Pap smear – A smear On Atypical Cells From The Cervical Channel

A cytology smear (syn: cytological smear, cytological analysis, cervical smear, oncocytology smear, Pap smear, Pap test) is completely safe, which allows you to assess the state of the cervical tissue. This analysis reveals atypical (abnormal) cells that may indicate the presence of cervical dysplasia.

Dysplasia is a change in the structure of the tissues of the cervix, which does not show any symptoms, may be imperceptible on a routine gynecological examination, but it increases the likelihood of developing cervical cancer in the future.

Due to regular cytology smear tests (or alternative tests), women can monitor their risk levels for dysplasia and can receive treatment (for many years) to remove altered tissues, which will help them to significantly reduce their personal risk of developing cervical cancer.

Regular cytology smear (once every 3 years) is recommended for all women aged 21 to 65 who would like to take care of themselves and reduce their personal risk of developing cervical cancer.

Currently, many laboratories formulate the results of cytological analysis according to the international classification of Bethesda:

  • Inadequate (unsatisfactory) results of the cytological analysis.
  • NILM (negative for intraepithelial lesion or malignancy, no signs of dysplasia or a malignant tumor, “negative,” normal cytological analysis);
  • Negative results of cytological analysis (NILM), but missing or insufficient endocervical component;
    ASC – US (atypical squamous cells of undetermined significance, atypical flat epithelium cells of indeterminate significance);
  • LSIL (low-grade squamous intraepithelial lesions, squamous intraepithelial lesions of low severity);
  • ASC – H (atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion, atypical squamous epithelium cells not allowing the exclusion of HSIL);
  • HSIL (high-grade squamous intraepithelial lesions, squamous intraepithelial lesions of high severity);
  • AGC (atypical glandular cells, atypical glandular cells);
  • AIS (adenocarcinoma in situ) or squamous cell carcinoma.

Inadequate (unsatisfactory) results of cytological analysis mean that the evaluation of the structure of cervical cells was difficult due to the fact that the material sent to the laboratory was contaminated with blood cells (this is possible with a cytological smear) or contained too few cells from the surface of the cervix.

In this case, it is impossible to make an adequate conclusion about the state of the tissues of the cervix (and the presence of HPV infection).

Women with unsatisfactory cytological analysis results and negative HPV analysis results (or if the HPV analysis was not performed) are recommended to repeat the cytological analysis in 2-4 months. This period is necessary for the regeneration of cervical tissue after the previous Pap test.

If the doctor suggests that the results were unsatisfactory due to inflammation or atrophy of the cervix, in the period before the new analysis, he may recommend treatment).

Women with unsatisfactory results of cytological analysis and with positive results of analysis for HPV are recommended to either repeat the cytological analysis after 2-4 months or immediately perform colposcopy (this solution is especially advisable if the woman is over 30 years old).

  • If the results of the repeated Pap test are negative, the woman is recommended to continue screening according to her program;
  • If the results of cytological analysis are again unsatisfactory, colposcopy is recommended;
  • If the results of cytological analysis show the presence of any changes, the decision on further actions will be made depending on the type of these changes, as shown below.

Negative cytology (NILM) results

NILM (negative for intraepithelial lesion or malignancy, no signs of dysplasia or malignant tumor, “negative”, normal cytological analysis)

This result means that no atypical cells were identified in the collected samples that could indicate the presence of dysplasia or more serious changes in the cervix.

Normal cytology results may also include:

  • presence of squamous cells,
  • the presence of cylindrical epithelial cells and metaplastic epithelium,
  • small amount of white blood cells
  • a few sticks (bacteria).

Together with a negative cytological result, conclusions about the presence of certain infections can also be indicated in conclusion: trichomoniasis, candidiasis or microflora, characteristic of bacterial vaginosis.

 

Negative results of cytological analysis (NILM), but missing or insufficient endocervical component

This result of cytological analysis means that cells from the outer surface of the cervix look normal, and that insufficient amount of cells from the initial segment of the cervical canal fell into the collected material, due to which the laboratory technician could not adequately assess their structure.

In this situation, women aged 21 to 29 years old are encouraged to continue screening for the normal program.

Women over 30 years old who have not yet passed the HPV test are advised to take this test:

  • If the test result for HPV is negative, the woman is recommended to continue screening for a normal program;
  • If the test result on HPV is positive and HPV 16 or 18 types are detected, colposcopy is recommended. If HPV 16 and 18 types are not detected (or if specific types of infection are not identified), it is recommended to repeat the cytological and HPV analysis after 1 year;
  • If the HPV test is not available, a repeat of cytology after 3 years is recommended.

Negative cytology, but positive for HPV

There is currently no evidence that testing for HPV as the primary screening method for women younger than 30 years old reduces the incidence of cervical cancer. In this regard, most organizations do not recommend testing for HPV instead of or before cytology in women younger than 30 years.

If the HPV test was performed on a woman younger than 30 years old and the result was positive, but the results of the cytological analysis are negative, the woman is recommended to continue screening her program.

Women over 30 years old with negative cytology results, but with positive HPV test results are recommended:

If HPV 16 or 18 types have been identified, colposcopy is recommended;

If HPV 16 and 18 types were not detected (or if specific types of infection were not identified), it is recommended to repeat the cytological and HPV analysis after 1 year:

  • If the HPV test gives a positive result again, or if the result of the cytological analysis is positive (reveals changes in the ASC-US type or more pronounced), colposcopy is recommended;
  • If the HPV analysis and cytological analysis are negative, it is recommended to repeat both analyzes after 3 years and make a decision based on their results.

 ASCUS

ASC – US (atypical squamous cells of undetermined significance, atypical flat epithelium cells of indeterminate significance)

This result means that the cells lining the surface of the cervix are not completely normal, but have no obvious signs of dysplasia or tumors. Changes of this type may be caused by HPV infection and may indicate the presence of dysplasia, but may be associated with other factors, such as inflammation caused by another infection (such as chlamydia) or cervical atrophy that occurs in women after menopause.

A review of a number of studies showed that among women with cytological analysis of the ASC-US type, upon further examination (colposcopy and biopsy), approximately 10% had CIN 2 dysplasia, and 6% had CIN 3 dysplasia. The cervix was very low and only marginally higher than in women with a negative cytological analysis.

One of the following examinations is recommended for women aged 21 to 24 years, in whom the Pap test results showed changes in the ASC – US type:

(1) Repeat cytological analysis one more time after 1 year:

  • If the results of the second analysis show changes in ASC-H, HSIL or more pronounced, colposcopy is recommended;
  • If the results of the repeated cytological analysis are negative or show changes in the ASC-US or LSIL type, it is recommended to repeat the cytological analysis after 1 year:
    • If the results of the third Pap test again show the presence of changes such as ASC-US or more pronounced, colposcopy is recommended. If no changes are detected on the colposcopy or if only changes of the CIN 1 type are detected, it is recommended that the woman continue monitoring according to the program chosen depending on the results of the cytological analysis. If colposcopy reveals changes in CIN2 or more pronounced, the woman is recommended treatment according to the algorithm presented in the appropriate section of this article;
    • If two cytological analyzes performed at one-year intervals give negative results, the woman is advised to return to her normal screening program.

Analyze for HPV infection:

  • If the test result for HPV is positive, it is recommended that a cytological test be performed after 1 year (it is not recommended to repeat the HPV test again);
  • If the test result on HPV is negative, the woman is advised to return to her screening program.

Women over 24 years of age, in whom the Pap test result showed changes in the ASC – US type, are recommended one of the following examinations:

Analyze for HPV:

  • If the test result on HPV is negative, a woman is recommended to repeat the Pap test and HPV analysis after 3 years;
  • If the test result for HPV is positive, a woman is recommended to have a colposcopy:
    • If dysplasia is detected during colposcopy, the decision is made according to the algorithm
    • If dysplasia is not detected during colposcopy, a woman is recommended to repeat the cytological and HPV analysis after 1 year. If the results of both tests are negative, it is recommended to repeat the cytology and HPV analysis after 3 years, and if their results are again negative, the woman is recommended to return to the usual screening program.

 If it is not possible to test for HPV, the doctor may recommend repeating the cytological analysis after 1 year:

  • If the Pap test results again show the presence of changes of type ASC-US or more pronounced, the woman is recommended to undergo colposcopy;
  • If the results of the repeated cytological analysis are negative, the woman is recommended to return to the usual screening program.

 LSIL

LSIL (low-grade squamous intraepithelial lesions, squamous intraepithelial lesions of low severity)

This result means that the cells lining the surface of the cervix have moderate signs of atypical growth. Such changes may be triggered by HPV infection and may indicate the presence of dysplasia.

At the subsequent examination of women in whom cytological analysis shows the presence of changes in the LSIL type, in 17% the presence of CIN 2 dysplasia is detected and in 12% CIN 3 dysplasia is detected.

Women aged 21–24 years, for whom Pap test results show a change in LSIL type, are recommended to repeat the cytological analysis one more time after 1 year:

  • If during the second analysis changes of ASC-H, HSIL or more pronounced are detected, colposcopy is recommended;
  • If the results of the repeated cytological analysis are negative or show changes in the ASC-US or LSIL type, it is recommended to repeat the cytological analysis after 1 year:
    • If the results of the third Pap test again show the presence of changes such as ASC-US or more pronounced, colposcopy is recommended. If no changes are detected on colposcopy or only CIN 1 type dysplasia is detected, the woman is recommended to continue monitoring depending on the results of the cytological analysis. If colposcopy reveals changes in CIN 2 or more pronounced, the woman is recommended treatment according to the algorithm presented in the appropriate section of this article;
    • If two cytological analyzes performed at one-year intervals give negative results, the woman is recommended to return to normal screening.

Testing for HPV in women aged 21-24 years, in which the results of cytological analysis show the presence of changes in the type of LSIL, is not recommended, since there is a high probability that the test will be positive. In one study, it was found that almost 77% of women with LSIL test for HPV gives a positive result.

For women over 25 years old, for whom Pap test results show changes in the LSIL type, one of the following examinations is recommended:

If the HPV test was not performed, or if it was performed and its result is positive, a colposcopy is recommended:

  • If dysplasia is detected during colposcopy, the decision is made according to the algorithm described in the next section;
  • If the results of both tests are negative, it is recommended to repeat the cytology and HPV analysis after 3 years and, if their results are again negative, the woman is recommended to return to the usual screening program.

 ASCH

ASC – H (atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion, atypical squamous epithelium cells not allowing the exclusion of HSIL)

This result means that the cells lining the surface of the cervix look abnormal, and that only on the basis of the collected material the technician could not exclude the presence of more pronounced changes.

Nearly 70% of women in whom cytological analysis shows ASC-H changes show CIN 2 dysplasia or CIN 3 dysplasia during colposcopy. However, invasive squamous cell carcinoma is detected in 2.9% of women and adenocarcinoma in 1.7% of women is detected. sieve (these are forms of cancer).

All women (regardless of age) in whom the results of cytological analysis show the presence of ASC-H type changes, it is recommended to carry out colposcopy.

HSIL

HSIL (high-grade squamous intraepithelial lesions, squamous intraepithelial lesions of high severity)

This result of cytological analysis indicates a high probability of the presence of changes (dysplasia), which, over time, can give rise to cervical cancer. In 60-90% of women whose Pap tests show changes in the type of HSIL, the presence of dysplasia of grade 2 or more pronounced changes is detected during subsequent examinations.

In approximately 2% of women with HSIL, follow-up examinations detect the presence of cervical cancer.

In women over 30 with HSIL, in whom the biopsy shows no signs of cancer, the probability of detecting cancer over the next 5 years is, on average, 7%.

Colposcopy and biopsy are recommended for women aged 21–24 years whose Pap test results show changes in the HSIL type:

  • If the results of the histological analysis show the presence of dysplasia of CIN 2 or more pronounced changes, treatment according to the algorithm presented in the next section is recommended;
  • If no changes are detected during the histological analysis, or if only CIN 1 dysplasia is detected, it is recommended to follow up for 2 years with a cytological analysis and colposcopy once every 6 months:
    • If no CIN 2 or more pronounced changes are detected, but the results of cytological analysis will indicate that changes in the HSIL type are preserved, it is recommended:
      • If HSIL persists for 1 year, a biopsy is recommended;
      • If HSIL persists for 2 years, recommends a diagnostic excision;
    • If, in two consecutive examinations, the results of cytological analysis are negative and colposcopy does not detect changes in CIN type 2 or more pronounced, the woman is recommended to return to the usual screening;
    • If CIN dysplasia with 2 or more pronounced changes is detected during one of the examinations, the woman is recommended treatment as shown in the appropriate section of this article.

* In women aged 21-24 years, treatment, that is, excision or ablation of cervical tissue, without prior examination is considered unreasonable.

Women over 25 years of age, for whom Pap test results show changes in the HSIL type, are recommended one of the following examination options:

Undergo colposcopy with biopsy:

  • If CIN 2 or higher dysplasia is detected during colposcopy and histological analysis, treatment is recommended according to the algorithm presented in the next section;
  • If colposcopy is inadequate, a diagnostic excision is recommended;

AGC и AIS

AGC (atypical glandular cells, atypical glandular cells)

These results of cytological analysis mean that the collected material contains cells that can occur either from altered glands from the cervical canal, or from the altered tissues of the uterine lining (endometrium). The presence of such cells indicates an increased likelihood of more rare forms of cervical cancer or cancer of the uterine lining.

Upon further examination of women with AGC-N (atypical glandular cells-favor neoplasia):

  • 7% show changes characteristic of CIN 1 dysplasia,
  • 36% show changes characteristic of CIN dysplasia 2 or 3,
  • 29% have cervical cancer,
  • 10% have uterine cancer (endometrial cancer).

AIS (adenocarcinoma in situ) or squamous cell carcinoma

All women in whom Pap test results show changes of AGC type and / or AIS and in which atypical endometrial cells were not found are recommended to perform colposcopy and to collect material from the cervical canal (for example, through curettage of the cervix).

Women over 35 years old (or women younger than 35 years old, but with risk factors for endometrial cancer, including unexplained vaginal bleeding, irregular menstruation), additionally recommend collecting material from the uterus (for example, by scraping the uterus) .

Women with atypia of glandular cells of unclear significance (AGC-NOS) are recommended to carry out colposcopy and biopsy:

If CIN dysplasia 2 or more pronounced changes are not detected during the biopsy, the woman is recommended to repeat the cytological analysis, the analysis of the material collected from the cervix and the HPV analysis twice (with an interval of 1 year):

  • If during both examinations, the test results are negative, the woman is recommended to repeat the cytological and HPV analysis once every 3 years until the age of 65;
    • If the result of any analysis is positive, colposcopy is recommended.
    • If CIN dysplasia 2 or more pronounced changes are detected during a biopsy, but adenocarcinoma is not detected, treatment is recommended according to the algorithm presented in the appropriate section of this article.
  • For women with the result of AGC-N (atypia of glandular cells, possibly neoplasia) or AIS (in situ adenocarcinoma), which did not show signs of cancer and did not show dysplasia during colposcopy, diagnostic excision is recommended.

(2) All women with AGC and / or AIS, in whom atypical endometrial cells were detected, are recommended to collect material from the cervical canal and the uterine cavity (for example, through curettage of the cervix and uterus):

  1. If the analysis of the collected material shows the presence of changes at the level of the uterus, the decision is made according to the recommendations.
  2. If the analysis of the collected material does not reveal changes in the endometrial tissue, colposcopy is recommended. Further decisions are made based on the results of colposcopy and biopsy, as shown above in paragraph 1.

Benign glandular changes

  • mature, atrophic metaplastic squamous epithelium;
  • ectopia (ectropion, pseudo-erosion) of the cervix;
  • nabot cysts.

     

How to prepare for colposcopy:

Colposcopy should be scheduled for the period after the completion of the next menstruation.

24 hours before the examination, you must refrain from sexual intercourse, douching, or from the introduction into the vagina of various drugs or tampons.

Women are advised to take a sanitary napkin with them, since after a colposcopy, slight bleeding is possible.

Recommendations for the period after colposcopy:

  • In the first hours after colposcopy and biopsy, more or less severe pain in the lower abdomen may be present. Paracetamol or Ibuprofen can be taken to relieve pain;
  • In the first few days after a colposcopy, there may be a slight bleeding from the vagina;
  • In the first 4 days after a colposcopy, a woman is recommended to refrain from sex and from using tampons (or any other means intended for insertion into the vagina).

Cervical biopsy

In cases where a woman undergoes colposcopy due to positive screening results (cytological analysis and / or HPV analysis) or when modified tissue sections become visible during colposcopy, using a special tool, the doctor collects (cuts out) small cervical tissue fragments uterus (this is called a biopsy). A biopsy can be a bit painful.

The collected fragments are sent to the laboratory, where they are stained and examined under a microscope (this is called histological analysis).

Using a special brush or surgical instrument, the doctor can also collect a sample of material from the cervical canal, and sends it for histological analysis. Cervical collection may be necessary:

  • If the Pap test or HPV test gave a positive result, however, no changes in the cervix were seen at colposcopy.
  • If part of the transformation zone is drawn into the cervical canal,
  • If cytological analysis showed changes in the type of AGC or AIS.

Biopsy and histological analysis allow a very accurate assessment of the structure of the tissues of the cervix uterus and can finally determine the presence of dysplasia (and its degree), as well as the presence of cancer foci: adenocarcinoma in situ or squamous cell carcinoma.

The results of the histological analysis of cervical tissue may be ready within 2-3 weeks.

Dysplasia is a change in the normal tissue of the cervix that occurs under the effect of HPV infection.

Cervical dysplasia is designated by the abbreviation CIN (cervical intraepithelial neoplasia) and is classified into three categories (degrees):

  • CIN 1
  • CIN 2
  • CIN 3

Dysplasia is often called the precancerous condition of the cervix, however, this does not mean that all women who show these changes develop cancer.

Cervical dysplasia of the first degree (CIN 1) may be a manifestation of infection caused by non-oncogenic HPV types (6 and 11), which can also cause the formation of genital warts (genital warts), but may also be associated with oncogenic types of HPV infection.

On average, 57% of women whose biopsy and histological analysis show the presence of first-degree dysplasia, changes regress (disappear) over time; 32% of women have first-degree dysplasia; in 11% of women, the changes progress to grade 3 dysplasia and in 1% – to cervical cancer.

The risk of developing grade 3 dysplasia (or more pronounced changes) depends on the results of cytological analysis. In one study, it was shown that, in cases where first-degree dysplasia is detected in women, in whom the result of cytological analysis showed changes in the ASC-US or LSIL type, the risk of developing grade 3 dysplasia over five years was relatively low (3 ,eight%). In women, in whom cytological analysis showed the presence of ASC-H, HSIL, or AGC changes, the probability of developing third-degree dysplasia within 5 years after detecting CIN 1 is about 15%.

Cervical dysplasia 2 and 3 degrees (CIN 2 and CIN 3)

The development of cervical dysplasia 2 and 3 degrees in all cases is associated with oncogenic HPV types.

The probability of spontaneous regression of CIN 2 over time is, on average, 43%, and the probability of regression of CIN 3 is 32%.

In 35% of women with second-degree dysplasia and in 56% of women with grade 3 dysplasia, the changes do not disappear, but they do not progress.

In cases where dysplasia 2 or 3 degrees persists, and the woman does not receive treatment, the probability of developing cancer in subsequent years is from 5 to 30%.