Gynecology Book

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Pap SmearAka: Cervical Smear, Papanicolaou Smear

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  1. See Also
    1. Pap Smear Intervals
    2. Cervical Cancer Screening
  2. Efficacy
    1. Specificity of pap smear: 70%
    2. Sensitivity of pap smear: 80%
      1. Thin Prep Pap Smear
        1. Liquid based pap smear improves sensitivity
        2. Can be used for HPV DNA testing
        3. Will allow Gonorrhea and Chlamydia testing
        4. Reduces sampling error (e.g. drying artifact)
        5. Use spatula and cytobrush (instead of broom)
          1. Improves endocervical sampling
      2. Repeating pap smear improves sensitivity
        1. Repeated in short interval, sensitivity: 96%
        2. Third repeated in short interval: 99.2%
        3. Short interval is approximately 1 year
  3. Technique
    1. Preparation: Water-based Speculum lubrication
      1. Does not contaminate conventional pap smear slide
        1. Amies (2002) Obstet Gynecol 100:889
        2. Harer (2002) Obstet Gynecol 100:887
      2. Does not affect thin prep pap smear
        1. Note that thin-prep manufacturer recommends water
        2. Hathaway (2006) Obstet Gynecol 107:66
    2. Tips to prevent unsatisfactory pap smears
      1. Avoid pap smear during time of Menses
      2. Avoid tampons and intercourse within 48 hours
      3. Blot cervix prior to pap smear
      4. Focus on endocervical canal in postmenopausal women
    3. Step 1: Clean Cervix (clean only if large discharge)
      1. Gently wipe excess Cervical Mucus from os
      2. Use large cotton tipped swab
      3. Do not rinse cervix with Saline
      4. Avoid performing pap smear during menstruation
    4. Step 2: Sample the Cervix
      1. Order is critical for less blood
        1. First: Chlamydia cultures (if needed)
        2. Option 1: Conventional pap smear
          1. Second: Exocervix with Ayres spatula (or similar)
          2. Last: Endocervix with Brush (rotate 180 degrees)
        3. Option 2: Thin prep
          1. Liquid pap (with broom or spatula/brush as above)
      2. Conventional pap smear pointers
        1. Get exo- and endocervix before applying to slide
          1. Prevents one from drying while collecting other
          2. Thin prep eliminates drying risk
        2. Samples may be placed on top of one another
        3. Spread spatula material in one smooth stroke
        4. Roll the brush along slide by twirling handle
      3. Pregnancy
        1. Place brush only 50% into canal and sample sides
    5. Step 3: Fix Pap Smear Sample (except thin prep)
      1. Fix sample immediately to prevent air drying
      2. Air drying is common reason for ASCUS Pap Smear
  4. Findings
    1. Normal
      1. Bethesda: Normal
      2. World Health Organization (WHO): Normal
    2. Inadequate Pap Smear
    3. Benign Pap Smear Changes
      1. Vaginal Infection
      2. Reactive changes (Inflammation)
    4. ASCUS Pap Smear
      1. Atypical Squamous Cells of Undetermined Significance
    5. AGUS Pap Smear
      1. Atypical Glandular Cells of Undetermined Significance
    6. Cervical Intraepithelial Neoplasia (Dysplasia)
      1. Mild Dysplasia (Human Papillomavirus Infection)
        1. Bethesda: Low Grade SIL
        2. WHO: CIN I
      2. Moderate Dysplasia
        1. WHO: CIN II
      3. Severe dysplasia
        1. Bethesda: High Grade SIL
        2. WHO: CIN III
    7. Carcinoma In-Situ (Pre-invasive Cervical Cancer)
    8. Cervical Cancer
  5. Management: Normal Pap Smear and Physical Exam
    1. High Risk for Cervical Cancer
      1. Repeat Pap Smear yearly
    2. Low Risk for Cervical Cancer with few prior pap smears
      1. Repeat Pap Smear Yearly
    3. Low Risk and 3 consecutive normal pap smears
      1. Repeat Pap smear every 2-3 years
      2. Yearly pap smear if even remote history of dysplasia
  6. Management: Benign or Mild Pap Smear Changes
    1. See Inadequate Pap Smear
    2. See Benign Pap Smear Changes
  7. Management: Abnormal Pap Smear
    1. See ASCUS Pap Smear (Pap Smear Atypia)
      1. ASC-H should be managed as abnormal with Colposcopy
    2. See AGUS Pap Smear
    3. Colposcopy Indications
      1. See Colposcopy Protocol
      2. ASCUS pap smear on 2 or more pap smears
      3. ASCUS pap smear with HPV positive for high risk type
      4. CIN: ASC-H, LGSIL or LSIL, HGSIL or HSIL
    4. See Cervical Cancer
  8. References
    1. Boon (1989) Acta Cytol 33(6):843
    2. Brotzman (1996) Am Fam Physician 53(4):1154
    3. Fowler (1993) Postgrad Med 93(2):57
    4. Kurman (1994) JAMA 271(23):1866
    5. Koss (1989) JAMA 261(5):737
    6. Miller (1992) Am Fam Physician 45(1):143
    7. Orr (1992) Gynecol Oncol 44:260
    8. Shepherd (1995) Am Fam Physician 51(2):434
    9. Stack (1997) Postgrad Med 101(4):207

Vaginal Smears (C1744620)

Definition (MSH)Collection of pooled secretions of the posterior vaginal fornix for cytologic examination.
Definition (NCI)A sample of secretions and superficial cells of the uterine cervix and uterus; examined with a microscope to detect any abnormal cells.
Definition (CSP)collection of pooled secretions of the posterior vaginal fornix for cytologic examination.
ConceptsDiagnostic Procedure (T060)
Englishcervical smear, cervical/vaginal smear, PAP SMEAR, PAP TEST, Papanicolaou Smear, Papanicolaou Test, Vaginal Smear, Vaginal Smears
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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