Pap tests are not always comfortable and the successful procedure is partly due to psychology and partly due to good technique. The following are some practical tips to minimise discomfort and to obtain a good quality smear.
Preparation for the Pap test:
1. Explain the procedure. Included in this explanation should be that the Pap test is NOT a test for cancer, but a test for changes that occur long before cancer occurs. Hence, if the result comes back abnormal, the patient should understand in advance that cancer is most unlikely as a diagnosis, but may be prevented by treating the abnormality. This in itself reassures many women and will encourage them to have regular Pap tests.
2. Ask the woman if she has any concerns about Pap testing and, in particular, is she anxious or has she had any bad experiences in the past?
3. Incidental chlamydia testing should be discussed and advised for women under 30 years of age and for other women as indicated on discussion. Liquid-based cytology should be discussed and, especially, advised for women who can afford it and who are under observation for, or have had treatment for, past abnormal Pap tests, for those who have abnormal bleeding and those who have had long gaps in between Pap smears.
4. It is wise for the woman to be told in advance not to have a Pap test a few days before her period, or within a couple of days of sexual intercourse or within a few days of using a tampon, due to the risk of bacterial overgrowth and traumatic inflammatory response affecting the result. All normal vaginal bleeding should have stopped several days prior to the test, as it is common to have a bloodstained discharge remaining for a day or so after bleeding ceases, and this may make the result less easy to interpret microscopically. Abnormal vaginal bleeding is an indication for a Pap test.
5. Women who are post-menopausal and likely to have vaginal atrophy will find it much more comfortable (and the quality of the Pap test much improved) if they use oestrogen cream topically deep internally nocte for five nights before the Pap test, omitting this on the sixth night and coming in on the seventh or eighth day. If the cream is used the night before the Pap test, all that is seen is cream.
The procedure itself:
1. Allow privacy and a comfortable room temperature for the patient to undress in. Lighting should be tested before the procedure begins and disposable bed covers should be clean and clearly unused.
2. Explain to the patient that you wish to first do a gentle internal examination beforehand to locate the cervix, how close it is to the introitus, and to feel the size of the uterus and ovaries.
3. Tell the patient to let you know if there is any pain and you will immediately stop what you are doing. This examination allows you also to gauge how tense the woman is about having an internal examination and allows you to help her to practice relaxing prior to the actual Pap test.
4. The cervix may be located as retroverted and if so, it will help to put a pillow under the woman’s buttocks to lift them up. Alternatively, she could form fists with both her hands and sit back down on these to lift her buttocks up, but this may be less comfortable for her. It helps if stirrups are available.
5. Use a water soluble lubricant sparingly on the speculum, avoiding the tip. It is usual to start with a small speculum, but women with a marked prolapse or requiring a longer speculum for retroverted cervix may need a larger size to view the cervix effectively.
6. A retroverted cervix may fall forwards more easily if the woman has the Pap test performed in the left lateral position. Very occasionally, this position is indicated if other techniques have failed.
7. Ensure the edge of the cervical erosion if seen has been effectively swabbed with a spatula or flat brush along its perimeter, as this is the transformation zone where abnormalities are best detected. A cytobrush should be rotated several times in the endocervix in order to obtain cells that may be missed through using the flat brush or spatula alone. Fix the microscopy slide as soon as the brushes have been applied to it.
8. Always warn the woman of the potential “click” sound when the speculum fixes in position and always let the speculum fall shut gently (without catching the labia) on withdrawal.
9. Offer tissues and privacy after the Pap test and advise the patient if there is likely to be any spot bleeding when they next wipe themselves. If the bleeding is any heavier, this should be explained and a sanitary pad supplied.
10. Women who have had cone biopsies are best referred to specialists for Pap smears if the cone biopsy is extensive on examination.
11. Explain the practice policy on follow-up of Pap results. Ensure contact details are up-to-date.
1. Karjane, N.W. Pap Smear, Medscape, 29 February 2016