o&g update course 2012 hospital segamat

1. DR. ARIVENDRAN
M.D (UKM ) MRCOG (UK)

2.  Papanicolaou test –
exfoliative cytology
test
 cells collected are
from normally
shedding epithelium .
 collected using
spatulas or brushes.
 Specimen is
fixed, stained and
studied for
morphology under
microscope.

3.  Initially using vaginal pool smears to
study hormonal status .
 Found cancer cells on a slide
containing a specimen from a woman's
uterus.
 Dr. George Papanicolaou reported the
usefulness of the technique for
detecting neoplastic cervical cells in
1941.
 late 1940s to early 1950s, Pap smear
became widely used as a screening
technique.
Dr. George Nicholas
Papanicolaou

5.  Visual inspection of the lower genital tract and
cervix.
 Locate the TZ.
 An optimal cervical specimen
 includes sampling of the squamous and columnar
epithelium
 encompassing in particular the transformation zone

6.  Correct timing
 Correct technique
Correct instruments
Correct sampling technique
Correct spreading technique
Correct fixation

7.  AYRE’S SPATULA

8.  CERVICAL BROOM/BRUSH

9.  CYTOBRUSH

10.  After menses preferably midcycle.
 When there is no signs of inflammation or
infections
 No prior vaginal douching or contraceptive cream
/ jelly .
 No sexual intercourse < 12 hours prior to pap
smear.
 Pregnancy is NOT a contraindication for pap
smear.

11.  Label the frosted end of the glass slide
with the patient's name prior to collection.
 Insert the speculum.
 Visually inspect the cervix for
abnormalities.
 Identify the transformation zone and direct
sampling efforts to encompass this area.
 The endocervical limit of the transformation
zone is dynamic, defined by the leading edge of
the migrating squamo-columnar junction.
 In post menopausal women, it is often high in
the endocervical canal and not visible.

12. An optimal cervical specimen includes sampling of the squamous
epithelium (Ectocervix) and columnar epithelium
(Endocervix) and in particular the TRANSFORMATION
ZONE, where the majority of cervical neoplasias arise.

13. OLD SCJ
NEW SCJ
TRANSFORMATION ZONE

14.  Choose the contoured end of the spatula which
best conforms to the cervix and the
transformation zone.
 Rotate the spatula 360o about the
circumference of the cervix, while maintaining
firm contact with the epithelial surface.
 With a clockwise rotation beginning and
ending at 9 o'clock (or counter-clockwise
rotation from 3 o'clock to 3 o'clock), the
collected material is retained on the upper
horizontal surface as the instrument is
removed.

15.  These brushes have circumferential bristles that
come into contact with the entire os surface on
insertion.
 The brush need only be turned 1/4 turn.
 Roll the brush across the slide by twirling the
handle.
 Not recommended for pregnancy.

16.  Spread : quick and even , cellular material in a
monolayer on the slide.
 Thin out large clumps of material as much as
possible, avoide excessive manipulation which
can damage cells.
 Fix the specimen by either immersing the slide
in 95% ethanol or coating the slide with a
surface fixative.

17. Spread the material collected on the
spatula / cervix brush evenly over the
slide with a painting action and single
smooth stroke motion using both sides

18. Spatula / Cervix brush
Endocervical brush
Spatula / Cervix brush
Endocervical brush
Endocervical brush
Spatula / Cervix brush

19. Alcohol fixation : Immediately immerse into 95% Alcohol
for 20-30 minutes.
Drying the slide – 5 minutes
Alcohol fixation
Slide jacket

20.  May be moistened with water or saline if necessary.
Traditionally, no other lubricants are recommended.
 study in 182 patients randomly assigned to have either only warm water
or a water soluble lubricant to assist speculum insertion, only 2
unsatisfactory smears were found among 93 patients with the lubricant
and two were found among 89 using only warm water.
 They concluded that use of a water soluble lubricant on the vaginal
introitus and external speculum facilitates examination with no adverse
effect on Pap smear interpretation.
Harer WB. Valenzuela G Jr. Lebo D. Lubrication of the vaginal introitus and speculum does not affect
Papanicolaou smears. Obstet Gynecol 2002; 100:887-8.
 Do not use any lubricants other than water or saline on
Thin-prep slides since they plug the filter and may
produce an unsatisfactory smear.

21. BETHESDA 2001
REPORTING SYSTEM

22.  Whether the pap is an adequate sample
 Incidental findings such as evidence of
infection
 Evidence of lesions: low-grade SIL, high-grade
SIL, or cancer

23. 1. Specimen adequacy
2. Negative for intraepithelial lesion or malignancy
3. Epithelial Cell Abnormalities
A. Squamous
Atypical (ASCUS/ASC-H)
LSIL ( Mild Dyskaryosis / HPV/CIN 1)
HSIL (Mod or Severe Dyskaryosis / CIN 2,3)
Invasive Squamous Carcinoma
B. Glandular / Columnar
Atypical (undetermined or favour neoplastic)
Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma
C. Endometrial cells in women age > 40

24.  Low-grade squamous lntraepithelial lesion (low-grade SIL)
 Cellular changes associated with HPV
 Mild (slight) dysplasia/CIN 1
 High-grade squamous intraepithelial lesion (high-grade SIL)"
 Moderate dysplasia/CIN II
 Severe dysplasia/CIN III
 carcinoma in situ/CIN III
 Atypical Squamous Cells (ASC)
 Unspecified (ASC-US) - includes uspecified and favor
benign/inflammation
 Cannot exclude HSIL (ASC-H)
 Atypical Glandular Cells of Uncertian Significance (AGC) AGC is
broken down into favoring endocervical, endometrial, or not
otherwise specified origin or endocervical adenocarcinoma in situ
(AIS)
 Unspecified (AGC-US)
 Atypical glandular cells, favor neoplastic (AGC-H)

25. 1. Abnormal due to dysplastic changes
2. Abnormal due to inadequacy
3. Abnormal due to inflammation
4. Abnormal due to infection

26.  Squamous
Atypical (ASCUS/ASC-H)
LSIL ( Mild Dyskaryosis / HPV/CIN 1)
HSIL (Mod or Severe Dyskaryosis / CIN 2,3)
Invasive Squamous Carcinoma
 Glandular
Atypical (undetermined or favour neoplastic)
Adenocarcinoma in situ (AIS)
Invasive adenocarcinoma

27.  Sampling
Scanty cells
Blood, mucous, pus
Mainly endocervical cells *
 Preparation
Too thick due to poor spreading
Air drying artifact

28.  Correct timing of smear
 Do not use cream or gel
 Cleaning of excessive mucus
 Choice of sampling devices
 Correct spreading
 Rapid fixation (< 10 second)

29.  Infection
 Chronic cervicitis
 Atrophic cervicitis

31. Observed and repeat pap smear
Treat (inflammation & infection)
and repeat pap smear
Refer for Colposcopy

32. Unsatisfactory/Inadequate smear
Reactive cellular changes due to radiation, repair or
IUCD
ASCUS with Low Risk HPV type or no facility for HPV
typing
Selected LSIL – repeat in 6 months, if persistent, do
colposcopy
HPV effect

33. 1. INFECTIONS
Trichomonas vaginalis ( Metronidazole 400mg
tds and Doxycyline 100mg bd for 1 week)
Fungal infection : Antifungal
Bacterial vaginosis (Metronidazole, Clindamycin)
Actinomyces species : Penicillin
Herpes simplex : Acyclovir
Repeat smear in 6-8 weeks, if persistent in 3
occasion, refer for colposcopy.
2. ATROPHIC SMEAR
Local oestrogen cream/tab (1 gm nighty
for 2 weeks then twice weekly) 6-8 weeks
and repeat pap smear in 3-4 months.

34. 
 Suspicious looking cervix.

 Unexplained post-coital bleeding.

 Persistent unsatisfactory smear on 3 occasions, 3 monthly.

 Persistent inflammatory smear on 3 occasions, 3 monthly
(despite treatment).

 Persistent Atypical Squamous Cells of Undetermined
Significance (ASC-US) on 2 occasions.

 Atypical Squamous Cells of Undetermined Significance (ASC-
US) positive for high risk HPV.

 Atypical Squamous Cells –cannot exclude high grade lesion
(ASC-H)


35.  Persistent Low Grade Squamous Intraepithelial Lesion (LSIL)
on 2 occasions, 6 monthly.

 Persistent Low Grade Squamous Intraepithelial Lesion (LSIL)
with high risk factors.

 High Grage Squamous Intraepithelial Lesion (HSIL).

 Squamous Cell Carcinoma (SCC).

 Atypical Glandular Cells (AGUS).

 Adenocarcinoma.

 High risk HPV DNA positive.

36. Complicates up to 5% of pregnancies
Most women will have low-grade disease
A significant degree of expertise and experience is
required in the colposcopic triage of the abnormal
pap smear in pregnancy
Cervical biopsy is safe in pregnancy.
Cone biopsy is best avoided and delayed until 6-8
weeks after delivery (Risk of spontaneous
miscarriage 25%, excessive bleeding in 5-15% and
risk of persistent disease 50%)
The most important aspect in management of
abnormal pap smear in pregnancy is to exclude
invasive cancer .

37. Satisfactory
and negative
PAP SMEAR
UNSATISFACTORY
FOR EVALUATION
Repeat smear in
3 months
2nd smear
unsatisfactory
Negative for
malignant cells
Repeat smear
in 3 months
3rd smear
unsatisfactory
Refer for
colposcopy
Refer to Flowchart for
Management of ‘Negative
For Malignant Cells’
Smear.
* NOTE
•Treat any infection.
•Give a course of estrogen if there are
atrophic changes.

38. changes
resolve
changes
resolve
PAP SMEAR
NEGATIVE FOR MALIGNANT
CELLS
Atrophic
changes
(without
inflammatio
n)
No
endocervic
al cells
seen
Specific
micro-
organisms
identified
Inflammatory
changes
Endometrial
cells seen
Correlate with
clinical
findings, client’s
age, hormonal
and menstrual
status
Refer
Gynaecologist
if necessary
Treat
appropriatel
y as
clinically
indicated
Treat any
infection or
atrophy.
Repeat
smear in 3–6
months.
2nd smear with
similar changes
3rd smear
with similar
changes
Treat any infection
or atrophy. Repeat
smear in 3–6
months.
Refer
Gynaecolog
ist
Repeat
smear in 1
year
Routine
screening
schedule
Routine
screening
schedule

39. Cannot exclude
high grade
lesion (ASC-H)
Undetermined
significance
(ASC-US)
PAP SMEAR
ATYPICAL SQUAMOUS CELLS
Refer for
colposcopy
Repeat smear
in 6 months
Negative for
malignant cells
Repeat smear
in 6 months
Resume routine
screening if
negative for
malignant cells
•Atypical
squamous cells
•Low-grade
squamous
intraepithelial
lesion
•High-grade
squamous
intraepithelial
lesion
Refer for
colposcopy
•NOTE
•HPV DNA testing should
be considered if available
•If positive for high risk
HPV, to refer for
colposcopy

40. NoYes
Presence of at least one
criteria:
•Age > 30 years
•Poor compliance
•Immunocompromised
•Symptomatic
•History of pre invasive
lesion
•High risk HPVpositive.
Repeat smear
in 6 months
PAP SMEAR
LOW-GRADE SQUAMOUS
INTRAEPITHELIAL LESION
(LSIL)
Negative for
malignant cells
Resume
routine
screening
schedule
Mild dysplasia
or CIN I
Refer for
colposcopy
Immediate
colposcopy
Assessm
ent of
client

41. HIGH-GRADE
SQUAMOUS
INTRAEPITHELIAL
LESION (HSIL)/
SUSPICIOUS FOR
INVASION
SQUAMOUS CELL
CARCINOMA
PAP SMEAR
Refer to
Gynaecological
Oncologist
Refer for
colposcopy

42. ALL ATYPICAL
GLANDULAR
CELLS (except
Atypical Endometrial
Cells)
ADENOCARCINOM
AIN SITU (AIS)
&
ADENOCARCINOM
A
PAP SMEAR
Refer to
Gynaecological
Oncologist
Refer to Gynaecologist
for:
•colposcopy (with
endocervical sampling)
•endometrial sampling
(if > 35 years or abnormal
bleeding)
ATYPICAL
ENDOMETRIAL
CELLS
Refer to
Gynaecologist

46.  Genital HPV is a common
virus that is passed from
one person to another
through direct skin-to-
skin contact during sexual
activity.
 Most sexually active
people will get HPV at
some time in their lives,
though most will never
even know it.
 HPV infection is most
common in people in their
late teens and early 20s

47.  Two HPV types (HPV-16 and HPV-18) that
cause 70% of cervical cancers, 80% of anal
cancers, 60% of vaginal cancers, and 40% of
vulvar cancers.
 These HPV types also cause most HPV induced
oral cancers, and some other rare genital
cancers.

48.  Bivalent vaccine
(CERVARIX)
 Quadrivalent vaccine
(GARDASIL).
 Gardasil, also
prevents HPV types
that cause most
genital warts
 Both vaccines are
given in 3 shots over 6
months.

49.  HPV vaccination is
recommended with
either vaccine for 11 and
12 year-old girls.
 It is also recommended
for girls and women age
13 through 26 years of
age who have not yet
been vaccinated or
completed the vaccine
series;
 HPV vaccine can also be
given to girls beginning
at age 9 years

50.  The vaccines are not recommended for
pregnant women.
 Studies show that HPV vaccines do not cause
problems for babies born to women who were
vaccinated while pregnant, but more research
is still needed.
 A pregnant woman should not get any doses of
either HPV vaccine until her pregnancy is
completed.
 Getting the HPV vaccine when pregnant is not
a reason to consider ending a pregnancy.

51.  The vaccines target the HPV types that most
commonly cause cervical cancer.
 Both vaccines are highly effective in preventing the
targeted HPV types
 The vaccines are less effective in preventing HPV-
related disease in young women who have already
been exposed to one or more HPV types.
 That is because the vaccines prevent HPV before a
person is exposed to it. HPV vaccines do not treat
existing HPV infections or HPV-associated
diseases

52.  Research suggests that
vaccine protection is
long-lasting.
 Current studies have
followed vaccinated
individuals for six
years, and show that
there is no evidence of
weakened protection
over time

53.  The vaccines do not protect against all HPV
types— so they will not prevent all cases of
cervical cancer.
 About 30% of cervical cancers will not be
prevented by the vaccines, so it will be
important for women to continue getting
screened for cervical cancer (regular Pap tests).
 Also, the vaccines do not prevent other
sexually transmitted infections (STIs)

54.  Both vaccines have been
licensed by the Food
and Drug
Administration (FDA).
 The CDC has approved
these vaccines as safe
and effective.
 Side effects reported in
these studies were
mild, including pain
where the shot was
given, fever, dizziness, a
nd nausea