as signs of infection with yeast, herpes, or Trichomonas vaginalis (a microscopic parasite), for example. Specimens from some women may also show “reactive cellular changes”, which is the way cervical cells appear when infection or other irritation is around.

Epithelial cell abnormalities

This means that the cells lining the cervix or vagina show changes that might be cancer or a pre-cancer condition. This category is divided into several groups for squamous cells and glandular cells.

Atypical squamous cells (ASCs) This category includes two types of abnormalities:

Atypical squamous cells of uncertain significance (ASC-US) is a term used when there are cells that look abnormal, but it is not possible to tell if this is caused by infection, irritation, or a pre-cancer. Most of the time, cells labeled ASC-US are not pre-cancer, but more testing is needed to be sure.
Atypical squamous cells where high-grade squamous intraepithelial lesion (HSIL) can’t be excluded (ASC-H) is a term used when the cells look abnormal but are more concerning for a possible pre-cancer that needs more testing and may need treatment.

Squamous intraepithelial lesions (SILs) These abnormalities are divided into two categories:

In low-grade SIL (LSIL) the cells look mildly abnormal.
In high-grade SIL (HSIL) the cells look severely abnormal and are less likely than the cells in LSIL to go away without treatment. They are also more likely to eventually develop into cancer if they are not treated.
Further tests are needed if SIL is seen on a Pap test. This is discussed in Work-up of abnormal Pap test results. If treatment is needed, it can cure most SILs and prevent true cancer from developing.

Squamous cell carcinoma

This result means that the woman is likely to have an invasive cancer. Further testing will be done to be sure of the diagnosis before treatment can be planned.

Glandular cell abnormalities

Atypical glandular cells: When the glandular cells do not look normal, but they have concerning features that could be cancerous, the term used is atypical glandular cells (AGC). In this case, the patient should have more testing done.

Adenocarcinoma: Cancers of the glandular cells are called adenocarcinomas. In some cases, the pathologist examining the cells can tell whether the adenocarcinoma started in the endocervix, in the uterus (endometrium), or elsewhere in the body.

Work-up of Abnormal Pap Test Results

The first step in finding cervical cancer is often an abnormal Pap test result. This will lead to further tests, which can diagnose cervical cancer.

Cervical cancer may also be suspected if you have symptoms like abnormal vaginal bleeding or pain during sex. Your primary doctor or gynecologist often can do the tests needed to diagnose pre-cancers and cancers and may also be able to treat a pre-cancer.

If there is a diagnosis of invasive cancer, your doctor should refer you to a gynecologic oncologist, a doctor who specializes in cancers of women's reproductive systems.

Medical history and physical exam

First, the doctor will ask you about your personal and family medical history. This includes information related to risk factors and symptoms of cervical cancer. A complete physical exam will help evaluate your general state of health. The doctor will do a pelvic exam and may do a Pap test if one has not already been done. In addition, your lymph nodes will be felt for evidence of metastasis (cancer spread).

The Pap test is a screening test, not a diagnostic test. It cannot tell for certain if you have cervical cancer. An abnormal Pap test result may mean more testing, sometimes including tests to see if a cancer or a pre-cancer is actually present. The tests that are used include colposcopy (with biopsy), endocervical scraping and cone biopsies.

Colposcopy

If you have certain symptoms that are worrisome for cancer or if your Pap test shows abnormal cells, you will need to have a test called colposcopy. You will lie on the exam table as you do with a pelvic exam. A speculum will be placed in the vagina to help the doctor see the cervix. The doctor will use a colposcope to examine the cervix. The colposcope is an instrument that stays outside the body and has magnifying lenses. It lets the doctor see the surface of the cervix closely and clearly. Colposcopy itself usually causes no more discomfort than any other speculum exam. It can be done safely even if you are pregnant. Like the Pap test, it is better not to have it during your menstrual period.

At the time of the procedure, the doctor will apply a weak solution of acetic acid (similar to vinegar) to your cervix to make any abnormal areas easier to see. If an abnormal area is seen, a biopsy (removal of a small piece of tissue) will be done. The tissue is sent to a lab to be looked at under a microscope. A biopsy is the best way to tell for certain whether an abnormal area is a pre-cancer, a true cancer, or neither. Although the colposcopy procedure is usually not painful, the cervical biopsy can cause discomfort, cramping, bleeding, or even pain in some women.

Colposcopic biopsy

For this type of biopsy, the cervix is examined with a colposcope to find the abnormal areas. A local anesthetic may then be used to numb the cervix before the biopsy. Using biopsy forceps, a small section of the abnormal area is removed.

Endocervical curettage (endocervical scraping)

Sometimes the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope, so something else must be done to check that area for cancer. This means taking a scraping of the endocervix by inserting a narrow instrument (called a curette) into the endocervical canal (the part of the cervix closest to the uterus). The curette is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the lab for examination.

Cone biopsy

In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The tissue removed in the cone includes the transformation zone where cervical pre-cancers and cancers are most likely to start.

A cone biopsy is not only used to diagnose pre-cancers and cancers. It can also be used as a treatment since it can sometimes completely remove pre-cancers and some very early cancers.

The methods commonly used for cone biopsies are the loop electrosurgical excision procedure (LEEP), also called the large loop excision of the transformation zone (LLETZ), and the cold knife cone biopsy. With both procedures, you might have mild cramping and some bleeding for a few weeks.

Loop electrosurgical procedure (LEEP or LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electricity and acts as a small knife. For this procedure, a local anesthetic is used, and it can be done in your doctor's office.
Cold knife cone biopsy: This method uses a surgical scalpel or a laser instead of a heated wire to remove tissue. · You will receive anesthesia during the operation (either a general anesthesia, where you are asleep, or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist) and it is done in a hospital.
Having any type of cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.

What tests will I need?

The tests (or treatment) you will need depend on the results of the Pap test.

The specific results of your Pap test, along with your age, will guide your doctor to the next step. It may involve a follow-up Pap test in a year, an HPV test, or one of the procedures above. Your doctor will most likely use the guidelines for abnormal Pap test results from the American Congress of Obstetricians and Gynecologists (ACOG) when deciding on what follow-up plan is best for you.