Pap Smears


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Pap Smears

  1. 1. Pap Smears Anna Mae Smith, MPAS, PA-C Lock Haven University Physician Assistant Program
  2. 2. Cervical Cancer <ul><li>8th most common malignancy in women </li></ul><ul><li>accounts for 18% of all gynecologic cancers in the US </li></ul><ul><li>Reduced mortality from cervical cancer as much as 75% </li></ul><ul><li>in past 45 years, its incidence has decreased from 45 to 15 per 100,000 women </li></ul><ul><li>an increase has occurred in the prevalence of dysplasia and preinvasive lesions </li></ul>
  3. 4. Pap Smears <ul><li>The Pap smear (more than many other screening tests) has proven its cost effectiveness. </li></ul><ul><li>Early detection of pre-malignant lesions by Pap smears prevent at least 70% of potential cervical cancers. </li></ul>
  4. 5. Of the 30% who actually develop cervical cancer: <ul><li>8% elude cytological detection because of </li></ul><ul><ul><li>imperfections in cytological technology </li></ul></ul><ul><ul><li>biologic behavior of malignant lesions </li></ul></ul><ul><li>22% represent women who develop cervical cancer because of failure to regularly seek Pap smears => women whose cancers could have been prevented with early detection and treatment. </li></ul>
  5. 6. Do not withhold OCPs from women with an abnormal Pap smear . <ul><li>No reason to believe OCPs will hasten the progression of an existing cervical lesion </li></ul><ul><li>Tragic result => unintended pregnancy => makes diagnosis more difficult => treatment is delayed. </li></ul>
  6. 7. Risk Factors for Cervical Cancer <ul><li>early onset of intercourse </li></ul><ul><li>three or more sexual partners </li></ul><ul><li>male partner who has had other partners </li></ul><ul><li>clinical history of HPV </li></ul><ul><li>first child prior to age 20 </li></ul><ul><li>exposure to DES in utero </li></ul><ul><li>cigarette smoking </li></ul>
  7. 8. Protective Factors <ul><li>virginity </li></ul><ul><li>long-term celibacy </li></ul><ul><li>life-long mutual monogamy </li></ul><ul><li>long-term use of condoms </li></ul>
  8. 9. No Effect on Cervical Cancer <ul><li>history of HSV </li></ul><ul><li>circumcision status of male partner </li></ul><ul><li>religious background </li></ul><ul><li>number of pregnancies </li></ul>
  9. 10. Effect of race and social economic status is controversial . <ul><li>higher rates among African-American women </li></ul><ul><li>higher rates among women of lower social economic status </li></ul><ul><li>unclear whether related to access to Pap smears and other medical care or other undetected confounding variables </li></ul>
  10. 11. HIV Infection and Cervical Cancer Risk <ul><li>Pap smears at least annually </li></ul><ul><li>baseline colposcopic evaluation at time of initial diagnosis of HIV </li></ul><ul><li>colposcopy after single reading of ASCUS or SIL Pap </li></ul><ul><li>aggressive treatment of cervical disease will prolong life in most cases </li></ul>
  11. 12. Timing of Pap Smear <ul><li>any time that menstrual bleeding is not present </li></ul><ul><li>optimal timing </li></ul><ul><ul><li>midcycle </li></ul></ul><ul><ul><li>no intercourse for 24 hours prior </li></ul></ul><ul><ul><li>nothing in vagina for 48 hours prior </li></ul></ul><ul><ul><li>no douching </li></ul></ul>
  12. 13. Pap Sampling <ul><li>Moisten speculum with warm water </li></ul><ul><li>Never use other lubricants </li></ul><ul><li>Visualize the entire cervix </li></ul><ul><li>Remove excess cervical mucus </li></ul><ul><li>Sample the ectocervix first using the spatula </li></ul><ul><li>Sample the endocervix using the brush </li></ul><ul><ul><li>Thinprep will do both at the same time. </li></ul></ul>
  13. 14. Pap Procedure continued <ul><li>Evenly distribute the sample over the side and spray immediately! </li></ul><ul><li>Must obtain cells from the transformation zone </li></ul><ul><li>Use correct order in collecting samples </li></ul><ul><ul><li>Pap smear </li></ul></ul><ul><ul><li>GC culture </li></ul></ul><ul><ul><li>chlamydia </li></ul></ul>
  14. 17. Pap Smear Technique <ul><li>Must obtain cells from the transformation zone </li></ul><ul><li>Use spatula </li></ul><ul><li>Spray </li></ul><ul><li>Use cytobrush …insert into OS of T-zone not visible </li></ul><ul><li>Spray again </li></ul>
  15. 19. Pap Slide Preparation <ul><li>1st, sample exocervix by rotating wooden spatula around 360 degrees </li></ul><ul><li>immediately spread sample on glass slide </li></ul><ul><li>2nd, sample endocervix with cytobrush or with saline-moistened cotton-tipped applicator plate this sample directly over 1st sample by gently rolling over the slide </li></ul><ul><li>fix the sample immediately to avoid air drying </li></ul>
  16. 21. Pap Smear Consensus Statement (August 1987) <ul><li>all women who are, or who have been sexually active, or who have reached 18 years of age, (should) have an annual Pap test and pelvic exam </li></ul><ul><li>after a woman has had 3 or more consecutive, satisfactory, normal annual exams, the Pap test may be performed less frequently at the discretion of her physician as long as she has no other risk factors! </li></ul>
  17. 22. Pap Smear Screening Intervals: Extremely Low-Risk <ul><li>virginal </li></ul><ul><li>never an abnormal Pap and > 5 benign Pap smears and hysterectomy for benign disease </li></ul><ul><li>> 10 benign Pap smears, including 1 at older than 60 years; presently over 65 years old </li></ul>
  18. 23. Pap Smear Screening Intervals: Low Risk <ul><li>onset of sexual activity at > 20 years old </li></ul><ul><li>< 3 sexual partners (ever) </li></ul><ul><li>user of barrier contraception </li></ul><ul><li>no history of HPV or STDs </li></ul><ul><li>Previously normal Pap smear </li></ul><ul><li>Yearly Pap smear for 3 years, then every 2-3 years </li></ul>
  19. 24. Pap Smear Screening Intervals: High-Risk <ul><li>onset of sexual activity at < 20 years old </li></ul><ul><li>3 or more sexual partners </li></ul><ul><li>history of HPV or STDs </li></ul><ul><li>previously abnormal Pap smear </li></ul><ul><li>cigarette smoker </li></ul><ul><li>New partner within the past year </li></ul><ul><li>Yearly Pap smear </li></ul>
  20. 25. Pap Smear Screening Intervals: Post-Hysterectomy <ul><li>cervical or uterine malignancy </li></ul><ul><li>premalignant cervical lesion </li></ul><ul><li>benign cervix and uterus </li></ul><ul><li>every 3 months for 2 years, every 6 months for 3 years, then yearly </li></ul><ul><li>every 6 months for 2-3 years, then yearly </li></ul><ul><li>every 3-5 years </li></ul>
  21. 26. Pap Smear Screening Intervals: DES-exposed Daughters <ul><li>first Pap at onset of menstruation, 14 years old, or onset of intercourse </li></ul><ul><li>baseline colposcopy after onset of intercourse </li></ul><ul><li>vaginal and cervical Pap smears every 6-12 months until 30 years old </li></ul><ul><li>thereafter, yearly cervical and vaginal Pap smears </li></ul>
  22. 27. Differences between the Bethesda System and the Papanicolaou System <ul><li>narrative descriptive diagnosis only </li></ul><ul><li>includes the diagnosis of HPV infections and limits use of the term “atypia”. </li></ul><ul><ul><li>squamous intraepithelial lesion = SIL </li></ul></ul><ul><ul><li>low-grade SIL = HPV change and CIN I </li></ul></ul><ul><ul><li>high-grade SIL = CIN II and CIN III lesions </li></ul></ul><ul><li>defines cervical cytological screening as a consultation with a cytopathologist </li></ul>
  23. 28. Bethesda System * CIN Classification * Papanicolaou <ul><li>Low-grade SIL </li></ul><ul><li>High-grade SIL </li></ul><ul><li>Atypia: koilocytotic, warty, condylomatous </li></ul><ul><li>Mild dysplasia </li></ul><ul><li>Moderate dysplasia </li></ul><ul><li>Severe dysplasia, carcinoma-in-situ </li></ul><ul><li>HPV change </li></ul><ul><li>CIN I </li></ul><ul><li>CIN II </li></ul><ul><li>CIN III </li></ul>
  24. 29. Normal cells with regular size & shape
  25. 30. Irregular, disfigured cervical cells--typical of cervical cancer.
  26. 31. New Technology <ul><li>AutoPap –computerized recheck of Pap </li></ul><ul><li>ThinPrep- cells placed in a solution, filtered, and then placed on a slide </li></ul><ul><ul><li>HPV testing </li></ul></ul><ul><ul><ul><li>low oncogenic potential (HPV types 6, 11, 35) </li></ul></ul></ul><ul><ul><ul><li>high oncogenic potential (HPV types 16, 18, 31, some 50s) </li></ul></ul></ul>
  27. 33. Bethesda System: Infection <ul><li>fungus consistent with Candida sp. </li></ul><ul><li>Trichomonas vaginalis </li></ul><ul><li>predominance of coccobacilli consistent with a shift in vaginal flora </li></ul><ul><li>bacteria morphologically consistent with Actinomyces sp. </li></ul><ul><li>cellular changes associated with HSV </li></ul>
  28. 34. Bethesda System: Reactive and Reparative Changes <ul><li>cellular changes associated with inflammation </li></ul><ul><li>atrophy with inflammation </li></ul><ul><li>miscellaneous: radiation, IUD, DES, etc. </li></ul>
  29. 35. Bethesda System: Squamous Cell Abnormalities <ul><li>atypical squamous cells of undetermined significance (ASCUS) </li></ul><ul><li>low-grade SIL </li></ul><ul><li>high-grade SIL </li></ul><ul><li>squamous cell cancer </li></ul>
  30. 37. Bethesda System: Gland Cell Abnormalities <ul><li>endometrial cells, cytologically benign, in a pre menopausal woman </li></ul><ul><li>atypical glandular cells of undetermined significance (AGCUS) </li></ul><ul><li>adenocarcinoma </li></ul>
  31. 39. Treatment of SIL <ul><li>cryotherapy </li></ul><ul><li>LEEP </li></ul><ul><li>laser </li></ul><ul><li>conization of the cervix </li></ul><ul><li>hysterectomy </li></ul>
  32. 41. Diethylstilbestrol (DES) Exposure <ul><li>used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births </li></ul><ul><li>studies during the late 1950s proved its ineffectiveness </li></ul><ul><li>DES use continued through 1971 </li></ul><ul><li>estimated 2 million women were exposed in utero </li></ul>
  33. 42. DES Exposure Sequelae <ul><li>structural changes </li></ul><ul><ul><li>transverse vaginal and cervical ridges (cocks combs, collars, and pseudopolyps) </li></ul></ul><ul><ul><li>abnormally shaped uterine cavity </li></ul></ul><ul><ul><li>uterine hypoplasia </li></ul></ul><ul><li>vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears </li></ul><ul><li>clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years </li></ul><ul><li>increased incidences of: </li></ul><ul><ul><li>spontaneous abortion </li></ul></ul><ul><ul><li>ectopic pregnancy </li></ul></ul><ul><ul><li>premature cervical dilation </li></ul></ul><ul><ul><li>premature rupture of membranes </li></ul></ul>
  34. 43. Cervical Polyps <ul><li>benign, pedunculated growths of varying size that extend from the ectocervix or endocervical canal </li></ul><ul><li>may occur singularly or may be multiple </li></ul><ul><li>etiology is unknown </li></ul><ul><li>believed to result from chronic inflammation </li></ul><ul><li>may be associated with hyper-estrogen states </li></ul><ul><li>found commonly with endometrial hyperplasia </li></ul><ul><li>most common among multiparous women in their 30s and 40s </li></ul><ul><li>most common benign neoplastic growth of the cervix </li></ul><ul><li>occurs in 4% of all gynecologic patients </li></ul>
  35. 45. Cervical Polyps: Symptoms <ul><li>usually asymptomatic </li></ul><ul><li>thick leukorrhea </li></ul><ul><li>postcoital bleeding </li></ul><ul><li>intermenstrual bleeding </li></ul><ul><li>menorrhagia </li></ul><ul><li>post-menopausal bleeding </li></ul><ul><li>mucopurulent or blood-tinged vaginal discharge </li></ul>
  36. 47. Cervical Polyps: Physical Exam <ul><li>single or multiple pear-shaped growths may protrude from the cervix into the vaginal canal </li></ul><ul><li>usually smooth, soft, reddish purple to cherry red </li></ul><ul><li>readily bleed when touched </li></ul><ul><li>may be small or very large </li></ul>
  37. 49. Cervical Polyps: Differential Diagnoses <ul><li>endometrial polyps </li></ul><ul><li>small prolapsed myomas </li></ul><ul><li>cervical malignancy </li></ul>
  38. 50. Endocervical Polyps: Management <ul><li>should be removed </li></ul><ul><ul><li>paint the cervix with Betadine </li></ul></ul><ul><ul><li>use ring forceps to grasp and twist the polyp at the base </li></ul></ul><ul><ul><li>apply silver nitrate or Monsel’s solution to the site to control bleeding </li></ul></ul><ul><ul><li>excessive bleeding is potential adverse effect </li></ul></ul><ul><li>pelvic rest for 24 hours to ensure that bleeding does not occur at the removal site </li></ul><ul><li>RTC if excessive bleeding or excessive vaginal discharge does occur </li></ul><ul><ul><li>re-evaluate </li></ul></ul><ul><ul><li>possible endometrial sampling </li></ul></ul><ul><li>send to Pathology laboratory </li></ul>