By means of a cervical smear, cervical epithelial cells can be obtained for cytological analysis. Epithelial cells are scraped from the surface of the cervix for microscopic assessment. Particularly at the transition from multilayered stratified squamous epithelium to single layered columnar epithelium, cytological abnormalities can develop: premalignant and malignant cell abnormalities.
Indications for a smear
- For screening as part of the Dutch national screening programme: women aged 30 years and older are ‘invited’ to have a PAP smear test every 5 years by the General Practitioner.
- With complaints of abnormal blood loss (particularly contact bleeding) and sometimes with discharge symptoms.
- As a follow-up in case of cervical abnormalities.
Genital infections may make the cytological assessment more difficult. It may be necessary to delay the smear until after treatment of the infection or to repeat it at this time.
Do not carry out a smear within 24 hours of vaginal medication use or vaginal irrigation, as the cells will be hard to assess.
It is preferable not to carry out a smear when a woman is pregnant. The mucus plug may be damaged and this would increase the risk of infection. However, if there is an appropriate indication then a PAP a smear should be taken. In such instances, use only the blunt side of a gynaecological smear spatula (Ayre spatula) to reduce the risk of damaging the mucus plug. During pregnancy it is difficult to assess cervical cytology due to the hormonal changes.
List of materials required [Figure 53]
Figure 53
Requirements for a speculum examination:
- Speculum, gloves, light source, lubricant if needed (providing this lubricant does not influence the smear test), sponge forceps with gauze swabs, cotton buds, kidney bowl.
- Glass slide(s) with frosted area; pencil to write patient information on the slide.
- Fixative spray or ether-alcohol for fixation.
- Smear material:
- Wooden (smear) spatula, broad / blunt tip, Ayre spatula.
- Wooden (smear) spatula, pointed / sharp tip, modified Ayre spatula [Figure 54]
- Cotton bud with bottle of NaCl 0.9% solution
- Cytobrush
- Cervex-brush
Combine a spatula [Figure 54], to obtain smear material from the ectocervix, with a cytobrush or cotton bud [Figures 55, 56] to obtain material from the endocervix. With a Cervex-brush [57], material is collected from both simultaneously.
Figure 54
Figure 55
Figure 56
Figure 57
Before you take a smear you should have a good idea of the gynaecological status of the patient, so you know what to expect. A general history-taking is a good method for achieving this (see section “History-taking”).
Important questions are:
- Age
- Fertility status (menarche / fertile / menopausal)
- Cycle (length, intensity, regularity, duration)
- First day of last menstruation
- Past medical history:
- obstetrics (including episiotomy: scar)
- gynaecology
- abdominal surgery
- (Hormonal) medication, both past and current.
- Contraception.
If the smear is carried out as part of a screening test, these questions will probably suffice. You will also find most of these on the form that needs to be filled in and sent off together with the smear sample. If the smear sample is taken as a result of a complaint, this complaint will have to be further addressed and more specific questions should be asked.
Apart from helping you assess the findings of the investigation, the answers to the questions are also important for a good cytological assessment of the smear. Hence the inclusion of these questions on the form.
- Prepare the required materials and write the patient’s information on the glass slide(s) – name / maiden name / date of birth – and possibly mark it with an E (endocervix and transformation zone) or a P (cervix: transformation zone and ectocervix) if you are taking a smear with a spatula and cytobrush / cotton bud.
- Decide whether you wish to use a lubricant (see note in the introduction).
- Insert the speculum as described previously.
- Assess the vaginal portion of the cervix prior to taking the smear.
- If needed you can dab away discharge or blood with a cotton bud or a gauze swab held in a pair of forceps.
- Ask the patient to hold the upper edge of the speculum.
Now take a smear by following either instructions I or II:
1. Two-step smear
A Endocervical smear
- For this you use a cytobrush or a cotton bud. Wet the latter first with physiological salt solution.
- Place the cotton bud or the cytobrush in the external os of the endocervix (up to 1 cm) and make two 360-degree clockwise rotations. Ensure that you have good contact with the wall.
- Pick up the glass slide for the endocervical sample (E) and place the cotton bud or the cytobrush flat on the slide. Now roll it across the slide [Figure 58a], in an anticlockwise direction. In this manner you evenly smear out the collected material.
- Immediately fix the slide:
- By dipping the slide into the ether-alcohol.
- Or by spraying the slide with fixative spray from a distance of about 20 cm [Figure 58b]. Always spray the slide at a right angle.
Figure 58a
Figure 58b
B Ectocervical smear
- For this you use a spatula. Use a wide cervix spatula if the transition from endocervix to ectocervix is clearly visible. Use a pointed spatula if the endo-ectocervix transition is not clearly visible. In premenopausal women the transformation zone is usually clearly visible, whereas in postmenopausal women it has moved moreinternally towards the endocervix.
- Place the tip of the spatula in the os and make two 360-degree clockwise rotations.
- Pick up the glass slide for ectocervical / endocervical sample (P) and place the spatula flat on the slide. Smear out the collected material in one movement in a thin layer on the slide.
- Immediately fix the slide:
- By dipping the slide into the ether-alcohol.
- Or by spraying the slide with fixative spray from a distance of about 20 cm; always spray the slide at a right angle.
2. One-step smear
Simultaneous streak of ectocervix and endocervix using a Cervex-brush [Figure 59]
- Use the Cervex-brush; you require only one glass slide.
- Place the tip of the Cervex-brush in the os and rotate the Cervex-brush 3-5 times through 360° in a clockwise direction [Figure 60]. The rotational direction is important because of the shape of the bristles of the Cervex-brush. Ensure that the lateral bristles sweep against the entire surface of the endocervix. If the cervix bleeds easily, stop after 3 rotations because blood can distort the cell analysis.
- Pick up the glass slide, place the Cervex-brush flat on it and firmly push the hairs onto the slide. Smear the hairs of the Cervex-brush firmly in the longitudinal direction, halfway up the slide. Allow the tip of the Cervex-brush to maintain contact with the slide and now turn the brush 180 degrees, so that the hairs of the other side are pushed onto the slide. Firmly smear the bristles of the Cervex-brush further in the longitudinal direction, to the end of the slide.
- Immediately fix the slide:
- By dipping the slide into the ether-alcohol.
- Or by spraying the slide with fixative spray from about a 20-cm distance; always spray the slide at a right angle.
Figure 59
Figure 60
Nowadays, laboratories are increasingly electing for ‘liquid-based’ thin layer cytology following cyto-centrifugation of the cells from the fixative and transport medium. In these cases, the Cervex-brush should not be smeared out onto the glass slide, but sent to the cytology laboratory in transport medium [Figure 61]. The sensitivity and specificity of the test are increased considerably with this procedure.
Figure 61
Remove the speculum and assist the patient from the examination table. Provide her with a sanitary towel if necessary. Inform her that some blood loss may occur if the cervix started bleeding while collecting the smear material. This is normal and is caused by the smear process.
The glass slides can be placed and locked in the holder straight away; they can be sent off like this. Always check the patient information on the samples before sending them off.
Agree clearly with the patient on the subsequent course of action. For example, phone after 6 weeks for the results.
After approximately 6 weeks you will receive the results of the PAP smear. The assessment is carried out using Papanicolaou’s classification (see table).