cervical smear


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Related to cervical smear: Cervical cancer

cer·vi·cal smear

a generic name for different types of smears of the cervix uteri, for example, ectocervical, endocervical, pancervical; used principally for cervical screening.

cervical smear

Etymology: L, cervix + AS, smero, grease
a small amount of the secretions and superficial cells of the cervix, secured from the external os of the cervix with a sterile applicator or special small wooden or plastic spatula. For a Papanicolaou's smear, it is obtained from the squamocolumnar junction of the uterine cervix and from the vaginal vault and endocervical canal. The specimen is spread on a labeled glass slide and sent for cytological examination. For bacteriological culture and identification, only the applicator is used; the specimen is spread on a glass slide and stained and examined under a microscope or placed in or on a culture medium and sent to a bacteriological laboratory for culture and identification.
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Obtaining a cervical smear

cervical smear

Pap smear, see there.

Papanicolaou Smear

Synonym/acronym: Pap smear, cervical smear.

Common use

To establish a cytological diagnosis of cervical and vaginal disease and identify the presence of genital infections, such as human papillomavirus, herpes, and cytomegalovirus.

Specimen

Cervical and endocervical cells.

Normal findings

Method: (Microscopic examination of fixed and stained smear) Reporting of Pap smear findings may follow one of several formats and may vary by laboratory. Simplified content of the two most common formats for interpretation are listed in the table.
Bethesda System
    Specimen type:
  •  Smear, liquid-based, or other.
    Specimen adequacy:
  • Satisfactory for evaluation—endocervical transformation zone component is described as present or absent, along with other quality indicators (e.g., partially obscuring blood, inflammation).
  • Unsatisfactory for evaluation—either the specimen is rejected and the reason given or the specimen is processed and examined but not evaluated for epithelial abnormalities and the reason is given.
    General categorization:
  • Negative for intraepithelial lesion or malignancy.
  • Epithelial cell abnormality (abnormality is specified in the interpretation section of the report).
  • Other comments
    Interpretation/result:
  • Negative for intraepithelial lesion or malignancy
    • List organisms causing infection:
      • Trichomonas vaginalis; fungal organisms consistent with Candida spp.; shift in flora suggestive of bacterial vaginosis; bacteria morphologically consistent with Actinomyces spp.; cellular changes consistent with herpes simplex virus
    • Other nonneoplastic findings:
      • Reactive cellular changes associated with inflammation, radiation, intrauterine device; glandular cell status post-hysterectomy; atrophy.
  • Epithelial cell abnormalities
    • Squamous cell abnormalities
      • ASC of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H)
      • LSIL encompassing HPV, mild dysplasia, CIN 1
      • HSIL encompassing moderate and severe dysplasia, CIS/CIN 2 and CIN 3 with features suspicious for invasion (if invasion is suspected)
      • Squamous cell carcinoma
    • Glandular cell
      • Atypical glandular cells (NOS or specify otherwise)
      • Atypical glandular cells, favor neoplastic (NOS or specify otherwise)
      • Endocervical adenocarcinoma in situ
      • Adenocarcinoma
  • Other
    • Endometrial cells (in a woman of 40 yr or greater)
    Automated review:
  • Indicates the case was examined by an automated device and the results are listed along with the name of the device.
    Ancillary testing:
  • Describes the test method and result.
    Educational notes and suggestions:
  • Should be consistent with clinical follow-up guidelines published by professional organizations with references included.
ASC = atypical squamous cells; ASC-H = high-grade atypical squamous cells; ASC-US = atypical squamous cells undetermined significance; CIN = cervical intraepithelial neoplasia; CIS = carcinoma in situ; HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion.

Description

The Papanicolaou (Pap) smear is primarily used for the early detection of cervical cancer. The interpretation of Pap smears is as heavily dependent on the collection and fixation technique as it is on the completeness and accuracy of the clinical information provided with the specimen. The patient’s age, date of last menstrual period, parity, surgical status, postmenopausal status, use of hormone therapy (including use of oral contraceptives), history of radiation or chemotherapy, history of abnormal vaginal bleeding, and history of previous Pap smears are essential for proper interpretation. Human papillomavirus (HPV) is the most common sexually transmitted virus and primary causal factor in the development of cervical cancer. Therefore, specimens for HPV are often collected simultaneously with the PAP smear. The laboratory should be consulted about the availability of this option prior to specimen collection because specific test kits are required to allow for simultaneous sample collection. HPV infection can be successfully treated once it has been identified. Gardasil, the first vaccine developed against HPV, is given in three doses, at 2 and 6 mo after the initial injection. The Centers for Disease Control and Prevention recommends vaccination for males and females age 11 and 12 yr. Vaccination is also recommended for females age 13 to 26 yr and males age 13 to 21 yr who have not been previously vaccinated. Cervarix is a second HPV vaccine available only for females.

A wet prep can be prepared simultaneously from a cervical or vaginal sample. The swab is touched to a microscope slide, and a small amount of saline is dropped on the slide. The slide is examined by microscope to determine the presence of harmful bacteria or Trichomonas.

A Schiller’s test entails applying an iodine solution to the cervix. Normal cells pick up the iodine and stain brown. Abnormal cells do not pick up any color.

Improvements in specimen preparation have added to the increased quality of screening procedures. Liquid-based Pap tests have largely replaced the traditional Pap smear. Cervical cells collected in the liquid media are applied in a very thin layer onto slides, using a method that clears away contaminants such as blood or vaginal discharge. Samples can be “split” so that questionable findings by cytological screening can be followed up with more specific molecular methods like nucleic acid hybridization probes, polymerase chain reaction, intracellular microRNA quantification, or immunocytochemistry to detect the presence of high-risk HPV, Chlamydia trachomatis, and Neisseria gonorrhoeae. Computerized scanning systems are also being used to reduce the number of smears that require manual review by a cytotechnologist or pathologist.

There are now some alternatives to cone biopsy and cryosurgery for the treatment of cervical dysplasia. Patients with abnormal Pap smear results may have a cervical loop electrosurgical excision procedure (LEEP) performed to remove or destroy abnormal cervical tissue. In the LEEP procedure, a speculum is inserted into the vagina, the cervix is numbed, and a special electrically charged wire loop is used to painlessly remove the suspicious area. Postprocedure cramping and bleeding can occur. Laser ablation is another technique that can be employed for the precise removal of abnormal cervical tissue.

This procedure is contraindicated for

    N/A

Indications

  • Assist in the diagnosis of cervical dysplasia
  • Assist in the diagnosis of endometriosis, condyloma, and vaginal adenosis
  • Assist in the diagnosis of genital infections (herpes, Candida spp., Trichomonas vaginalis, cytomegalovirus, Chlamydia, lymphogranuloma venereum, HPV, and Actinomyces spp.)
  • Assist in the diagnosis of primary and metastatic neoplasms
  • Evaluate hormonal function

Potential diagnosis

Positive findings in:

    (See table [Bethesda system])

Decreased in

    N/A

Critical findings

    N/A

Interfering factors

  • The smear should not be allowed to air dry before fixation.
  • Lubricating jelly should not be used on the speculum.
  • Improper collection site may result in specimen rejection. Samples for cancer screening are obtained from the posterior vaginal fornix and from the cervix. Samples for hormonal evaluation are obtained from the vagina.
  • Douching, sexual intercourse, using tampons, or using vaginal medication within 24 hr prior to specimen collection can interfere with the specimen’s results.
  • Collection of other specimens prior to the collection of the Pap smear may be cause for specimen rejection.
  • Contamination with blood from samples collected during the patient’s menstrual period may be cause for specimen rejection.

Nursing Implications and Procedure

Potential nursing problems

ProblemSigns & SymptomsInterventions
Sexuality (Related to alterations in sexual role secondary to sexually transmitted infection)Hesitancy to discuss sexual relationship with significant otherFacilitate a discussion of realistic changes to sexual intimacy associated with sexually transmitted infection; provide a relaxed atmosphere in which to discuss sexuality concerns; provide contact information for a support group
Infection (Related to unprotected sexual activity; lack of knowledge to take precautions to prevent infection)Genital wartsAdminister prescribed medication for wart removal (antimitotic gel, immune-enhancing cream); explain to the patient that sometimes the warts will clear on their own
Fear (Related to potential terminal diagnosis secondary to development of cancer)Verbalization of fear; restlessness; increased tension; continuous questioning; increased blood pressure, heart rate, respiratory rateEvaluate verbal and nonverbal indicators of fear; assess for the cause of fear; acknowledge the patient’s awareness of his or her fear; explain all procedures with simple age- and cultural-appropriate language; administer proscribed mild tranquilizer; maintain a confident, assured professional manner in all patient interactions
Knowledge (Related to new condition or diagnosis; lack of familiarity or understanding with disease and treatment)Lack of interest or questions; multiple questions; anxiety in relation to disease process and managementIdentify sexual orientation; teach the process of disease transmission; teach that infection risk increases with the number of sexual partners over time; identify the patient’s sexual activity; discuss importance of notifying sexual partners of disease exposure; assess for cultural, literacy, or vision and hearing concerns that would interfere with learning; administer prescribed medication; explore with the patient the value of monogamous relationship to support positive health; teach the importance of taking the prescribed medication in its entirety to resolve infection

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in diagnosing disease of the reproductive system.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s immune and reproductive systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Note any recent procedures that can interfere with test results.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Instruct the patient to avoid douching or sexual intercourse for 24 hr before specimen collection. Verify that the patient is not menstruating. Address concerns about pain and explain that there may be some discomfort during the procedure. Inform the patient that specimen collection is performed by a health-care provider (HCP) specializing in this procedure and takes approximately 5 to 10 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.
  • Note that if the patient is taking vaginal antibiotic medication, testing should be delayed for 1 mo after the treatment has been completed.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications: N/A
  • Have the patient void before the procedure.
  • Have the patient remove clothes below the waist.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to breathe normally and to avoid unnecessary movement during the procedure.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
  • Assist the patient into a lithotomy position on a gynecological examination table (with feet in stirrups). Drape the patient’s legs.
  • A plastic or metal speculum is inserted into the vagina and is opened to gently spread apart the vagina for inspection of the cervix. The speculum may be dipped in warm water to aid in comfortable insertion.
  • After the speculum is properly positioned, the cervical and vaginal specimens are obtained. A synthetic fiber brush is inserted deep enough into the cervix to reach the endocervical canal. The brush is then rotated one turn and removed. A plastic or wooden spatula is used to lightly scrape the cervix and vaginal wall.
  • Conventional Collection

  • Specimens from both the brush and the spatula are plated on the glass slide. The brush specimen is plated using a gentle rolling motion, whereas the spatula specimen is plated using a light gliding motion across the slide. The specimens are immediately fixed to the slide with a liquid or spray containing 95% ethanol. The speculum is removed from the vagina. A pelvic and/or rectal examination is usually performed after specimen collection is completed.
  • ThinPrep Collection

  • The ThinPrep bottle lid is opened and removed, exposing the solution. The brush and spatula specimens are then gently swished in the ThinPrep solution to remove the adhering cells. The brush and spatula are then removed from the ThinPrep solution, and the bottle lid is replaced and secured.
  • Chlamydia Vaginal Swab Collection Followed by NAA

  • Care provider specimen: Collect vaginal fluid sample using the Gen-Probe APTIMA Vaginal Swab Kit by contacting the swab to the lower third of the vaginal wall, rotating the swab for 10 to 30 sec to absorb the fluid. Immediately place the swab into the transport tube, and carefully break the swab shaft against the side of the tube. Tightly screw on the cap.
  • Patient self-collection instructions: Partially open the package. Do not touch the soft tip or lay the swab down. If the soft tip is touched, the swab is laid down, or the swab is dropped, use a new APTIMA Vaginal Swab Specimen Collection Kit. Remove the swab. Carefully insert the swab into the vagina about 2" past the introitus, and gently rotate the swab for 10 to 30 sec, making sure the swab touches the walls of the vagina so that moisture is absorbed by the swab. Withdraw the swab without touching the skin. Immediately place the swab into the transport tube, and carefully break the swab shaft against the side of the tube. Tightly screw on the cap.
  • Chlamydia Endocervical Swab

  • Remove excess mucus from the cervical os and surrounding mucosa using the cleaning swab (white shaft swab in the package with red printing). Discard this swab. Insert the specimen collection swab (blue shaft swab in the package with green printing) into the endocervical canal. Gently rotate the swab clockwise for 10 to 30 sec in the endocervical canal to ensure adequate sampling. Withdraw the swab carefully; avoid contact with the vaginal mucosa. Remove the cap from the swab specimen transport tube, and immediately place the specimen collection swab into the transport tube. Carefully break the swab shaft at the scoreline using care to avoid splashing of the contents. Recap the swab specimen transport tube tightly.
  • Chlamydia Male Urethral Swab

  • Note that the patient should not have urinated for at least 1 hr prior to specimen collection. Insert the specimen collection swab (blue shaft swab in the package with the green printing) 2 to 4 cm into the urethra. Gently rotate the swab clockwise for 2 to 3 sec in the urethra to ensure adequate sampling. Withdraw the swab carefully. Remove the cap from the swab specimen transport tube, and immediately place the specimen collection swab into the specimen transport tube. Carefully break the swab shaft at the scoreline using care to avoid splashing of contents. Recap the swab specimen transport tube tightly.
  • Urine Specimen

  • Note that the patient should not have urinated for at least 1 hr prior to specimen collection. Direct patient to provide a first-catch urine (approximately 20 to 30 mL of the initial urine stream) into a urine collection cup free of any preservatives. Collection of larger volumes of urine may result in specimen dilution that may reduce test sensitivity; lesser volumes may not adequately rinse organisms into the specimen. Female patients should not cleanse the labial area prior to providing the specimen. Add urine to the APTIMA COMBO 2 urine collection device. The final volume must be between the two black lines on the device (about 2 mL).
  • General

  • Place samples in properly labeled specimen container and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Cleanse or allow the patient to cleanse secretions or excess lubricant (if a pelvic and/or rectal examination is also performed) from the perineal area. Provide a sanitary pad if cervical bleeding occurs.
  • Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Decisions regarding the need for and frequency of conventional or liquid-based Pap tests or other cancer screening procedures should be made after consultation between the patient and HCP. The American Cancer Society’s (ACS) guidelines for preventing cervical cancer recommend cytological screening every 3 yr for women age 20 to 29 yr; co-testing for HPV and cytological screening every 5 yr (or cytological screening alone every 3 yr for women age 30 to 65 yr; no screening is recommended for women who have had a hysterectomy. The most current guidelines for cervical cancer screening of the general population as well as of individuals with increased risk are available from the ACS (www.cancer.org) and the American College of Obstetricians and Gynecologists (ACOG) (www.acog.org).
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
  • Patient Education

    • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
    • Provide information regarding vaccine-preventable diseases where indicated (e.g., cervical cancer and sexually transmitted diseases such as hepatitis B and human papillomavirus).
    • Provide contact information, if desired, for the Centers for Disease Control and Prevention (www.cdc.gov/vaccines/vpd-vac).
    • Answer any questions or address any concerns voiced by the patient or family.
  • Expected Patient Outcomes

    • Knowledge
    • Acknowledges the prescribed medication to treat the infection should be completed in its entirety
    • Skills
    • Displays appropriate coping skills related to changes in future sexual activity
    • Demonstrates proficiency on applying prescribed medication to genital warts
    • Attitude
    • Agrees to discuss concerns regarding the possibility of social stigma associated with diagnosis
    • Agrees to notify sexual partner regarding diagnosis of infection

Related Monographs

  • Related tests include biopsy cervical, cancer antigens, Chlamydia group antibody, colposcopy, culture anal/genital, culture throat, culture urine, culture viral, CMV, cytology urine, laparoscopy gynecologic, US pelvis, and UA.
  • Refer to the Immune and Reproductive systems tables at the end of the book for related tests by body system.
References in periodicals archive ?
This was understandably one of the determining factors in the decision to change the DoH's current national screening policy in 2001 to offer women a free cervical smear only at 30, 40 and 50 years of age.
In the United Kingdom, screening intervals were recently lengthened to 5 years for women 50-64 years of age, after an analysis of UK screening data showed that the protective effect after a negative cervical smear persisted longer for older women (30).
There also was an increased risk of having a cervical smear abnormality among patients who had more active disease as reflected by the Systemic Lupus Activity Measure (SLAM) score, she said.
Q I HAVE had two cervical smears in the last year, both of which have been 'unsatisfactory'.
Time interval effect on repeat cervical smear results.
The success can be traced back to a collaboration with Bangor University which led to the company developing and manufacturing a novel set of dyes for use in cervical smear tests and other medical procedures.
The mean time from the date of taking the cervical smear to the date of attending the colposcopy clinic was 170 days in 2007 and 141 days in 2009, i.
Furthermore, three quarters of the 373 women who died from cervical cancer had not had a cervical smear in the recommended time frame.
Women who had their last cervical smear with the woman are being offered a repeat test and some extra vaccinations are also being offered.
HEALTH chiefs are urging women in Huddersfield to make sure they attend their cervical smear appointments.
Peterborough and Stamford Hospitals NHS Foundation Trust admitted two cervical smear tests she had in 2001 were misdiagnosed.
Since then, Claire's family has been campaigning for the minimum age limit for cervical smear tests to be dropped.