PAP SMEAR
Position the Patient
Position the patient with her buttocks just at the edge or just over the edge of the exam table. If
she is not down far enough, inserting the speculum can be more difficult for you and
uncomfortable for her.
Appropriate draping should be used to help make the patient more comfortable but not to the
point that it obstructs your view. Good lighting is important and is often accomplished with a
goose-neck lamp.
Pad the Stirrups
Pad the stirrups so that they don't dig into the patient's foot.
Oven mitts or socks can be used to cushion the stirrup. Allowing the patient to keep her socks on
will provide additional padding and help keep the patient's feet warm during the exam.
Inspect the Vulva
Gently spread the labia apart and inspect the vulva, looking for:
Skin lesions
Masses
Drainage
Discolorations of the skin
Signs of trauma
Pubic hair distribution (triangular = normal)
Insect movement (pubic lice) within the pubic hair
Explain what you are doing to the patient to keep her relaxed.
You will need to move the labia and skin folds. Otherwise, you won't be able to see everything.
Warm the Speculum
Warm the vaginal speculum.
Running water works well for this as it also lubricates the speculum. Some health care providers
use a heated drawer or heating pad to keep the speculums warm. Do not overheat as a speculum
that is too hot is just as uncomfortable as one that is too cold.
Never use K-Y Jelly(r), Surgilube(r), petroleum jelly or other lubricant to moisten the speculum
as it may render your Pap smears unreadable under the microscope.
Insert the Speculum
After warming the speculum, separate the labia and keep them apart.
Insert the speculum into the vagina, letting the speculum follow the path of least resistance.
Some vaginas go straight back, parallel to the floor. Other vaginas tilt slightly downward toward
the floor as the speculum advances. Others angle upward, away from the floor. Keep the
speculum blades closed until the speculum is completely inserted.
Open the speculum and usually the cervix is immediately visible. If not, the cervix is usually just
below the lower blade or just above the upper blade. Rocking the speculum downward and
upward usually causes the hidden cervix to drop into view.
Lock the blades in the open position, wide enough apart to allow complete visualization of the
cervix but not to far open as to be uncomfortable for the patient.
With practice, insertion of the speculum should be painless.
Start with the Spatula
The Ayer spatula is specially designed for obtaining Pap smears. The concave end (curving
inward) fits against the cervix, while the convex end (curving outward) is used for scraping
vaginal lesions or sampling the "vaginal pool," the collection of vaginal secretions just below the
cervix.
The spatula is made of either wood or plastic. Both give very satisfactory results.
The concave end of the spatula is placed against the cervix and rotated in circular fashion so that
the entire area around the cervical opening (os) is sampled.
Usually this can be done without causing any discomfort, although some women are sensitive to
the sensation and may experience minor cramping. Sometimes, obtaining this sample causes
some bleeding. In this case, reassure the patient that:
although she may have some minor bleeding or spotting for a few hours, it is not
dangerous,
it will stop spontaneously and promptly
it is caused by the Pap smear.
Sample the SQJ
In obtaining the Pap smear, it is important to sample the "Squamo-columnar Junction." This is
the circular area right at the opening of the cervix where the pink, smooth skin of the cervix
meets the fiery-red, fragile, mucous-producing lining of the cervical canal.
If there is a problem with cancer or precancerous changes, it is this area that is most likely to be
effected. This area of unstable skin is also known as the transition zone.
The transition zone location varies with age and estrogen status.
Make a Thin Smear
Spread the sample taken from the cervix on a glass slide. Try to make the smear as thin as
possible since this makes it easier for the pathologist to read. Make sure the slide is labeled
(using pencil on the frosted end).
In your zeal to make a thin slide, don't spend too much time or else the slide will dry, making it
harder to read.
This is a pathology diagram of a Pap smear from normal to more severe dysplasia, from
left to right. As you can see, the cells get smaller and the depth of abnormality increases
with worsening dysplasia (abnormal growth). CIN stands for cervical intraepithelial
neoplasia. 'Neo' means new, 'dys' means abnormal. I would call it CID instead of CIN,
but this nomenclature changes every few years anyway.
In Situ carcinoma is basically 'cancer sitting there.' At the bottom right, the abnormal
cells have grown through the basement membrane or floor, such that they can now
invade a woman's body. This is true cancer. Everything else is precancerous. No one
should get cervical cancer because it can be reduced with Gardisil and prevented with
yearly Pap smears.
Here are pictures of normal pap smears:
A normal Pap Smear at the screening power of 400X. Benign squamous cells.
A normal Pap Smear at 400X. Benign endocervical cells.
Here are pictures of abnormal pap smears:
An abnormal Pap Smear showing changes consistent with Human Papilloma Virus (HPV) and
Mild Dysplasia. Note the irregular perinuclear cytoplasmic clearing, which is the key
characteristic of identifying HPV visually on a Pap Smear. 400X.
An abnormal Pap Smear showing Severe Dysplasia. 100X.
An abnormal Pap Smear showing Squamous Cell Carcinoma. 400X.
An abnormal Pap Smear showing Adenocarcinoma of the endometrium. 400X.
Here are pictures of miscellaneous pap smear findings:
Herpes virus changes.
Not curable but outbreaks can be controlled with medication.
One little trichomonad with a bunch of inflammatory cells.
Antibiotics such as Flagyl for you and your partner will eliminate trichomonas.
Actinomyces: a bacteria, sometimes found in women with an intrauterine device (IUD). Pelvic
Inflammatory Disease (PID) and decreased fertility have been associated with Actinomyces.
Removal of the IUD and antibiotics will successfully eliminate actinomyces.
