Pap Smear (Papanicolaou Smear) Nursing Responsibilities

The Papanicolaou smear (Pap smear, cervical smear) is a safe, noninvasive cytologic exam for early detection of cervical cancer. In the 1900s, cervical cancer was a leading cause of death among women. In 1928, Greek physician George Nicholas Papanicolaou identified the microscopic difference between normal and malignant cervical cells, and the Pap smear followed.

Screening guidance has shifted toward HPV testing, since the human papillomavirus is the primary cause of cervical cancer. The American Cancer Society now recommends that screening begin at age 25 and that people with a cervix at average risk get a primary HPV test (an HPV test alone) every 5 years through age 65, the preferred approach. If primary HPV testing is not available, a co-test (HPV plus Pap) every 5 years or a Pap test alone every 3 years is acceptable (American Cancer Society). Note that the CDC and the U.S. Preventive Services Task Force still describe screening starting at age 21 with cytology every 3 years for ages 21 to 29, then HPV-based options for ages 30 to 65 (CDC), so confirm which protocol your facility follows. A positive or suspicious result is followed up with HPV typing, colposcopy, or cervical biopsy as indicated.

Nurses drive screening uptake by informing and encouraging patients to follow through on Pap smears.

Indications

• Identify sexually transmitted infections such as HPV, herpes, chlamydia, cytomegalovirus, Actinomyces spp., Trichomonas vaginalis, and Candida spp.
• Detect primary and metastatic neoplasms
• Evaluate abnormal cervical changes (cervical dysplasia)
• Detect condyloma, vaginal adenosis, and endometriosis
• Assess hormonal function
• Evaluate response to chemotherapy and radiation therapy

Interfering Factors

• Delay in fixing the specimen, which dries the cells, ruins the stain, and makes interpretation difficult
• Wrong collection site. Hormonal samples come from the vagina, cancer-screening samples from the vaginal fornix
• Lubricating jelly on the speculum, which can affect organism viability
• Collection during menstruation, since blood contaminates the sample
• Douching, tampon use, or intercourse within 24 hours, which washes away cellular deposits
• Existing vaginal infection, which interferes with hormonal cytology

Procedure

A practitioner performs the Pap smear in about 5 to 10 minutes.

1. Position the patient. Supine, dorsal lithotomy, feet in stirrups.
2. Insert the speculum. Gloved, the practitioner inserts an unlubricated plastic or metal speculum and opens it to expose the cervix. Saline or warm water may ease insertion.
3. Collect cervical and vaginal specimens. A cytobrush is inserted into the cervix, rolled firmly into the endocervical canal, rotated one turn, and removed. A plastic or wooden spatula scrapes the outer cervix and vaginal wall.
4. Conventional collection. The brush and spatula are wiped on a slide and fixed immediately by immersing it in equal parts 95% ethanol or using a spray fixative.
5. ThinPrep collection. The brush and spatula are immersed in ThinPrep solution with a swirling motion to release the material, then removed, and the lid is secured.
6. Label the specimen. With the patient's name, age, collector's initials, and date and time of collection.
7. Send to the lab. Transport for cytologic analysis.
8. Bimanual exam may follow. After the speculum is removed, the provider inserts two fingers into the vaginal canal to palpate the uterus and ovaries with the other hand on the abdomen.

Nursing Responsibilities

Before the procedure

• Secure consent. Explain the test and obtain written, informed consent.
• Obtain health history. Parity, date of last menstrual period, surgical status, contraceptive use, history of vaginal bleeding, prior Pap smears, and history of radiation or chemotherapy.
• List current medications. If the patient is on a vaginal antibiotic, delay the Pap smear 1 month after treatment ends.
• Set expectations. The cervix is scraped. The patient may feel minimal discomfort but no pain from the speculum.
• Rule out interfering factors. No intercourse within 24 hours, no douching within 48 hours, and no tampons, vaginal creams, or lotions before the test, since these wash away cells and change vaginal pH.
• Empty the bladder. The speculum presses on the lower abdomen.

After the procedure

• Cleanse the perineal area. Remove secretions and excess lubricant.
• Provide a sanitary pad. Slight spotting may occur.
• Review screening frequency. Per the American Cancer Society, begin at age 25 and screen with a primary HPV test every 5 years through age 65 (preferred), or co-test every 5 years or Pap alone every 3 years where primary HPV testing is unavailable. Confirm against the protocol your facility uses, since CDC and USPSTF guidance still start at age 21.
• Address concerns. Anxiety about results is common. Discuss what abnormal results would mean for the patient.

Results

A negative result means no abnormal, malignant, or atypical cells were found. A positive result means abnormal or unusual cells were found, which is not the same as having cervical cancer.

The Bethesda System (TBS) is the current method for interpreting cervical cytology. It includes the following components.

1. Adequacy of specimen

• Satisfactory for evaluation: Note the presence or absence of the endocervical transformation zone component and other quality indicators such as partially obscuring blood or inflammation.
• Unsatisfactory for evaluation: Specimen rejected (specify reason), or processed and examined but unsatisfactory for evaluating epithelial abnormalities (specify reason).

2. Interpretation/result

• Negative for intraepithelial lesion or malignancy
• Organism causing infection: Trichomonas vaginalis; fungal organisms consistent with Candida spp.; a shift in flora indicating bacterial vaginosis (coccobacillus); bacteria consistent with Actinomyces spp.; cellular changes consistent with herpes simplex virus.
• Other non-neoplastic findings: Reactive cellular changes from inflammation (including repair), radiation, intrauterine device use, atrophy, and glandular cell status after hysterectomy.
• Epithelial cell abnormalities
• Squamous cell abnormalities
• Atypical squamous cells of undetermined significance (ASC-US) cannot exclude HSIL (ASC-H)
• Low-grade squamous intraepithelial lesion (LSIL), encompassing HPV, mild dysplasia, cervical intraepithelial neoplasia (CIN) grade 1
• High-grade squamous intraepithelial lesion (HSIL), encompassing moderate and severe dysplasia, CIS/CIN grade 2 and CIN grade 3 with features suspicious for invasion (if invasion is suspected)
• Squamous cell carcinoma: cancerous cells present
• Glandular cell
• Atypical glandular cells (not otherwise specified)
• Atypical glandular cells, favor neoplastic (not otherwise specified)
• Endocervical adenocarcinoma in situ
• Adenocarcinoma
• Others
• Endometrial cells (in women >=40 years of age)

Frequently Asked Questions

At what age should cervical cancer screening start? The American Cancer Society recommends starting at age 25 with a primary HPV test every 5 years through 65 (American Cancer Society). The CDC and USPSTF still describe starting at age 21 with cytology every 3 years for ages 21 to 29, so confirm which protocol your facility follows (CDC).

What is the difference between a Pap test and an HPV test? A Pap (cytology) test looks for abnormal cervical cells, including precancers. An HPV test looks for the high-risk human papillomavirus strains that cause nearly all cervical cancer. Current guidance favors primary HPV testing, with cytology or co-testing as alternatives.

How should a patient prepare for a Pap smear? Avoid intercourse for 24 hours, douching for 48 hours, and tampons, vaginal creams, or lotions before the test, since these wash away cells and change vaginal pH. Schedule outside menstruation, because blood contaminates the sample and can force a repeat.

Does an abnormal Pap result mean cancer? No. An abnormal or positive result means atypical cells were found, which is not the same as cervical cancer. Most abnormalities reflect HPV-related changes or low-grade lesions that are monitored or treated; a suspicious result is confirmed with HPV typing, colposcopy, or biopsy.

What can cause an inaccurate or unsatisfactory Pap result? Recent intercourse, douching, tampon use, menstrual blood, lubricant on the speculum, delayed fixation of the specimen, an active vaginal infection, or sampling the wrong site. Screening for these factors before the speculum is inserted protects the sample.

Can patients collect their own sample for HPV testing? Yes. The American Cancer Society now includes HPV self-collection as a screening option where available, which can expand access for people who avoid or cannot reach in-office screening (American Cancer Society).