Abnormal

Pap Smear
Senior Obstetrics + Gynaecology Clerkship
Kimberly Clarke | MBBS 2023
 Screening
Screening is important because cervical cancer:
► Was once the leading cause of cancer death especially
for women in the US.
► But in the past 40 years, the number of cases and deaths
has gone down significantly because many women are
getting regular Pap tests.
 Incidence
► Cervical cancer is the fourth most common cancer
among women globally (WHO, 2022)
► It is the most common gynecological cancer (in front of
endometrial cancer).
Methods of Screening

► Pap Smear
► HPV DNA test
► HPV mRNA test
► Visual Inspection with Acetic Acid (VIA)
► Visual Inspection with Lugol’s Iodine (VILI)/ Schillers test
Recommendations for Screening
 Recommendations
The recommendations apply to persons who:
1. Have a cervix
2. Asymptomatic of cervical cancer
*Regardless of their sexual history and HPV vaccination
status.
 Recommendations
The recommendations do NOT apply to individuals who:
1. At high risk of the disease such as those previously
diagnosed with precancerous cervical cancer lesion
2. In utero exposure to diethylstilbestrol
3. Immunocompromised individuals (e.g. persons with HIV)
Normal Cervical
Histology
 Endocervix
► Columnar epithelium
► Mucus secreting
► Undergoes metaplasia when exposed to
low pH
Ectocervix
► Non-keratinizaing stratified squamous
epithelium
► Resistant to low pH
 Squamocolumnar Junction

► There is an abrupt squamocolumnar junction

► Present since birth but the LOCATION changes (dynamic
point)
► This area is sensitive to estrogen hence, it changes
during puberty.
► Estrogen results in increased glycogen in the cells.
Lactobacillus act on glycogen to produce lactic acid 🡪
lower the pH
Squamocolumnar Junction
 Transformation Zone
► Predominant site for the development of cervical squamous cells. It
contains reserve cells.
► Physiological metaplasia observed here
 Cervical Squamous Epithelium
This consist of 4 layers
► Superficial cells
► Intermediate cells (navicular
cells)
► Parabasal cells
► Basal cells – do not ordinarily
exfoliate
 Superficial cells (Stratum corneum
layer)
► Flat, elongated cells
with small pyknotic
nuclei

► Collagen is present in
the more superficial
cells
 Intermediate cells (Navicular cells)

► Flattened cells
► Glycogen-rich clear
cytoplasm
► Comprises the majority of
the squamous cells

► The nuclei are small, dark,

and round
► Nucleoli are not seen
 Parabasal cells (Prickle Cell Layer)

► Irregular polyhedral cells

► Large, dark, oval nuclei
► Nucleoli can be seen in the
majority of these cells
► Numerous desmosomes
(cell adhesion sites) are
also seen
 Basal cells (Germinal Layer)

► One to two layers of small

cuboidal cells
► Large darkly staining
round- to oval-shaped
nuclei

► Mitotic figures are

occasionally seen here
► Does not exfoliate
Abnormal
Cervical
Histology
Top two risk factors for cervical
cancer :
 Human Papillomavirus
► Accounts for 99.7% of cervical cancer
► Changes from HPV called Koilocytosis
► Nuclear abnormalities
► Typical central clearing (perinuclear halo)
► Peripheral condensation of cytoplasm
► Nucleus irregularly enlarged
► Hyperchromasia
► Multinucleation
 Dyskaryosis
► Cytological diagnosis
► Dysplasia
► Increased nuclear:
cytoplasm ratio
► Mitotic figures
► Nuclear hyperchromasia
 PAP
SMEAR
 Pap Smear

Pap Smear is a screening procedure for cervical cancer that

involves exfoliative cytology.
► Sensitivity 60%
► Specificity 100%
► Positive Predictive Value 100%
► Negative Predictive Value 99.4%
► Accuracy 99.4%
 Preparation
Patient should
► Informed and consented
► Not be menstruating
► Ideally* avoid the following 24-48hrs before a pap smear:
► Intercourse
► Douching
► Using any vaginal medicines or spermicidal foams, creams or jellies
These may wash away or obscure abnormal cells Pap smear can be done
on a pregnant patient.
 Apparatus
1. Cytology form
2. Microscope Slide (Conventional Cytology)
3. Cytology Specimen Jar (Liquid-based Cytology)
4. Sterile Gloves
5. Lubricating jelly
6. Bivalve Speculum (Grave’s is more advantageous)
7. Ayre’s Spatula/Endocervical broom/Cytobrush
8. Fixative spray
9. Good light source
10. Examination table with stirrups
Cytology Form
Microscope Slide

► Used in Conventional
Cytology
► Label before the
procedure:
► Name
► Date
► Registration #
Cytology Specimen Jar
► Used in Liquid-based
Cytology
► Allows smears to be
processed more efficiently
► Gives less percentages of
inadequate smears
► Label before procedure
Sterile Gloves; Lubricating Jelly

► Sterile procedure
► Sterile set (kidney dish,
sponge holder, cusco’s)
► Sterile gloves

► Lubricating jelly (use none

or a very small amount as it
might obscure results.
Cusco’s Bivalve Self-Retaining Vaginal
Speculum

Description:
► Metal (reusable) or plastic (disposable)
► Anterior and posterior blades (equal in
length)
► Only the bottom blade moves
► Various sizes: small, medium, and large
► Fixation screw for adjustment and
locking
► Handle
 Cusco’s Bivalve Self-Retaining Vaginal
Speculum
Use:
► The valves are to retract the anterior and posterior vaginal wall so as to
have a good look to the cervix.
Indications:
► To visualize the cervix and vaginal fornices.
► To collect cervical smear for cytologic screening and vaginal pool materials.
► To have cervicovaginal swabs for Gram stain and culture.
► To insert or to remove IUCD or to check the threads.
► To perform minor operations like punch biopsy, surface cauterization or snipping a
small polyp
 Ayre’s Spatula
Description:
► Wooden with U shaped openings on one end and a flat surface on
the other. (wooden so that cells adhere)
► Plastic
Pointed tip: used in post-menopausal patients to sample the
endocervix (which is higher up in post-menopausal patients)
► Ends:
► 1- for nulliparous
► 1 – for multiparous
► Broad end usually for - vaginal sample collection

► Narrow end- cervical sample collection

 Ayre’s Spatula
Use:
► Collection of cells for cytology screening (ectocervix)
Procedure:
► Projected end of the spatula goes within the external
os
► The spatula is rotated 360° to collect cells from the
entire ectocervix
 Cytobrush
Description:
► Plastic

► Nylon bristles

Use:
► Endocervical brush are used for collection of
cells for cytology screening (endocervix)
Procedure
► The cytobrush goes within the cervical canal and
is rotated to collect cells
Endocervical Broom
Description:
► Plastic with brittles of varying
sizes:
► central long brittles used for
endocervix
► peripheral shorter brittles used
for ectocervix
Use:
► Collect cells from both
endocervix and ectocervix
(liquid-based cytology)
Endocervical Broom

Procedure:
► Insert the center of the
plastic broom the external os
► Rotate broom 360° five
times
 Fixative
► Methylated spirits
► 95% Ethyl alcohol
 Preparation
Patient should
► Informed and consented
► Not be menstruating
► Ideally* avoid the following 24-48hrs before a pap smear:
► Intercourse
► Douching
► Using any vaginal medicines or spermicidal foams, creams or jellies

These may wash away or obscure abnormal cells Pap smear can be done
on a pregnant patient.
 Procedure
► Position the patient on their
backs in the frog-leg position
that is, with their knees and
knees apart
► Inspection: perineum, vulva

► Ask patient to

► Cough (hernia and stress

incontinence)
► Bear down (prolapse)
 Procedure

► Gently lubricate bivalve

speculum
► Gently part the labia with
left hand
► Insert blades vertically until
the blades are fully in the
vagina and slowly rotate
horizontally
► Slowly open blades to see
the cervix
 Procedure

Conventional
► Insert the ayre’s spatula and
place the long part at the
external os
► Rotate 360°
► Spread across the glass
slide
► Immediately fix for 3-4
minutes
 Procedure
Liquid-based Cytology
► Insert the endocervical broom
and place the long part at the
external os
► Rotate 360° five times
► Push broom 10 times against the
bottom of the specimen
container
► Twirl five times through 360° to
dislodge the sample
► Firmly close the lid
► BIMANUAL EXAMINATION
 Procedure

► https://www.youtube.com/watch?v=5EIqLqpjWiQ
 Reporting Findings

► Papanicolaou Classification
► Dysplasia-carcinoma/ CIN Classification
► Bethesda Classification
Papanicolaou Classification
 Papanicolaou Classification

► While this system is adequate for differentiating

benign from malignant
► Inconsistent with our current understanding of
the dysplasia carcinoma process.
► Interlaboratory comparison was impossible
► No tissue equivalent for classes II through IV
Papanicolaou Classification
Dysplasia-carcinoma vs CIN
To alleviate some of the
shortcomings of the
Papanicolaou numerical system,
some laboratories adopted the
following:

► Dysplasia-carcinoma system

► Cervical intraepithelial
neoplasia (CIN) system
 Dysplasia-carcinoma
The dysplasia carcinoma similar to the
classifications on cervical biopsy:
► mild dysplasia
► moderate dysplasia
► severe dysplasia
► carcinoma in situ (CIS)
► squamous cell carcinoma

► Directly comparable to tissue biopsy

► Well understood by clinicians and
pathologists
 Cervical Intra-epithelial Neoplasm
Classification
► The CIN system is somewhat similar to the dysplasia-carcinoma
system:
► CIN I is mild dysplasia
► CIN II is moderate dysplasia
► CIN III combines severe dysplasia and carcinoma in situ.
► Pathologists cannot reliably differentiate severe dysplasia from CIS,
even with a biopsy specimen
► CIS implies inevitable invasion without treatment, whereas severe
dysplasia may regress.
► Since these were not easily differentiated, they were combined as
CIN III.
Bethesda Classification
Bethesda Classification
Bethesda Classification
Bethesda Classification
Bethesda Classification
► CIN 1 affects only one-third of the cervical surface area

► CIN 2 grade refers to two-thirds of the thickness of the surface

layer of the cervix

► CIN 3 affects the full thickness

► CIN 1 affects only one-third of the cervical surface area
► CIN 2 grade refers to two-thirds of the thickness of the surface layer of the
cervix
► CIN 3 affects the full thickness
Atypical Squamous Cell of Unknown
Significance

► Squamous cells
with enlarged
and
hyperchromatic
nuclei.
 Low-grade squamous intraepithelial
lesion (LSIL): mild dysplasia (CIN 1)
Mild dyskaryosis/CIN I
► Cells:
► superficial or intermediate type squamous cells.
► Have angular borders with translucent cytoplasm.
► The nucleus
► occupies less than half of the total area of cytoplasm
► Binucleation
 Low-grade squamous intraepithelial
lesion (LSIL): HPV‡ infection
Koilocytosis
► Typical central clearing (perinuclear halo)

► Peripheral condensation of cytoplasm

► The nucleus
► irregular enlarged

► shows hyperchromasia

► multinucleation
 High-grade squamous intraepithelial
lesion (HSIL): moderate (CIN 2)
Moderate dyskaryosis/ CIN II—
► Cells

► intermediate, parabasal or superficial type squamous cells

► More disproportionate nuclear enlargement
► More hyperchromasia

► Nucleus
► occupies one half to two-thirds of the total area of the cytoplasm
 High-grade squamous intraepithelial
lesion (HSIL): severe dysplasia (CIN 3)
Severe dyskaryosis/ CIN III –
► Cells
► Basal type
► round, oval, polygonal or elongated in shape.
► In clumps or singly
► Different in size and shape
► Elongated are sometimes called fiber cells
► An elongated tail of cytoplasm is described as a tadpole cell

► Nucleus
► practically fills the cell or there may be a thick, dense and narrow rim of cytoplasm
around it.
► Irregular with coarse chromatin pattern.
 High-grade squamous intraepithelial
lesion (HSIL): Carcinoma In-Situ (CIN 3/CIS)
Carcinoma in situ
► Cells
► Parabasal type
► increased nuclear cytoplasmic
ratio.
► Nucleus
► Irregular sometimes multiple.
► The chromatin pattern is granular.

► Cytoplasm is scanty.
 Squamous cell carcinoma

► Cells
► Single or grouped in
clusters
► Irregular nuclei and
clumping of nuclear
chromatin, which is
also coarse.
► Large tadpole cells
are seen.
Treatment
 References
American College of Obstetricians and Gynecologists. (2021, April 12). Updated Cervical Cancer Screening
Guidelines. ACOG. Retrieved September 14, 2022, from
https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-s
creening-guidelines

Cervical cancer. (2022, February 22). World Health Organization (WHO). Retrieved September 14, 2022,
from https://www.who.int/news-room/fact-sheets/detail/cervical-cancer

Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smears
for cervical cancer screening. (n.d.). ecancer. Retrieved September 14, 2022, from
https://ecancer.org/en/journal/article/262-comparative-study-of-visual-inspection-of-the-cervix-using-acetic-a
cid-via-and-papanicolaou-pap-smears-for-cervical-cancer-screening

Cost-Effectiveness of Cervical Cancer Interventions | Power of Prevention. (n.d.). CDC. Retrieved

September 14, 2022, from https://www.cdc.gov/chronicdisease/programs-impact/pop/cervical-cancer.htm
Distinction between moderate and severe dyskaryosis. (n.d.). Eurocytology. Retrieved September 14, 2022,
from https://www.eurocytology.eu/en/course/1291
 References

Konar, H., & Dutta, D. C. (2014). DC Dutta's Textbook of Gynecology (H. Konar, Ed.).
Jaypee Brothers Medical Publishers Pvt. Limited.

Marrow. (n.d.). Gynaecology Notes by Marrow.

Mitrea, M. (n.d.). -ASCUS: squamous cells with enlarged and hyperchromatic nuclei.
Pap... | Download Scientific Diagram. ResearchGate. Retrieved September 14, 2022,
from
https://www.researchgate.net/figure/ASCUS-squamous-cells-with-enlarged-and-hyperchr
omatic-nuclei-Pap-staining-200_fig2_340299162

Oguntayo, A. (n.d.). Fig. 12. Pap smear of CIN 1. Note large, dark nuclei, but also large...
ResearchGate. Retrieved September 14, 2022, from
https://www.researchgate.net/figure/Pap-smear-of-CIN-1-Note-large-dark-nuclei-but-also-
large-amount-of-surrounding_fig7_221924099

TORONTO NOTES 2021: Comprehensive Medical Reference and a Review for the
Medical. (2021). Toronto Notes for Medical Students, Incorporated.