Taking Quality Smear

The sensitivity of the cervical smear depends greatly on the quality of the smear.

• Appropriate timing: avoid cervical screening during menstruation because blood stained
smear may be difficult to interpret and may give rise to false negative smear results.
• Correct site of sampling (transformation zone).
• Adequate cervical cells obtained (both ectocervical and endocervical components) using
appropriate sampler: the presence of endocervical cells on the sample has been
recommended as a marker of adequacy of cervical cell collection as they imply the upper
limit of transformation zone was included in the specimen.
• Proper fixation and proper storage of specimen.
• Correct labeling of specimen and cytology request form filled with adequate clinical
details.
• Timely delivery to laboratory.

Common reasons for screening failure leading to false negative results:

Causes of false negative results

Source of error
Sampling failure - Failure in sampling the abnormal area
- Failure in obtaining adequate cellular
component for diagnosis
- Excessive blood, traumatized cells, mucus
or inflammation
- The lesion fails to exfoliate despite
adequate sampling.
Transfer failure - Failure in transferring the abnormal cells
onto the slide. Only about 20% of cells
collected can be transferred to the slide.
- Unsatisfactory preparation of the slide such
as blood smear with traumatized cells,
layering of cells, air-drying of slide and
fixation artefact
Laboratory failure - Smear of poor quality
- Cells distorted by air-drying
- Scanty material for interpretation
Solution
- Ensure adequate exposure
of cervix
- Target the sampler towards
the transformation zone
- Circumferential collection
of adequate samples
- Liquid-based cytology may
provide better cells sample
- Fixate soon after taking the
smear
- Liquid-based cytology may
provide better cells sample
- Properly trained staff for
slide interpretation
- Computer assisted slide
interpretation

Taking Quality Smear

i. Timing of Smear Taking
i. Timing for taking a good cervical smear

• Cervical smear should be avoided during menstruation because blood

stained smears may be difficult to interpret.
• Smear should be taken despite bleeding if local cervical lesion is seen or
the woman has abnormal vaginal bleeding that needs investigation.
• If there are signs of infection or atrophy, they should be treated before
having cervical cancer screening. If problems with compliance or return
for testing are anticipated, a cervical cancer screening test should be
done at the first visit.

• Postmenopausal women with clinical evidence of cervical or vaginal

atrophy may be given a 7-day course of topical estrogen and stopped 2
days before taking cervical cancer screening test as it is difficult to
interpret smears with atrophic cellular changes.
ii. Notes to clients on booking appointment

• Avoid vaginal douching, sexual intercourse and use of vaginal medicines

for 24 hours before taking the smear as these may wash away or
conceal abnormal cells.

• Remind the clients of the optimal timing for a good cervical smear.

ii.

Communication with Clients

i. Review record

• For old cases, always review records.

• Check for previous smear results.
• Check for history of cervical cancer/pre-cancerous cell change.

• Check for history of hysterectomy.

ii. History taking

• Confirm whether or not clients are sexually active, their parity and last
menstrual period.
• Contraceptive methods / hormonal drug usage.
• Previous smear taking history and results / previous history of cervical
cancer or CIN lesions.
• Previous history of hysterectomy / sub-total hysterectomy / LEEP or cone
biopsy.
• Present history of chemotherapy and radiotherapy.
• Present gynaecological problems: abnormal vaginal discharge, post-coital
bleeding,

• ntermenstrual bleeding and postmenopausal bleeding. Go through the

 checklist for women.
iii. Explanation

• Explain to the client the reasons for cervical cancer screening and the
procedures. Use of anatomical models and sample instruments may be
helpful.
• Tell the client to alert you if she feels uncomfortable during the test.
• Advise the client on relaxation techniques, such as deep breathing during
the test to reduce discomfort.
• Explain benefits of providing personal data and smear result to the
Cervical Screening Registry and obtain client's consent.

• Address any concerns and questions from the client.

iii.

Equipment for Smear Taking

i. Light source should be adequate and adjustable.

ii. Speculum:

• Bivalve Cusco's speculum (equal length blades) is commonly used. Other

types include single-blade Sims' speculum (for use in clients with posterior
prolapse), Graves and Pederson speculum (the latter two have lower blade
1 cm longer than the upper blade for placement in the more distal fornix).
• Metal speculum should be sterilized properly before re-use. Beware of hot
speculum taken out from autoclave. Disposable speculum should be used
only once.

• Choose a speculum of appropriate size according to history such as parity,

age, menopausal stage and experience from previous smear taking.
iii. Cervical cell samplers:

•
• Ayre's spatula: wooden spatula [Cervical cell samplers ]
is cheaper but is too porous
leading to trapping of cells in
the sampler. Both the wooden
and plastic samplers can be used in conventional smear but liquid-based
cytology requires plastic sampler.
• Cervex brush: it provides more efficient sampling and reliable cell transfer,
hence improving quality and accuracy of the test and reducing
unsatisfactory smear but more expensive

• Cytobrush: obtain good endocervical sample but not ectocervical sample.

In pre-menopausal women with an adequate external os, only the spatula
 or cervical broom is needed. In postmenopausal women and in pre-
menopausal women who have previous cervical surgery, endocervical
brush should also be used to ensure adequate sampling from the retracted
squamo-columnar junction.
iv. Fixative: alcohol aerosol spray or vial containing 95% alcohol.

v. Glass slide or vial for liquid based cytology labelled with client's full name and ID
number should be ready before sampling. Label the frosted end of glass slide
with pencil as ink and paper labels would be washed off during processing in the
laboratory.

vi. Cytology request form: apart from personal details, clinical information should be
included, as it would assist the cytologist in slide interpretation. Details should
include client's age, last menstrual period, whether the client is pregnant,
postnatal, postmenopausal, using hormone or Intrauterine Contraceptive Device
(IUCD). Any risk factors such as prior CIN or treatment, abnormal cervical
appearance, or presence of contact or postcoital bleeding should also be written
down on the request form.

iv.

Right Environment & Correct Positioning

• Male doctors are advised to be accompanied by female chaperone.

• Ensure privacy: e.g. close bed screen, lock room door and lower window curtain.
• Ask client to remove trousers and underpants.
• Provide cover sheet to cover the abdomen may reduce embarrassment.
• Ask the client to lie supine on the examination couch, with knees flexed, thighs spread, and feet
rest on the pedals or bed end.
• The left lateral position can be used if smears are difficult to obtain, such as in older women with
lax anterior vaginal wall.
• Ensure the client is comfortable.
• Provide a running commentary of what you are doing during the examination may help alleviating
anxiety of the client.

v.

Insertion of Speculum

• Cervical cancer screening should be done before doing bimanual examination.

• Put on gloves before handling instruments.
• Lubricate speculum with warm water. Avoid using cream or jelly as they may interfere with
cytological examination.
 • Hold the speculum with blades closed with your right hand. Inspect the vulva for any abnormality
or atrophic changes before gently separating the labium minora to expose the vaginal orifice with
your left hand.
• Align the speculum with the handle pointing towards the right side of the client. Slowly insert the
speculum into the vagina with the tip pointing 45° downward to avoid touching the clitoris. Most of
the discomfort is caused by pressure on the urethra and trigone.
• Ask the client to see if she feels any discomfort. Look for non-verbal cues of discomfort such as
facial grimacing, clenching of fist and tense leg muscle. Encourage deep breathing and muscle
relaxation.
• On full insertion, turn the handle downwards (for anteverted uterus, which is more common) or
upwards (for retroverted uterus) and open the speculum gently to slip the blades into the anterior
and posterior fornices, thus exposing the cervix adequately.
• If the handle hit the examination couch, the client's hip could be raised with a plastic wedge,
pillow or phone book.
• The bivalve speculum could also be used in the lateral position, which may be more comfortable
for some women.

Reasons for failure to visualize the cervix

Reason
The commonest reason of failure to
expose the cervix is the tip of speculum
slipped into anterior vaginal fornix,
especially in nulliparous women.
The speculum is not pointing downward
on insertion.
Solution
- Elevate your hand, thus pivoting the
speculum across the perineal body and
depressing the speculum tips into the
same axis as the cervix (arrow), or
- Retrieve the speculum a little bit, then
reinsert in downward direction.

The uterus is retroverted with the cervix - Depress your wrist, thus pivoting the
pointing upward and forward. anterior blade into the anterior fornix,
or

- Retrieve the speculum a little bit, then

turn it in upward direction. Insert
slightly deeper and open again.

The speculum is inserted not deep - Close the blades and try to insert
enough. deeper, or

- Use a longer speculum.

Lateral vaginal walls bulge inwards on opening - Use a larger size speculum, or
the speculum in:
- Apply a condom onto the speculum
- Vaginal prolapse
- Obese women (make a small scissor cut in the tip of
the condom before re-insertion).
vi.

Cervical Cells Sampling

• Look for any obvious abnormality of the cervix. If there are signs of infection, you may postpone
the test until the infection has been treated. Reassure the woman if her cervix looks normal.
• Choose sampling device according to the appearance of the cervix.
• A cervical ectropion (often wrongly called cervical erosion) is a normal area of columnar cells on
the ectocervix. Its appearance is a well-demarcated, red velvety area on the ectocervix. It is more
common in premenopausal women. No treatment is needed. If it is present, a smear including its
border should be obtained as this represents the upper margin of the transformation zone.
• Acceptable smear collection instruments include wooden/plastic Ayre's spatula, plastic cervical
broom (Cervex brush) and endocervical brush (Cytobrush). Both the conventional and the liquid-
based cytology methods for smear examination are acceptable.
• The sampling technique for conventional smears and liquid based cytology is the same.
• Any large mucus plug obscuring the external os should be removed with dry cotton ball or swab
before taking smear.
• The transformation zone must be selectively sampled as most cancers and precancers arise from
it.
• In postmenopausal women or those with retracted transformation zone up into the endocervical
canal, endocervical brush should also be used in addition to spatula/Cervex brush. It should not
be used in pregnant women because of the risk of rupturing the fetal membranes and introducing
infection.

i. Spatula

• Insert the spatula into the cervix through the speculum.

• Press the tip onto the ectocervix and rotate 360 degree in one direction.

• If an ectropion is present, sampling of its margin using the flat end of a

spatula is needed.
ii. Cervex brush

• Insert the Cervex brush into the cervix through the speculum.

• Insert the central bristles of the broom into the endocervical canal deep
enough to allow the shorter bristles to fully contact the ectocervix. Push
gently and rotate 360 degree in one direction for 5 times.
iii. Endocervical brush

• Use the spatula first to avoid the bleeding result from cytobrush sampling.
Use the cytobrush second, as endocervical cells deteriorate more rapidly
than ectocervical cells.
• Insert the cytobrush into the cervix until only the bottommost fibers are
exposed outside the os.

• Slowly rotate 1/4 to 1/2 turn in one direction, Do NOT over-rotate as this
may lead to trapping of cells in the bristles, which may not be transferred
to the slide.
vii.

Management of Cells Collected

i. Conventional cervical smear using glass slide

• Paint both sides of the spatula/ Cervex brush onto the glass slide to
produce an even and thin layer of cells.
• Fix the cells immediately with 2 sprays from 15 cm (6 inches) within 30
seconds to prevent air-drying of cells. If spray too close, some cells will be
washed away or causing freezing artefact. Air-drying will cause
degenerative changes with loss of cellular features, thus affecting the
accuracy of diagnosis. Allow the slide to stand for 5-7 minutes before
storage to allow the fixative to reach all cells evenly. Alternatively, each
glass slide can be placed in a separate container with 95% alcohol.
• If two sampling instruments are used, place both samples on one slide.
Paint one end of the slide with Cervex brush or spatula, but do not fix it
yet. Then paint the other end with Cytobrush by rolling it on the slide.
Finally, fix the whole slide with spray.
• Transfer the slides to the laboratory in a slide box.

[Conventional cervical smear using glass slide ]

ii. Liquid-based cytology

The two commonly used methods are:

• Collect the cervical cytology sample by plastic spatula or Cervex brush

(broom head device) and endocervical sample by endocervical brush (as
described in the following figure).
• Collect cervical cytology sample by Cervex brush and simply drop the
removable head into the collection vial.

[Liquid-based cytology ]

Communicating Abnormal Results

i. Ensure privacy, interruption-free environment.

ii. Develop rapport: greet, handshake, offer seat.

iii. Check awareness: check background knowledge and how much information needed.

iv. Warning shot: to prime the client of a bad news, e.g. "I'm afraid that the result is more
serious than expected".

v. Give information: avoid jargon, tailored amount and pace. Correct misconception according
to awareness. Break down information into categories to facilitate recall. Be sensitive to
 nonverbal cues of doubt. Repeat or emphasize on important information.

vi. Check understanding: ensure the client understands the meaning of the result and answer any
questions raised.

vii. Acknowledge feeling and emotion: initial responses to bad news include shock, disbelief,
sadness and anger, etc. Acknowledge that her reaction is a normal response to bad news.

viii.Elicit all concerns: ask the client what does the result mean to her, in the light of her
knowledge, family, occupational and social background. Try to address her concerns.

ix. Discuss management plan: explain the management /referral options and involve the client in
decision making.

x. Arrange follow up: to provide shared care with specialist. Respond to on-going medical,
psychological and social needs.

Laboratory Reporting
(i) The Bethesda 2001 System

(ii) SNOMED

(i) The Bethesda 2001 System

1.Specimen type Conventional smear (Pap smear) vs liquid-based vs others

2.Specimen adequacy 1.Satisfactory for evaluation

2.Unsatisfactory for evaluation e.g. unlabelled specimen,

broken slide, inadequate cellularity, absent
transformation zone, excessive obscuring factors

3.General categorization 1.Negative for intraepithelial lesion or malignancy

(optional)
2.Epithelia cell abnormality

3.Other

4.Automated review Specify automated device and result, if used

5.Ancillary testing Brief description of test methods and result

6.Interpretation / result 1. Negative for intraepithelial lesion or malignancy: (state if the
following findings exist)

- Organisms e.g. Trichomonas, Candida, HSV

- Non-neoplastic findings e.g. reactive changes, glandular cells

status post-hysterectomy, atrophy
2. Epithelia cell abnormality:

- Squamous cell:
Atypical squamous cells (ASC),
Low-grade squamous intraepithelial lesion (LSIL),
High-grade intraepithelial lesion (HSIL),
Squamous cell carcinoma (SCC),

- Glandular cell:
Atypical glandular cells (AGC),
Adenocarcinoma in situ (AIS)
3.Other: endometrial cells in a woman >= 40 years old

7.Education notes and suggestions (optional)

(ii) SNOMED

SNOMED for histology coding

Technologies for Cervical Cancer Screening
(i) Conventional Smear

(ii) Liquid-based Cytology

(iii) PathFinder

(iv) AutoPap Primary Screening System

(v) HPV DNA Testing

(i) Conventional Smear

George Papanicolaou introduced cervical cytology into clinical practice in 1940. Cervical
smear (Pap smear) is a simple test that can detect early abnormal changes in the cells of the
cervix. Smear collection instruments include the wooden or plastic Ayre's spatula and the
broom type. The specimens are transferred to glass slides and fixed with spray to avoid air
drying. The specimens are then reviewed by trained professionals. Sensitivity of cervical
smear for detection of high-grade squamous intraepithelial lesion (SIL) is in the range of
70-80%. Specificity of cervical smear has been reported to be higher than 90%. Factors that
limit test sensitivity include small size of the lesion, inaccessible location of the lesion, the
lesion not being sampled or the presence of inflammation and/or blood obscuring cell
visualization.

(ii) Liquid-based Cytology

Thin layer smears are collected with a non-absorbent instrument such as Cervex brush.
Instead of being smeared onto glass slides, the cells are rinsed into an alcohol-bases
solution. The advantages are elimination of drying changes, less unsatisfactory smear,
speeding up microscopic exam because blood, mucus and inflammatory cells are removed
during processing. Moreover, the cells are deposited in a thin-layer located within a circle
of 13-20mm diameter instead of over a large area in conventional smear. Studies found that
the detection rate for SIL and cancers are superior to conventional smear. However, it is
more expensive. Examples of liquid based cytology are Thin-prep or Autocyte prep.

(iii PathFinder

This is a computer-based device consisting of a computer and a small monitor that are
attached to the microscope. A 'map' is created when the screener examine a smear. If the
screener has a tendency to overlook area on the slide, it could be detected and corrective
action could then be taken. This system also allows the electronic tagging and labeling of
abnormal cells for storage and later retrieval. Screening efficiency can be improved by up
to 15%
Accreditation Scheme of Pathology Laboratories

When a laboratory is accredited, it indicates that a structural mechanism is in place, which allows
high-quality lab work to proceed, and that the workplace is safe for staff. To pass an
accreditation inspection, all aspects of lab activity are scrutinized. The way in which tests are
performed, staff qualifications and experience, methodology, reporting practice, record-keeping,
and quality-control programmes (both internal and external, staff training, continuing medical
education, and safety) are considered. The Hong Kong College of Pathologists will work with
the Hong Kong Laboratory Accreditation Scheme (HOKLAS) for the development of laboratory
accreditation schemes.

For more information about the list of laboratories accredited for performing cytopathology test
under HOKLAS, please refer to the following link:
Hong Kong Laboratory Accreditation Scheme (HOKLAS) and view the list under the testing
type: "Gynaecological Cytology"