Background Info

What is a smear?

A smear is a screening test for the presence of dyskaryosis of cervical cells (CIN). It is not actually a screening test for cancer. The abnormal cells of CIN have the potential to become cancerous, but in many women, the dyskaryosis resolves itself, without intervention.
  • 1 in 10 smears will show dyskaryosis
  • The vast majority of these cases will spontaneously resolve

Methods

  • Pap smear – older method, in which sample cells are transferred directly to slide for viewing
  • Liquid-based cytology – sample cells are placed in liquid solution for transport to the lab, whereby they are extracted for cytologic analysis.

Indications for smear

  • Clinical suspicion – E.g. IMB, PMB
  • Screening

Indications for swabs

  • Suspected infection
  • Elective: to test for subclinical infection
  • Before insertion of IUD / IUS

The Screening Programme

  • NHS screening programme began in 1988
  • It is estimated to have reduced cervical cancer incidence by 90%
  • Estimated to save 4,500 lives per year
  • Now less than 1,00 deaths per year in the UK from cervical cancer
  • Offered to all women aged 25 – 65
  • Every three years between 25-50
  • Every 5 years between 50-65
  • Age 65+ – offered to those:
    • Who have not been screened since 50
    • Who have had recent abnormal smears
    • Used to be offered to all women aged 20-65 – but at age 20, the physiological changes seen in puberty may still be apparent, and thus there was a very high percentage of false positives.
  • What does it involve?
    • A smear test – usually performed at the GP surgery.
    • If this is abnormal, then the patient will be referred for colposcopy, at which time, treatment can be performed if necessary.
  • Attendance
    • Roughly 80% of those eligible attend for smear screening
    • Reminders – usually, if one appointment is missed, a second invitiation is sent, then if this is missed, another reminder probably won’t be sent, but whenever the patient attends to GP, it will be flagged that a smear has been missed.

Results

Result
Comments
Action
Negative
————-
Inform the patient of the result. Invite any questions. Treat any ongoing infection
Inadequate sample
Usually the result of poor sampling technique, but could just be a difficult case
Repeat the sample as soon as possible. If three inadequate samples, the refer for colposcopy
Borderline
 
Borderline changes in endocervical cells
  • Refer for colposcopy
Borderline changes in squamous cells
  • Repeat screen within 6 months – most cases will have resolved, and smear will be normal at this stage
  • Compare past results – if there are >3 borderline changes within 10 years, Refer for colposcopy.
  • Three consecutive normal smears are required before patient can return to the normal screening programme
Mild dyskaryosis
 
Usual practice to refer for colposcopy after one abnormal smear, but acceptable to have two, six months apart before referral.
  • 60% of cases will ultimately resolve spontaneously by the time of the 2nd smear (within 6 months)
Moderate dyskaryosis
 
Refer for colposcopy
Severe dyskaryosis
 
Refer for colposcopy

Performing the procedure

  1. Introduction and explanation – introduce yourself, check the right patient (name, DOB, wrist band). Explain the procedure, state you would like to use a chaperone , and gain consent – this may involve a brief explanation of what a positive result might mean for the patient.  Explain that you will be taking a smear and/or swabs, and what the swabs are for.
    1. Ask the patient to get undressed below the wait, and cover up with a sheet provided, whilst you fetch a chaperone
  2. 2)      Collect your equipment. You will need:
    1. Cousco’s speculum
    2. Cervical brush
    3. Transport medium for smear
    4. Cytology Forms
    5. Lubricant
    6. Gloves
    7. Light source
    8. Tissues / gauze
    9.  Endocervical swab
    10. Charcoal swab
    11. CHAPERONE!
    12. Wash your hands. Wash out the tray with soap/water (if visibly dirty) or alcohol wipe (if visible clean). Collect the equipment.
  3. Brief inspection / palpation of abdomen – feel for any pain / tenderness in the pelvic region. Ask if any pain soreness in pelvic region or vagina
    1. Wash your hands again and put on gloves
  4. Inspect vulva and vagina – ask the patient to lie back on the bed, bend her knee, and gently allow her legs to fall apart. Look for any signs of discharge, blood or lesions, prolapse. Don’t forget to check the peroneal area.
  5. Speculum – ask the patient to try to relax, and breathe deeply. Apply some lubricant to the speculum. Ask the patient to take a deep breath in, and insert the speculum, , with the handle at 3 o’clock, as you hold the labia open with your other hand. Once inside the vagina, you can rotate the handle 90’, and slowly open the speculum, to allow viewing of the cervix. Lock the speculum in place.
    1. Look at the cervix and vaginal walls – and comment on their appearance
    2. Take a cervical smearusing the smear brush, insert the middle of the brush into the os, then rotate the brush through 360’, five times. Take the brush out of the vagina, and remove the head, placing it into the transport medium.
    3. Taking swabs – make sure you have explained what the swabs are for. It is not normal practice to perform swabs at the same time as smear. Usually three samples are taken “Triple swabs”
      1. Endocervical – charcoal – “Stuarts medium” Gonorrhoea 
      2. High vaginal – charcoal – “Stuarts medium”HVS high vaginal swabfor TB & BV [anaerobes], group B strep, and candida. swab around the posterior fornix. White Physiological discharge in this area is normal, but if excessive and/or offensive, may indicate infection, particularly in the case of TB, BV and candida. Return the swab to the tube containing the sticky transport medium
      3. Endocervical –Chlamyia – uses a different type of swab. These come in two sizes with different diameters. Use the larger one, but in nulliparus women, this may not be possible. Put the swab into the endocervix, and rotate through 360’, 3x. This is a test for chlamydia. The smaller of the two swabs can be used to test for chlamydia in the male urethra. When you have taken the sample, put the swab into the liquid for cytology, and break off the end of the stick, to seal it in the tube.                               
  6. Remove the speculum – have a look at the vaginal walls as you do so. Then wipe away any lube, and thank and cover the patient, and allow them to get dressed
  7. Filling in the forms – label your samples (gonorrhoea, general and chlamydia), and fill out the forms.
Cervical Smear
Stuarts Medium
Used for HVS and Gonorrhoea (endocervical)
 
 
 
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Bi-manual examination and smear/swabs

  • Always perform the smear / swabs / speculum examination first – so you can see any lesions that you might want to palpate
  • Offer a full abdominal exam with your bi manual

 

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