HOME

TheInfoList



OR:

The Papanicolaou test (abbreviated as Pap test, also known as Pap smear (AE), cervical smear (BE), cervical screening (BE), or smear test (BE)) is a method of
cervical screening Cervical screening is the process of detecting and removing abnormal tissue or cells in the cervix before cervical cancer develops. By aiming to detect and treat cervical neoplasia early on, cervical screening aims at secondary prevention of cer ...
used to detect potentially precancerous and cancerous processes in the
cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...
(opening of the uterus or womb) or colon (in both men and women). Abnormal findings are often followed up by more sensitive diagnostic procedures and, if warranted, interventions that aim to prevent progression to
cervical cancer Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal ...
. The test was independently invented in the 1920s by Georgios Papanikolaou and Aurel Babeș and named after Papanikolaou. A simplified version of the test was introduced by Anna Marion Hilliard in 1957. A Pap smear is performed by opening the vagina with a speculum and collecting
cells Cell most often refers to: * Cell (biology), the functional basic unit of life Cell may also refer to: Locations * Monastic cell, a small room, hut, or cave in which a religious recluse lives, alternatively the small precursor of a monastery w ...
at the outer opening of the cervix at the transformation zone (where the outer squamous cervical cells meet the inner glandular endocervical cells), using an Ayre spatula or a cytobrush. A similar method is used to collect cells in anus of both women and men. The collected cells are examined under a microscope to look for abnormalities. The test aims to detect potentially precancerous changes (called
cervical intraepithelial neoplasia Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous ...
(CIN) or cervical dysplasia; the
squamous intraepithelial lesion A squamous intraepithelial lesion (SIL) is an abnormal growth of epithelial cells on the surface of the cervix, commonly called squamous cells. This condition can lead to cervical cancer, but can be diagnosed using a Pap smear or a colposcopy. It c ...
system (SIL) is also used to describe abnormalities) caused by
human papillomavirus Human papillomavirus infection (HPV infection) is caused by a DNA virus from the '' Papillomaviridae'' family. Many HPV infections cause no symptoms and 90% resolve spontaneously within two years. In some cases, an HPV infection persists and re ...
, a sexually transmitted
DNA virus A DNA virus is a virus that has a genome made of deoxyribonucleic acid (DNA) that is replicated by a DNA polymerase. They can be divided between those that have two strands of DNA in their genome, called double-stranded DNA (dsDNA) viruses, an ...
. The test remains an effective, widely used method for early detection of precancer and cervical cancer. While the test may also detect infections and abnormalities in the endocervix and
endometrium The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer ...
, it is not designed to do so. In the United States, Pap smear screening is recommended starting around 21 years of age until the age of 65. Guidelines on frequency vary from every three to five years.American Cancer Society. (2010)
Detailed Guide: Cervical Cancer. Can cervical cancer be prevented?
Retrieved August 8, 2011.
If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in six to twelve months. If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the cervix by
colposcopy Colposcopy ( grc, κόλπος, kolpos, hollow, womb, vagina + ''skopos'' "look at") is a medical diagnostic procedure to visually examine the cervix as well as the vagina and vulva using a colposcope. The main goal of colposcopy is to prevent ...
, which magnifies the view of the cervix, vagina and vulva surfaces. The person may also be referred for HPV DNA testing, which can serve as an adjunct to Pap testing. Additional biomarkers that may be applied as ancillary tests with the Pap test are evolving.


Medical uses

Screening guidelines vary from country to country. In general, screening starts about the age of 20 or 25 and continues until about the age of 50 or 60. Screening is typically recommended every three to five years, as long as results are normal.
American Congress of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts o ...
(ACOG) and others recommend starting screening at age 21. Many other countries wait until age 25 or later to start screening. For instance, some parts of Great Britain start screening at age 25. ACOG's general recommendation is that people with female reproductive organs age 30–65 have an annual
well-woman examination A well-woman examination is an exam offered to women to review elements of their reproductive health. The exam includes a breast examination, a pelvic examination and a Pap smear but may also include other procedures. Hospitals employ strict poli ...
, that they not get annual Pap tests, and that they do get Pap tests at three to five year intervals., which cites * * * * HPV is passed through skin to skin contact; sex does not have to occur, although it is a common way for it to spread. It takes an average of a year, but can take up to four years, for a person's immune system to control the initial infection. Screening during this period may show this immune reaction and repair as mild abnormalities, which are usually not associated with cervical cancer, but could cause the patient stress and result in further tests and possible treatment. Cervical cancer usually takes time to develop, so delaying the start of screening a few years poses little risk of missing a potentially precancerous lesion. For instance, screening people under age 25 does not decrease cancer rates under age 30. HPV can be transmitted in sex between females, so those who have only had sex with other females should be screened, although they are at somewhat lower risk for cervical cancer. Guidelines on frequency of screening vary—typically every three to five years for those who have not had previous abnormal smears. Some older recommendations suggested screening as frequently as every one to two years, however there is little evidence to support such frequent screening; annual screening has little benefit but leads to greatly increased cost and many unnecessary procedures and treatments. It has been acknowledged since before 1980 that most people can be screened less often. In some guidelines, frequency depends on age; for instance in Great Britain, screening is recommended every three years for women under 50, and every five years for those over. Screening should stop at about age 65 unless there is a history of abnormal test result or disease. There is probably no benefit in screening people aged 60 or over whose previous tests have been negative. If a woman's last three Pap results were normal, she can discontinue testing at age 65, according to the USPSTF, ACOG, ACS, and ASCP; England's NHS says 64. There is no need to continue screening after a complete hysterectomy for benign disease. Pap smear screening is still recommended for those who have been vaccinated against HPV since the vaccines do not cover all HPV types that can cause cervical cancer. Also, the vaccine does not protect against HPV exposure before vaccination. Those with a history of
endometrial cancer Endometrial cancer is a cancer that arises from the endometrium (the lining of the uterus or womb). It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most ...
should discontinue routine Pap tests after hysterectomy. Further tests are unlikely to detect recurrence of cancer but do bring the risk of giving false positive results, which would lead to unnecessary further testing. More frequent Pap smears may be needed to follow up after an abnormal Pap smear, after treatment for abnormal Pap or biopsy results, or after treatment of cancer ( cervical, colon, etc. ).


Effectiveness

The Pap test, when combined with a regular program of screening and appropriate follow-up, can reduce cervical cancer deaths by up to 80%. Failure of prevention of cancer by the Pap test can occur for many reasons, including not getting regular screening, lack of appropriate follow-up of abnormal results, and sampling and interpretation errors. In the US, over half of all invasive cancers occur in females who have never had a Pap smear; an additional 10 to 20% of cancers occur in those who have not had a Pap smear in the preceding five years. About one-quarter of US cervical cancers were in people who had an abnormal Pap smear but did not get appropriate follow-up (patient did not return for care, or clinician did not perform recommended tests or treatment).
Adenocarcinoma Adenocarcinoma (; plural adenocarcinomas or adenocarcinomata ) (AC) is a type of cancerous tumor that can occur in several parts of the body. It is defined as neoplasia of epithelial tissue that has glandular origin, glandular characteristics, or b ...
of the cervix has not been shown to be prevented by Pap tests. In the UK, which has a Pap smear screening program, adenocarcinoma accounts for about 15% of all cervical cancers. Estimates of the effectiveness of the United Kingdom's call and recall system vary widely, but it may prevent about 700 deaths per year in the UK. Multiple studies have performed sensitivity and specificity analyses on Pap smears. Sensitivity analysis captures the ability of Pap smears to correctly identify women with cervical cancer. Various studies have revealed the sensitivity of Pap smears to be between 47.19 - 55.5%. Specificity analysis captures the ability of Pap smears to correctly identify women without cervical cancer. Various studies have revealed the specificity of Pap smears to be between 64.79 - 96.8%. While Pap smears may not be entirely accurate, they remain one of the most effective cervical cancer prevention tools. Pap smears may be supplemented with HPV DNA testing.


Results

In screening a general or low-risk population, most Pap results are normal. In the United States, about 2–3 million abnormal Pap smear results are found each year. Most abnormal results are mildly abnormal ( ASC-US (typically 2–5% of Pap results) or low-grade squamous intraepithelial lesion ( LSIL) (about 2% of results)), indicating HPV infection. Although most low-grade cervical dysplasias spontaneously regress without ever leading to
cervical cancer Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal ...
, dysplasia can serve as an indication that increased vigilance is needed. In a typical scenario, about 0.5% of Pap results are high-grade SIL ( HSIL), and less than 0.5% of results indicate cancer; 0.2 to 0.8% of results indicate Atypical Glandular Cells of Undetermined Significance (AGC-NOS). As liquid-based preparations (LBPs) become a common medium for testing, atypical result rates have increased. The median rate for all preparations with low-grade squamous intraepithelial lesions using LBPs was 2.9% in 2006, compared with a 2003 median rate of 2.1%. Rates for high-grade squamous intraepithelial lesions (median, 0.5%) and atypical squamous cells have changed little. Abnormal results are reported according to the
Bethesda system The Bethesda system (TBS), officially called The Bethesda System for Reporting Cervical Cytology, is a system for reporting cervical or vaginal cytologic diagnoses, used for reporting Pap smear results. It was introduced in 1988 and revised in ...
. They include: * Squamous cell abnormalities (SIL) ** Atypical squamous cells of undetermined significance (ASC-US) ** Atypical squamous cells – cannot exclude HSIL (ASC-H) ** Low-grade squamous intraepithelial lesion (LGSIL or LSIL) ** High-grade squamous intraepithelial lesion (HGSIL or HSIL) **
Squamous cell carcinoma Squamous-cell carcinomas (SCCs), also known as epidermoid carcinomas, comprise a number of different types of cancer that begin in squamous cells. These cells form on the surface of the skin, on the lining of hollow organs in the body, and on the ...
* Glandular epithelial cell abnormalities ** Atypical glandular cells not otherwise specified (AGC or AGC-NOS) Endocervical and endometrial abnormalities can also be detected, as can a number of infectious processes, including
yeast Yeasts are eukaryotic, single-celled microorganisms classified as members of the fungus kingdom. The first yeast originated hundreds of millions of years ago, and at least 1,500 species are currently recognized. They are estimated to constit ...
,
herpes simplex virus Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known by their taxonomical names '' Human alphaherpesvirus 1'' and '' Human alphaherpesvirus 2'', are two members of the human ''Herpesviridae'' family, a set of viruses that produce viral in ...
and
trichomoniasis Trichomoniasis (trich) is an infectious disease caused by the parasite '' Trichomonas vaginalis''. About 70% of affected people do not have symptoms when infected. When symptoms occur, they typically begin 5 to 28 days after exposure. Symptoms c ...
. However it is not very sensitive at detecting these infections, so absence of detection on a Pap does not mean absence of the infection. Image:Normal PAP (Cervical) Smear.jpg,
Micrograph A micrograph or photomicrograph is a photograph or digital image taken through a microscope or similar device to show a magnified image of an object. This is opposed to a macrograph or photomacrograph, an image which is also taken on a mic ...
of a normal pap smear Image:Low-grade sil and endocx.jpg,
Micrograph A micrograph or photomicrograph is a photograph or digital image taken through a microscope or similar device to show a magnified image of an object. This is opposed to a macrograph or photomacrograph, an image which is also taken on a mic ...
of a Pap test showing a low-grade intraepithelial lesion (LSIL) and benign endocervical mucosa. Pap stain. Image:Trichomonas pap test.jpg,
Micrograph A micrograph or photomicrograph is a photograph or digital image taken through a microscope or similar device to show a magnified image of an object. This is opposed to a macrograph or photomacrograph, an image which is also taken on a mic ...
of a Pap test showing
trichomoniasis Trichomoniasis (trich) is an infectious disease caused by the parasite '' Trichomonas vaginalis''. About 70% of affected people do not have symptoms when infected. When symptoms occur, they typically begin 5 to 28 days after exposure. Symptoms c ...
. Trichomonas organism seen in the upper right. Pap stain. Image:Herpes simplex virus pap test.jpg,
Micrograph A micrograph or photomicrograph is a photograph or digital image taken through a microscope or similar device to show a magnified image of an object. This is opposed to a macrograph or photomacrograph, an image which is also taken on a mic ...
of a Pap test showing changes of
herpes simplex virus Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known by their taxonomical names '' Human alphaherpesvirus 1'' and '' Human alphaherpesvirus 2'', are two members of the human ''Herpesviridae'' family, a set of viruses that produce viral in ...
. Pap stain. Image:Adenocarcinoma on pap test 1.jpg, Endocervical
adenocarcinoma Adenocarcinoma (; plural adenocarcinomas or adenocarcinomata ) (AC) is a type of cancerous tumor that can occur in several parts of the body. It is defined as neoplasia of epithelial tissue that has glandular origin, glandular characteristics, or b ...
on a pap test. Image:Candida pap 1.jpg, Candida organisms on a pap test. Image:Herpes_simplex_virus_pap_test.jpg, Viral cytopathic effect consistent with
herpes simplex virus Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known by their taxonomical names '' Human alphaherpesvirus 1'' and '' Human alphaherpesvirus 2'', are two members of the human ''Herpesviridae'' family, a set of viruses that produce viral in ...
on a pap test. Image:Pap test normal.jpg, Normal squamous epithelial cells in
premenopausal Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often ...
women Image:Pap test atropy.JPG, Atrophic squamous cells in
postmenopausal Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often ...
women Image:Pap test endocervical cells.JPG, Normal endocervical cells should be present into the slide, as a proof of a good quality sampling Image:Pap test citolysis.JPG, The cytoplasms of squamous
epithelial cells Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellul ...
melted out; many Döderlein bacilli can be seen. Image:Pap test trichomonas.JPG, Infestation by
Trichomonas vaginalis ''Trichomonas vaginalis'' is an anaerobic, flagellated protozoan parasite and the causative agent of a sexually transmitted disease called trichomoniasis. It is the most common pathogenic protozoan that infects humans in industrialized countries ...
Image:Pap test abnormal.JPG, An obviously atypical cell can be seen


Pregnancy

Pap tests can usually be performed during pregnancy up to at least 24 weeks of
gestational age In obstetrics, gestational age is a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. ...
.PapScreen Victoria > Pregnant women
from Cancer Council Victoria 2014
Pap tests during pregnancy have not been associated with increased risk of
miscarriage Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical ...
. An inflammatory component is commonly seen on Pap smears from pregnant women and does not appear to be a risk for subsequent
preterm birth Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between ...
. After childbirth, it is recommended to wait 12 weeks before taking a Pap test because inflammation of the cervix caused by the birth interferes with test interpretation.


In transgender individuals

Transgender women who have not had vaginoplasties are not at risk of developing cervical cancer because they do not have cervices. Transgender women who have had vaginoplasties and have a neo-cervix or neo-vagina have a small chance of developing cancer, according to the Canadian Cancer Society. Surgeons typically use penile skin to create the new vagina and cervix, which can contract HPV and lead to cancer. Therefore, routine cervical cancer screenings are recommended for transgender women with vaginoplasties. Transgender men are also at risk for HPV due to retention of the uterine cervix in the majority of individuals in this subgroup. As such, professional guidelines recommend that transgender men be screened routinely for cervical cancer using methods such as Pap smear, identical to the recommendations for cisgender women. Many transgender men report barriers to receiving gender-affirming healthcare, including lack of insurance coverage and stigma/discrimination during clinical encounters, due to provider misconceptions regarding risk in this population for cervical cancer. As such, transgender men have lower rates of cervical cancer screening than cisgender women. Pap smears may be presented to patients as non-gendered screening procedures for cancer rather than one specific for examination of the female reproductive organs. Pap smears may trigger gender dysphoria in patients and gender-neutral language can be used when explaining the pathogenesis of cancer due to infection, emphasizing the pervasiveness of HPV infection regardless of gender.


Procedure

For best results, a Pap test should not occur when a woman is menstruating, partly because the additional cells can obscure cervical cells and partly because this part of the menstrual cycle is when the female organs are most inflamed. However, Pap smears can be performed during a woman's menstrual period, especially if the physician is using a liquid-based test; if bleeding is extremely heavy, endometrial cells can obscure cervical cells, and it is therefore inadvisable to have a Pap smear if bleeding is excessive. Obtaining a Pap smear should not cause much pain, but it can if the woman has certain untreated vaginal problems such as cervical stenosis or
vaginismus Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often, it begins when vaginal intercourse is first attempted. ...
. It is, however, not comfortable, for two reasons: the cervix is full of nociceptors (pain nerves), and the brush used to collect cells has to be stiff enough to scrape them off of the surrounding tissue. So it can be uncomfortable, but it is generally quick, and the information obtained may be critical. People with underlying pain or tissue diseases that can react to nociceptors being scraped or to excessive cold in the mucous membranes should take appropriate precautions and discuss the process ahead of time with their providers. Many people experience spotting or mild
diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin w ...
afterward. The spotting is usually from the scrape on the cervix, and the diarrhea may be due to indirect stimulation of the lower intestine during the exam. A number of studies have shown that using a small amount of water-based gel lubricant does not interfere with, obscure, or distort the Pap smear. Further, cytology is not affected, nor are some STD testing. The health care worker begins by inserting a speculum into the woman's vagina, which spreads the vagina open and allows access to the
cervix The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...
. The health care provider then collects a sample of cells from the outer opening or os of the cervix by scraping it with an Aylesbury spatula. An endocervical brush is rotated in the central opening of the cervix. The cells are placed on a glass slide and taken to the
laboratory A laboratory (; ; colloquially lab) is a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed. Laboratory services are provided in a variety of settings: physicia ...
to be checked for abnormalities. A plastic-fronded broom is sometimes used in place of the spatula and brush. The broom is not as good a collection device, since it is much less effective at collecting endocervical material than the spatula and brush. The broom is used more frequently with the advent of liquid-based cytology, although either type of collection device may be used with either type of cytology. The sample is stained using the Papanicolaou technique, in which
tinctorial A tincture is typically an extract of plant or animal material dissolved in ethanol (ethyl alcohol). Solvent concentrations of 25–60% are common, but may run as high as 90%.Groot Handboek Geneeskrachtige Planten by Geert Verhelst In chemi ...
dyes and acids are selectively retained by cells. Unstained cells cannot be seen adequately with a light microscope. Papanicolaou chose stains that highlighted cytoplasmic keratinization, which actually has almost nothing to do with the nuclear features used to make diagnoses now. A single smear has an area of 25 x 50 mm and contains a few hundred thousand cells on average. Screening with light microscopy is first done on low (10x) power and then switched to higher (40x) power upon viewing suspicious findings. Cells are analyzed under high power for morphologic changes indicative of malignancy (including enlarged and irregularly shaped nucleus, an increase in nucleus to cytoplasm ratio, and more coarse and irregular chromatin). Approximately 1,000 fields of view are required on 10x power for screening of a single sample, which takes on average 5 to 10 minutes. In some cases, a computer system may prescreen the slides, indicating those that do not need examination by a person or highlighting areas for special attention. The sample is then usually screened by a specially trained and qualified cytotechnologist using a light
microscope A microscope () is a laboratory instrument used to examine objects that are too small to be seen by the naked eye. Microscopy is the science of investigating small objects and structures using a microscope. Microscopic means being invisib ...
. The terminology for who screens the sample varies according to the country; in the UK, the personnel are known as
cytoscreener Cytotechnology is the microscopic interpretation of cells to detect cancer and other abnormalities. This includes the examination of samples collected from the uterine cervix (Pap test), lung, gastrointestinal tract or body cavities. A cytotechno ...
s,
biomedical scientist A biomedical scientist is a scientist trained in biology, particularly in the context of medical laboratory sciences or laboratory medicine. These scientists work to gain knowledge on the main principles of how the human body works and to find new w ...
s (BMS), advanced practitioners and
pathologist Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...
s. The latter two take responsibility for reporting the abnormal sample, which may require further investigation.


Automated analysis

In the last decade, there have been successful attempts to develop automated, computer image analysis systems for screening. Although, on the available evidence automated cervical screening could not be recommended for implementation into a national screening program, a recent NHS Health technology appraisal concluded that the 'general case for automated image analysis ha(d) probably been made'. Automation may improve sensitivity and reduce unsatisfactory specimens. Two systems have been approved by the FDA and function in high-volume reference laboratories, with human oversight.


Types of screening

* Conventional Pap—In a conventional Pap smear, samples are smeared directly onto a microscope slide after collection. However this method hurts as wooden spatulas are used. This causes pain during the procedure. * Liquid-based cytology—The sample of (epithelial) cells is taken from the transitional zone, the squamocolumnar junction of the cervix, between the ectocervix and the endocervix. Liquid-based cytology often uses an arrow-shaped brush rather than the conventional spatula. The cells taken are suspended in a bottle of preservative for transport to the laboratory, where they are analyzed using Pap stains. Pap tests commonly look for epithelial abnormalities/ metaplasia/ dysplasia/ borderline changes, all of which may be indicative of CIN. Nuclei will stain dark blue, squamous cells will stain green and keratinised cells will stain pink/ orange. Koilocytes may be observed where there is some dyskaryosis (of epithelium). The nucleus in koilocytes is typically irregular, indicating possible cause for concern; requiring further confirmatory screens and tests. In addition, human papillomavirus (HPV) test may be performed either as indicated for abnormal Pap results, or in some cases, dual testing is done, where both a Pap smear and an HPV test are done at the same time (also called Pap co-testing).


Practical aspects

The endocervix may be partially sampled with the device used to obtain the ectocervical sample, but due to the anatomy of this area, consistent and reliable sampling cannot be guaranteed. Since abnormal endocervical cells may be sampled, those examining them are taught to recognize them. The endometrium is not directly sampled with the device used to sample the ectocervix. Cells may exfoliate onto the cervix and be collected from there, so as with endocervical cells, abnormal cells can be recognised if present but the Pap test should not be used as a screening tool for endometrial malignancy. In the United States, a Pap test itself costs $20 to $30, but the costs for Pap test visits can cost over $1,000, largely because additional tests are added that may or may not be necessary.


History

The test was invented by and named after the Greek doctor Georgios Papanikolaou, who started his research in 1923. Aurel Babeș of
Romania Romania ( ; ro, România ) is a country located at the crossroads of Central, Eastern, and Southeastern Europe. It borders Bulgaria to the south, Ukraine to the north, Hungary to the west, Serbia to the southwest, Moldova to the east, and ...
independently made similar discoveries in 1927. However, Babeș' method was radically different from Papanicolaou's. Papanicolaou's name was repeatedly submitted to the Nobel Committee and rejected every time. The Nobel Committee delegated the in-depth investigation of Papanicolaou's merits and demerits to Professor Santesson, who was at that time the head of pathology at the Stockholm Cancer Institute (
Radiumhemmet Radiumhemmet is a non-surgical cancer treatment and radiotherapy research institution in Solna, Sweden. Since 1938, it has been a division of what is now the Karolinska University Hospital. It was founded in 1910 in central Stockholm as the fir ...
). Santesson discovered Babeș' contributions that had never been cited by Papanicolaou and duly reported this fact to the committee, which then rejected Papanicolaou's Nobel award.


Experimental techniques

In the developed world, cervical biopsy guided by colposcopy is considered the "
gold standard A gold standard is a monetary system in which the standard economic unit of account is based on a fixed quantity of gold. The gold standard was the basis for the international monetary system from the 1870s to the early 1920s, and from the la ...
" for diagnosing cervical abnormalities after an abnormal Pap smear. Other techniques such as triple smear are also done after an abnormal Pap smear. The procedure requires a trained colposcopist and can be expensive to perform. However, Pap smears are very sensitive and some negative biopsy results may represent undersampling of the lesion in the biopsy, so negative biopsy with positive cytology requires careful follow-up. Experimental visualization techniques use broad-band light (e.g., direct visualization, speculoscopy, cervicography, visual inspection with acetic acid or with Lugol's, and colposcopy) and electronic detection methods (e.g., Polarprobe and ''in vivo''
spectroscopy Spectroscopy is the field of study that measures and interprets the electromagnetic spectra that result from the interaction between electromagnetic radiation and matter as a function of the wavelength or frequency of the radiation. Matter wa ...
). These techniques are less expensive and can be performed with significantly less training. They do not perform as well as Pap smear screening and colposcopy. At this point, these techniques have not been validated by large-scale trials and are not in general use.


Access


Australia

Australia has used the Pap test as part of its cervical screening program since its implementation in 1991 which required women past the age of 18 be tested every two years. In December 2017 Australia discontinued its use of the Pap test and replaced it with a new HPV test that is only required to be conducted once every five years from the age of 25. Medicare covers the costs of testing; however, a patient's doctor does not allow bulk billing, they may have to pay for the appointment and then claim the Medicare rebate.


Taiwan

Free Pap tests were offered from 1974–1984 before being replaced by a system in which all women over the age of 30 could have the cost of their Pap test reimbursed by the National Health Insurance in 1995. This policy was still ongoing in 2018 and encouraged women to screen at least every three years. Despite this, the number of people receiving Pap tests remain lower than countries like Australia. Some believe this is due to a lack of awareness regarding the test and its availability. It has also been found that women who have chronic diseases or other reproductive diseases are less likely to receive the test.


England

the NHS maintains a cervical screening program in which women between the age of 25–49 are invited for a smear test every three years, and women past 50 every five years. Much like Australia, England uses a HPV test before examining cells that test positive using the Pap test. The test is free as part of the national cervical screening program.


Coccoid bacteria

The finding of coccoid bacteria on a Pap test is of no consequence with otherwise normal test findings and no infectious symptoms. However, if there is enough inflammation to obscure the detection of precancerous and cancerous processes, it may indicate treatment with a broad-spectrum antibiotic for
streptococci ''Streptococcus'' is a genus of gram-positive ' (plural ) or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci occur ...
and
anaerobic bacteria An anaerobic organism or anaerobe is any organism that does not require molecular oxygen for growth. It may react negatively or even die if free oxygen is present. In contrast, an aerobic organism (aerobe) is an organism that requires an oxygenat ...
(such as
metronidazole Metronidazole, sold under the brand name Flagyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vaginosis. It is e ...
and
amoxicillin Amoxicillin is an antibiotic medication used to treat a number of bacterial infections. These include middle ear infection, strep throat, pneumonia, skin infections, and urinary tract infections among others. It is taken by mouth, or less ...
) before repeating the smear. Alternatively, the test will be repeated at an earlier time than it would otherwise.OB-GYN 101: Introductory Obstetrics & Gynecology > Coccoid Bacteria
by Michael Hughey Hughey at Texas Tech University Health Sciences Center. Retrieved Feb 2014.
If there are symptoms of
vaginal discharge Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amou ...
, bad odor or irritation, the presence of coccoid bacteria also may indicate treatment with antibiotics as per above.


References

;Notes


External links


The Pap Test: Questions and Answers
nbsp;— from the U.S.'s
National Cancer Institute The National Cancer Institute (NCI) coordinates the United States National Cancer Program and is part of the National Institutes of Health (NIH), which is one of eleven agencies that are part of the U.S. Department of Health and Human Services. ...

MedlinePlus: Cervical Cancer Prevention/Screening
nbsp;— from
MedlinePlus MedlinePlus is an online information service produced by the United States National Library of Medicine. The service provides curated consumer health information in English and Spanish with select content in additional languages. The site brings t ...

NHS Cervical Screening Programme
nbsp;— from the UK's
National Health Service The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...

Cervical cancer screening information
nbsp;– from
Cancer Research UK Cancer Research UK (CRUK) is the world's largest independent cancer research organization. It is registered as a charity in the United Kingdom and Isle of Man, and was formed on 4 February 2002 by the merger of The Cancer Research Campaign and ...

Pap Smear
nbsp;– from Lab Tests Online
Pap Smear
nbsp;— from eMedicineHealth
PapScreen
nbsp;– Australian information about Pap tests (or Pap smears)
Canadian Guidelines for Cervical Cancer Screening
nbsp;–
Society of Obstetricians and Gynaecologists of Canada The Society of Obstetricians and Gynaecologists of Canada (SOGC) is a national medical society in Canada, representing over 4,000 obstetricians/gynaecologists, family physicians, nurses, midwives, and allied health professionals in the field of ...
{{DEFAULTSORT:Pap Test Cytopathology Diagnostic obstetrics and gynaecology Greek inventions Gynaecological cancer Infectious causes of cancer Medical tests Papillomavirus-associated diseases