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Quick Reference for Clinicians: Cervical Guidelines
PAP Smear Screening Protocol for the Primary Care Provider
Warning
- Colposcopy is indicated for signs or symptoms of
cancer, even if the Pap smear is normal.
- Need colposcopy when there is a visible lesion or
unexplained, persistent vaginal bleeding.
Frequency
- Yearly starting at 3 years after the onset of sex (or age
21). After 3 normal annual Paps, then every 3 years.
- If any HSIL need Pap smears yearly thereafter, for life.
- Not needed after hysterectomy with no cervical stump
unless history of HSIL/cancer Pap smears.
- Not needed in well screened woman after age 65, if no
Paps have been abnormal (HSIL/cancer)
- Not necessary in women who have never had any
sexual activity. However, lesbian women with only
female sexual partners do need Pap smears.
- Need for Pap smears depends on woman?s entire lifetime
sexual experience (including sexual abuse).
Ideal Preparation
- No washing vagina or douching within 48 hours before
Pap
- Nothing in vagina within 48 hours before Pap - no sexual intercourse, tampons, vaginal contraceptives, medications.
- 1-2 weeks after menses, about mid-cycle
- No bleeding or infection
- Eight weeks postpartum if recent pregnancy
- Perform speculum pelvic examination without lubrication
(except water)
Equipment
- Glass slide with frosted end - to make thin smear with
identification labeling
- Wooden (preferred for slide) or plastic (for liquid-base)
Ayre spatula - samples ectocervix
- Endocervical - brush (preferred) turn times; saline
moistened swab may be safer if pregnant
- Broom - not recommended
- Alcohol or similar fixative - liquid for pour-on, pump
spray, or immersion better than propellent spray
Order of Specimens - if other tests are taken
- Vaginal pH and wet smear - collect first, before
contamination with blood or cervical discharge
- Pap smear - first instrument to touch cervix as
dysplastic cells are often shed in cervical mucus
- Gram stain of cervix - collect mucus or pus, examine
at least if PID or cervicitis suspected
- HPV test - rotate swab, provided in kit, in cervical os for
half turns, clockwise and counterclockwise, 3 times
each, and swab the transformational zone.
- Gonorrhea test - collect mucus or pus
- Chlamydia test - scrub to obtain cells
Proper Preparation of Specimen
- Don?t clean the cervix first, if excess material or
infection, very gently pat cervix, or use two slides
- Collect from entire transformation zone - include
endocervical sample
- Make thin (mono-layer) smear on slide - arch spatula
and then roll brush
- Fix promptly - avoid air drying
Proper Labeling of Specimen - slide will be rejected if lacks
proper identification and history
- Name and other identifiers on frosted end of slide and
on package
- Lab slip with complete identification and clinical
information
Laboratory statistics - expected ranges, higher if lab
mainly serves high risk (STD, colposcopy, cancer)
- Unsatisfactory - 0.2% to 1% (range up to 20%), suspect
if none.
- Lack endocervical cells/TZ Component - 2% to 10%
(range up to 40%). If high ( >5%) improve client
preparation and collection technique. Ask lab to
review.
- ASC-US (Atypical) - 2% to 5% (median 2.9%). If > 9%
or double SIL suspect overuse of category.
- Ratio of ASC-US/SIL should be under 2 (mean 1.3)
- LSIL - 0.5% to 3%. May be higher if high risk
population (STD or colposcopy clinic)
- HSIL - < 1% (higher if high risk population)
- AGC - 0.2% - 1.8%
References:
National Committee for Clinical Laboratory Standards. Papanicolaou Technique; Approved Guideline. Villanova, PA: NCCLS, 1994. (771 East Lancaster Avenue, Villanova, PA, 19085, GP15-A)
USPSTF, Screening for Cervical Cancer: Recommendations and Rationale. Am Fam Physician 2003;67:1759-66.
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