Pap Smear (cont.)
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
- Pap smear facts
- What is a Pap smear?
- Who should have a Pap smear?
- Which women are at increased risk for having an abnormal Pap smear?
- How is a Pap smear done?
- What are the risks of having a Pap smear?
- How is a Pap smear read (analyzed)?
- What information is included on a Pap smear report?
- Why is a woman's menstrual status important for the Pap smear?
- Why is a woman's past Pap smear history pertinent?
- When might a Pap smear not be adequate for interpretation?
- How is the final Pap smear diagnosis made?
- What are the possible recommendations for follow-up after a Pap smear?
- What treatments are available if a Pap smear is abnormal?
- What is the follow-up after treatment for an abnormal Pap smear?
- What is the current status of human papilloma virus (HPV) testing?
- When should women start and stop having Pap smears, and how often should Pap smears be performed?
- What is the current status of the newer Pap smear technologies?
- With Pap smears so available, why are women still dying of cervical cancer?
- Historical note: Dr. Pap
- Find a local Obstetrician-Gynecologist in your town
What treatments are available if a Pap smear is abnormal?
If a Pap smear is interpreted as abnormal, there are a number of different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, and large-loop excision of the transformation zone.
All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in a number of other respects and so will be discussed separately.
Colposcopy: Colposcopy is a procedure that allows the physician to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.
During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This acid not only cleans the surface of the cervix but it also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).
If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist and the biopsy results determine the next step in the treatment.
The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterwards if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.
In unusual circumstances, colposcopy does not allow an adequate view of the cervix and another procedure called conization is necessary in order to obtain a tissue biopsy.
Conization: This is still the standard method to which all other methods are compared. Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch long and 3/4 inch wide) is taken from around the endocervical canal.
Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual intercourse.
Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.
With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis of cancer) already, or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.
Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments. It may also be appropriate for women with certain specific findings after conization.
Cryocauterization: Cryocauterization is a simple and safe procedure. A probe, called a cryoprobe, is first cooled by carbon dioxide and then touched to the abnormal cervical area. This freezes and kills the cells, resulting in the sloughing of the abnormal tissue.
A woman undergoing cryocauterization can expect a watery vaginal discharge for several weeks after the procedure.
Laser therapy: Laser therapy makes use of the principle that laser light can be produced by electricity running through gas. In the treatment of cervical lesions, the gas is usually carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells.
When a laser beam (using a tiny wand called a micromanipulator) is directed into the cervix at an area of abnormal cervical tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization. However, the laser apparatus is expensive, and its use requires more skill than other treatment options, such as cryocauterization. The procedure is also painful and generally requires general anesthesia.
The benefit of laser therapy is that it may cause less cervical scarring as compared to cryocauterization. This in turn may mean that, should the woman need colposcopy in the future, the chances of adequately viewing her cervix may be better after laser therapy.
Large-loop excision (LEEP) of the transformation zone: Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.
Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. When there is no more evidence of abnormal cervical tissue, it may be possible to resume annual screening Pap smears.
What is the follow-up after treatment for an abnormal Pap smear?
Follow-up is crucial after treatment for an abnormal Pap test. Women who have undergone any one of the above-described treatment procedures require special follow-up schedules. They must be evaluated and checked until the physician is fully convinced that routine Pap smears can be resumed.
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