Learning Objectives #
1-To understand the indications and proper technique for performing a Pap smear
Introduction #
The Pap smear is a screening test and is used to evaluate an asymptomatic woman who has a clinically normal appearing cervix. If a clinically suspicious lesion is seen immediate biopsy should be done and the patient referred for further investigation.
The use of a lubricant on the speculum is not recommended as it can obscure cellular detail, interfere with cellular adherence and cause bacterial over-growth on the slide. If the patient is menstruating or infection is present the exam should be rescheduled.
The sample should be taken from squamocolumnar junction which is the area between the columnar epithelium of the endocervix and the mature epithelium of the ectocervix. If the cervix is obscured with discharge or secretions a cotton pledget should be used to gently cleanse the cervix.
The location of squamocolumnar junction is dependent on the patient’s age, parity, hormonal status and any previous surgery on the cervix. In the reproductive age group the junction is often visible, but in post menopausal women the junction is often in the canal.
If the squamocolumnar junction is visible a spatula is used to obtain a single specimen by scraping the cervix circumferentially through 360. Fixation is not necessary in this case.
If the squamocolumnar junction is not visible a spatula should first be used for the exocervical specimen followed by a cytobrush for the endocervical specimen. The brush is inserted into the endocervix until only the bottom-most fibers are exposed. The brush is then slowly rotated 180 degrees in one direction to obtain a sample. Do not over-rotate. Both specimens should be placed on a single slide and fixed immediately. The specimen should be smeared for the spatula and rolled for the brush. The spray should be held at least 10 inches away from the slide to prevent disruption of cells by the propellant. The use of cytobrush is not recommended in pregnant patients.
Alternatively, specimens may be collected using a cervical broom. The central bristles sample the endocervix while the outer bristles sample the transformation zone. The broom should be rotated in the same direction for five turns.