Why is a pap test prescribed, how is it carried out, decoding of the analysis. Cytological examination of scrapings of the cervix and cervical canal (Papanicolaou stain, Pap test)

The basis for the early diagnosis of cervical cancer is a Pap smear ( Pap test). A smear is a scraping of uterine tissue and examination of cells under a microscope. Like all human organs, the uterus is made up of different layers of cells. The outer surface consists of epithelium, they are constantly replaced by new ones. During the process of maturation and replacement, cells move along the surface, where they are sometimes deposited and can be taken for analysis. The widespread use of a simple cytological study has reduced the incidence of cervical cancer by 2 times. The Pap test is also informative in some other cases. For example, when examining any secretions (urine, feces, sputum, etc.), it is possible to recognize cancer of the bladder, stomach, and lungs. However, most often the Pap test is used in gynecology.

Georgios Papnikolaou, the founder of medical cytology, discovered that malignant tumor cells enter the vaginal secretion. Accordingly, the study of this secret for pathological cells has become the basis for the early diagnosis of tumors.

The Pap test is mandatory for all women during a gynecological examination, starting at the age of 21, annually. Thanks to the introduction of this test into the work of gynecologists, the incidence of cancer among women has been reduced by 60-70%. To obtain the material, the doctor conducts a scraping of the epithelium from the surface of the cervix and cervical canal. The analysis is best done on the 10-20th day of the cycle. In the lab, samples are stained for better examination. The type of cells, their size, number and structural features, etc. are evaluated. The result is usually ready in 1-3 days. The smear may be positive or negative. With a negative result, there are no atypical cells, the cells have the same size and shape. A positive result reveals cells that are different in shape and size, their location is not normal. The results of the smear indicate what changes were found:

ASC US- abnormal cells of the surface epithelium, their appearance is associated with dysplasia, papillomavirus, chlamydia and other infections, mucosal atrophy during menopause. It is recommended to be tested for the human papillomavirus (HPV), which is one of the main causes of cervical cancer.

LSIL- Squamous cell lesions of low severity. Causes may be dysplasia, papilloma virus. The risk of cancer is low. It is recommended to conduct an HPV test, colposcopy.

ASC-H- Abnormal epithelial cells. Causes of cell detection: precancerous changes, the initial form of cancer. An extended colposcopy is recommended.

HSIL- high-grade squamous cell lesions. These lesions can develop into cancer cells. Causes - high-grade dysplasia, cervical cancer. Colposcopy or biopsy recommended .

AGC- Abnormal glandular cells. Causes: high-grade dysplasia, endometrial cancer, cervical cancer. HPV analysis, colposcopy, endometrial scraping are recommended.

AIS- squamous cell carcinoma, cells typical of cervical cancer. Causes - cervical cancer, high-grade dysplasia. Recommended diagnostic curettage, diagnostic excision (removal of the mucosal area).

Benign glandular changes- wandering connective tissue cells. Their detection may be evidence of endometrial cancer, precancerous changes. For women who have not reached menopause and do not have other adverse symptoms, benign glandular cells are considered a normal option. Diagnostic curettage is recommended.

Despite all the informativeness and high significance of the PAP test, its results depend on the quality of the material sampling and some other factors. Therefore, the results may be erroneous.

False positive Pap test- the result indicates the presence of dysplasia, although the woman is healthy. Such a result may be due to past inflammatory or infectious diseases of the genital organs, erosion, hormonal disorders. A repeat Pap test and colposcopy are recommended.

False negative Pap test- indicates the absence of the disease, although it is present. The reason may be incorrect sampling of material for analysis, laboratory error. It is recommended to carry out a colposcopy in addition to the Pap test.

Possible pathologies in the conclusion of the Pap test:

- inflammatory process - the inflammation caused by the infection should be treated, after which a second PAP test is prescribed. If the papilloma virus is detected during the examination, then the patient undergoes long-term treatment under the constant supervision of the attending physician.

- atypical epithelial cells - moderate changes, deviations from the norm, but not yet cancerous cells. Most often, atypical cells disappear on their own. If dysplasia is detected, treatment is carried out.

- pathology of the epithelium of a high level - a serious pathology of cells, but not yet cancer. Only in 1-2% of cases of such a conclusion, cancer is detected during a biopsy. Further examination, colposcopy, biopsy is required.

Epithelial neoplasia is a serious form of pathology of epithelial cells. A thorough examination and immediate treatment is required.

- cancer in situ - the development of cancer cells in a limited area, without moving to other areas.

Thus, the Pap test helps to identify not only cancerous and precancerous conditions. During the analysis, inflammation, infection, atrophy of the cervix can be detected. Modern cytological examination is one of the most effective methods for diagnosing neoplasms.

Description

Material under study See in the description

The Papanicolaou staining method is a specially developed method that allows, with the greatest degree of certainty, to detect early precancerous diseases of the cervix.

Cervical cancer ranks third in the structure of malignant neoplasms of the reproductive system. Until 1992, the incidence of cervical cancer was declining, but now there is again a trend towards an increase in this pathology. The development of the tumor occurs gradually, over several years, so preventive examinations of women using the cytological method of research are very important.

Currently, when conducting screening programs to detect cervical cancer, precancerous and background conditions, Papanicolaou staining of cellular material - Pap test is used. The Papanicolaou staining method allows assessing the degree of maturation of the cytoplasm, well stains nuclei with atypia. The term "atypia" has a different interpretation in different countries: in central Europe it is defined as malignancy, in the WHO nomenclature - "less than dysplastic intraepithelial changes".

The Rap test has a number of features. An important point is the correct taking of the material and its fixation. The cellular material is taken with brushes of a special configuration in "mirrors" to avoid the ingress of foreign material. Transfer of material should be fast, without drying; rapid fixation of a wet smear in 96% ethanol is required. Papanicolaou staining of smears goes through a series of stages, then the cellular material enclosed in the balm is subjected to cytological analysis.

Material under study: scrapings from endocervix, exocervix, as well as mixed scrapings applied to a glass slide.

Literature

Kulakov V.I. “Modern approaches to the diagnosis of human papillomavirus infection of the genitals of women and their significance for cervical cancer screening. Gynecology". 2000; 1 (2): 4 - 8.

Training

Special preparation for the study is not required. Please note that in children under 16 years of age, gynecological tests are taken only in the presence of parents. Medical offices do not do cervical scrapings and swabs for pregnant women who are 22 weeks or more, as this procedure can cause complications. If necessary, you can contact your doctor to take the material.

Interpretation of results

The interpretation of test results contains information for the attending physician and is not a diagnosis. The information in this section should not be used for self-diagnosis or self-treatment. An accurate diagnosis is made by the doctor, using both the results of this examination¤ and the necessary information from other sources: history, results of other examinations, etc.

The standardized cytological report protocol, based on the Bethesda classification (revised 2001), as well as on the standardized cytological description according to the Order of the MoH, consists of the following sections:

drug quality: - adequate; - inadequate.
cytogram/description: - epithelial cells within normal limits replaced by - negative for intraepithelial pathology or malignancy; - or the detected pathological changes in the epithelium are described.
cytogram/features: main categories of pathological changes in the epithelium: a) atypical squamous cells (ASC) - PCNZ (ASC-US) - of uncertain significance - reactive changes or dysplasia I–weak-CIN-1, most often associated with inflammation; - non-exclusive B-PIP (ASC-H); - Low degree of squamous intraepithelial lesions (LSIL): - H-PIP (ASC-H) - CIN 1 (dysplasia I - mild), human papillomavirus infection - HPV. - a high degree of squamous intraepithelial lesions (HSIL): - B-PIP (ASC-B) - CIN 2 (moderate dysplasia II), CIN 3 (III-pronounced dysplasia), cancer in situ. - squamous cell carcinoma; b) atypical glandular cells (AGS)
cytogram/other types: other non-neoplastic changes (if detected);
additional clarifications: a specific infectious agent is indicated (if it is detected).

Pap smear(PAP test, cervical smear, PAP Smear) is an important screening test for the early diagnosis of cervical cancer. It is sometimes referred to as “cervical cytology smear, oncocytology smear”. This affordable, simple and painless method helps to identify precancerous conditions or the development of a cancerous tumor in the cervix, start treatment at an early stage and prevent the progression of the disease. The PAP smear has significantly reduced the incidence and mortality from cervical cancer, especially in developed countries.

Increased risk factors for cervical cancer: a large number of sexual partners, early onset of sexual activity (before 18 years), a history of genital warts, bad habits (smoking).

It is recommended to undergo regular preventive examinations, at least once a year, for all sexually active women, especially if she has a high oncogenic risk human papillomavirus or mucosal changes are detected during colcoscopy. The doctor will then determine how often you will need to repeat this test based on the results of a cervical smear.

The gynecologist takes a scraping of the cells lining the cervical canal and applies it to a glass slide. Usually 2 preparations are prepared: from the endocervix (the mucous membrane covering the vaginal part of the cervix)> and the exocervix (the mucous membrane lining the cervical canal). To identify atypical cells, a special Papanicolaou stain is used. The swabs are then examined under a microscope to look for possible changes such as inflammation, abnormal or cancerous cells.

Preparing for the pap test. To obtain the most accurate result, a number of conditions must be met before performing a Pap test. It is not recommended to conduct an examination during menstruation, in the presence of an inflammatory process. For 48 hours before taking a Pap smear, you must refrain from sexual intercourse, the use of tampons, the use of any vaginal creams, suppositories and medicines, douching and vaginal douche. The smear should be taken before a gynecological examination, colposcopy or not earlier than 48 hours after these manipulations. It is also advisable to take a shower instead of a bath 2 days before the Pap test.

Interpretation of results. First, the quality of the smear is assessed: high-quality, poor-quality. If the quality of the smear is unsatisfactory, the smear must be repeated. The Pap smear may be positive or negative (Pap class I).

Norm. Normally, there are no atypical cells, all cells are of the same shape and size (negative Pap smear).

Deciphering a cytological smear, the results of a pap test. The presence of cells of different shapes and sizes, their pathological position is characterized as a positive Pap smear. these tests show the presence of abnormal cells, which often sounds scary to women who do not understand what this means. A positive smear result for atypical cells does not mean that you have cancer or a precancerous condition, but only indicates the need for further research. The cause of the appearance of atypical cells may be the presence of inflammation (chlamydia, herpes infection, gonorrhea, trichomoniasis), infection with the human papillomavirus (HPV). These changes are more often characterized as grade II dysplasia. In this case, it is necessary to carry out the necessary treatment and repeat smear after 3-6 months. With papillomavirus infection, koilocytosis of cells is often detected. Koilocytes are irregularly shaped squamous epithelial cells with distinct boundaries. Koilocytes vary in size and are usually larger than normal cells. The nuclei are enlarged to varying degrees, the nuclear membrane is uneven, folded. Around the nucleus, there is clarification of the cytoplasm.

Cytological classification according to Papanicolaou:

1st class — normal cytological picture;
2nd class - a change in cell morphology due to an inflammatory process in the vagina and (or) cervix;
3rd class - single cells with anomalies of nuclei and cytoplasm (suspicion of a malignant neoplasm);
4th class - individual cells with obvious signs of malignancy;
Grade 5 - a large number of typical cancer cells. The diagnosis of a malignant neoplasm is not in doubt.

When classifying according to the Bethesda System (The Bethesda System -TBS), the following terms may occur in the conclusion of a cytologist:

ASCUS (atypical squamous cells of undetermined significance) or APNZ (squamous cell atypia of uncertain significance);
CIN (cervical intraepithelial neoplasia) or CIN (cervical intraepithelial neoplasia) (the term is used as a synonym for cervical dysplasia)
LSIL Low-Grade Squamous Intraepithelial Lesions) or N-PIP (low-grade squamous intraepithelial lesion)
HSIL (High-Grade Squamous Intraepithelial Lesions) or B-PIP (high-grade squamous intraepithelial lesion).

If the conclusion of a cytologist's doctor shows mild, moderate or pronounced dysplasia (N-PIP and V-PIP), in these cases, colposcopy is performed, as well as separate diagnostic curettage of the mucous membrane of the cervical canal and the body of the uterus with a histological examination of scrapings.

How much does it cost to have a Pap smear test from the cervix?
Overview of the price of a pap test in leading laboratories in Moscow(as of August 2014)
- 825 rubles + 250 rubles for taking a smear;
— 1,100 rubles + Taking a swab / scraping: 390 rubles
- 1730 rubles.
1545 rub. + 380 rub. for taking the material.
— 1020 rub. + 300 rub. for taking a swab
- 1030 rubles. + taking a smear 390 rubles.

S.I. Rogovskaya, V.N. Prilepskaya. Prevention of human papillomavirus infection and cervical cancer (Gynecology. Volume 9/N 1/2007::: Subject of the issue: PATHOLOGY OF THE CERVICAL AND GENITAL INFECTIONS)

In fact, Papanicolaou cytological examination is one of the staining methods for microscopic examination and is based on the different reaction of cell structures to acidic and basic dyes.
But the undoubted merit of George Papanicolaou is that he first applied this staining method and substantiated its importance for the diagnosis of precancerous and cancerous diseases of the cervix. worldwide. Currently, the Pap test (named after the scientist) is the main diagnostic method for this common deadly disease in women.

How is the Pap test (Pap test) performed?

After taking the material, it is sent to the laboratory, where it is first stained with basic hematoxylin or orange dyes, and then with an acid dye
more often eosin. As a result of staining, changes in the nuclei and cytoplasm of cells can be easily determined. First, the nature of the pathological process is determined - inflammatory,
reactive, malignant, then, according to the composition and changes (degrees of severity of signs of atypia) of cellular elements, a differential diagnosis of malignant and benign processes is carried out.

How is the PAP test (Par test) evaluated?

Since 1954, a five-class classification has been used, which was developed by D. Papanikolaou. This classification is still used in some laboratories in Russia, but in world practice it is not used and represents
only of historical interest.

Classes (1954)	Cytological picture
	Normal cytological picture
	Change in the morphology of cellular elements due to an inflammatory process in the vagina or cervix
	Solitary cells with abnormalities of the cytoplasm and nuclei. The diagnosis is not clear enough, a repeat cytological examination is required, or a histological examination of the biopsy tissue is necessary to study the condition of the cervix.
	Individual cells with signs of malignancy: enlarged nucleus, altered nucleus, abnormal cytoplasm, chromatic aberrations
	A large number of malignant cells

What systems are used to evaluate the Pap test

WHO classification

In 1968, the World Health Organization proposed a new descriptive system for assessing the test based on morphological criteria. Class 2 according to the Papanicolaou classification was divided into three forms of atypia, class 3 was described in three forms of dysplasia - mild, moderate and severe, class 4 was described as cancer in situ and 5 as invasive cancer.

Description (1968)	CIN (1978)	Bethesda 1988	Classes (1954)
Fine	Fine	Negative for intraepithelial lesion or malignancy (NIL)	Class I
	Inflammatory atypia or tumor	ASCUS	Class II
HPV	HPV	Low Grade SIL	Class II
Atypia with HPV	Atypia, "condylomatous atypia" and "koilocytic atypia"	Low Grade SIL	Class II
mild dysplasia	I CIN	Low Grade SIL	Class III
moderate dysplasia	II CIN	High Grade SIL	Class III
Severe dysplasia	CIN III	High Grade SIL	Class III
Cancer in situ	Cancer in situ	High Grade SIL	Class IV
Invasive Cancer	Invasive Cancer	Invasive Cancer	Class V

CIN classification

In 1978, Richart proposed a histological classification and introduced the term CIN (cervical intraepithelial neoplasia) - cervical intraepithelial neoplasia, the degrees of which corresponded to the degrees of dysplasia of the WHO classification.

Bethesda system classification

In 1988, the US National Cancer Institute proposed a new,
cytological, Papanicolaou test assessment system - Bethesda system, which is still used in world medicine. All changes were divided into 2 types - ASCUS (atypical squamous cells of undetermined significance) squamous cell atypia of uncertain significance and SIL (Squamous Intraepitelial Lesions) squamous intraepithelial lesions , which in turn were divided into 2 categories - low severity (LSIL - Low-Grade Squamous Intraepithelial Lesions) and high severity - (HSIL - High-Grade Squamous Intraepithelial Lesions)

What are benign cell changes

In some processes, benign changes in the cells of the epithelium of the cervix occur. These changes are evaluated by the Pap test as inflammatory atypia, atypia caused by papillomavirus, or as mixed atypia or atypia of uncertain significance.

Causes of benign changes

Pregnancy
Exposure to chemicals (drugs)
Infection caused by actinomycetes
Atrophic vaginitis
Radiation damage (with radiation therapy)
Intrauterine contraceptive (spiral)

What are atypical squamous cells

What is cervical dysplasia

Dysplasia (or cervical intraepithelial neoplasia - cervical intraepithelial neoplasia - CIN) of the cervix is a pathological process that begins in the transitional metaplastic epithelium and is expressed in the appearance of atypical cells against the background of increased proliferation of basal and parabasal cells. Dysplasia can progress to squamous cell carcinoma (cervical cancer ) or spontaneously regress or regress after treatment.

What is ASCUS

What is Low Grade SIL

What is High Grade SIL

What are atypical glandular cells

With the help of the Pap test, atypical cells of the glandular epithelium can be determined.

What to do with an abnormal Pap test (Pap test)

For cytological features such as LSIL (low-grade cervical intraepithelial lesions or features of HPV and CIN I), the International Agency for Research on Cancer recommends:

Options	Events
Option 1	Repeat cytological examination after 3 months. Then, with a normal smear (negative) - repeat again after 6 months, after 1 year and after 2 years. If LSIL results are repeated (positive), refer the woman for a colposcopy
Option 2	Do a colposcopy. In the absence of abnormal colposcopic signs (normal), a cytological examination should be repeated after 6 or 12 months (depending on whether an oncogenic type of HPV is present or not). When indicated, a biopsy and diagnostic curettage of the mucous membrane of the cervical canal are performed. If the results of colposcopy are unsatisfactory (when an adequate conclusion cannot be made), therapy for concomitant pathology should be prescribed (anti-inflammatory or estrogen therapy is possible) and the colposcopy should be repeated

This is a test that evaluates the structure of the cells of the cervix. It got its name in honor of the Greek physician Papanikolaou, who first introduced it into medical practice in the 50s of our century. In Russia, this study is also called the Pap test or its other name is "cervical cytology" (from the word "cyto" - cell). The Pap test helps to identify various changes in the structure of the cells of the cervix, which can lead to the development of cancer. Detection of these changes and their appropriate treatment prevents the development of cancer.

Thus, the main goal of performing cytology is the prevention (ie prevention) of cancer. For example, in the United States, where the Pap test is mandatory during preventive examinations by a gynecologist, the incidence and mortality from cervical cancer has decreased by 70% over the past 40 years.

Can a Pap Test Detect Cervical Cancer?

Yes. But the main role of the test is to detect cell changes that usually precede the onset of cancer. These changes are also called precancerous changes. It usually takes several years from the onset of abnormalities in the structure of cells to the onset of cancer. And if a Pap test is regularly performed in this time interval, which will reveal these disorders, then with the help of early treatment it is possible to prevent the development of cancer or to detect it at a very early stage. To confirm and clarify the diagnosis of cancer found in the cytology of the cervix, other additional studies are carried out.

Does the Pap test detect or prevent cancer in other organs?

No. This test allows you to evaluate the structure of only the cells of the cervix and no other organs. The cervix is a narrow tube located in the lower part of the uterus, which opens into the vagina with its outer end. Outside, it is covered with a thin pink epithelium, which in appearance resembles the tissue in your mouth. This epithelium consists of 4 layers of cells of different structure and is called "stratified squamous epithelium".

From the inside, the neck is covered with epithelium, consisting of one row of cylindrical cells. Therefore, this epithelium is called "column epithelium". It has a bright red color. Cytology of the cervix examines the structure of cells located both outside and inside.

How is cervical cytology performed?

A Pap test is done during a gynecological exam. The doctor will ask you to undress and lie down on the gynecological chair. In order to see the cervix, the doctor will insert a special instrument called a speculum into the vagina. After removing the discharge from the vagina, using a small brush and a wooden spatula, the doctor makes a scraping for examination from the outer and inner surface of the cervix. This is a completely painless procedure that lasts 5-10 seconds.

Cells are applied to special glasses, sent to the laboratory, where they are examined under a microscope by a cytologist. The cytologist determines whether the sent material contains cells with a modified structure or not, and informs the gynecologist about this (usually in the form of a written opinion). Since the doctor scrapes off the cells during the collection, some women, after cytology, may have extremely slight, spotting bloody discharge from the genital tract over the next 1-2 days.

Do I need to prepare for a Pap test in any way?

Yes. To take cytology, come in the first few days after the end of menstruation. 2 days before the Pap test, it is not recommended to use any medications for vaginal use, spermicidal contraceptives, vaginal lubricants, moisturizers. All this can affect the true picture of the structure of the cells of the cervix.

It is not recommended to conduct a study in the presence of symptoms such as itching and which may indicate a possible infection. In this case, it is better to consult a doctor to find out the cause of these symptoms.

How often should cytology be performed?

The first Pap test should be performed immediately after the onset of sexual activity. Then once a year, during your annual preventive visits to the gynecologist, regardless of whether you are sexually active or not. If for 3 years in a row you have good results of the Pap test (i.e. you do not find changes in the structure of the cells of the cervix), then the Pap test is carried out once every 2-3 years until the age of 65. After age 65, the Pap test can be stopped, provided that all previous results were good.

Of course, the frequency of a Pap test can vary. Your doctor may recommend that you do this test more frequently if you have a history of cervical abnormalities and/or risk factors for cancer, such as:

more than one sexual partner or a partner who has other sexual partners besides you
early onset of sexual activity (before 18 years of age)
past or current sexually transmitted diseases (), especially such as genital herpes and papillomas on the genitals
HIV infection
smoking

How accurate is the Pap test?

Like any medical test, the Pap test is not always 100% accurate. Those. sometimes pathological changes are described in the conclusion of the cytology of the cervix, but in fact they are absent. Such a result is called a false positive. Or vice versa, the conclusion of the Pap test is good, while in reality there are violations in the structure of the cells. Such a result is called a false negative.

The most common cause of false-positive cervical cytology results is the presence of inflammation in the vagina or cervix. In this situation, if the doctor sees an abnormal Pap test + signs of inflammation, then it is usually recommended to conduct a course of anti-inflammatory treatment and repeat the Pap test after it has ended.

Reasons for a false negative Pap test may include:

too few cells on the slide for examination
infection in the vagina and cervix
blood in the test
use of vaginal medications, lubricants 1-2 days before the test

Proper preparation, regular testing (as recommended by your gynecologist) helps to minimize the frequency of inaccurate Pap test results.

BUT what if the Pap test shows abnormal cells?

In this case, the doctor recommends an additional examination. This may be as simple as repeating the Pap test some time after the first result. Sometimes a special study is prescribed - colposcopy. - this is a study when the cervix is examined by a gynecologist under strong magnification (usually 7-15 times) using an instrument called a colposcope (similar to a large microscope). During such an examination, the doctor can see the area where the pathological changes found in the Pap test are located.

In addition, during a colposcopy, the doctor decides whether you need to clarify the diagnosis. Depending on the result of the Pap test and colposcopy (with or without a biopsy), your doctor may recommend either simple follow-up with periodic cervical cytology, or removal of abnormal cells found.