Pap smear

A Pap test is usually performed with the pelvic examination. In the women above 30 years, Pap test is combined with a test for HPV i.e. human papillomavirus. This is a sexually transmitted disease-causing virus that can lead to cervical cancer in many women.

Usually, the doctor and the patient decide on when to undergo the Pap test and how frequently it should be done. The doctors generally advised going for Pap smear at the age of 21 years and then once every 2 to 3 years. In the women aged 30 years or above, the doctor advises the Pap test every 3 years or 5 years, in combination with the HPV test. In some cases, if the woman has certain risk factors for developing cervical cancer, the doctor can suggest a Pap test more frequently. Some of the factors, which can increase the risk of cervical cancer include:

• A diagnosis of cancer of the cervix or a previous Pap test that showed some precancerous cells.
• An HIV infection in a woman
• Exposure to DES i.e. diethylstilbestrol, before birth.
• Weak immune system due to the organ transplant, chronic use of corticosteroid or chemotherapy.

There are certain cases, wherein patients do not require pap test, as mentioned below.

• After the total hysterectomy procedure – After the removal of the uterus and the cervix of the woman, the patient should consult the doctor if the Pap test is to be continued. In case, the surgical procedure of hysterectomy was conducted to eliminate the non-cancerous lesions, then the routine Pap test can be discontinued. However, if the hysterectomy procedure was conducted for a cancerous or precancerous lesion, then the doctor advises to continue undergoing Pap test regularly.

Age factor – Older women can discontinue routine Pap testing. In the women aged 30 years or above, the doctor generally advises the Pap test every 3 years or 5 years, in combination with the HPV test. However, after the age of 65 years, and in case of normal screening results, the patient might be advised to stop the Pap test.

Pap test is a quick, simple and painless screening test for cervical cancer detection. However, sometimes, the Pap smear may give false-negative results, which means that the test report shows no abnormality, when actually there is a presence of abnormal cells. There are some factors which may cause a false-negative report, as mentioned below.

• A very small number of abnormal or cancer cells
• Inappropriate sample collection of the cervical cells
• Presence of some unclear inflammatory blood cells.

Cervical cancer takes a long time to develop. Hence, it is possible for the abnormal or cancer cells to go undetected. In case, the Pap test gives unclear results, the doctor might advise undergoing some other test to confirm the diagnosis.

Some side effects and complications associated with the Pap smear test are as mentioned.

• Vaginal bleeding or blood spotting after the Pap test. Excessive or heavy bleeding is specifically a concern.
• Chances of infection if the instrument is not sterilized.

Before the procedure:

The doctor or the nurse explains the procedure in detail to the patient. Some pointers to be considered, before the Pap test to ensure its efficacy are as mentioned.

• Avoid using any vaginal medicines
• Avoid douching
• Avoid having intercourse
• Do not use tampons for at least 24 hours before the Pap test.
• Avoid using spermicidal foams, jellies or creams for at least two days before the Pap test, as using such products may wash away the abnormal cells.
• Avoid scheduling the Pap test during the menstrual period.

During the procedure:

The Pap test is done in the outpatient facility or the doctor’s examination room. The Pap test takes only a few minutes to complete. The patient may be asked to change into a hospital gown or undress the part below the waist for testing.

The patient is asked to lie down on the back on the examination table with the knees bent. The heels are rested on the stirrups for support. The doctor then inserts or puts an instrument known as a speculum, into the patient’s vagina. The speculum helps to hold the vaginal walls apart for the doctor to clearly see inside the cervix of the woman. The speculum insertion may cause a feeling of pressure exertion in the vagina or pelvic part.

The doctor then collects the samples of the cells of the cervix with the help of a small and soft brush or sometimes with a small scraping instrument known as a spatula. The process of scraping or collecting cervical cells is completely painless.

After the procedure:

Pap test can be of multiple types, depending on the type of instrument used in collection of sample. In case the doctor puts the collected cervical sample in a container with a special liquid to preserve the cervical sample, the test is known as a liquid-based Pap test. In case, the collected sample is directly put onto a glass slide, the procedure is known as a conventional Pap test.

The collected cervical sample is then sent to the lab for further testing for the detection of cancer cells. The collected cervical sample is put under the microscope to examine closely for any precancer or cancer cells.

After the test, the patient can change back to normal clothes and can return back to normal routine activities without any problem. The patients can easily drive back home on their own.

After the report for the test is ready, it is sent from the lab to the concerned doctor. The doctor discusses the Pap test report with the patient in detail.

If the report is normal or negative, it means that the cervical cells are normal and there is no sign of cancer growth in the vagina of the patient. In such cases, the patient is asked not to go for further testing and wait until the next routine Pap test schedule. If the results are positive or abnormal, the physician would assess the type of abnormal cells detected in the test.

The doctor may inform the patient about some of the following mentioned abnormal cells:

• Atypical squamous cells of undetermined significance (ASCUS) – The squamous cells are flat and thin in nature and usually grow on the healthy cervix's surface. On the detection of ASCUS, the Pap test report states the growth of some abnormal squamous cells, however, these changes do not give a certain diagnosis of the presence of precancerous cells. If the patient undergoes a liquid-based Pap test, the doctor can analyze the sample again to examine the presence of viruses such as HPV (Human Papilloma Virus), that may develop cancer cells in later stages. If even after the liquid-based Pap test, no high-risk viruses are found, then the abnormal cells identified by the Pap test earlier are of no concern. Further testing is advised only if the high-risk viruses are found in the sample collected.
• Squamous intraepithelial lesion – Presence of such type of cells in the Pap smear, indicates that there are precancerous or cancer cells present. If the cell changes found are of low-grade, then the doctors can detect from the cell shape, size, and other characteristics, if there is a presence of a precancerous lesion. This detection of precancerous lesion determines that the precancer cells will grow into cancer cells in a later period or over years. If the cell changes are of high grade, then there is a high risk of development of cancer very soon. In such cases, the doctor advises the patient to go for some further testing.
• Atypical glandular cells – Glandular cells secrete mucus and grow within the uterus and the opening of the cervix. The presence of atypical glandular cells is slightly abnormal but there is no clear evidence if they are cancerous or not. Further testing may be advised in this case as the doctor will know the source and significance of these abnormal cells, only through further tests.
• Adenocarcinoma cells or squamous cell cancer – The presence of these cells in the collected sample strongly indicate the presence of cancer. Adenocarcinoma refers to the cancer cell growth in the glandular cells. Squamous cell cancer, refers to the arising of cancer in the flat surface cells of the cervix or vagina. In case of detection of these cells, the doctors advise a prompt evaluation.

If the Pap test shows abnormal results, the doctor may suggest the patient to go for a procedure known as colposcopy. This procedure is done with the help of a special instrument known as colposcope, and is performed to examine closely the tissues of vulva, vagina, and cervix. Sometimes, the doctors also recommend a biopsy test, wherein a small tissue sample is taken from the area, which has an abnormality. This small tissue sample is then sent to the lab for further testing, in order to get a confirmed diagnosis.

Q1. When should a woman stop getting Pap smear done?

A1. The woman should stop getting Pap smear done if there is no history of any precancerous conditions or cervical cancer. Also, if the woman has reached the age of 65 years and above, she can stop undergoing the test, after consultation with the doctor. The doctors can also advise stopping Pap test after a woman undergoes a hysterectomy for a non-cancerous growth, like in case of fibroids.

Q2. What does an abnormal Pap test stand for?

A2. Results of Pap test showing positive results do not always indicate presence of cancer cells. The abnormal results may also indicate the presence of abnormal cells in the patient’s cervix. There are various levels of abnormal cells, as mentioned below.

• Atypia
• Mild
• Moderate
• Severe dysplasia
• Carcinoma in situ

A further evaluation, by the physician, might be necessary to make a confirmed diagnosis for cancer.