Pap Smear

• Screening for cervical cancer
• Posttreatment follow-up for cervical dysplasia, malignancy
• Any visible or palpable lesion of the cervix (also need colposcopy)
• Any abnormal vaginal bleeding or discharge
• After hysterectomy for dysplasia, carcinoma
• After supracervical (subtotal) hysterectomy
• As part of the initial workup for victims of rape, incest, abuse

• No absolute contraindications to obtaining a Pap smear are known.
• Relative contraindications include clinical circumstances in which sample collection is difficult to obtain or difficult to interpret.

• Speculums of various sizes.
• Water-soluble lubricant.
• Nonsterile examination gloves.
• Large swabs for gentle blotting of excess discharge.
• Wooden spatulas or plastic spatulas for ectocervical sample.
• Cytobrush Plus for endocervical sample.
• As an alternative to taking two samples, a "broom" device can be used for ectodermal and endocervical samples.
• Microscope slides, fixative or media for liquid-based testing.
• Appropriate patient identification and history forms.
• Culture or transport media and swabs as necessary for culture and KOH/wet mount.
• Cervical tenaculum or cervical hook (rarely needed).
• Ring forceps.
• Materials and solutions for liquid-based Pap smears (e.g., ThinPrep).

Cervical Anatomy

• The area of the squamocolumnar junction marks the transition from the squamous epithelium of the exterior cervix to the columnar epithelium of the endocervical canal.
• Transformation zone sampling:
• Successful Pap smear technique requires sampling from the active transformation zone in women with an intact cervix or vaginal cuff for those status post hysterectomy.

Endocervical Canal

• The endocervical canal is lined with a layer of columnar epithelium that secretes mucus.

• Inform the patient to expect minor spotting or cramping.
• Make sure that you have accurate follow-up contact information and patient preferences for contact methods.
• When results are available, take time to explain your recommendations for follow-up.
• All Pap smears reported as abnormal require some form of intervention.

• The Pap smear is only a screening test. False-negative rates are high.
• Minor spotting and occasional uterine cramps commonly follow Pap smear sampling.

Adequacy

The Pap smear report should indicate whether the smear was adequate. Unless the patient has had a hysterectomy, this report should include cytologic evidence that the transformation zone was sampled.

Interpretation System

The Bethesda system has provided a uniform nomenclature for Pap smear cytology interpretation and attempts to address much of the confusion regarding Pap smear terminology. In September 2001, the Bethesda consensus conference convened for the third time and provided revisions of the reporting system.

Follow-up Recommendations

• A consensus group hosted by the American Society of Colposcopy and Cervical Pathology (ASCCP) has developed guidelines for the management of abnormal cervical cytology. See Colposcopy for more information. The ASCCP Guidelines are summarized with algorithms that can be found at http://www.asccp.org/consensus/cytological.shtml. These algorithms can guide clinicians through evidence-based recommendations for most abnormal Pap smear scenarios.
• A report that describes glandular or adenomatous atypia warrants immediate colposcopy with endocervical curettage to rule out a high-grade lesion and cervical adenocarcinoma. If the findings of AGS are definite, conization, pelvic ultrasound, and even laparoscopy may be indicated. See Endometrial Biopsy and Colposcopy for more information.
• Patients who are immunocompromised may require different and, in general, more aggressive follow-up and management strategies. See Colposcopy for more information.