Cervical smear: its importance for women's health

Cytological examination (cytology) is the main method of screening for assessing the condition of the cervical epithelium. The main task of cytological screening is to search for altered epithelial cells (atypical, having a structure different from normal epithelial cells).

The term “atypical cells” includes both cells with signs of dysplasia - mild, moderate or severe (precancerous cells), and cancer cells themselves. The difference between them is the degree of severity of changes in the structure of cells.

Cytological screening must be performed by all women (excluding virgins and patients who have undergone hysterectomy), starting at 21 years of age and ending at 69 years of age (if there are no changes in the studies), the frequency of testing is once a year, according to order 572n ( November 1, 2012), however, it is permissible to take an analysis once every three years (order of the Ministry of Health of the Russian Federation No. 36 an, dated February 3, 2015).

Currently, there are two alternative methods for fixing and studying biological material, the key difference between which for patients is their effectiveness.

Why do a cervical smear?

The cervical canal is a tubular section of the cervix that connects the uterine cavity to the vaginal cavity. It is easily accessible to the gynecologist during an examination with an obstetric speculum. The question of examining a smear from the cervical canal arises when it is necessary to detect:

• infectious pathogens,
• human papilloma virus,
• inflammatory processes of the genital area;
• benign formations.

The human papillomavirus can cause cervical erosions and cause malignant processes. A smear from the cervix (PAP test, cervical smear) helps to identify dangerous cancer processes of degeneration long before the onset of oncology. This is a highly effective way to prevent cervical cancer.

Who is the study for?

Cervical cytology is necessary if:

1. A woman is planning to get pregnant.
2. Childbirth occurred several times in a row (for example, 3 times in 4–5 years).
3. The first time a woman gave birth was at an early age.
4. Frequent change of sexual partners.
5. It is planned to install a spiral.
6. For a long time, no cytological examination was carried out or it never happened at all.
7. The results of the latest study are poor.
8. Diseases associated with the human immunodeficiency virus (HIV) have been discovered.
9. One of the relatives suffered from cancer, that is, the family history is burdened.

In general, it is advisable for every woman to undergo a screening cytological examination every year. If there are significant deviations from the norm, then the procedure must be completed every 6 months.

There are also contraindications to the study:

1. Active inflammatory process in the vagina and directly on the cervix.
2. Menstruation.

Although this procedure is completely harmless and painless, it is not recommended if these factors are present. During inflammation or infection, the number of white blood cells increases, which can greatly affect the accuracy of the results.

When to take a cervical smear: indications

It is important that a woman does not forget to visit a gynecologist annually and have cervical smears. Indications for the study are:

• vaginal discharge;
• pulling pain in the lower abdomen;
• disruptions of the menstrual cycle;
• absence of such studies in the anamnesis;
• heredity burdened with cancer;
• presence of HPV (human papillomavirus);
• taking combined oral contraceptives;
• first trimester of pregnancy;
• rash, redness of the external genitalia.

What does an oncocytology smear show: normal and interpretation

A cytological study is aimed at identifying the pathology of cell structure, as well as the extent of the process.

There are several classifications of the results obtained. One of them was proposed by Dr. Papanicolaou, the inventor of the method.

What does an oncocytology smear show ? Interpretation of Papanicolaou tests:

• I – negative result . No atypical cells were found.
• II – inflammatory process.
• IIIa – first degree cervical dysplasia. There is slight atypia of the cellular structure of the epithelium. The changed cells cover less than 1/3 of the thickness of the organ walls.
• IIIb – moderate changes in cellular structure. The process extends to half or more of the thickness of the cervical mucosa.
• IIIc – pronounced pathology of the cellular epithelium of the organ, which covers 2/3 of its thickness.
• IV – malignant cells in the field of view. Suspicion of cancer.
• V – cervical cancer.

The interpretation of the smear for oncocytology should be carried out by a gynecologist. The test result is not a diagnosis.

With type I, everything is clear - a negative result means a completely healthy organ. It is also clear with IV and V - these are malignant processes. But, if a smear for oncocytology showed an inflammatory process or dysplasia, what does this mean?

The inflammatory process requires finding out its causes and treatment, and then retaking the test.

Important! The result of a cytological analysis in itself is not a diagnosis. A PAP test is a primary screening that provides the basis for further research. Diagnoses of “dysplasia” or “cervical cancer” can only be made based on histology results.

If a PAP test reveals dysplasia, they usually say “ a bad smear came for oncocytology.”

However, there is no reason for the disorder - dysplasia detected in time is treated. And even the third degree, in most cases, is not an indication for cervical amputation.

Dysplasia IIIa (initial) - the doctor can choose a wait-and-see approach and monitor the dynamics of the disease. As mentioned, atypical cells constantly appear in the body. In the initial stage of dysplasia, there is a chance that the body will cope with it without special intervention.

Treatment is provided for inflammatory gynecological diseases, hormonal disorders, and treatment for HPV.

After 3 months, the smear is repeated. If it is negative, the next one is performed after 6 months, and another after 12 months. Obtaining two repeated positive results requires in-depth examination and surgical treatment.

Dysplasia IIIb and IIIc immediately require further instrumental and laboratory examination.

Colposcopy is prescribed - examination of the cervix under a special microscope. This allows you to detect the lesion and take a piece of tissue from it for histological examination.

Depending on the result obtained, the doctor prescribes treatment. In case of dysplasia of the 2nd degree, destruction of the affected areas using a laser, low temperatures, electrocoagulation, or radio wave therapy can be prescribed. In the 3rd degree process, conization is most often performed - removal of the pathological area or cone-shaped amputation of the cervix. These surgical interventions are performed by gynecological oncologists.

Early stages of cervical cancer in a large number of cases allow only amputation of the cervix while preserving fertility. Removal of the uterus is indicated for severe cases of cancer.

When is it possible to get erroneous results?

Many laboratory tests may produce false positive or false negative results. The PAP test is no exception.

A false positive result indicates the presence of a pathological process when there is none.

This can occur with severe inflammation of the cervix. However, the degree of dysplasia shown will not be high.

A false negative result indicates the absence of cell atypia where it exists. This is a dangerous situation, since without treatment the pathological process will worsen.

Such errors can happen if the patient violated the rules for preparing for the test - for example, she used vaginal products or douched. This also happens when the material collection is unsuccessful. If the manipulation did not affect the affected area or little tissue was taken, atypical cells in this case will not fall into the field of view of the microscope and will not be detected. Dear women, take responsibility for your health - when preparing for the study, follow all the doctor’s recommendations and choose clinics that employ experienced professionals.

Preparing for a cervical smear test

The optimal period for visiting a gynecologist is 5 days before the start of your period or 5 days after its end (the beginning of the cycle). Taking a smear in the middle of the cycle prevents blood from entering the test material. 2-3 days before the procedure you must:

• abstain from sexual intercourse;
• carefully observe intimate hygiene;
• stop using vaginal medications (suppositories, etc.);
• do not use vaginal contraception.

After meeting all the above conditions, you can make an appointment with a gynecologist to take a smear from the cervix.

How to properly prepare for the test?

The preparation is quite simple. The procedure itself is performed very quickly and causes almost no discomfort or discomfort. The preparation is as follows:

1. It is necessary to exclude sanitation in the form of douching.
2. You cannot use hygiene liquids, tablets, tampons, creams, suppositories and gels the day before.
3. A few days before the test, you should refrain from intimate relationships.
4. You must refrain from urinating two hours before the test.

To make the test result as reliable as possible, you should know the following information:

1. The result will not be accurate if there is any infectious disease, especially when it is in the acute phase. Usually in such cases the analysis is taken after basic treatment. The only exception is if there is a need to urgently obtain results. But then you need to perform cervical cytology 2 times. The first time the procedure is performed during illness, and the second time after 2 months.
2. The Pap test is not compatible with menstruation. Testing is performed a few days before or after the start of menstruation. It is advisable to carry out the analysis approximately on the 10th day of the menstrual cycle.
3. During intravaginal therapy, the smear will be uninformative. Testing is done one week after the end of treatment.
4. It is undesirable to collect biomaterial if there is an inflammatory process in the vagina. Symptoms of inflammation may include burning, itching and discharge.

These are general recommendations. More precise conditions for preparing for the collection of biological material should be obtained from the treating gynecologist.

How should biological material be collected?

During screening or preventive examination, material should be collected by a gynecologist or a trained nurse. It is necessary that the smear is taken from the transformation zone. The fact is that approximately 90% of malignant tumors are formed at the junction of columnar and squamous epithelium. On the columnar epithelium of the cervical canal, cancer occurs only in 10% of cases.

For diagnostics, biomaterial is obtained separately from the cervical canal and ectocervix using a special brush and spatula. During a preventive examination, different types of Eyre spatula, Cervex-Brush and other instruments are used to simultaneously obtain biological material from the cervical canal, the junction area and the vaginal part of the cervix.

Before collecting the material, the cervix is ​​exposed in the “mirrors”. No other additional manipulations are required. The mucus is not removed, the cervix is ​​not lubricated. An Eyre spatula is inserted into the external pharynx and carefully directed to the central part along the axis of the cervical canal. After this, the tip is rotated 360 degrees clockwise. Thanks to this movement, the required number of cells is obtained from the transformation zone and ectocervix. The instrument is inserted very carefully so as not to damage the cervix. After all manipulations, the spatula is removed from the canal.

With traditional smearing, transferring the sample onto the glass must be done as quickly as possible so that it does not dry out. This must also be done without losing any adherent cells or mucus to the instrument. When transferring the sample onto the glass, the material is taken from both sides of the brush or spatula.

If the sampling was carried out using the liquid cytology method, the brush head is quickly disconnected and placed in a special container containing a stabilizing solution. Strokes are recorded depending on the staining method. Papanicolaou staining is considered the most informative in terms of assessing the condition of the cervical epithelium.

Smears consist of desquamated cells that are located on top of the epithelial layer. If biomaterial is correctly collected from the cervical canal (cylindrical epithelium) and the mucous membrane of the cervix, the sample will contain cells from the transformation zone, the vaginal portion (non-keratinizing stratified squamous epithelium) and the cervical canal.

Cells of non-keratinized stratified squamous epithelium are conventionally divided into 4 types:

• basal;
• intermediate;
• superficial;
• parabasal.

The maturity of the cells caught in the smear depends on the ability of the epithelial layer to mature. If there are atrophic changes, then less mature cells will be included in the sample.

Taking a cervical smear

The procedure is carried out quickly and almost painlessly. The gynecologist takes a cytological smear from the cervical canal with a special spatula. He obtains several epithelial samples from different parts of the cervical canal. The biological material is then applied to a glass slide and sent to the laboratory for detailed cytological examination. Compliance with the rules for taking a smear is very important, since neglecting them can lead to false results of the smear analysis or it will be uninformative and the study will have to be repeated.

Smear for oncocytology - procedure

The cervix is ​​a narrow, hollow tube, one end of which opens into the uterine cavity and the other into the vagina.

The epithelium adjacent to the vagina has a multilayer structure and is called “stratified squamous epithelium.” In the cervical canal the epithelium is cylindrical.

Pathological changes can affect both types of tissue; areas of altered epithelium can be very small. Therefore, in order for the analysis to reveal the true picture, it is necessary to qualitatively collect the material.

It is especially important that the area of ​​the smear includes the junction of squamous and columnar epithelium - the zone of tissue transformation accounts for up to 90% of tumor processes.

For the reliability of the analysis, there must be a sufficient amount of material, since there may be few cells, which means there is a risk of them escaping from the inspection area. The extent to which these conditions are met depends on the professionalism of the doctor and the technique used.

Why is liquid cytology more reliable?

When using this method, the doctor uses a brush to perform a smear, which penetrates deeply into the tissue and covers all areas of the epithelium.

With the traditional method, the biomaterial is applied directly to the glass and dried, which reduces its quality.

When taking an analysis using liquid cytology, the brush is placed in a special preservative solution in which the cells retain their properties as much as possible. Thus, the material reaches the laboratory in its original form, which significantly increases the accuracy of diagnosis.

How to take a smear for oncocytology?

This procedure is usually performed by a gynecologist, but may be performed by a midwife or a specially certified nurse.

The patient lies down in the gynecological chair. The doctor places the brush in the external os of the cervix and makes a rotational movement, removing the epithelium from the walls of the organ. Then the brush is removed.

The manipulation is performed very carefully, it is completely painless, and the process itself lasts only 10-20 seconds.

A day or two after taking the test, vaginal discharge may increase. You shouldn't be afraid of this - it's normal.

The essence of cytological research

This type of research has several main goals. The very first thing you can find out is the condition of the material being studied. Doctors make an opinion based on shape, size and structure. A study is also carried out to determine the presence of special inclusions in the cells.

Content:

• The essence of cytological research
• What is needed for cytological examination
• How the research is carried out

Cytological examination can promptly diagnose the presence of cancer cells in the body.

During the examination, doctors should be alerted by the presence of leukocytes in the material, indicating inflammation. Leukocytes are blood cells that perform protective functions in the human body. Exceeding the permissible number of microorganisms or the presence of pathogenic species indicates an infectious process.

Atypical cells can be detected in a smear. Their presence indicates malignant degeneration of the tissues from which the sampling was carried out. If such cells are found, the patient is referred for examinations that will help determine whether there is cancer in his body. In this way, it is possible to diagnose an oncological process at an early stage, which does not yet give clinical manifestations.

Very often cytology is confused with histology. If cytology studies the accumulation of cells, then histology studies the tissues of organs and various neoplasms.

Can pregnant women undergo a cytology test?

Pregnant women are not recommended to undergo cytology testing. During pregnancy, the cervix swells and fills with blood. Material for analysis is taken with a brush with elastic bristles, but even a carefully done smear can cause bleeding, causing a miscarriage. And when removing cells from the surface of the cervical canal under unfavorable circumstances, careless movement can cause the canal to open. Therefore, pregnant women undergo cytology testing only if absolutely necessary.

Features and advantages of the technique

BD SurePath™ technology based on liquid cytology was officially approved by the FDA in the USA in 1999. Since 2011. widely used throughout the world and recommended in Russia.

Scraping is carried out with a special Rovers Cervex brush. Once collected, the tip is placed into a vial containing BD SurePath Special Liquid Media. The study uses all cells, including those remaining on the brush. Thanks to this, the technology is characterized by a maximum number of cells in the sample, which is 2-3 times higher than the number of cells in a traditional smear. The BD PrepStain concentrates the cells, then automatically spreads the cells in a thin layer onto the glass and automatically stains them. To view samples, a special imaging system with automatic analysis is used, BD FocalPointTM GS - high-precision optics with artificial intelligence, which analyzes all cells for more than 300 indicators. The system then aims a high-precision microscope, through which a specialist cytologist looks, at cells that differ from normal ones. Thus, cell analysis occurs twice: by the intelligent high-precision BD FocalPoint system and by a person. This approach ensures the highest quality of diagnosis of changes and pathologies of the cervix.

Advantages of BD SurePath™ technology: 1. The use of a special combined brush, which ensures the collection of biomaterial material from the endo-, ectocervix and transformation zone. 2. The biomaterial is placed in BD ShurePath liquid transport medium, and all collected cells are preserved. 3. A standardized preparation can be prepared with a small number of cells - up to 5000. A typical traditional smear contains from 8000 to 12,000 cells. 4. The automated BD FocalPoint™ system provides a quick overview of the entire specimen area. With conventional cytology, only a few hundred cells can be seen. 5. The system marks all atypical areas for examination by a cytologist, reducing the number of uninformative samples from 24% to 0.13% compared to traditional cytology. 6. Only part of the biomaterial contained in the vial is used; the remainder can be used for repeated analysis, screening for HPV infection or for diagnosing urogenital infections.

Who should get Pap smears more often?

There are times when a test needs to be repeated because, for example, the result is ambiguous or false due to inflammation.

If during a cytological examination cells with an abnormal structure are detected at least once, the cytology is not checked by another cytology, because the next result can reassure the patient when it is time to act. It should be remembered that the classic Pap test has a sensitivity of about 60%.

When and who needs such screenings? According to modern clinical guidelines, cervical cancer screening with cytological examination is recommended for all women over 21 years of age. In general, it is recommended to start it 3 years after the first sexual intercourse. So early entry into intimate life is the basis for the early start of preventive gynecological examinations. In the first 2 years, screening for cervical cancer is carried out annually. Subsequently, if the results of repeated cytological studies are negative, preventive examinations become more rare and are carried out once every 2-3 years. After 65 years, the frequency of screening studies is determined individually. The reason for conducting liquid cytology is the presence of background and precancerous diseases of the cervix in a woman (cervical erosion, changes in the cervix identified during examination, an atypical colposcopic picture - examination of the cervix under magnification, the presence of human papillomavirus of high carcinogenic risk - (12 types) , since there has been a proven connection between the presence of the virus and the development of cervical cancer, precancerous changes according to the traditional oncocytogram) In this case, the patient is classified as a high-risk group for the development of cancer, and a cytological examination of gynecological smears is carried out on her annually. Additional screening activities are carried out during the preparation of a woman for conception. How to prepare for research. Preparation for liquid cytology of the cervix begins 2-3 days before the test and includes: sexual rest for 2-3 days, refusal to douche, stopping the use of any means for vaginal insertion. When is the best time to do screening? Cytological examination is not carried out during menstruation, 5 days before it and 5 days after it. Preference is given to the first half of the menstrual cycle, although this recommendation is not strict. If the patient has had a colposcopy, a cytological examination is permissible no earlier than 24 hours after it. And in the case of a cervical biopsy - only after 3 weeks. Methodology and advantages: automated preparation of cytospecimen. Includes vacuum filtration of a portion of the suspension from a test tube, centrifugation, application of the resulting cell sediment in a uniform layer on a glass slide, staining using the Papanicolaou method using wet fixation. Microscopy of a cytospecimen. The PAP test based on liquid cytology is carried out according to the same principles as in the case of the traditional technique. But at the same time, the peculiarities of coloring, position and size of cells after wet fixation of the cytopreparation are taken into account. In a traditional oncocytological study, the information content depends on many factors - human (the doctor’s eye may simply be “blurred”), the quality and adequacy of the collection of material and the preparation of the drug in the laboratory. The results of the analysis are deciphered only by a gynecologist or oncologist. An answer from the laboratory can be received in 5-10 days after taking the material. But often this period is extended to 2-3 weeks. If necessary, an express study is carried out, in this case the doctor will know the result within the first 24 hours. And what after the study? The recovery period after liquid cytology is not fundamentally different from such when taking a regular smear for oncocytology or a biopsy of the cervix. It is recommended to maintain sexual rest for 1.5 weeks, refuse to use vaginal tampons and douching. In the first days after the test, light bleeding from the vagina is acceptable, so it is advisable for a woman to use sanitary pads. An increase in body temperature, prolonged or heavy bleeding, pain in the lower abdomen is an alarming sign. The appearance of such symptoms requires immediate consultation with a doctor. How does liquid-based cytology differ from conventional cytology? The key differences between these screening methods include: during a conventional cytological examination, tissue samples are taken in a targeted manner, and the areas for examination are selected by the doctor based on visual changes in the mucous membrane. In the case of the liquid technique, material from any woman is obtained from the entire circumference of the cervix. This significantly reduces the likelihood that any modified section will be missed. When performing conventional cytology, the biomaterial is dried on glass at room temperature before sending. And in liquid cytology, it is placed in a special test tube (bottle) with a special stabilizing medium, which extends the permissible period of transportation and storage of the resulting sample. The biomaterial placed in a test tube is suitable for research for several months and does not require special conditions. With the traditional method, no filtration is performed. Therefore, if there are inflammatory elements, a large amount of mucus and other impurities in the smear, the result of a cytological study is not reliable enough and usually requires a repeat PAP test after treatment. The liquid method does not have this drawback. With the traditional method, not the entire volume of the resulting tissue ends up on glass and is subjected to subsequent examination. Liquid cytology is performed using an automated method. With traditional oncocytology, up to 35-40% of cells remain on the instrument and the doctor’s gloves. This creates the possibility that existing malignant tissue will remain undiagnosed. With the liquid method, such loss of biomaterial does not occur! This is ensured by placing the cytobrush in a stabilizing and suspending medium, followed by automated centrifugation of the sample and the formation of a special cytopreparation with a standardized, even layer of cells on a glass slide. When taking a traditional smear for oncocytology, cells on a glass slide are usually located in several layers, overlapping each other and thereby impairing visualization. Liquid cytology does not have this drawback; the resulting cytopreparation is monolayer. Possibility of re-analysis of the same biomaterial or other studies using liquid cytology. After all, the suspension in a test tube does not lose its properties for several months, and its volume is sufficient to obtain several cytopreparations. With the traditional method, the tissues being examined are not protected in any way, and there is a high risk of damage during storage. In general, liquid-based cytology using automatic screening is a significantly more informative technique compared to traditional collection of smears from the cervix for oncocytology. And its main advantage is the low percentage of false-negative results of gynecological cancer screening, which is ensured by the progressive technological features of the test with strict adherence to the rules for collecting biomaterial. Diagnostic capabilities: liquid cytological screening is aimed at identifying a variety of cellular atypia in the early stages, which indicates that a woman has a precancerous condition or cervical cancer. The single-layer and uniformity of the cytospecimen ensures a high degree of visualization, allowing the laboratory technician to reliably determine the nature of the changes. This minimizes the likelihood of diagnostic errors and false negative results. The presence of the suspension and its sufficient volume allow additional studies to be carried out according to indications: analysis for tumor markers; any PCR studies; HPV testing; immunocytochemical studies with determination of proliferation markers. Liquid cytology is recommended by WHO, FDA and global anti-cancer communities as the “gold standard” for the early diagnosis of cervical cancer due to the high efficiency of the method.