What does an abnormal Pap smear mean?
An abnormal Pap smear means abnormal cells are seen under the microscope. These can be from numerous causes including temporary minor irritations, but it is most important to determine whether they represent a treatable precancerous condition called cervical intraepithelial neoplasia (CIN), which is also known as “dysplasia.”
The abnormal cells usually come from the cervix (the “neck” of the uterus that extends into the vagina), but less commonly abnormal cells may be from other sources such as the endometrium (uterine lining) or vaginal walls.
Important: Paps are a screening tool, not a diagnosis
It’s very important to remember that the Pap smear is a screening test. It screens for abnormal cells but cannot provide a final diagnosis. The Pap smear evaluates exfoliated cells – that is cells that are loose or apart from their tissue of origin. These cells are obtained by gently sweeping the cervix with a blunt wooden or plastic spatula and/or a small brush.
The appearance of these loose cells provides insight into the nature of the tissue from which they came, but it is sometimes necessary to obtain a biopsy, an actual small sample of the tissue itself, for a reliable diagnosis. One fact that makes the Pap smear such an effective technique is that abnormal cells tend to not be as adherent as healthy cells, so the abnormal cells are more likely to be shed and appear when a sample is obtained.
Must a diagnosis be made?
It is known that many milder abnormalities will resolve without treatment. Therefore, sometimes the decision is simply to repeat the Pap later to check for resolution. However, for more severe abnormalities or those that don’t resolve, a specific diagnosis must be made to to direct the treatment of precancerous disorders and prevent the development of cancer.
The decision of which cases require a procedure for diagnosis is critical and based on the type of Pap smear abnormality, the previous Pap results, the patient’s age, and other factors that can estimate the chances of whether the abnormality is more likely to resolve or progress (potentially to cancer). This decision requires expert knowledge and advice from the gynecologist and shared decision-making with the patient.
How is a diagnosis made?
Unlike the Pap smear, which is obtained from a broad sweep of the entire cervical area, a small physical sample, or biopsy, must be directed to the specific, potentially small area of abnormality to be accurate. This is usually done during procedure called a colposcopy.
What is a colposcopy?
The colposcope is a magnifying instrument that looks like a small pair of binoculars mounted on a stand. The cervix is viewed from the outside through a vaginal speculum and areas with potential abnormalities are sampled with small (about 1/8 inch) snips. The unseen narrow inner canal of the cervix is also gently scraped to sample tissue from the area that cannot be seen. This is an office procedure that does not require anesthesia and may be associated with no or mild discomfort or cramping.
What happens after colposcopy?
If the Pap smear suspected CIN and it is confirmed from the colposcopic biopsy, treatment is usually planned. There are several office or outpatient procedures to eradicate or remove the CIN. In almost all cases the treatment will not have a significant impact on fertility. The particular technique depends on the severity and location of the abnormality, the patient’s desires, and the surgeon’s preferences and resources. This is another opportunity for shared decision-making.
What is the follow-up from treatment of CIN?
The most important aspect is a routine of follow-up Pap smears to be sure the treatment was successful and to check for recurrences. Because CIN may be precancerous and can recur, it is important to follow recommendations for screening Pap smears for at least 25 years after treatment of CIN (except for the mildest forms).
Because cervical cancer is preceded by treatable precancerous states, almost every case of cervical cancer can be prevented if the guidelines for Pap smear follow-up are followed.
What is HPV testing?
HPV testing detects the presence of human papilloma virus, the cause of CIN and cervical cancer. There are dozens of types of HPV. The most important screening involves determination for the presence of types 16 and 18, the types most likely to cause severe CIN or cervical cancer.
HPV testing of the cervix may be used as an addition to or a substitute for the Pap smear, particularly after the age of 30. A test that is positive for HPV, especially the high-risk types 16 or 18, requires careful follow-up, probably including colposcopy to evaluate for CIN and cancer.
Note: The management of abnormal Pap smears and HPV screening is a complex topic. The discussion above is intended for information and an introduction to the orientation of this practice. It is vital for each case to be evaluated and managed individually. For questions or an appointment, please call 919-916-3333.
