Management of Abnormal Cervical/Vaginal Pap Smears

Tables

Table I - Methods to Improve Accuracy of Pap Smears

Perform a Pap smear when the patient is in the proliferative phase (in the week following cessation of menses).
The patient should avoid intercourse or intravaginal products/douches for 24-48 hours before the examination.
Use no lubricant prior to performing the Pap smear.
Have cytobrush, spatula, slide, and other supplies on hand before starting the pelvic exam.
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.
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.
Rapidly apply fixative to the slide. If using a spray, hold it about 10 inches from the slide to avoid dispersing the cells.
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.

Cite this: Management of Abnormal Cervical/Vaginal Pap Smears - Medscape - Mar 29, 1996.

Sidebar: Common Questions About Pap Smear Screening

Should women undergo routine HPV testing?

"Silent" HPV infection is extremely common. These cases are detectable only with tests for HPV DNA such as Southern blot or PCR and not by Pap smear. The risk of progression to HSIL or cancer is 0.08% per year, or a 3.7% lifetime risk.^[1] This modest increase in risk does not support the routine use of these tests in their present forms. Furthermore, commercially available tests are negative in 30% of cases of HSIL.

What is the value of HPV typing?

Low-risk HPV types that are generally associated with warts or low-grade dysplasia are 6, 11, and 42 through 44. High-risk HPV types--16, 18, 31, 33, 35, 39--are associated with warts, low-grade lesions, and high-grade lesions, including cancer. More than 90% of cervical cancers contain one of these high-risk HPV types. However, since high-risk HPV types are found in many women with low-grade disease, or even in those who are clinically normal, routine HPV typing is not clinically useful. Presence of high-risk HPV types seems to better predict persistence of dysplasia rather than progression to higher-grade lesions. Possible future roles for HPV typing may be in women with ASCUS smears (see below) or with LSIL lesions (in deciding whether to treat). Preliminary studies of the use of HPV testing in the triage of patients with ASCUS or LSIL Pap smears show a possible role (and cost savings) for ASCUS but not for LSIL.^[2] A large, multicenter NCI-funded trial to resolve this issue is planned for 1995-2001.

If HPV infection is so common, why is cervical cancer relatively rare?

Not all patients infected with HPV develop dysplasia or malignancy. Furthermore, when cancers develop, they are monoclonal, even though the entire lower genital tract has HPV present. It is thought that the action of specific cofactors are required for malignant transformation. For example, tobacco smokers, who secrete mutagenic substances in their cervical mucus, have a 2- to 3-fold increased rate of development of cervical cancer. Immunosuppressed patients have increased incidence of both benign and malignant HPV disease. Other lower genital tract infections may also impact on progression of HPV.

At what age should Pap smears no longer be performed?

There is controversy about whether to stop Pap smear screening after 65 years of age. The yield of Pap smear screening of older women is highest in those who have not undergone regular screening in the past.^[3] It may be safe to stop regular Pap smear screening at age 65 in women who have had lifelong normal and regular Pap smears and who have no high-risk factors for cervical intraepithelial neoplasia. If a woman has a hysterectomy for reasons unrelated to dysplasia or cancer, vaginal Pap smears may be performed at 3- to 5-year intervals,^[4] although the usefulness of this approach is unknown.

References

De Villiers EM, Wagner D, Schneider A, et al: Human papillomavirus DNA in women without and with cytological abnormalities: Results of a five year follow-up study. Gynecol Oncol 44:33-39, 1992.
Wright TC, Sun XW, Koulos J: Comparison of management algorithms for the evaluation of women with low-grade cytologic abnormalities. Obstet Gynecol 85:202-210, 1995.
Fahs MC, Mandelblatt J, Schechter C, et al: Cost effectiveness of cervical cancer screening for the elderly. Ann Intern Med 117:520-527, 1992.
Kurman RJ, Henson DE, Herbst AL, et al. Interim Guidelines for Management of Abnormal Cervical Cytology. JAMA 271(23):1866-1869, 1994.

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