This document outlines the procedure and findings of Pap smear screening and management of abnormal results. A Pap smear involves collecting cervical cells to screen for precancerous lesions. Findings are reported using the Bethesda system and include categories like normal, atypical squamous cells, low-grade lesions, and high-grade lesions. Abnormal results require follow up like colposcopy, treatment of precancerous lesions, or hysterectomy for more severe cases. Regular Pap smear screening can effectively reduce cervical cancer incidence and mortality.

1. ABNORMAL CERVICAL SMEAR –
PROCEDURE SCREENING &
MANAGEMENT
OPS UNIT

2. OUTLINE
• Introduction: Pap smear
• Overview: Cervical cancer
• Pap smear procedure
• Pap smear findings
• Management
• Conclusion
• References

3. • A cervical smear is a cytology-based screening test for cervical
cancer in which vaginal cells are collected and stained as a means of
detecting cytologic abnormalities of the uterine cervix.
• Developed by Dr George Papanicolaou in 1943.
• It has been implemented in countries around the world as a
screening strategy, and subsequent reductions in rates of cervical
cancer by 50% or more have been seen.
• It is recommended to be performed once every 3-5 years for women
between the ages of 25 to 65 years.
• The reported sensitivity and specificity of Pap smear varies: sensitivity
ranges from 30-87%, and specificity ranges from 86-100%.
INTRODUCTION

4. INTRODUCTION
• For more than 95% of women, cervical cytology is normal
and normal squamous cells are seen.
• Abnormal cervical cytology shows squamous cells at different
stages of maturity(dyskaryosis).
• When abnormal cells are detected on the pap smear,
diagnostic testing in the form of colposcopy is often indicated.

5. • 2nd most common cancer among women in developing
countries.
• Most common gynaecological cancer and a leading cause of
cancer deaths among women in Nigeria.
• Established aetiology is a persistent Human Papillomavirus
infection (most implicated serotypes are high-risk 16 and 18),
mainly acquired from sexual contact.
• Risk factors include: early coitarche, multiple sexual partners,
promiscuous male partners, history of STIs,
immunosuppression (HIV), multiparity, COCP use, smoking.
CERVICAL CANCER

6. PAP SMEAR PROCEDURE
Preparation
• Cervical screening should be done when the patient is not menstruating.
• Avoid vaginal intercourse, douching, use of tampons, use of medicinal
vaginal or contraceptive cream for 24-48 hours prior to the test.
• Ideally, pre-existing cervicitis should be treated prior to cervical screening.
• Screening should proceed in the presence of bleeding or cervicitis, as
these symptoms may be related to cervical dysplasia or neoplasia.

7. PAP SMEAR PROCEDURE
Positioning
• Patient should be supine, in dorsal
lithotomy position to correctly
perform the procedure.
• The coccyx of the patient should be
at the edge of the examination table
to provide adequate visualization of
the cervix once the speculum is
inserted.

8. • Cervix is visualized using a speculum.
• Samples of the cervix are taken from the transformation zone; where the
ectocervix and endocervix meet and where dysplasia is most likely to be
identified.
• Samples are taken using an Ayres spatula.
• Smear spread on a slide and the slide fixed in 90% ethanol.
• Smear is sent to a cytopathologist, who provides a cytologic analysis.
PAP SMEAR PROCEDURE

10. PAP SMEAR FINDINGS
• Pap smear results are routinely reported according to the
Bethesda system.
• The Bethesda system provides a framework for consistent
interlaboratory terminology for the reporting of
cervicovaginal cytology specimens.
• Most recent update to the system was done in 2014.
• A satisfactory smear should have squamous cells, metaplastic
cells and columnar cells.

11. THE BETHESDA SYSTEM
• Specimen Type
• Specimen Adequacy
• General categorization*
• Interpretation/Results
• Ancillary Testing
• Automated Review
• Educational Notes & Suggestions

12. Negative for Intraepithelial Lesion or Malignancy (NILM)
• Non-Neoplastic Findings (non-neoplastic cellular variations, reactive cellular
changes, glandular cells)
• Organisms
Epithelial Cell Abnormality
• Squamous Cell
• Atypical squamous cells: of undetermined significance (ASC-US) OR cannot
exclude HSIL (ASC-H)
• Low-grade squamous intraepithelial lesion (LSIL) (encompassing: HPV/mild
dysplasia/CIN 1)
• High-grade squamous intraepithelial lesion (HSIL) (encompassing: moderate
and severe dysplasia, CIS; CIN 2 and CIN 3)
• Squamous cell carcinoma
BETHESDA SYSTEM (2014) – GENERAL CLASSIFICATION (1)

13. Epithelial Cell Abnormalities (cont.)
• Glandular Cell
• Atypical endocervical cells OR endometrial cells OR glandular
cells (NOS or specify in comments)
• Atypical endocervical cells (favour neoplastic) OR glandular
cells (favour neoplastic)
• Endocervical adenocarcinoma in situ
• Adenocarcinoma: endocervical, endometrial, extrauterine,
not otherwise specified (NOS)
BETHESDA SYSTEM (2014) – GENERAL CLASSIFICATION (2)

14. ASC-US and ASC-H cells
• Degree of nuclear atypia is not sufficient for the cells to be defined as either a high-grade
or low-grade squamous intraepithelial lesion.
Low-grade squamous intraepithelial lesions
• Suggestive of mild dysplasia or expected CIN-1 on histology and HPV infections with
high-risk types. Approximately 50% will regress, while 20% will progress to HSILs in 24
months.
High-grade squamous intraepithelial lesions
• Consistent with moderate and severe dysplasia, corresponding with CIN-2, CIN-3, and
carcinoma in-situ on histology. Only 35% will regress.
PAP SMEAR FINDINGS – CYTOLOGIC ABNORMALITIES

15. • Cervical Intraepithelial Neoplasia (CIN) is a precancerous lesion of the cervix
• Identified in cytology by:
• Koilocytes (atypical cells with a perinuclear cavitation or halo in the
cytoplasm)
• Dysplastic cells with increased nucleo-cytoplasmic ratio.
• Low-grade CIN/CIN-1: one-third of epithelial thickness has dysplastic
changes
• CIN-2: half to two-thirds of epithelial thickness has dysplastic changes
• CIN-3: full-thickness involvement of epithelium
• Carcinoma in-situ: dysplasia seen throughout the epithelium, resembles
cervical cancer, but no basement membrane invasion.
PAP SMEAR FINDINGS – CIN

16. NILM
• Repeat in 3-5 years as recommended
ASC-US
• Repeat cytology in 1 year; if negative, repeat cytology in 3 years
• HPV testing is preferred; if negative, repeat cotesting in 3 years; if
positive, perform colposcopy
ASC-H cells, LSIL, HSIL
• Perform colposcopy
Colposcopy involves visualization the cervix and obtaining biopsies of
lesions identified by acetic acid stain (sharp, distinct, well defined, dense
aceto-white lesions).
MANAGEMENT (1)

19. Precancerous lesions can be treated via:
• Ablative Methods
• Cryotherapy
• Laser
• Cold coagulation
• Excisional Methods
• Large Loop Excision of the Transformation Zone (LLETZ)/Loop Electrosurgical Excision
Procedure (LEEP)
• Laser cone biopsy
• Cold knife cone biopsy
• Hysterectomy (in cases of co-existing uterine conditions such as fibroids)
Annual follow-up with Pap smears following treatment of precancerous lesions.
MANAGEMENT (2)

21. CONCLUSION
Cervical/Pap smear is a useful screening tool to control the most common gynaecological
cancer among women in Nigeria.

22. REFERENCES
1. Cervical Screening: Overview, Human Papillomavirus, Papanicolaou Test. 2021 Aug 22
[cited 2022 Mar 10]; Available from: https://emedicine.medscape.com/article/1618870-
overview
1. Gynaecology by ten teachers, 20E
1. HPV and premalignant disease of the cervix by Prof Anorlu