Management of Abnormal Cervical/Vaginal Pap Smears

, University of California, San Francisco


Medscape General Medicine. 1996;1(1) 

In This Article


Table I - Methods to Improve Accuracy of Pap Smears

  1. Perform a Pap smear when the patient is in the proliferative phase (in the week following cessation of menses).

  2. The patient should avoid intercourse or intravaginal products/douches for 24-48 hours before the examination.

  3. Use no lubricant prior to performing the Pap smear.

  4. Have cytobrush, spatula, slide, and other supplies on hand before starting the pelvic exam.

  5. Rotate the Ayers spatula through a 360-degree arc over the squamocolumnar junction if visible. Gently brush the spatula over the entire slide, taking care to avoid a thick smear or shearing of cells by excessive pressure.

  6. Collect the endocervical specimen using a cytobrush (about one full turn with the brush mostly inside the cervix), or use a saline-moistened cotton swab for pregnant women. Apply this to the same slide using a rolling motion as noted in step 5.

  7. Rapidly apply fixative to the slide. If using a spray, hold it about 10 inches from the slide to avoid dispersing the cells.

  8. Provide the cytologist with complete clinical information about the patient including age, menopausal status, hormone use, history of radiation, dysplasia, malignancy, etc.

Table II - The 1991 Bethesda System for Classification of Pap Smears

  • Adequacy of the specimen

    • Satisfactory for evaluation

    • Satisfactory for evaluation but limited by. . . (specify reason)

    • Unsatisfactory for evaluation (specify reason)

  • General categorization (optional)

    • Within normal limits

    • Benign cellular changes

    • Epithelial cellular abnormalities

  • Descriptive diagnoses

    • Benign cellular changes

      • Trichomonas

      • Fungal organisms morphologically consistent with Candida species

      • Predominance of coccobacilli consistent with shift in vaginal flora

      • Bacteria morphologically consistent with Actinomyces species

      • Cellular changes consistent with herpes simplex virus

      • Other

    • Reactive changes

      • Reactive cellular changes associated with:

        • Inflammation

        • Atrophy with inflammation

        • Radiation

        • Intrauterine contraceptive device

        • Other

    • Epithelial cell abnormalities

      • Squamous cell

        • Atypical squamous cells of undertermined significance

        • Low-grade squamous intraepithelial lesion

        • High-grade squamous intraepithelial lesion

        • Squamous cell carcinoma

      • Glandular cell

        • Endometrial cells, cytologically benign in postmenopausal women

        • Atypical glandular cells of uncertain significance

        • Endocervical adenocarcinoma

        • Endometrial adenocarcinoma

        • Extrauterine adenocarcinoma

        • Adenocarcinoma, NOS

    • Other malignant neoplasms

    • Hormonal evaluation

Source: Reference 9.

Table III - Terminology for Describing Degree ("Thickness") of Dysplasia

  Lower 1/3 of Epithelium Middle 1/3 of Epithelium > 2/3 of Epithelium
Bethesda (NCI) squamous intraepithelial lesion[9] LSIL HSIL HSIL
Cervical intraepithelial neoplasia[20] CIN1 CIN2 CIN3
Reagan terminology[10] mild moderate severe/CIS (dysplasia)

LSIL = Low-grade squamous intraepithelial lesion; HSIL = High-grade squamous intraepithelial lesion; CIN = Cervical intraepithelial neoplasia

Table IV - Sensitivity and Specifity of Pap Smear for Gynecologic Infections

Organism Sensitivity Specificity Finding
HSV[23] 0.25-0.66 0.97-0.99 Multinucleate giant cells
Trichomonas[23] 0.33-0.79 0.89-1.0 Protozoan
Bacterial vaginosis[24] 1.0 0.9 Clue cells*

*Squamous cells that are coated by cocci so that their margins become obscured.