Taking A Pap Smear

1. Taking a PAP SMEAR

2. Cervical Cancer : Pap smear
George N Papanicolaou introduced cervical cytology in
clinical practice in 1940
In 1945, PAP smear was endorsed by American cancer
society as an effective method for prevention of cervical
cancer
Many countries now have National cervical screening
programs

3. Indian scenario
Commonest cancer in women in India
Major cause of deaths in women due to cancer
Usually diagnosed at advanced stage
No National program
Uniformly low incidence of cervical screening in India
(6% in rich & 4% in poor)

4. Histological Types 30
Squamous Cell Carcinoma : 80-95%
Adenocarcinoma : 5-20%
Other : Clear cell, sarcomas

5. Transformation zone
Cervix develops from 2 embryonic sites
* from Mullerian duct - lined by columnar epithelium
* from urogenital plate - lined by stratified
squamous epithelium
Point at which columnar and squamous epithelium
meet is called as original squamo-columnar
junction

6. Transformation zone
Under influence of estrogen, original SCJ moves
onto the portio.
Exposure of delicate columnar cells to vaginal
environment leads to squamous metaplasia.
Transformation zone -
- Area of squamous metaplasia
- Area between original and new SCJ

7. Transformation zone

8. Transformation Zone -TZ
Exposure of TZ to carcinogens begins the process of
intraepithelial neoplasia
While exact role of carcinogens in this process remains poorly
understood, it is clear that HPV and cigarette smoking can
cause dysplasia at the TZ
95% of cervical cancers develop in TZ
Important to take sample from TZ

9. Transformation Zone
Transformation zone may not be viewed during
routine speculum examination

10. Why cervical screening is a
feasible and useful strategy?
Relative accessibility of cervix to take the smear
Long natural history of cervical carcinogenesis
Relative conservative treatment for premalignant lesions
Cost effectiveness3

11. PAP Smear
PAP smear sampling of cervix involves scraping of
cervical surface and a portion of non visualised
cervical canal using various sampling devices

12. Significance of Pap smear
Detect precancerous & invasive cancer cervix cases in
early stages
Positive screeners can be selected for selective tests and
management
With treatment, progression of disease is halted. Thus
morbidity associated with advanced cancer decreases
Mortality reduces by 20-60 %.
Helps us to study natural history of disease.

13. Cervical Cancer : Pap smear
Early detection of pre-malignant lesions by Pap
smears prevent at least 70% of potential cervical
cancers.

14. Of the 30% who actually
develop cervical cancer:
8% elude cytological detection
- imperfections in cytological technology
- biologic behavior of malignant lesions
22% represent women who develop cervical cancer because of
failure to regularly seek Pap smears => women whose cancers
could have been prevented with early detection and treatment.

15. How to take a Pap Smear ?
Proper technique is very important
More problems are due to improper sampling than
screening
Not to be collected during menses
Avoid vaginal contraceptives, vaginal medications for at
least 48 hrs before taking smear
Abstinence for 24 hrs
Postpartum smear should be taken only after 6 - 8 weeks of
delivery

16. Patient in dorsal position
Good illumination is necessary
Cusco’s speculum is inserted to visualise & fix
the cervix
Inspection of cervix done & findings are noted
Ayres spatula is inserted first. It is placed at
cervical os so that longer end goes into cervical
canal and smaller end rests on ectocervix
How to take a Pap Smear ?

17. How to take a Pap Smear ?
Spatula is rotated through 360 degrees
maintaining contact with ectocervix
Do not use too much force [bleeding /pain]
Do not use too less force [inadequate sample]
Sample is smeared evenly on the slide and fixed
immediately
Both sides of spatula are to be smeared

18. How to take a Pap Smear ?
Endocervical sample is collected using an
endocervical brush
Insert the cytobrush into canal, so that last bristles
of brush are visible
Rotate the brush through 180 degrees. [more
rotations increase the chance of bleeding]
Sample is rolled on the slide and fixed.

19. Fixation of smear
Fixation is done immediately with
fixative like 95% alcohol or cytofix
spray to avoid air drying
Spray should be kept at 10 inches, to
avoid destruction of cells by
propellent in the spray
Smear should monolayer for proper
penetration of cell surface by fixative

20. How to take a Pap Smear ?
Slide should be labeled properly with patients name,
identification no. and details
Detailed history and clinical examination findings are to be
mentioned
Patient details and clinical findings are to be maintained in a
register
Advice is given regarding further follow up and treatment

21. Systems for cervical cytology reporting
George N Papanicolaou (1954)
5 classifications based on certainty of finding malignant cells
Descriptive system – WHO - (1968)
based on morphologic criteria – included mild, moderate,
severe dysplasia and Ca In Situ
Richart – CIN –based on histologic diagnosis

22. Systems for cervical cytology reporting
Bethesda system – TBS (1988)
National cancer institute revised in 1991 and 2001
Adequacy of smear must be determined before reporting
Smear is adequate when
- Patient identification
- adequate clinical history

23. Bethesda system
Interpretable cellular cytology
not obscured by inflammation, debris, blood, drying
not scanty smear
Adequate sampling from transformation zone
presence of at least 2 clusters of well preserved
endocervical cells or metaplastic cells

24. Bethesda system
Results :
Within normal limits ( WNL )
Benign cellular changes - this term was removed and
group was included in WNL in 2001
Reactive or Reparative changes – seen with atrophy,
inflammation, surgery, radiation, IUCD, tampoons
Infections – trichomoniasis, fungal, bacterial, HSV.

25. Bethesda system - results
Epithelial cells abnormalities
Squamous cells
•ASCUS
•ASCUS-H - suggestive of high grade lesion
•LSIL - changes associated with HPV, atypical
changes, mild dysplasia/ CIN1
•HSIL – moderate to severe dysplasia / CIN2, 3
and Ca In Situ
•HSIL – where invasion cannot be ruled out
•Squamous cell carcinoma

26. Bethesda system
Results :
Glandular cells – AGUS (Endocervical, endometrial)
Adenocarcinoma
(endocervical, endometrial, extrauterine)
Other malignant neoplasms

27. Normal cervix-cytology
Squamous cells
Exfoliated indivisual cells
Navicular in shape with abundant cytoplasm and small,
dark, round /oval, pyknotic nuclei
Glandular cells
Many times seen in clumps - linear or honeycombed
pattern.
Slightly larger and basal nuclei

28. Cervical cytology - Inflammation
Interpretation difficult due to inflammatory
background
Lot of neutrophils and blood can obscure
cellular details

29. Low grade lesions

30. High grade lesions
High grade squamous
lesion
High grade glandular
lesion

31. Abnormal Pap smear- HPV
Peripherial condensation of cytoplasm -
wire looping effect
Koilocyte

32. InvasiveInvasiveInvasiveClass 5
HSILCIN3Ca In SituClass 4
LSIL(HPV)
HSIL
HSIL
CIN1
CIN2
CIN3
Mild dysplasia
Moderate dysplasia
Severe dysplasia
Class 3
Reactive, reparatative
changes, ASCUS,
LSIL(HPV)
Inflammatory,
squamous, koilocytic
atypia
Class 2
WNLnegativenegativeClass-1
BethesdaCINDescriptivePAP

33. Single test will not detect cervical abnormality but with 3
negative tests there is less than 1% chance of cervical
abnormality
Conventional cytology has specificity of 98% and
sensitivity of 51%.
PAP smear

34. PAP Smears - Limitations
Low sensitivity 51%
False negative rates are due to faulty sampling, improper
fixation or interpretation problems
Large group population & high risk group screening not
possible
No consensus regarding testing

35. Pap smear as screening method
New guidelines
Target group - All women aged 18-70 yrs who have ever had sex
Timing of Initial Screening -
Initial screening at age of 21 years or within 3 years of sexual activity
ACOG Guidelines-(Aug2003), American Cancer Society (Nov 2002) and
U.S. Preventative Services Task Force (Jan 2003)

36. Pap smear - guidelines
Screening interval - yearly till the age of 30 then 3 yearly
 When to End Screening
- After 70 yrs
- Post Hysterectomy
- done for benign lesions
- previous 3 normal PAP reports
- confirmed complete removal of cervical epithelium

37. Pap smear - guidelines
In high risk group after treatment for CIN
every 3 monthly for 2 years
every 6 monthly for 3yrs
Yearly thereafter
Women who had hysterectomy for CIN, it is necessary to do
vault smears
In women who received vaccination against HPV, it is
necessary to continue screening

38. Liquid Based Cytology
To improve results of PAP newer techniques like liquid
based cytology are recommended
Cells are obtained with a broom, then the head is broken
off in to a vial containing preservative fluid
In the laboratory the sample is spun to remove obscuring
material
It gives clearer image, no cell clumps
It will assist in future automated reading

39. Several slides can be prepared from one smear
Chlamydia, HPV testing can be done at later date
Reduces the incidence of inadequate and repeat smears
Liquid Based Cytology

40. Cancer Cervix IS PREVENTABLE ,
IF Detected EARLY!!!!!!!!!
Thank You