# Papanicolaou (Pap) Smear

## Overview

This module describes how to perform a Papanicolaou smear, better known as a Pap smear, a test used for cervical cancer screening.

## Indications

1. Asymptomatic persons, every 10 years starting at age 30

2. Asymptomatic HIV positive persons every year

3. Persons presenting with a gynaecological complaint that could indicate a risk of cervical cancer

## Contraindications

1. No cervix

2. Known cervical cancer

3. A

   lesion
   lesion

   Ulcers or masses should be biopsied. A Pap smear should not be used to diagnose a lesion suggestive of malignancy.

   suggestive of cervical cancer

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“A Pap smear is a test for cervical cancer, or for changes to the cervix that put you at risk of developing cancer later. Although the thought of it might make you feel uncomfortable, every woman should have Pap smears regularly as a part of looking after yourself.”

### What can my patient expect?

“I will use a speculum, a tool that allows me to see your cervix. The speculum may feel very cold. Once the speculum is in place, the procedure will go very quickly. I will use a spatula to scrape some cells from your cervix to send to the lab. This is usually not painful, but it can be slightly uncomfortable. There should not be bleeding after the test. The results will come back in a month’s time. I will call you with the results.”

### What is my patient’s role?

“If you have a full bladder, it is best to void before the procedure. Take deep breaths and try not to tense or squeeze your legs; when you are relaxed, it’s less uncomfortable. Tell me if it is painful at any point, or if you wish me to stop.”

## Preparation

Prepare a trolley with equipment. Ensure a female chaperone is present.

### Documentation

1. Patient notes

2. Cytology request form

### Equipment

1. Non-sterile gloves

2. Alcohol-based hand rub

3. Sterile

   speculum
   speculum

   Check beforehand to ensure that the locking mechanism is working properly.

4. Lubricant

5. A glass slide and pencil

6. A slide case/envelope

7. A wooden Ayre’s spatula or cytobrush

8. Fixative spray

## Site & Positioning

The patient should be positioned reclining or supine, with their heels drawn up to their buttocks and knees apart. This procedure requires strong, focused lighting.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene.

2. Label the slide with the patient’s name and folder number in pencil.

3. Open the speculum packaging and apply a small amount of

   lubricant
   lubricant

   Some lubricants may interfere with cytology, so be sure to only use as much as needed to ensure comfortable insertion of the speculum, and make sure none gets on the cervix.

   to the outside of the valves of the speculum.

4. Don gloves.

5. Insert and open the

   speculum
   speculum

   Gentle downward pressure against the rectovaginal septum may open the vaginal vault. Avoid abutting the sensitive clitoris and urethra. Insert the speculum vertically, then turn it horizontal. When the speculum is fully inserted to the hub, open the valves by pressing on the thumb hinge. Rotate the thumb screw to hold the valves in place.

   . Inspect the vaginal walls and cervix for any abnormalities.

6. If using a spatula, place the long arm of the spatula into the external os of the cervix and rotate 360°. If using a cytobrush, insert it into the external os and rotate

   clockwise
   clockwise

   The brush bristles are designed to scoop up cells with a one-sided edge. Don't turn the brush counter-clockwise, as it will not be effective.

   5 times.

7. Remove the spatula and wipe it gently on the slide. If using a cytobrush, wipe one side of the brush on the top half of the slide, turn the brush over, and wipe a second time over the bottom half of the slide.

8. Spray the slide with fixative from a 30 cm distance until the slide is wet and place in a slide case.

9. Remove
   Remove

   Unscrew the thumb screw and allow the speculum to close itself while withdrawing it. If you try to close it using the thumb hinge, you risk pinching the vaginal walls.

   the speculum.

10. Dispose of medical waste safely.

11. Complete the cytology form and send it with the sample to the lab.

12. Document completion of the procedure.

## Troubleshooting

The patient’s vaginal walls bulge between the speculum valves and I can’t see past them.

Cut the fingers off a small glove and slip the palm section over the speculum valves. Once inserted and opened, the glove will stretch to form a sleeve, holding back the vaginal walls and allowing you to see past them.

My patient is very anxious and is struggling to relax enough for me to pass the speculum.

Ask the patient to cough or strain while inserting the speculum. Warming the speculum valves in your hand before insertion can also help. Make sure that you provide lots of reassurance and are sensitive to the patient’s emotional state during the procedure.

My patient’s results have returned and I want to arrange follow-up.

Report shows 'Inadequate': Repeat the smear.

Report shows

LSIL

LSIL

Low-grade squamous intraepithelial lesion

or

ASCUS

ASCUS

Atypical Squamous Cells of Undetermined Significance

: Repeat smear in 6-12 months. If normal, do another smear in 12 months. If the same or worse, refer for colposcopy.

Report shows

DSIL

DSIL

High-grade Squamous Intraepithelial Lesion

or

AGUS

AGUS

Atypical Glandular Cells of Undetermined Significance

: refer for colposcopy.

## Risks

1. Vasovagal response

2. Minor cervical bleeding

3. Inadequate smear

4. Mild post-procedural pain and cramping

## References

1. Kitchen FL, Cox CM. Papanicolaou Smear. [Updated 2020 Oct 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470165/

2. Woods D, Dyer S, Kennedy D. Women’s Health Care. Bettercare. 2021.