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LABORATORY TESTS
Cytopathology Test eg the Papanicolaou smear
A. Screening test, not diagnostic as in a biopsy..
B. Procedure.
Obtain cells from the S-Q junction or Transformation zone via swab, Cytobrush, spatula.
Rotate 180 - 360 degrees.
Fix immediately to avoid drying effect.
Order of the procedure varies. That is, some recommend that you get endocervical cells first, then ectocervical. Others suggest the opposite.
If you suspect GC or clamydia,do
the Gen Probe first.
If you expect bleeding from the cervix, do ectocervix first, then endocervix.
C. Patient preparation. No douching or intercourse or vaginal products for at least 24 hours prior to the procedure.
D. Problems with false negative results. Cytotechnicians reading too many report led to the 1988 CLIA rules.
Even though there are false negatives, the more frequent Pap smears (annually) have a good chance of finding the true positives
The risk of a false-negative with one smear is 20%; 2 smears 4%; 3 smears 0.8;
1/2 to 2/3 of cervical cancers occur in women who have not had a Pap smear for 5 or more years.
E. The Pap smear screens for abnormal cells, infections such as monilia, , trichomonas.
F. Patient response. Non painful, may have some post procedure bleeding,
G. Bethesda System, Revised is the current internationally accepted system for Reporting Cervical Cytologic Results
Bethesda System, II Revised
| Specimen Adequacy | If you do not have an adequate specimen, your results are worthless. You must have endocervical cells, readable cells, no drying effect, not
obscured by blood, etc)
Satisfactory for evaluation |
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General category |
Within normal limits Metaplasia. This is a normal process. Epithelial cell abnormality: see descriptive diagnosis |
| Benign cellular changes
Infection Reactive changes |
Benign reactive cellular changes may occur in response to factors such as infection, inflammation, irritation, radiation or chemotherapy These changes have no premalignant potential, so they are reported only when it appears that they may be clinically significant or when they affect the adequacy or interpretability of the smear. When ASCUS is associated with and night be due to inflammation/reaction, these changes are noted so that the condition can be treated before the smear is repeated. |
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Epithelial cell abnormalities. Squamous cell |
Squamous cell abnormalities include: carcinomas, lesions known to have premalignant potential, cellular changes associated with an increased risk of cancer or a premalignant condition. |
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Atypical squamous cell of undetermined significance (ASCUS) The BIG problem area!! favor reactive changes |
These cellular changes exceed those which can be a benign process, but fall short of an intraepithelial lesion or cancer. Many of these will revert to normal 10-15% will progress |
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Low-grade squamous intraepithelial lesion (LSIL) This is the HPV catagory |
Low-grade SIL (HPV/ mild dysplasia/ CIN 1) About 25% will have a high grade SIL at colposcopy Lesion has a 15% chance of progress to in situ cancer (CIS) |
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High grade squamous intraepithelial lesion (LGSIL) |
High-grade SIL (Moderate and severe dysplasia CIN 2, 3 and CIS) Lesion has a 50% chance of progression to CIS |
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Squamous cell carcinoma |
Probable invasive cancer, requires histology |
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Glandular Cell |
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Endometrial cells |
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Atypical glandular cells of undetermined significance. (AGUS) |
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Endocervical adenocarcinoma |
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Endometrial adenocarcinoma |
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Adenocarcinoma NOS (not otherwise specified) |
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Other malignant neoplasms |
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Hormonal evaluation Hormonal pattern compatible with age and history |
Follow-up of Abnormal Pap Smear
| Atypical squamous cell of undetermined significance (ASCUS) |
1. Perform a colposcopy 2. Follow with a shorter Pap screening interval, every 4-6 months for three intervals in the following cases: 3. If any second Pap smear during the next 12 to 18 months shows ASCUS or SIL, colposcopy should be recommended |
| Low-grade squamous intraepithelial lesion (SIL)
This catagory encompasses HPV change (koilocytotic atypia, condylomatous atypia) and CIN I. Only 15-20% of women with low-grade SIL lesions will progress to a higher-grade lesion. There is a relatively slow progression of lesions. |
1. Pap smears every 4-6 months for a woman who is a good candidate for follow-up 2. If any subsequent report over the next 12-18 months shows ASCUS/premalignant change or SIL, recommend colposcopic evaluation. 3. If all Pap smears normal, return to usual schedule. 4. Colposcopy women a. who may not reliably return for follow-up b. women who request colposcopy c. women with immunodeficiency disease 5. Determine viral type. |
| High-grade squamous cell lesion (SIL) | 1. Refer for colposcopy.
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Glandular Cell Abnormalities (AGUS)
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1. Colposcope all AGUS |
Treatment of SIL
| Low grade SIL |
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| High grade SIL | Treat aggressively |
II. Endometrial Biopsy
A. Scraping, Jet Wash,
B. Patient response. May cause vagal response, some bleeding post procedure
III. Wet preparation tests
A. Potassium hydroxide (KOH).
1. Yeast
B. Saline
1. Trichomonas
2. Clue cells
IV. Bacterial vaginosis criteria. Must have 3 of the following 4.
IV. Other organism studies.
V. Blood studies for hormone assays
A. FSH, LH, Estrogen, Progestin, Testosterone, Prolactin, other.
VI. Arborization or fern test
VII. Pregnancy tests
VIII.Colposcopy
Johnson et al (1997). Discussed in detail on page 640.
Advanced practice nurses are attending colposcopic examination training programs.
IX. Schiller's test
X. Sonography
X. Laparoscopy
XI Hysteroscopy
XII Sonography
Many OB nurses are attending "limited sonography" training programs.
AWHONN has set standards.
Procedures
Wet mount
Equipment
Vaginal speculum
Small test tubes
Normal saline in test tube of slide
10% KOH
Glass slides and coverslips
Microscope
pH strip
Organisms and Preparations
pH
Technique
Effectiveness
Wet mounts are only 80% true positive; 20% false negative
Results
Obtaining a Pap Smear
adequate view of cervix
Use cytobrush for endocervix
Spatula for ectocervix
Transformation zone; SQ. junction
Fix immediately
Use a reliable laboratory
Position
Lithotomy
Have patient lying down, drape and have patient move down to your hand
Lift up head of bed to 15 or so degrees
Place feet in stirrups
Drape so that legs are fully covered, perineum is exposed and you can see patient’s face.
Always have an attendant or assistant
Preparation
No intercourse or douching for 24 hours prior to exam
Empty bladder
Ask patient to relax her legs, NOT spread her legs
Before beginning tell patient you are going to touch her.
Touch her thigh first, then vulva
Use firm touch
Examination
Abdomen
Examination, External
Vulva
Hair pattern
Lesions, excoriations, discharge, odor
HPV common
Spread the labia with left or right hand
BUS palpation
Examination, External, Vulva
Test tone of the perineum by pressing down with index finger.
Common problems
Relaxed vaginal outlet
Cystocele
Rectocele
Prolapse of uterus
Ask patient to bear down and assess for cystocele, rectocele, uterine prolapse
Examination, speculum
Choose correct size and length
May need to cover blades of large speculum with a condom to hold back wall for very heavy women
Warm the speculum and lubricate with water not lubricant
Press down on the perineum with left index finger.
Anterior pressure in the Urethral area is uncomfortable
Introduce the speculum at oblique angle, slowly and gently toward the coccyx
Slide the index finger of the left hand out of the vagina
Open the blades of the speculum
You may need to adjust the speculum anterior or posterior to see cervix
If you cannot find the cervix, remove the speculum and manually palpated for the position of the cervix
Lock speculum in place
Inspect the cervix and visible vaginal walls
Mucosal color, rogation
SQ junction, lesions, discharge
Obtain cultures (Gyn Probe) and wet mount
saline for yeast; KOH for yeast and clue cells
do cultures for chlamydia and GC on all women under 25
Cytobrush for internal os
Spatula for SQ junction
FIX IMMEDIATELY
Common findings
Nabothian cysts
Gartner’s duct cysts
Close blades of speculum as it is removed
Inspect vaginal walls as speculum is removed
Examination, Bimanual
Standing position
Use warmed lubricant insert index and middle finger into vagina, pressure posteriorly
Palpate cervix for contour, nodularity, mobility, pain
Bimanual exam
Lift cervix
Palpate uterus with abdominal hand
Midway between symphasis and umbilicus
Abdominal hand placed between umbilicus and cervix
Vaginal hand into anterior fornix, palpate uterus between your hands, relax wrist
Note size, shape, tenderness
If uterus nonpalpable, may be retroverted
Palpate for masses, tenderness
Palpate adnexa by lateral hand in lateral fornix, abdominal hand in right or left lower quadrant
Rectovaginal examination
Same exam except with index finger in vagina and middle finger in rectum
Can feel a retroverted uterus in this position
Can get higher into the pelvis
Usual rectal exam
Test stool for occult blood
Bethesda System, Revised
Precise terminology tells the provider what the findings
Eliminates traditional "class"
Indicates the need for greater concern about atypia
New grouping of findings
SIL(Squamous intraepithelial lesion)
Low grade SIL = HPV and CIS changes
High grade SIL = moderate and severe Dysplasia and CIN
Specimen adequacy
Satisfactory
Satisfactory, but limited by no endocervical cells
Unsatisfactory
Descriptive diagnoses
Benign Cellular changes
Infection (Trichamonas; monilia; bacterial vaginosis; herpes; actinomyces [associated with IUD’s; treat with ampicillin, doxycycline, erythromycin]
Reactive changes (Infection; radiation; atrophy; IUD)
Epithelial cell abnormalities
Squamous cell
Squamous cell carcinoma
Glandular cell
Metaplasia is a normal process
Pap Smears
Frequency
Preparation.
No douching or intercourse for 24 hrs prior to procedure. No period
Abnormal?
Treatment of abnormal?
Colposcopy
Cryosurgery, LEEP, LASER, Con
Readings:
Text: Hatcher, et al. (current edition).
Text: Johnson, et al. (2000).
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