Management of Pap Smears Without Endocervical Component in 2017
No, a Pap smear in 2017 should not have been repeated solely due to the absence of an endocervical component if the cytology was otherwise negative. The evidence consistently demonstrates that women with negative Pap smears lacking endocervical cells do not have higher rates of subsequent cervical abnormalities compared to those with endocervical cells present.
Evidence-Based Rationale
Research Findings on Clinical Outcomes
A large longitudinal study of 20,222 women found no significant difference in the incidence of cervical intraepithelial neoplasia (CIN) between women whose negative smears lacked an endocervical component versus those with endocervical cells present 1
In fact, the incidence of definite cytological CIN was actually lower in women whose first smear lacked endocervical cells 1
A Dutch study of 1,002 Pap smears showed that 84.1% of initial endocervical cell-negative smears had no abnormalities on subsequent testing, demonstrating the low clinical yield of repeat testing 2
An analysis of 18,914 women over four years found no differences in rates of cervical atypia between women with and without endocervical cells on serial Pap smears 3
HPV Testing Correlation
Modern HPV testing data shows no significant correlation between the presence of endocervical cells and HPV positivity in negative Pap smears 4
Among negative (NILM) cases, HPV positivity rates were similar: 11 of 250 endocervical cell-positive cases versus 14 of 250 endocervical cell-negative cases 4
Appropriate Management in 2017
When Endocervical Component is Absent
Return to routine screening intervals (annual or per age-appropriate guidelines) rather than early repeat testing 1
The American Cancer Society 2002 guidelines recommended that specimen adequacy should be considered when determining timing of repeat screening, but this was meant for cases with obscuring factors, not simply absent endocervical cells 5
Earlier repeat testing of women lacking endocervical cells is of little value in further detecting disease, and a sample without endocervical cells is not necessarily inadequate 4
Important Clinical Context
Women with prior Pap smears without endocervical cells are much more likely to have subsequent smears also lacking endocervical cells, suggesting anatomical or sampling factors rather than inadequate technique 3
The low follow-up rate for endocervical cell-negative smears (43.5% within 36 weeks) suggests that even clinicians and patients recognize the limited clinical necessity of repeat testing 2
Common Pitfalls to Avoid
Do not automatically classify a negative Pap smear as "unsatisfactory" or "inadequate" solely due to absent endocervical cells - this outdated practice leads to unnecessary repeat procedures and patient anxiety 4, 1
Avoid confusing the absence of endocervical cells with truly unsatisfactory specimens (those with obscuring blood, inflammation, or insufficient cellularity) which do warrant repeat testing 5
Do not apply guidelines for abnormal cytology to negative smears lacking endocervical cells - these are distinct clinical scenarios with different management 5