What is a Pap smear?
is a medical procedure in which
a sample of cells from a woman's
cervix is collected and spread
(smeared) on a microscope slide.
The cells are examined under a
microscope in order to look for
pre-malignant or malignant
changes.
A Pap smear is a simple,
quick, and relatively
painless screening test.
Who should have a Pap smear?
Start the test at :
– 3 years after initiation of sexual intercourse
– OR the age of 21
– If did not have intercourse ??? Why
Then an annual screening
Who should have a Pap smear?
• After age of 30 :
If had 3 consecutive normal smear
AND no high risk factors
(DES exposure, HIV infection, or other
immunodeficiencies)
screen every 2-3 years
Who should have a Pap smear?
• HPV test :
– Indicated at age 30 if  –ve
the screening can be delayed for 3 years
• Another option :
– Every 3 years do pap smear + HPV DNA test
• At the age 0f 70 screening could be stoped if 3 con.
tests were normal & no risk factors
Who should have a Pap smear?
Pregnancy does not prevent a
Women
who have
had
anot
hysterectomy
in which
Pap
smear
testing
is
indicated
for
woman from having a Pap
the
cervixwho
is nothave
removed,
called subtotal
women
had
a
smear. Pap smears can be safely
hysterectomy,
should
continueof
screening
hysterectomy
(with
removal
the
done during pregnancy.
following
thebenign
same guidelines
cervix) for
conditions.as women who
have not had a hysterectomy.
The screening guidelines of several key medical organizations
are summarized in the table below :
Which women are at increased risk for having an
abnormal Pap smear?
HPV:
The principal risk factor is infection with the
genital wart virus, also called the human
papillomavirus (HPV)
About 95%-100% of cervical cancers are
related to HPV infection.
Which women are at increased risk for having an
abnormal Pap smear?
Smoking:
common risk factor for premalignant and
malignant changes in the cervix is smoking.
Smoking increased the risk of cervical cancer
about two to four fold.
Which women are at increased risk for having an
abnormal Pap smear?
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.
Which women are at increased risk for having an
abnormal Pap smear?
Medications: Women whose mothers took the
drug diethylstilbestrol (DES) during pregnancy
also are at increased risk.
Other risk factors: for precancerous changes in
the cervix and an abnormal Pap testing include
having multiple sexual partners and becoming
sexually active at a young age.
Risks of having PAP smear
Generally no risks even in pregnant lady.
there is a very remote chance of infection from a
Pap smear .
How is a PAP smear done?
Prerequisites :
Explain to the patient what are you doing.
1- Should be not menstruating.
The result will be available within two to
2-three
Avoidweeks.
using vaginal douche, spermicidal
gel or medications.
3-Position
Avoid sexual
intercourse
to the
her buttocks
just atprior
the edge
ortest.
just over the edge of the exam table.
PAP smear kit
How is a PAP smear done?
Inspect the Vulva
look for:
-Discolorations of the skin
-Skin lesions
-Masses
-Discharge
-Signs of trauma
-Pubic hair distribution (triangular = normal)
Warm the speculum by hot water,
Insert it in the vagina.
Open the speculum and usually the cervix is immediately visible.
How is a PAP smear done?
- Using a spatula>> Ectocervical sample
- Cervical brush>>Endocervical sample
Types of PAP smear:
- Traditional PAP smear.
- Liquid cytology.
How is a PAP smear done?
How to read and analyze pap smear
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 2001
How to read and analyze pap smear
There are two types of epithelial cells in the cervix :
A- Squamous Abnormalities (cells that cover most of the
external part of the cervix)




(ASC-US) Atypical Squamous Cells: Unknown Significance .
(LSIL) Low Grade Squamous Intraepithelial Lesion
(HSIL); High Grade Squamous Intraepithelial Lesion
Squamous Cell Carcinoma
How to read and analyze pap smear
B- Glandular Abnormalities (cover the lining of the
uterus opening and canal)
Atypical cells, not otherwise specified
 Atypical cells, favor neoplastic
 Adenocarcinoma in situ
 Adenocarcinoma (can be endometrial (uterus), endocervical
(cervix), extrauterine (origin from outside uterus and cervix),
or the site of the malignancy cannot be determined based on
the Pap smear ) .

How to read and analyze pap smear
Glandular abnormalities are much less common
than squamous abnormalities.
A diagnosis like adenocarcinoma in situ is one of
the rarest diagnosis made on a Pap smear
frequently requires consultation among
pathologists.
What information is included on a Pap smear
report?
Bethesda system used to:
To reduces the possibility that different
laboratories might report different results for
the same smear .
To make Pap smear reports less confusing
for the clinicians who request the tests and
for their patients.
Past Pap Smear Classification Systems
(Some pathologists may still use terms from these systems)
Bethesda system
Smear report should include all the following :
The Pap
•The name of the woman.
•The name of the pathologist and/or the cytotechnologist
who read the smear.
•The source of the specimen.
•The date of the least menstrual period of the woman.
• Menstrual status of the woman.
•Relevant medical history of the woman.
•The number of slides .
•The specimen adequacy.
•The final diagnosis.
How is the final Pap smear diagnosis made?
The final Pap smear diagnosis is based on three determining factors:
1.
2.
3.
The patient's history
Sample adequacy
The presence or absence of cellular abnormalities.
How is the final Pap smear diagnosis made?
The final diagnosis is a short
statement that summarizes
what the reader has found.
Example of the final Pap smear diagnosis
Within normal limits
Absence of endocervical cells on the Pap smear
Unreliable Pap smear due to inflammation
Atypical squamous cells of undetermined
significance (ASCUS)
Low-grade squamous intraepithelial lesion (LSIL)
High-grade squamous intraepithelial lesion (HSIL)
What are the possible recommendations for
follow-up after a Pap smear?
What are the possible recommendations for
follow-up after a Pap smear?
What are the possible recommendations for
follow-up after a Pap smear?
What are the possible recommendations
for follow-up after a Pap smear?
What are the possible recommendations for
follow-up after a Pap smear?
What are the possible recommendations
for follow-up after a Pap smear?
What are the possible recommendations
for follow-up after a 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 .
large-loop excision of the transformation
zone.
What treatments are available if a
Pap smear is abnormal?
 Colposcopy :
• is a procedure that allows the physician to take a
closer look at the cervix. The colposcopey 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.
Colposcopy
• During colposcopy, the cervix is cleaned
and soaked with 3% acetic acid.
• This 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).
Colposcopy
Colposcopy
If suspicious areas of cervical tissue are seen
The procedure is essentially painless and quite
during colposcopy, a biopsy (tissue sampling)
simple, usually taking only several minutes to
is often done. The sample is sent to the
perform. Generally, the woman is instructed
laboratory for analysis by a pathologist and
not to have intercourse, douche, or use tampons
the biopsy results determine the next step in
for about a week afterwards if a biopsy is done.
the treatment.
Colposcopy
Colposcopy
Pregnancy is not a contraindication to
colposcopy.
Colposcopy can adequately evaluate 90% of
women who have abnormal Pap smear
results.
Colposcopy
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 coneshaped specimen of tissue (perhaps 1/2-1 inch
long and 3/4 inch wide) is taken from around the
endocervical canal.
Conization
Conization
For three weeks after the procedure, the woman
Conization
is usually
done
onusing
an out-patient
needs to avoid
douching
and
tampons and
basis
under
in a hospital or surgical
refrain
fromanesthesia
sexual intercourse.
facility.
Cure rates close to 100% are achieved with
conization as long as the cells along the margins
of treatment are normal.
Conization
Hysterectomy (surgical removal of the uterus
Conization
is generally
performed onlyabnormal
on women
and
the cervix)
for non-cancerous
With
conization,
there
are
associated
risks
from
who
have
had
unsatisfactory
colposcopy
results,
Pap smears is now rarely done. A hysterectomy
anesthesia
and
postoperative
hemorrhage
have
adenocarcinoma
in
situ
(a diagnosis
is appropriate only for those women
whoofare
(bleeding-in
about
10%
of
cases)
as
well
as
possible
cancer)
already,
or
whose
Pap
smears
suggest
finished with childbearing and have severe they
mayadverse
have some
invasion
of cancer
future
effects
on
fertility
. into the nearby
pre-cancerous abnormalities that have
tissue.
persisted despite other treatments. It may also
be appropriate for women with certain specific
findings after conization.
Conization
Cryocauterization
 Cryocauterization:
• is a simple and safe procedure. A probe, called a
cryoprobe, is first cooled by carbon dioxide and then
touched to the abnormal cervical area. This freezes
and kills the cells, resulting in the sloughing of the
abnormal tissue.
• A woman undergoing cryocauterization can expect
a watery vaginal discharge for several weeks after
the procedure.
Cryocauterization
Cryocauterization
Laser Therapy
Laser therapy:
When
a laser
beam
(using
a tiny
wand
calledthat
Laser
therapy
makes
use
of the
principle
a micromanipulator)
is directed
the
laser light can be produced
byinto
electricity
running
In the cervical
treatment
of
cervix
at anthrough
area of gas.
abnormal
tissue,
lesions,
gas is usually
thecervical
light energy
is the
converted
to heat,carbon
which in
dioxide.
of as
laser
can instantly
boil
turn
causesThis
celltype
death,
occurs
with
water and therefore can also be used to kill and
cryocauterization.
vaporize cells.
Laser Therapy
However, the laser apparatus is expensive, and
The
benefit
of
laser
therapy
is
that
it
may
cause
less
its use requires more skill than other treatment
cervical
as compared to cryocauterization.
options,scarring
such as cryocauterization.
The
This
in turnismay
that,
should
the woman
procedure
alsomean
painful
and
generally
requires
need
colposcopy
in the future, the chances of
general
anesthesia.
adequately viewing her cervix may be better after
laser therapy.
Laser Therapy
LEEP
 Large-loop excision (LEEP) of the transformation
zone :
removes the cervical transformation zone (the area
where the vaginal-type lining changes to the uterinetype 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.
LEEP
Specialized (more frequent) follow-up is
necessary after LEEP. This follow-up includes
Pap smears, colposcopy, and sometimes other
techniques. When there is no more evidence
of abnormal cervical tissue, it may be possible
to resume annual screening Pap smears.
LEEP
What is the follow-up after treatment for an
abnormal Pap smear?
Women who have undergone any one of
the above-described treatment procedures
Follow-up is crucial after treatment for an
require special follow-up schedules. They
abnormal Pap test.
must be evaluated and checked until the
physician is fully convinced that routine
Pap smears can be resumed.
What is the current status of human
papilloma virus (HPV) typing?
HPV IS SEXALLY TRANSMITTED VIRUS.
MANY SEXALLY ACTIVE PEOPLE ARE
CARRIERS OF HPV.
Types (16,18) are more likely to be
associated with cervical cancer.
Combined test : primary screening test for
cervical cancer ,consists of HPV testing
+pap screening.
HPV
When should women start and stop having Pap smears, and
how often should Pap smears be performed?
-Pap smears should be started within 3 years of
first sexual activity or age 21, which ever
comes first.
- Older women who have had many normal Pap
smears in a row and have been regularly
screened are highly unlikely to have an
abnormal Pap smear.
When should women start and stop having Pap smears, and
how often should Pap smears be performed?
- Women who have had a total hysterectomy
do not derive any benefit from screening for
cervical cancer.
- women who have had a subtotal hysterectomy
should be screened .
When should women start and stop having Pap smears, and
how often should Pap smears be performed?
- Women who have had a hysterectomy for abnormal Pap
smears have their own special recommendations.
- women who have had cervical cancer, exposure to
diethylstilbestrol, or a compromised immune system
should continue annual screening .
When should women start and stop having Pap smears, and
how often should Pap smears be performed?
- Women who have had a hysterectomy for CIN2 or CIN3
should be screened until they have had three normal
Pap
smears.
if no abnormal Paps show up in 10 years, they can stop
having Pap tests .
What is the current status of the newer Pap smear
technologies?
 liquid-based cytology :
• cervical cells are obtained as usual but a new technique
is used to prepare the slides for analysis. The physician
puts the cell sample into a vial of liquid preservative. The
cells are then sent to the laboratory where they are
filtered and spread on glass slides. This method removes
any contamination from blood or mucous.
What is the current status of the newer Pap smear
technologies?
• Computer systems are now being developed to
assist by providing an automated analysis of
slides. Slides containing abnormally appearing
cervical cells can first be automatically
identified and then subjected to a second,
manual re-screening.