The patient should be instructed to avoid douching or using vaginal creams for at least 24 hours before her examination. Also, Papanicolaou smears should not be obtained during menstruation because the red blood cells may obscure the sample. Sampling should be done before a bimanual pelvic examination, and the use of lubrication should be avoided if possible. However, water used to warm the speculum will not affect the sample. After the patient is positioned in the dorsal lithotomy position, choose a speculum that allows visualization of the entire cervix. Note any abnormalities of the cervix at this time.
Liquid-based screening systems have been approved by the Food and Drug Administration and were developed to improve the transfer of cells from the collection device to the slide, provide uniformity of the cell population in each sample, and thus decrease interpretationai errors. The two systems currently available are ThinPrep and SurePath. Liquid-based cytology has been shown to result in an increased detection rate of both low-grade and high-grade cervical dysplasia, as well as a decrease in the ambiguous diagnosis of atypical squamous cells of undetermined significance (ASCUS). An added benefit of liquid-based cytology systems is the ability to perform “reflex” human papillomavirus (HPV) testing, if desired. For this and other reasons, many health care providers have made liquid-based cytology their test system of choice despite higher cost.
In the ThinPrep test kit, cervical specimens are collected in the usual fashion with either a broom-type device or a spatula and endocervical brush, and cells are collected directly in the methanol-based fixation liquid.
GRADING OF THE SMEAR
Table 1 lists the classification of Papanicolaou smears.
|Bethesda System||WHO System||CIN System||Class|
|cells of undetermined|
|Low-grade SIL: HPV||Mild||CIN I|
|High-grade SIL||Moderate||CIN II|
|Squamous cell cancer||Squamous||Squamous||V|
|cell cancer||cell cancer|
SIL, Squamous intraepithelial lesion; HPV, human papillomavirus; CIN, cervical intraepithelial neoplasia.