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DR.

ARIVENDRAN
M.D (UKM ) MRCOG (UK)
 Papanicolaou test –
exfoliative cytology
test
 cells collected are
from normally
shedding epithelium .
 collected using
spatulas or brushes.
 Specimen is fixed,
stained and studied
for morphology
under microscope.
 Initially using vaginal pool smears to
study hormonal status .

 Found cancer cells on a slide


containing a specimen from a woman's
uterus.

 Dr. George Papanicolaou reported the


usefulness of the technique for
detecting neoplastic cervical cells in
1941.
Dr. George Nicholas
Papanicolaou
 late 1940s to early 1950s, Pap smear
became widely used as a screening
technique.
 Visual inspection of the lower genital tract and
cervix.
 Locate the TZ.
 An optimal cervical specimen
 includes sampling of the squamous and columnar
epithelium
 encompassing in particular the transformation zone
 Correct timing
 Correct technique
Correct instruments
Correct sampling technique
Correct spreading technique
Correct fixation
 AYRE’S SPATULA
 CERVICAL BROOM/BRUSH
 CYTOBRUSH
 After menses preferably midcycle.
 When there is no signs of inflammation or
infections
 No prior vaginal douching or contraceptive cream
/ jelly .
 No sexual intercourse < 12 hours prior to pap
smear.
 Pregnancy is NOT a contraindication for pap
smear.
 Label the frosted end of the glass slide
with the patient's name prior to collection.
 Insert the speculum.
 Visually inspect the cervix for
abnormalities.
 Identify the transformation zone and direct
sampling efforts to encompass this area.
 The endocervical limit of the transformation
zone is dynamic, defined by the leading edge of
the migrating squamo-columnar junction.
 In post menopausal women, it is often high in
the endocervical canal and not visible.
An optimal cervical specimen includes sampling of the squamous
epithelium (Ectocervix) and columnar epithelium
(Endocervix) and in particular the TRANSFORMATION ZONE,
where the majority of cervical neoplasias arise.
NEW SCJ

OLD SCJ

TRANSFORMATION ZONE
 Choose the contoured end of the spatula which
best conforms to the cervix and the
transformation zone.

 Rotate the spatula 360o about the


circumference of the cervix, while maintaining
firm contact with the epithelial surface.

 With a clockwise rotation beginning and


ending at 9 o'clock (or counter-clockwise
rotation from 3 o'clock to 3 o'clock), the
collected material is retained on the upper
horizontal surface as the instrument is
removed.
 These brushes have circumferential bristles that
come into contact with the entire os surface on
insertion.
 The brush need only be turned 1/4 turn.

 Roll the brush across the slide by twirling the


handle.

 Not recommended for pregnancy.


 Spread : quick and even , cellular material in a
monolayer on the slide.

 Thin out large clumps of material as much as


possible, avoide excessive manipulation which
can damage cells.

 Fix the specimen by either immersing the slide


in 95% ethanol or coating the slide with a
surface fixative.
Spread the material collected on the
spatula / cervix brush evenly over the
slide with a painting action and single
smooth stroke motion using both sides
Spatula / Cervix brush

Endocervical brush

Endocervical brush
Spatula / Cervix brush

Spatula / Cervix brush

Endocervical brush
Alcohol fixation

Slide jacket

Drying the slide – 5 minutes

Alcohol fixation : Immediately immerse into 95% Alcohol


for 20-30 minutes.
 May be moistened with water or saline if necessary.
Traditionally, no other lubricants are recommended.
 study in 182 patients randomly assigned to have either only warm water
or a water soluble lubricant to assist speculum insertion, only 2
unsatisfactory smears were found among 93 patients with the lubricant
and two were found among 89 using only warm water.
 They concluded that use of a water soluble lubricant on the vaginal
introitus and external speculum facilitates examination with no adverse
effect on Pap smear interpretation.
Harer WB. Valenzuela G Jr. Lebo D. Lubrication of the vaginal introitus and speculum does not affect
Papanicolaou smears. Obstet Gynecol 2002; 100:887-8.

 Do not use any lubricants other than water or saline on


Thin-prep slides since they plug the filter and may
produce an unsatisfactory smear.
BETHESDA 2001
REPORTING SYSTEM
 Whether the pap is an adequate sample
 Incidental findings such as evidence of
infection
 Evidence of lesions: low-grade SIL, high-grade
SIL, or cancer
1. Specimen adequacy
2. Negative for intraepithelial lesion or malignancy
3. Epithelial Cell Abnormalities
A. Squamous
Atypical (ASCUS/ASC-H)
LSIL ( Mild Dyskaryosis / HPV/CIN 1)
HSIL (Mod or Severe Dyskaryosis / CIN 2,3)
Invasive Squamous Carcinoma

B. Glandular / Columnar
Atypical (undetermined or favour neoplastic)
Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma

C. Endometrial cells in women age > 40


 Low-grade squamous lntraepithelial lesion (low-grade SIL)
 Cellular changes associated with HPV
 Mild (slight) dysplasia/CIN 1
 High-grade squamous intraepithelial lesion (high-grade SIL)"
 Moderate dysplasia/CIN II
 Severe dysplasia/CIN III
 carcinoma in situ/CIN III
 Atypical Squamous Cells (ASC)
 Unspecified (ASC-US) - includes uspecified and favor
benign/inflammation
 Cannot exclude HSIL (ASC-H)
 Atypical Glandular Cells of Uncertian Significance (AGC) AGC is
broken down into favoring endocervical, endometrial, or not
otherwise specified origin or endocervical adenocarcinoma in situ
(AIS)
 Unspecified (AGC-US)
 Atypical glandular cells, favor neoplastic (AGC-H)
1. Abnormal due to dysplastic changes
2. Abnormal due to inadequacy
3. Abnormal due to inflammation
4. Abnormal due to infection
 Squamous

Atypical (ASCUS/ASC-H)
LSIL ( Mild Dyskaryosis / HPV/CIN 1)
HSIL (Mod or Severe Dyskaryosis / CIN 2,3)
Invasive Squamous Carcinoma

 Glandular

Atypical (undetermined or favour neoplastic)


Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma
 Sampling
Scanty cells
Blood, mucous, pus
Mainly endocervical cells *
 Preparation
Too thick due to poor spreading
Air drying artifact
 Correct timing of smear
 Do not use cream or gel
 Cleaning of excessive mucus
 Choice of sampling devices
 Correct spreading
 Rapid fixation (< 10 second)
 Infection
 Chronic cervicitis

 Atrophic cervicitis
Observed and repeat pap smear

Treat (inflammation & infection)


and repeat pap smear

Refer for Colposcopy


Unsatisfactory/Inadequate smear

Reactive cellular changes due to radiation, repair or


IUCD

ASCUS with Low Risk HPV type or no facility for HPV


typing

Selected LSIL – repeat in 6 months, if persistent, do


colposcopy

HPV effect
1. INFECTIONS
Trichomonas vaginalis ( Metronidazole 400mg
tds and Doxycyline 100mg bd for 1 week)
Fungal infection : Antifungal
Bacterial vaginosis (Metronidazole, Clindamycin)
Actinomyces species : Penicillin
Herpes simplex : Acyclovir

Repeat smear in 6-8 weeks, if persistent in 3 occasion,


refer for colposcopy.

2. ATROPHIC SMEAR
Local oestrogen cream/tab (1 gm nighty
for 2 weeks then twice weekly) 6-8 weeks
and repeat pap smear in 3-4 months.

 Suspicious looking cervix.



 Unexplained post-coital bleeding.

 Persistent unsatisfactory smear on 3 occasions, 3 monthly.

 Persistent inflammatory smear on 3 occasions, 3 monthly
(despite treatment).

 Persistent Atypical Squamous Cells of Undetermined
Significance (ASC-US) on 2 occasions.

 Atypical Squamous Cells of Undetermined Significance (ASC-
US) positive for high risk HPV.

 Atypical Squamous Cells –cannot exclude high grade lesion
(ASC-H)

 Persistent Low Grade Squamous Intraepithelial Lesion (LSIL)
on 2 occasions, 6 monthly.

 Persistent Low Grade Squamous Intraepithelial Lesion (LSIL)
with high risk factors.

 High Grage Squamous Intraepithelial Lesion (HSIL).

 Squamous Cell Carcinoma (SCC).

 Atypical Glandular Cells (AGUS).

 Adenocarcinoma.

 High risk HPV DNA positive.
Complicates up to 5% of pregnancies

Most women will have low-grade disease

A significant degree of expertise and experience is


required in the colposcopic triage of the abnormal pap
smear in pregnancy

Cervical biopsy is safe in pregnancy.

Cone biopsy is best avoided and delayed until 6-8


weeks after delivery (Risk of spontaneous miscarriage
25%, excessive bleeding in 5-15% and risk of persistent
disease 50%)

The most important aspect in management of abnormal


pap smear in pregnancy is to exclude invasive cancer .
PAP SMEAR

UNSATISFACTORY
FOR EVALUATION

* NOTE
Repeat smear in •Treat any infection.
3 months •Give a course of estrogen if there are
atrophic changes.

2nd smear Negative for


unsatisfactory malignant cells

Satisfactory
Repeat smear and negative
in 3 months

3rd smear
unsatisfactory

Refer for Refer to Flowchart for


colposcopy Management of ‘Negative
For Malignant Cells’
Smear.
PAP SMEAR

NEGATIVE FOR MALIGNANT


CELLS

Atrophic No Specific Inflammatory Endometrial


changes endocervic micro- changes cells seen
(without al cells organisms
inflammatio seen identified
n) changes
resolve Treat any Correlate with
Repeat Treat infection or clinical findings,
smear in 1 appropriatel atrophy. client’s age,
year y as Repeat hormonal and
clinically smear in 3–6 menstrual status
indicated months.

2nd smear with


similar changes

Treat any infection


changes or atrophy. Repeat
resolve smear in 3–6
months.

3rd smear
with similar
changes

Routine Routine Refer Refer


screening screening Gynaecolog Gynaecologist
schedule schedule ist if necessary
PAP SMEAR

ATYPICAL SQUAMOUS CELLS

•NOTE
Cannot exclude Undetermined •HPV DNA testing should
high grade significance be considered if available
lesion (ASC-H) (ASC-US) •If positive for high risk
HPV, to refer for
colposcopy
Refer for Repeat smear
colposcopy in 6 months

•Atypical Negative for


squamous cells malignant cells
•Low-grade
squamous
intraepithelial Repeat smear
lesion in 6 months
•High-grade
squamous
intraepithelial
lesion Resume routine
screening if
negative for
Refer for malignant cells
colposcopy
PAP SMEAR

LOW-GRADE SQUAMOUS
INTRAEPITHELIAL LESION
(LSIL)

Yes No
Assessm
Presence of at least one ent of
criteria: client
•Age > 30 years
•Poor compliance
•Immunocompromised
•Symptomatic
•History of pre invasive Repeat smear
lesion in 6 months
•High risk HPVpositive.

Immediate Negative for Mild dysplasia


colposcopy malignant cells or CIN I

Resume Refer for


routine colposcopy
screening
schedule
PAP SMEAR

HIGH-GRADE SQUAMOUS CELL


SQUAMOUS CARCINOMA
INTRAEPITHELIAL
LESION (HSIL)/
SUSPICIOUS FOR
INVASION

Refer for Refer to


colposcopy Gynaecological
Oncologist
PAP SMEAR

ALL ATYPICAL ATYPICAL ADENOCARCINOM


GLANDULAR ENDOMETRIAL AIN SITU (AIS)
CELLS (except CELLS &
Atypical Endometrial ADENOCARCINOM
Cells) A

Refer to Gynaecologist Refer to Refer to


for: Gynaecologist Gynaecological
•colposcopy (with
endocervical sampling)
Oncologist
•endometrial sampling
(if > 35 years or abnormal
bleeding)
 Genital HPV is a common
virus that is passed from
one person to another
through direct skin-to-
skin contact during sexual
activity.
 Most sexually active
people will get HPV at
some time in their lives,
though most will never
even know it.
 HPV infection is most
common in people in their
late teens and early 20s
 Two HPV types (HPV-16 and HPV-18) that
cause 70% of cervical cancers, 80% of anal
cancers, 60% of vaginal cancers, and 40% of
vulvar cancers.

 These HPV types also cause most HPV induced


oral cancers, and some other rare genital
cancers.
 Bivalent vaccine
(CERVARIX)
 Quadrivalent vaccine
(GARDASIL).
 Gardasil, also
prevents HPV types
that cause most
genital warts
 Both vaccines are
given in 3 shots over 6
months.
 HPV vaccination is
recommended with
either vaccine for 11 and
12 year-old girls.
 It is also recommended
for girls and women age
13 through 26 years of
age who have not yet
been vaccinated or
completed the vaccine
series;
 HPV vaccine can also be
given to girls beginning
at age 9 years
 The vaccines are not recommended for
pregnant women.
 Studies show that HPV vaccines do not cause
problems for babies born to women who were
vaccinated while pregnant, but more research
is still needed.
 A pregnant woman should not get any doses of
either HPV vaccine until her pregnancy is
completed.
 Getting the HPV vaccine when pregnant is not
a reason to consider ending a pregnancy.
 The vaccines target the HPV types that most
commonly cause cervical cancer.
 Both vaccines are highly effective in preventing the
targeted HPV types
 The vaccines are less effective in preventing HPV-
related disease in young women who have already
been exposed to one or more HPV types.
 That is because the vaccines prevent HPV before a
person is exposed to it. HPV vaccines do not treat
existing HPV infections or HPV-associated
diseases
 Research suggests that
vaccine protection is
long-lasting.
 Current studies have
followed vaccinated
individuals for six
years, and show that
there is no evidence of
weakened protection
over time
 The vaccines do not protect against all HPV
types— so they will not prevent all cases of
cervical cancer.
 About 30% of cervical cancers will not be
prevented by the vaccines, so it will be
important for women to continue getting
screened for cervical cancer (regular Pap tests).
 Also, the vaccines do not prevent other
sexually transmitted infections (STIs)
 Both vaccines have been
licensed by the Food
and Drug
Administration (FDA).
 The CDC has approved
these vaccines as safe
and effective.
 Side effects reported in
these studies were mild,
including pain where
the shot was given,
fever, dizziness, and
nausea