What are the requisites for taking a Pap (Papanicolau) smear?

Requisites for Taking a Pap Smear

For optimal cervical cancer screening, a Pap smear should be performed on women aged 21-65 years using either conventional or liquid-based cytologic tests, with appropriate collection devices and proper patient preparation. 1

Patient Selection and Timing

• Cervical screening should begin at age 21 years, regardless of sexual activity history, due to the low incidence of cervical cancer in younger women 2
• Women under 21 years should not be screened, regardless of sexual history 3, 4
• For women aged 21-29 years, screening should be performed every 3 years with Pap tests 2, 3
• For women aged 30-65 years, the preferred approach is screening every 5 years with both HPV test and Pap test (co-testing) 2, 3
• An acceptable alternative for women 30-65 years is screening every 3 years with Pap test alone 2, 3
• Women over 65 years with adequate prior normal screening can discontinue screening 2, 3
• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons and have no history of high-grade precancerous lesions should discontinue screening 2, 3

Pre-Procedure Requirements

• Ensure proper patient identification and documentation of previous Pap test results 1
• Discuss with the patient:
  • The purpose and importance of a Pap test 1
  • The need for regularly scheduled Pap tests 1
  • Whether a Pap test will be obtained during the current visit 1
  • If a Pap test will not be obtained, provide information about local providers who can perform Pap tests 1
• Avoid scheduling during menstruation as blood may interfere with interpretation 1
• Patient should avoid vaginal medications, douching, or sexual intercourse for 48 hours before the test 1

Equipment and Materials

• Speculum of appropriate size 1
• Adequate lighting 1
• Collection device options:
  • Conventional or liquid-based cytologic tests 1
  • Spatula with endocervical brush (cytobrush) or Papette brush (both shown to have similar satisfactory result rates of approximately 93%) 5
• Glass slides and fixative (for conventional method) or liquid transport medium (for liquid-based method) 1
• Gloves 1
• Patient drape 1

Specimen Collection Procedure

• Position the patient appropriately (lithotomy position) 1
• Insert speculum without lubricant (water can be used if necessary) 1
• Visualize the cervix completely 1
• The sample must include cells from the transformation zone, where most cervical neoplasias develop 1
• For conventional method:
  • Use spatula to sample ectocervix and cytobrush for endocervical canal 1, 5
  • Transfer cells immediately to glass slide and fix promptly 1
• For liquid-based method:
  • Use appropriate collection device (spatula with cytobrush or Papette brush) 5
  • Transfer cells to preservation solution according to manufacturer's instructions 1

Laboratory Requirements

• Samples should be sent to CLIA-certified laboratories 1
• Laboratories should report cytopathology findings according to the Bethesda 2001 terminology 1
• Results should be categorized as:
  • Atypical squamous cells (ASC), further subdivided into ASC-US and ASC-H
  • Low-grade squamous intraepithelial lesions (LSIL)
  • High-grade intraepithelial lesions (HSIL) 1

Documentation and Follow-up

• Document that a Pap test was performed 1
• Provide patients with a copy of their Pap test result when available 1
• Establish a protocol for following up on abnormal results 1
• Ensure appropriate referral pathways for women with abnormal screening results 1

Common Pitfalls to Avoid

• Failure to adequately sample the transformation zone, resulting in unsatisfactory specimens 1
• Over-screening women under 21 years or more frequently than recommended intervals 3, 4
• Under-screening high-risk populations (HIV-positive, immunocompromised) 3
• Patients often confuse pelvic examinations with Pap tests; clarify that a Pap test was specifically performed 1
• Inappropriate use of HPV testing in women under 30 years for primary screening 1
• Discontinuing screening too early (before age 65) in women without adequate prior screening 3