A pap smear is a screening test to check if abnormal changes have occurred in cells of the cervix. The cervix is the lowest part of the uterus and connects the uterus to the vagina. A pap smear is also called a cervical smear. A layer of cells called squamous cells covers the outside surface of the cervix. A layer of cells called glandular cells lines the endocervical canal. These two types of cells meet at the “transformation zone”, which is usually on the outside of the cervix but may be just inside the endocervical canal. When taking a Pap smear, the doctor gently scrapes cells from these areas. The cells are then prepared on a microscope slide for examination in a pathology laboratory. The examination will determine whether the cells are normal or abnormal. Treatment to remove abnormal cells on the cervix in most cases:
- Result in the growth of healthy cells, and
- Significantly reduces the risk of cervical cancer.
Without treatment, the risk is that the abnormal cells may develop into cervical cancer. Regular pap smears are important because the growth of precancerous cells on the surface of the cervix does not usually cause pain or other physical symptoms. A pap smear is the only means of detecting precancerous cells.
Human Papilloma Virus
HPV is a very common virus that can cause harmless skin warts and plantar warts. Most of these minor infections are cleared by the body’s immune system.
However, genital infection with HPV can be troublesome, HPV infection may occur during sexual skin-to-skin contact if one of the partners has genital HPV. Of the 200 types of HPV, at least 16 are believed to be “high-risk”, that is, capable of causing abnormalities of cervical cells that are precancerous or, rarely, cancerous.
Most genital HPV infections resolve without treatment. Of 100 women with genital HPV, about 98 will not develop any signs of HPV infection because their immune system has cleared the virus.
Nearly all cases of cervical cancer are caused by chronic infection with high-risk HPV. This is why cervical screening and early detection are so important.
Although many women have had an HPV vaccine, they still need to have regular CST because the vaccine does not protect against all types of cancer-causing HPV.
In every 100 cases of cervical cancer, about 95 are related to HPV infection.
Many risk factors for cervical cancer
- HPV
- Smoking
- Not having regular CST
- A weak immune system
Abnormal cervical cells
Changes in cells may be seen when they are examined. The important changes are called dysplasia (an abnormal change in the size and shape of cells). Dysplasia is not cancer, but severe dysplasia might develop into cancer over a long and unpredictable period if left untreated.
Most cervical cancers take years to develop. Dysplasia of cervical cells is classified as mild, moderate or severe.
The term to describe abnormal cervical cells is “cervical intraepithelial neoplasia or CIN. Intraepithelial means “within the tissue”, and neoplasia means “new growth of (abnormal) cells”. CIN-1 is mild dysplasia. CIN-2 is moderate dysplasia. CIN-3 is severe dysplasia.
CIN-1 is due to infection with HPV. Of every 10 cases of HPV infection, eight will go away without treatment within 12 months. In addition to CIN changes, other minor abnormalities are commonly seen. These often need follow-up but do not always mean that precancerous changes are developing.
Squamous Cell & Gladular Cell Abnormalities
Two types of cells in the cervix may develop abnormal changes. The most commonly affected are the squamous cells. Abnormalities of the glandular cells are much less common.
- Squamous Cell Abnormalities– Most of the abnormalities reported from the pap smear are die to infection with HPV. In the early stages of infection, HPV on the cervix does not cause any sign or symptoms. HPV infection is usually cleared by the body’s own immune system with 80% of infections cleared in 12 months. Abnormalities are classified in the following ways:
- Possible LSIL (low-grade Squamous Intraepithelial Lesion): Sometimes a Pap smear shows possible low-grade changes, and the exact cause is uncertain. These atypical cells may be due to tissue inflammation, changes caused by HPV, or infection with some other micro-organism (bacteria, virus, fungi or yeast). Usually, the condition gets better with time. The woman is usually advised to have another Pap smear in 12mths. If changes persist the doctor may recommend a colposcopy.
- LSIL (Low-grade Squamous Intraepithelial Lesion): This Pap smear report suggests that there are definite changes usually due to infection with HPV. These changes may be called HPV alone, or other cells may be present which are called CIN-1. 80% of these LSIL abnormalities go away within 12mths. If this is the first time you have had abnormal cells on your cervix, your doctor will recommend that you have a repeat Pap smear test in 12mths. If the changes are still present in 12mths, your doctor will recommend you have a colposcopy. If you are over 30yrs and have not had a normal Pap test in previous two to three years, your doctor may recommend a repeat Pap test in 6mths or may refer you for a colposcopy. If a diagnosis of low-grade abnormality is confirmed then you will NOT need any treatment, just observation with regular Pap smears each year until the abnormality has gone away.
- Possible HSIL (High-grade Squamous Intraepithelial Lesion): This pap smear report means that the pathologist is uncertain of the exact abnormality but is suspicious that there may be a HSIL (high-grade abnormality) such as CIN-2 or CIN-3. You doctor will refer you for a colposcopy.
- HSIL (High-grade Squamous Intraepithelial Lesion): This smear means that it is very likely that a high grade abnormality is present on your cervix. Your doctor will refer you for a colposcopy.
- Cancer: This smear report means that there are cells in the smear that may be due to the presence of a cancer of the cervix. Your doctor will refer you for a colposcopy, which is often performed by a gynaecologist oncologist who is a specialist in caring for women with cancer of the cervix.
- Glandular Cell Abnormalities: These are uncommon changes in the cells of the cervix. It is recommended that women who have these cell changes should be referred for colposcopy as it is more difficult to rely on Pap smears for follow-up. Based on the results of the colposcopy or biopsy, your doctor may advise you to have more frequent pap smears or treatment to remove the abnormal cell.
Cervical Intraepithelial Neoplasia (CIN-1/HPV)
Minor changes in the size, shape and number of cervical cells are called CIN-1 or mild dysplasia. Nearly all of the low-grade abnormalities (CIN-1) will go away without treatment, as they are due to an HPV infection. Treatment is no longer recommended for this abnormality as the harm outweighs the benefits. In a small number of women, the low-grade abnormality persists, or rarely, progresses to a high-grade change. Following the diagnosis of CIN-1/HPV, the woman is usually advised to have a Pap smear with her GP every year until the Pap smear returns to normal. In a small number of women, the low-grade change may persist due to ongoing HPV infection. In this situation the woman should continue to have a yearly Pap smear until it returns to normal. If a high-grade abnormality develops, she should have a colposcopy.
High-Grade Abnormalities CIN-2 & CIN-3
Precancerous cells may be present that are very different from normal cells. These are described as moderate dysplasia (CIN-2) or severe dysplasia (CIN-3).
Precancerous changes involve only cells in the surface layer of the cervix. These cells are more likely to become cancerous and invade deeper layers of the cervix if left untreated. If high-grade abnormalities are detected on a Pap smear, the woman is advised to have a colposcopy and biopsy. If the diagnosis of CIN-2 or CIn-3 is confirmed, then treatment is recommended to remove the abnormal cells. Though not all CIN-2 and CIn-3 will progress to cancer, it is not possible to predict which abnormality will clear up. Therefore it is advised that all CIN-2 and CIN-3 be treated, except in certain circumstances. It is dangerous to leave CIN-2 and CIN-3 untreated. If, over a long period, the abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is called cervical cancer and will require more aggressive treatment. High-grade lesions (CIN-3) usually take many years to develop into cancer.
Colposcopy
Colposcopy is a visual examination of the cervix to check for precancerous changes. The procedure is usually undertaken in a doctor’s rooms. The woman is asked to undress from the waist down and to lie on a specially designed couch that supports her legs. As in the Pap smear test, a speculum is inserted to keep the vagina open, so that the cervix can be seen clearly. The doctor uses a colposcope (a magnifying instrument similar to a pair of binoculars with a light attached) to examine the cervix. The colposcope is not put inside the vagina, only the speculum. The cervix is painted with weak acetic acid (vinegar), which causes abnormal cells to turn white; both iodine and acetic acid may be used. The resulting pattern can help you doctor to decide if this is a high-grade or low-grade lesion. It is important to tell your doctor if you have ever had an allergic reaction to iodine. Your doctor may remove a small sample of tissue (biopsy) from any abnormal-looking area. A special solution may be applied to the biopsy area to stop any bleeding. If a biopsy has been taken, you may have some pain or discomfort similar to menstrual cramping, which can be treated with a pain reliever. The biopsy is then sent to a pathology lay for diagnosis. The results are usually reported in about a week. After a biopsy, you have minor bleeding and a slight vaginal discharge for up to a week. Avoid sex, tampons or baths (shower instead) for a week to allow the cervix to heal.
Treatment for Dysplasia
If the results of colposcopy and biopsy indicate a high-grade abnormality (CIN-2 or CIN3), you doctor will recommend treatment to remove the abnormal cells. Treatment may also be recommended for persistent low-grade abnormalities. Several methods of treatment are effective, as described below. The best treatment for you will depend on the type and severity of the abnormal cells.
Wire Loop Excision – Wire loop excision is also known as LEEP (loop electrosurgical excision procedure) or LLETZ (large loop excision of transformation zone). A semi-circular wire loop is used to remove the portion of the cervix that contains the precancerous changes. Many doctors prefer wire loop excision to other methods because the removed tissue is not destroyed, and it can be sent to a pathology laboratory for examination. Wire loop excision is often preferred when abnormal cells are present in the endocervical canal. Using wire loop, it is possible to:
- Confirm whether abnormal cells have been completely removed, and
- Determine the type of abnormality present.
During the procedure, a speculum is inserted to open the vagina and allow the cervix to be seen clearly. Weak acetic acid (vinegar) and/or iodine solution is applied to the surface of the cervix to make the areas of abnormal cells more visible. Local anaesthetic is injected to make the cervix numb. Layers of abnormal cells are then cut away from the cervix with a fine wire loop that has an electrical current flowing through it. Diathermy is used to stop any significant bleeding. The procedure takes about 15-30mins and is usually performed in a day procedure centre. A bloody, brown or black discharge occurs soon after the procedure. A bloody discharge may occur for 2 to 4 weeks afterwards, and occasionally longer. Cramps and pain may persist in the lower abdomen for a day or two after the procedure. Most women are able to return to normal activities within 2-3 days.
Cone Biopsy – A cone biopsy is usually done when:
- A Pap smear results indicate abnormal changes in glandular cells
- Abnormal cells are in the endocervical canal, or
- Early cancer is suspected
Cone biopsy is an operation in which a cone-shaped or cylindrical section of the cervix containing the abnormal cells is removed using a laser or scalpel (cold cone biopsy). A day or overnight stay in hospital may be required. A cone biopsy may be done as diagnosis usually treats the problem at the same time. After a general anaesthetic is administered, the patient’s legs are placed in supports, with the lower half of the body draped with sterile sheets. (in some cases, a urinary catheter may be passed to empty the bladder). After painting the cervix with iodine to stain any abnormal cells, the doctor makes a circular incision in the cervix to include the abnormal areas and removes a cone-shaped cylindrical wedge of tissue. This tissue is sent to a pathology laboratory where it is examined. The operated area is cauterised, or a solution applied, to stop bleeding. Sutures may be inserted to close the wound. An endoscopic examination of the uterus (hysteroscopy) may be undertaken at this time. After cone biopsy, avoid heavy physical work and take things easy for several days. You may have some abdominal pain after treatment. It is normal to have some clear or blood-stained vaginal discharge for up to 6wks. If you have a cone biopsy and later become pregnant you must tell your doctor. Uncommonly, the cervix may be weakened by the cone biopsy, and your doctor may wish to take special precautions in your pregnancy.
Hysterectomy
Hysterectomy is rarely used to treat cervical dysplasia. In some cases, however it may be considered if other problems sexist, including:
- Other gynaecological conditions (such as prolapse of the uterus, fibroids or heavy menstrual bleeding)
- Results from cone biopsy indicate that CIN-2 or CIN-3 is too extensive to be removed by the other techniques described above
- Early cancer is diagnosis in the course of treating dysplasia
Recovery & Care After Treatment
For 3-4wks after any treatment to removed abnormal cervical tissue:
- Avoid having sex to reduce the risk of infection
- Use sanitary napkins rather than tampons
- If there is any bleeding or spotting, avoid baths, spas and public swimming pools; shower instead.
Follow-up
Any remaining disease is usually detected in the first year or two after treatment. Sometimes your treatment will confirm that you did not actually have a high grade abnormality (CIN-2 or CIN-3) and that had a low-grade abnormality (CIN-1 or HPV only). In this situation you should have a check-up colposcopy with your gynaecologist 4-6mths after treatment when a Pap smear will be taken. If the Pap smear is normal, you will be advised to have another Pap smear a year later, and if that is normal, you can return to have Pap smears every 2yrs.
After treatment for a high-grade abnormality (CIN-2 or CIN-3), you should have a colposcopy and a Pap smear about 4-6mths after treatment. If the smear is normal or low grade, you should see your GP in 6mths later (12mths after treatment) when a Pap smear and an HPV test will be performed. These tests should be repeated one year later (245mths after treatment). Once you have normal results for 2 consecutive years, you can return to routine Pap smear testing. If your Pap smear shows low-grade change or the HPV test is positive you should continue to have BOTH of these testes with your GP, until both have returned to normal. If any follow-up Pap smear shows a high-grade change or you develop abnormal vaginal bleeding, you should see your doctor.
QUIT SMOKING: It is important to stop smoking permanently.
The Possible Complications of Treatment
Laser treatment, wire loop excision, diathermy and cone biopsy are relatively safe procedures but do have risks.
Wire loop excision, laser treatment and cone biopsy:
- Haemorrhage: of every 100 women who are treated, about 5 women may have bleeding that is severe enough to require admission to hospital for observation, vaginal packing, suturing or rarely, blood transfusion.
- Infection: about 5 in every 100 treated women may develop an infection or the uterus or cervix. This is usually treated with antibiotics
- Cervical stenosis (narrowing): Rarely the opening of the endocervical canal may narrow, resulting in painful periods, difficulty with labour or fertility
- Cervical incompetence: after a cone biopsy or wire loop excision, the cervix may be weakened, increasing the risk of late miscarriage or premature labour.
- Rarely, damage to the bowel or bladder may occur
- LEEP or LLETZ: Burns can occur at the top of the vagina and vulva. They are usually not painful and usually heal well without complication.
Effect of treatment on pregnancy
Treatment to remove abnormal cells of the cervix does not affect the ability of most women to become pregnant. However, the ability of some women may be affected. Cone biopsy may cause a problem for future pregnancies. Uncommonly, the cervix can become weakened, increasing the risk of miscarriage or early onset of labour. If you later become pregnant, your obstetrician may have to place a stich in the cervix to strengthen it, ensuring that the endocervical canal remains closed for the duration of the pregnancy. Cone biopsy may also scar the cervix so that it does not open in labour. If you have had a cone biopsy, tell your doctor so that the cervix is carefully monitored during pregnancy and labour.
Distress
For some women, the tests, treatment and discussions about precancerous cells can be especially distressing. The presence of HPV infection can also be a concern. You may find it helpful to speak with your doctor, partner or friends about how you are feeling.
Any surgical or invasive procedure carries risks.
Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.