GYNECOLOGIC PROCEDURES AND SURGERY pdf

841

GYNECOLOGIC PROCEDURES

EXFOLIATIVE CERVICAL CYTOLOGIC STUDY

(PAPANICOLAOU SMEAR)

Exfoliative cytologic examination of specimens from the lower gen￾ital tract (Pap smear) is a screening tool that has been so valuable

in the detection of premalignant and malignant lesions that it has

been almost universally adopted as the primary cancer screening

method for cervical cancer, an integral part of the health care of

women. This has resulted in a
50% reduction of invasive cancers

of the cervix alone. Although cervical cytology may detect en￾dometrial cancer (in 15%–50%), it does not carry the same relia￾bility as a screening tool for endometrial neoplasia.

SCREENING GUIDELINES

● Initial gynecologic screening at age 18, or when the indi￾vidual becomes sexually active. ● Women whose initial smear is negative (without significant

atypia) should have a second smear within 1 year to rule

out a false-negative smear. ● High-risk women should be screened annually (i.e., those

with a history of early sexual activity or those with multi￾ple sexual partners). ● Low-risk women may be screened every 1–3 years at the dis￾cretion of the physician. These are women with late expo￾sure to coitus, those with only one sexual partner, and

women after two successive negative annual smears. (Some

authorities contend it is too difficult to ascertain low risk

and simply recommend annual screening.)

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BENSON & PERNOLL’S

842 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

● Postmenopausal women should receive annual screening. ● Women after hysterectomy should have an initial smear fol￾lowing surgery; if this is negative, cytology should be re￾peated every 3 years.

TECHNIQUE

Materials necessary for a Pap smear include a cervical spatula,

shaped tongue depressor or cotton swab, glass slides and a means

to identify the slide and patient, a speculum (warm, without lubri￾cant), and a jar of fixative (97% ethanol) or spray fixative (e.g.,

Pro-Fixx or AquaNet) (Fig. 31-1).

The objective is to sample secretions from the endocervical

canal, the transformation zone, and the vaginal pool. The last site

is less productive and, therefore, of lesser priority. Sampling is ac￾complished by gently wiping away excess mucus and obtaining en￾docervical canal samples using the moist cotton swab or cervical

spatula. This is smeared onto a glass slide and fixed. A spatula with

an endocervical extension, or similar device is used to lightly scrape

the entire transformation zone. In those with a small external os, a

brush device may be helpful in guaranteeing that endocervical cells

are sampled. This sample is spread on a slide and fixed immedi￾ately. Finally, the vaginal pool may be sampled by using the same

spatula (again, fixing immediately). The reporting of cervical cyto￾logic results is discussed on p. 524.

COLPOSCOPY

The colposcope is a binocular microscope of low magnification

(10–40) used for direct visualization of the cervix. Although col￾poscopy does not replace other methods of diagnosing cervical ab￾normalities, it is an important additional tool. The patients who most

benefit from colposcopy are those with abnormal Pap smears. Col￾poscopy is also used to evaluate women who were exposed to DES

in utero and in gynecologic cancer therapy follow-up.

Occult neoplasms in the upper cervical canal, where 10% –15%

of cervical cancers develop, cannot be detected by colposcopy.

Therefore, endocervical curettage should be performed in women

who are being evaluated for abnormal cervical cytology.

Normally, columnar epithelium covers the ectocervix until ado￾lescence, when it gradually changes to a squamous surface. The

transformation zone can be inspected easily with the colposcope,

and dysplastic surface changes can be identified. These include

white epithelium (e.g., sheet of layered metaplastic cells), a mosaic

pattern (e.g., sharply outlined cells and cell groups), punctation (e.g.,

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GYNECOLOGIC PROCEDURES AND SURGERY 843

FIGURE 31-1. Preparation of a Papanicolaou cytosmear.