Neobook — clinical reference

Patients who should have cervical smears

The Bethesda Classification 2001

Cervical screening by means of cervical smears (Pap smears) provides a safe, simple & effective method of preventing cervical cancer. This allows early detection of its precursor, cervical intraepithelial neoplasia (CIN).

The Aylesbury spatula is superior to the Ayre’s particularly in the parous patient. Cervical brushes may be better still, but are expensive. Endocervical brushes have special applications (see below). Shaking the spatula or brush into fluid (‘liquid based’ preparation) rather than wiping on a slide may give a higher yield of cells, but is more expensive.

HPV testing may be of value, although only in women over the age of 35 years when nuclear inclusion makes infection more persistent. Prior to this many infections are transient. Its application is not yet fully agreed upon. If CIN 1 is discovered on biopsy, a finding of HPV 16 or 18 may necessitate an excisional or ablative procedure.

Patients who should have cervical smears

All sexually active women should have regular Pap smears but not <20 years
Suggested guidelines for South African public health facilities is for 3 Pap smears in a woman’s lifetime – at 30, at 40 and at 50 years
Avoid doing smears on teenagers, unless there are risk factors, e.g. sexually transmitted infections.
All patients who have been treated for CIN 1,2, or 3 should have annual smears for life, & ideally 4 smears in the first 2 years
All patients going for operations must have recent Pap smear results
Pap smears should always be done for patients presenting without a Pap in the previous 3 years, e.g. infertility workup, fibroid uterus, abnormal vaginal bleeding, any patient for hysterectomy or tubal ligation etc.

How to take a cervical smear

Write the patient’s details clearly on both the slide & the form
Use a small amount of lubricant jelly on the outside of the vaginal speculum
Good visualization of the cervix is essential
If the cervix cannot be seen clearly, reposition the speculum or ask a colleague to try
Turn the spatula or brush around several times with the extended tip in the cervical os.
The endocervical brush may be of benefit in patients with a previous glandular abnormality, if the squamocolumnar junction is not clearly seen, or if there has been a previous excisional procedure with a positive endocervical margin. Twist the brush inside the canal & wipe it onto the slide at a different point or onto a separate slide
Wipe the spatula or brush several times onto the slide
Spray the slide immediately with fixative from about 10-20 cm
Make clear arrangements for follow-up

The Bethesda Classification 2001

This is the third classification. The first, in 1989, was previously revised in 1991.

Squamous abnormalities

HSIL: High grade squamous intra-epithelial lesion (suggesting CIN 2 or 3)
LSIL: Low grade squamous intra-epithelial lesion (suggesting CIN1)
ASC-H: Atypical squamous cells – high grade abnormality cannot be excluded
ASCUS: Atypical squamous cells of uncertain significance

Glandular abnormalities

AIS: Adenocarcinoma-in-situ
AGC: Atypical glandular cells
AGNOS: Atypical glandular cells not otherwise specified

Adequate cervical smears

An adequate smear is one with at least 10 endocervical cells and/or squamous metaplastic cells. There are 8 000 to 12 000 cells per slide, & no more than 75% of the slide should be obscured by blood or inflammatory cells

ABNORMAL SMEARS and how to act

Many patients with an abnormal smears should be referred for colposcopy (HSIL, recurrent LSIL, ASC-H, AIS, AGC)
In certain cases it is permissible to defer colposcopy & repeat the smear (ASCUS, AGNOS, or first LSIL).
Before referral, explain to the patient that:
- The abnormality is not cancer
- The possible treatment involves removal of a coin-sized piece of cervix which grows back
- Colposcopy & follow-up will help to prevent cervical cancer