Pap test

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=20

Micrograph of a Pap = test=20 showing a high-grade squamous intraepithelial lesion (HSIL). Atypical = (abnormal)=20 cells are seen in the lower left of the image. Pap=20 stain.

The Papanicolaou test (also called Pap smear, Pap = test,=20 cervical smear, or smear test) is a screening = test used=20 in gynecology to = detect=20 premalignant and malignant (cancerous) processes in the ectocervix.=20 Significant changes can be treated, thus preventing cervical = cancer. The=20 test was invented by and named after the prominent Greek doctor Georgios=20 Papanikolaou. An anal=20 Pap smear is an adaptation of the procedure to screen and detect = anal=20 cancers.

In taking a Pap smear, a speculum is used to = gather cells from the = outer=20 opening of the cervix (Latin=20 for "neck") of the uterus and=20 the endocervix. The cells are examined under a microscope to look for=20 abnormalities. The test aims to detect potentially pre-cancerous changes = (called=20 = cervical=20 intraepithelial neoplasia (CIN) or cervical dysplasia), which are = usually=20 caused by sexually transmitted human=20 papillomaviruses (HPVs). The test remains an effective, widely used = method=20 for early detection of pre-cancer and cervical cancer. The test may also = detect=20 infections and abnormalities in the endocervix and endometrium.

In general, in countries where Pap smear screening is routine, it is=20 recommended that females, age 18 to 65, who have had sex seek regular = Pap smear=20 testing. Guidelines on frequency vary, from annually to every five = years.= [1][2][dead=20 link] If results are abnormal, and depending on the = nature=20 of the abnormality, the test may need to be repeated in six to twelve=20 months.^[<=
/SPAN>3]=20 If the abnormality requires closer scrutiny, the patient may be referred = for=20 detailed inspection of the cervix by colposcopy. The = patient may=20 also be referred for HPV DNA testing, = which can=20 serve as an adjunct to Pap testing.

1 Indications=20
2 Procedure=20
3 Results=20
4 Effectiveness=20
5 Types of=20 screening=20
- 5.1 Conventional=20 cytology=20
- 5.2 Liquid-based monolayer=20 cytology
6 Human = papillomavirus=20 testing=20
- 6.1 Testing in=20 resource-poor areas=20
- 6.2 Other=20 options
7 Automated=20 analysis=20
8 Practical=20 aspects=20
<= SPAN=20 class=3Dtocnumber>9 Experimental=20 techniques=20
- 9.1 Visual = inspection to=20 detect pre-cancer or cancer
10 Gallery=20
11 References=20
12 External = links=20

Indications

Screening guidelines vary from country to country. In general, = screening=20 starts about age 20 or 25 and continues until about age 50 or 60.[4]

Women should wait a few years after they first have intercourse = before they=20 start screening. For example, United=20 States Preventive Services Task Force (USPSTF) recommends waiting = three=20 years.^=
[1]=20 American=20 Congress of Obstetricians and Gynecologists (ACOG) recommends = starting=20 screening at age 21 (since that is a few years after initial sex for = most=20 American women).^[5]=20 Many other countries wait until age 25 or later to start screening. For=20 instance, Great Britain starts screening at age 25.

Most women contract HPV soon after becoming sexually active.[2][dead=20 link] It takes an average of a year, but can take = up to=20 four years, for a woman's immune system to control the initial = infection.=20 Screening during this period may show this immune reaction and repair as = mild=20 abnormalities, which are usually not associated with cervical cancer, = but could=20 cause the woman stress and result in further tests and possible = treatment.=20 Cervical cancer usually takes time to develop, so delaying the start of=20 screening a few years poses little risk of missing a potentially = precancerous=20 lesion. For instance, screening women under age 25 does not decrease = cancer=20 rates under age 30.^[6]

There is little or no benefit to screening women who have not had = sexual=20 contact. HPV can be transmitted in sex between women, so women who have = only had=20 sex with other women should be screened, although they are at somewhat = lower=20 risk for cervical cancer.^=
[7]

Guidelines on frequency of screening vary=E2=80=94typically every = three to five years=20 for those who have not had previous abnormal smears.^=
[1][8]=20 Some older recommendations suggested screening as frequently as every = one to two=20 years,^[2][dead=20 link] but acknowledge that most women can be = screened less=20 often.^[9]=20 Some guidelines recommend more frequent screening for younger women, for = instance in Great Britain, screening is recommended every 3 years for = women=20 under 50, and every 5 years for those over.

Guidelines vary on when to stop screening. There is probably no = benefit=20 screening women aged 60 or over whose previous tests have been = negative.[10]=20 If a woman's last three Pap results were normal, she can stop at age 65, = according to the USPSTF,^=
[1]=20 ACS says 70, ACOG says 65 or 70,^[5]=20 England's NHS says 64. There is no need to continue screening after a = complete=20 hysterectomy for benign disease.

Pap smear screening is still recommended for those who have been vaccinated=20 against HPV,^[8]=20 since the vaccines do not cover all of the HPV types that can cause = cervical=20 cancer. Also, the vaccine does not protect against HPV exposure before=20 vaccination.

More frequent Pap smears may be needed to follow-up after an abnormal = Pap=20 smear, or after treatment for abnormal Pap or biopsy results, or after = treatment=20 for cancer.

Procedure

=20

Cervix in relation to upper part of vagina and = posterior=20 portion of uterus.

For best results, a Pap test should not occur when a woman is = menstruating.=20 However, Pap smears can be performed during a woman's menstrual period,=20 especially if the physician is using a liquid-based test; if bleeding is = extremely heavy, endometrial cells can obscure cervical cells, and it is = therefore inadvisable to have a Pap smear if bleeding is excessive.

Getting a pap smear should not cause pain,^[11]=20 but it can if the patient has certain untreated vaginal problems such as = cervical = stenosis or=20 vaginismus, or = if the=20 person performing it is too harsh, or uses the wrong size speculum. The = patient=20 should speak up if they are in pain. Many women experience spotting or = mild=20 cramping afterward.

The health care worker begins by inserting a speculum = into the=20 woman's vagina, which spreads the vagina open and allows access to the = cervix. The health care = provider=20 then collects a sample of cells from the outer opening or os of = the=20 cervix by scraping it with an Aylesbury=20 spatula. An endocervical brush is rotated in the central opening of = the=20 cervix. The cells are placed on a glass slide and taken to the laboratory to be = checked for=20 abnormalities.

A plastic-fronded broom is sometimes used in place of the spatula and = brush.=20 The broom is not as good a collection device, since it is much less = effective at=20 collecting endocervical material than the spatula and brush.^[12]=20 The broom is used more frequently with the advent of liquid-based=20 cytology, although either type of collection device may be used with = either=20 type of cytology.

The sample is stained using the Papanicolaou=20 technique, in which tinctorial dyes and = acids are=20 selectively retained by cells. Unstained cells cannot be seen with a = light=20 microscope. Papanicolaou chose stains that highlighted cytoplasmic=20 keratinization, which actually has almost nothing to do with the nuclear = features used to make diagnoses now.

In some cases, a computer system may prescreen the slides, indicating = those=20 that do not need examination by a person or highlighting areas for = special=20 attention. The sample is then usually screened by a specially trained = and=20 qualified cytotechnologist using a light microscope. The = terminology=20 for who screens the sample varies according to the country; in the UK, the=20 personnel are known as Cytoscreeners, Biomedical=20 scientists (BMS), Advanced=20 Practitioners and Pathologists. The = latter two=20 take responsibility for reporting the abnormal sample which may require = further=20 investigation.

Results

<= IMG=20 class=3Dthumbimage height=3D147 alt=3D""=20 src=3D"http://upload.wikimedia.org/wikipedia/commons/thumb/4/46/Low-grade= _sil_and_endocx.jpg/220px-Low-grade_sil_and_endocx.jpg"=20 width=3D220>=20

<= IMG=20 height=3D11 alt=3D""=20 src=3D"http://bits.wikimedia.org/skins-1.17/common/images/magnify-clip.pn= g"=20 width=3D15>

Micrograph of a = Pap=20 test showing a low-grade intraepithelial lesion (LSIL) and benign endocervical = mucosa. Pap = stain.

=20

Micrograph of a = Pap=20 test showing trichomoniasis. = Trichomonas organism seen in the upper right. Pap=20 stain.

=20

Micrograph of a = Pap=20 test showing changes of herpes = simplex=20 virus. Pap = stain.

In screening a general or low-risk population, most Pap results are=20 normal.

In the United States, about 2-3 million abnormal Pap smear results = are found=20 each year.^[13]=20 Most abnormal results are mildly abnormal (ASC-US (typically 2-5% of Pap = results) or low-grade squamous intraepithelial lesion (LSIL) = (about 2% of=20 results)), indicating HPV infection.^{[citation =

needed]} Although most low-grade cervical dysplasias = spontaneously=20 regress without ever leading to cervical = cancer,=20 dysplasia can serve as an indication that increased vigilance is = needed.

In a typical scenario, about 0.5% of Pap results are high-grade SIL = (HSIL), = and less=20 than 0.5% of results indicate cancer; 0.2 to 0.8% of results indicate = Atypical=20 Glandular Cells of Undetermined Significance (AGC-NOS).^{[citation =

needed]}

As liquid based preparations (LBPs) become a common medium for = testing,=20 atypical result rates have increased. The median rate for all = preparations with=20 low-grade squamous intraepithelial lesions using LBPs was 2.9% compared = with a=20 2003 median rate of 2.1%. Rates for high-grade squamous intraepithelial = lesions=20 (median, 0.5%) and atypical squamous cells have changed little.[14]

Abnormal results are reported according to the Bethesda = system. They=20 include:

Squamous cell abnormalities (SIL)=20
- Atypical squamous cells of undetermined significance (ASC-US)=20
- Low-grade squamous intraepithelial lesion (LGSIL or LSIL)=20
- Atypical squamous cells - cannot exclude HSIL (ASC-H)=20
- High-grade squamous intraepithelial lesion (HGSIL or HSIL)=20
- Squamous = cell=20 carcinoma

Glandular epithelial cell abnormalities=20
- Atypical Glandular Cells not otherwise specified (AGC or = AGC-NOS)=20

Endocervical and endometrial abnormalities can also be detected, as = can a=20 number of infectious processes, including yeast, herpes = simplex=20 virus and trichomoniasis. = However=20 it is not very sensitive at detecting these infections, so absence of = detection=20 on a Pap does not mean absence of the infection.

Effectiveness

Prior to the introduction of the Pap test, carcinoma of the = cervix was a=20 leading cause of cancer death in women.^{[citation =

needed]} Since the introduction of the Pap test, deaths = caused by=20 carcinoma of the cervix have been reduced by up to 99% in some = populations=20 wherein women are screened regularly.^=
[15][dubiou= s=20 =E2=80=93 discuss]=20 A regular program of pap smear screening, with appropriate follow-up, = can reduce=20 cervical cancer incidence by up to 80%.^[8]

Failure of prevention of cancer by the Pap test can occur for many = reasons,=20 including not getting regular screening, lack of appropriate follow up = of=20 abnormal results, and sampling and interpretation errors.^=
[15]=20 In the US, over half of all invasive cancers occur in women that have = never had=20 a Pap smear; an additional 10 to 20% of cancers occur in women that have = not had=20 a Pap smear in the preceding five years. About one-quarter of US = cervical=20 cancers were in women that had an abnormal Pap smear, but did not get=20 appropriate follow-up (woman did not return for care, or clinician did = not=20 perform recommended tests or treatment).

Adenocarcinoma = of=20 the cervix has not been shown to be prevented by Pap tests.^=
[15]=20 In the UK, which has a Pap smear screening program, Adenocarcinoma = accounts for=20 about 15% of all cervical cancers^[16]

Estimates of the effectiveness of the United Kingdom's call and = recall system=20 vary widely, but it may prevent about 700 deaths per year in the UK. A = medical=20 practitioner performing 200 tests each year would prevent a death once = in 38=20 years, while seeing 152 women with abnormal results, referring 79 for=20 investigation, obtaining 53 abnormal biopsy results, and seeing 17 = persisting=20 abnormalities lasting longer than two years. At least one woman during = the 38=20 years would die from cervical cancer despite being screened.^[17]

Since the population of the UK is about 61 million, the maximum = number of=20 women who could be receiving Pap smears in the UK is around 15 million = to 20=20 million (eliminating the percentage of the population under 20 and over = 65).=20 This would indicate that the use of Pap smear screening in the UK saves = the life=20 of 1 person for every approximately 20,000 people tested (assuming = 15,000,000=20 are being tested yearly). If only 10,000,000 are actually tested each = year, then=20 it would save the life of 1 person for every approximately 15,000 people = tested.

Types of = screening

Conventional=20 cytology

In the conventional Pap smear, the physician collecting the cells = smears them=20 on a microscope slide and applies a fixative. In general, the slide is = sent to a=20 laboratory for evaluation.

Studies of the accuracy of conventional cytology report:^[18]

sensitivity= 72%=20
specificity= 94%=20

Liquid-based=20 monolayer cytology

Since the mid-1990s, techniques based on placing the sample into a = vial=20 containing a liquid medium that preserves the cells have been = increasingly used.=20 Two of the types are Sure-Path=20 (TriPath=20 Imaging) and Thin-Prep=20 (Cytyc Corp). The = media are=20 primarily ethanol-based for=20 Sure-Path and methanol for ThinPrep. Once placed into the vial, the = sample is=20 processed at the laboratory into a cell thin-layer, stained, and = examined by=20 light microscopy. The liquid sample has the advantage of being suitable = for=20 high-risk HPV testing and may reduce unsatisfactory specimens from 4.1% = to=20 2.6%.^[19]=20 Proper sample acquisition is crucial to the accuracy of the test, as a = cell that=20 is not in the sample cannot be evaluated.

Studies of the accuracy of liquid based monolayer cytology = report:

sensitivity= =20 61%^[20]=20 to 66%^[18]=20
specificity= =20 82%^[20]=20 to 91%^[18]=20

Some,^[19]=20 but not all studies,^[18][20]=20 report increased sensitivity= from the=20 liquid-based smears.

Human = papillomavirus=20 testing

Most women will successfully clear HPV infections within 18 months. = Those=20 that have a prolonged infection with a high-risk type^[21]=20 (e.g. types 16, 18, 31, 45) that are more likely to develop Cervical=20 Intraepithelial Neoplasia, due to the effects that HPV has on DNA. = Studies of=20 the accuracy of HPV = testing=20 report:

sensitivity= 88% to=20 91% (for detecting CIN 3 or higher)^[20]=20 to 97% (for detecting CIN2+)^[22]=20
specificity= 73% to=20 79% (for detecting CIN 3 or higher)^[20]=20 to 93% (for detecting CIN2+)^[22]=20

By adding the more sensitive = HPV Test,=20 the specificity= may=20 decline. However, the drop in specificity is not definite.^[23]=20 If the specificity= does=20 decline, the result is increased numbers of false positive tests and, = for many=20 women that did not have disease, an increased risk for colposcopy[24]=20 and treatment. A worthwhile screening = test=20 requires a balance between the sensitivity= and specificity= to=20 ensure that those having a disease are correctly identified as having it = and=20 those without the disease are not identified as having it.

Regarding the role of HPV = testing, random= ized=20 controlled trials have compared HPV to colposcopy. HPV = testing appears=20 as sensitive = as=20 immediate colposcopy while=20 reducing the number of colposcopies needed.^[25]=20 Randomi= zed=20 controlled trial have suggested that HPV = testing could=20 follow abnormal cytology^[20]=20 or could precede cervical cytology examination.^[22]

A study published in April 2007 suggested that the act of performing = a Pap=20 smear produces an inflammatory cytokine response, = which may=20 initiate immunologic clearance of HPV, therefore reducing the risk of = cervical=20 cancer. Women that had even a single Pap smear in their history had a = lower=20 incidence of cancer. "A statistically significant decline in the HPV = positivity=20 rate correlated with the lifetime number of Pap smears received."[26]

HPV testing can reduce the incidence of grade 2 or 3 = cervical=20 intraepithelial neoplasia or cervical cancer detected by subsequent=20 screening tests among women 32=E2=80=9338 years old according to a randomi= zed=20 controlled trial.^[27]=20 The relative = risk=20 reduction was 41.3%. For patients at similar risk to those in this = study=20 (63.0% had CIN 2-3 or cancer), this leads to an absolute = risk=20 reduction of 26%. 3.8 patients must be treated for one to benefit = (number = needed to=20 treat =3D 3.8). Click here to adjust these results for patients at = higher or=20 lower risk of CIN 2-3.

Testing in=20 resource-poor areas

Many resource-poor areas cannot provide regular screening, and must = rely on=20 infrequent screening. A study of cervical cancer screening of 131,746 = women in=20 rural India found that a single DNA test reduced the number of advanced = cervical=20 cancers and deaths over 8 years, while a single acetic acid examination = or a=20 single Pap screening did not. However, the DNA test cost US = $30=E2=80=9340, which was=20 unaffordable in many regions, it is time-consuming, and requires a = sophisticated=20 laboratory infrastructure. A simple, affordable, and accurate test is = being=20 evaluated in China and other countries.^[28][29][30]=20 The new test may become available on the market in 2010 at significantly = lower=20 cost than current tests.

With HPV testing, there was a 50 percent reduction ^[31][32]=20 in the number of deaths from cervical cancer compared to unscreened = women.=20 Compared to other methods, the research showed the HPV testing reported = the=20 fewest false negatives.^[33]

Other = options

The B= ill and=20 Melinda Gates Foundation has funded an eight-year study of a DNA = test for=20 the virus that causes cervical cancer. The test manufactured by Qiagen = for a low=20 cost per test with results available in only a few hours may allow = reduction in=20 use of annual Pap smears. The test has been shown to work "acceptably = well" on=20 women who take the swabs themselves rather than allowing a physician to = test.=20 This may improve the chances of early diagnosis for women who are = unwilling to=20 be screened due to discomfort or modesty.^[34]

Automated = analysis

In the last decade, there have been successful attempts to develop = automated,=20 computer image analysis systems for screening.^[35]=20 Although, on the available evidence automated cervical screening could = not be=20 recommended for implementation into a national screening program, a = recent NHS=20 Health technology appraisal concluded that the 'general case for = automated image=20 analysis ha(d) probably been made'.^[36]=20 Automation may improve sensitivity= and=20 reduce unsatisfactory specimens.^[37]=20 Two systems have been approved by the FDA and function in high-volume = reference=20 laboratories, with human oversight.^{[citation =

needed]}

Practical = aspects

The endocervix may be partially sampled with the device used to = obtain the=20 ectocervical sample, but, due to the anatomy of this area, consistent = and=20 reliable sampling cannot be guaranteed. As abnormal endocervical cells = may be=20 sampled, those examining them are taught to recognize them.

The endometrium is not directly sampled with the device used to = sample the=20 ectocervix. Cells may exfoliate onto the cervix and be collected from = there, so=20 as with endocervical cells, abnormal cells can be recognised if present = but the=20 Pap Test should not be used as a screening tool for endometrial = malignancy.

Experimental=20 techniques

Colposcopy is the "gold = standard" tool=20 in the developed world for diagnosing cervical abnormalities after an = abnormal=20 pap smear. The procedure requires a trained colposcopist and can be = expensive to=20 perform.

Experimental visualization techniques use broad-band light (e.g., = direct=20 visualization, speculoscopy, cervicography, = visual=20 inspection with acetic acid or with Lugol's, and colposcopy) and = electronic=20 detection methods (e.g., Polarprobe=20 and in-vivo Spectroscopy). = These=20 techniques are less expensive and can be performed with significantly = less=20 training. They do not perform as well as Pap smear screening and = colposcopy. At=20 this point, these techniques have not been validated by large-scale = trials and=20 are not in general use.

Visual inspection = to detect=20 pre-cancer or cancer

This section's representation of one or = more=20 viewpoints about a controversial issue may be unbalanced or=20 inaccurate.
Please improve the article or discuss the issue on the = talk=20 page.(September = 2010)

In areas where Pap smear screening is not available or affordable, = other=20 methods of testing have been evaluated.

Visual inspection of the cervix, using acetic acid (VIA) or = Lugol=E2=80=99s iodine=20 (VILI) to highlight precancerous lesions so they can be viewed with the = "naked=20 eye", shifts the identification of precancer from the laboratory to the = clinic.=20 Such procedures eliminate the need for laboratories and transport of = specimens,=20 require very little equipment and provide women with immediate test = results. A=20 range of medical professionals=E2=80=94doctors, nurses, or professional = midwives=E2=80=94can=20 effectively perform the procedure, provided they receive adequate = training and=20 supervision. As a screening test, VIA may perform as well as or better = than=20 cervical cytology in accurately identifying pre-cancerous lesions.[38]=20 This has been demonstrated in various studies where trained physicians = and=20 mid-level providers correctly identified between 45% and 79% of women at = high=20 risk of developing cervical cancer.^[39]=20 By comparison, the sensitivity of cytology has been shown to be between = 47 and=20 62%. Cytology provides higher specificity (fewer false positives) than = VIA. Like=20 cytology, one of the limitations of VIA is that results are highly = dependent on=20 the accuracy of an individual's interpretation. This means that initial = training=20 and on-going quality control are of paramount importance. Increased = false=20 positives are particularly important in a screen-and-treat setting, = since=20 over-treatment and resulting impairment of fertility is more likely.

VIA can offer significant advantages over Pap in low-resource = settings,=20 particularly in terms of increased screening coverage, improved = follow-up care=20 and overall program quality. Due to the need for fewer specialized = personnel and=20 less infrastructure, training, and equipment, with VIA public health = systems can=20 offer cervical cancer screening in more remote (and less equipped) = health care=20 settings and can achieve higher coverage. Furthermore, providers can = share the=20 results of VIA with patients immediately, making it possible to screen = and treat=20 women during the same visit. This helps ensure that follow-up care can = be=20 provided on the spot and reduces the number of women who may miss out on = treatment because they are not able to return to the clinic at another = time. In=20 a "screen and treat" project in Peru, for example, only 9% of women who = screened=20 positive failed to receive treatment in the single-visit approach, = compared with=20 44% of women who were lost to treatment using a multi-visit model.[40]

VIA has successfully been paired with cryotherapy, a relatively = simple and=20 inexpensive method of treating cervical lesions that can be performed by = primary=20 care physicians and mid-level providers.^[41]

Gallery

Endocervical adenocarcinoma = on a pap=20 test.
Candida = organisms on a=20 pap test.
Viral cytopathic effect consistent with herpes = simplex=20 virus on a pap test.
Normal squamous epithelial cells in premenopausal=20 women
Atrophic squamous cells in postmenopausal=20 women
Normal endocervical = cells=20 should be present into the slide, as a proof of a good quality=20 sampling
the cytoplasms of squamous epithelial cells = melted=20 out; many D=C3=B6derlein=20 bacilli can be seen
Infestation by Trichomonas=20 vaginalis
An obviously atypical cell can be = seen

References

Notes

^ ^=
a=20 ^=
b=20 ^=
c=20 ^=
d=20 U.S. Preventive Services Task Force = (2003). "Screening for Cervical Cancer: Recommendations and = Rationale.=20 AHRQ Publication No. 03-515A.". Rockville, MD.: Agency for = Healthcare=20 Research and Quality. http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm= . Retrieved June 5, = 2010..= =20
^ ^=
a=20 ^=
b=20 ^=
c=20 American Cancer Society. (2010). Detailed Guide: Cervical Cancer. Can Cervical Cancer Be = Prevented? Retrieved June 5, 2010.=20
^=20 The American College of Obstetricians and = Gynecologists (2009). "ACOG Education Pamphlet AP085 -- The Pap Test". = Washington,=20 DC.. http://www.acog.org/publications/patient_education/bp085.c= fm. Retrieved June 5, = 2010.. =20
^ = Strander B (2009). "At what age should = cervical=20 screening stop?". Brit Med J 338: 1022=E2=80=9323. doi:<= A=20 class=3D"external text" href=3D"http://dx.doi.org/10.1136%2Fbmj.b809"=20 rel=3Dnofollow>10.1136/bmj.b809. =20
^ a=20 b=20 ACOG Committee on Gynecological = Practice=20 (2009). "ACOG Committee on Gynecologic Practice; Routine Pelvic = Examination=20 and Cervical Cytology Screening, Opinion #413". Obstetrics and=20 Gynecology 113 (5): 1190=E2=80=931193. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1097%2FAOG.0b013e3181a6d022"=20 rel=3Dnofollow>10.1097/AOG.0b013e3181a6d022. PMID 19384150. =20
^ = Sasieni, P; Castanon, A; Cuzick, J; Snow, = J; (2009).=20 "Effectiveness of Cervical Screening with Age: Population based = Case-Control=20 Study of Prospectively Recorded Data". BMJ 339:=20 2968=E2=80=932974. =20
^=20 Marrazzo, JM; et al. (2001). "Papanicolaou Test Screening and Prevalence of Genital = Human=20 Papillomavirus Among Women who have Sex with Women". American = Journal=20 of Public Health 91 (6): 947=E2=80=93952. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.2105%2FAJPH.91.6.947"=20 rel=3Dnofollow>10.2105/AJPH.91.6.947. PMC 1446473. PMID 11392939. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D1446473. =20
^ a=20 b=20 c=20 M. Arbyn; et al. (2010). [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D2826099=20 "European Guidelines for Quality Assurance in Cervical Cancer = Screening.=20 Second Edition"]. Annals of Oncology 21 (3): = 448=E2=80=93458. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1093%2Fannonc%2Fmdp471"=20 rel=3Dnofollow>10.1093/annonc/mdp471. PMC 2826099. PMID 20176693. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D2826099. =20
^ = Smith, RA; et al. (2002). American = Cancer Society=20 Guideline for the Early Detection of Cervical Neoplasia and = Cancer.=20 52. pp. 8=E2=80=9322. "ACS and others have recommended, since = before 1980, that=20 conventional cytology can be safely performed up to every three years = for most=20 women.". =20
^ = Saiseni P, Adams J, Cuzick J (2003). "Benefit of cervical screening at different ages: = evidence from=20 the UK audit of screening histories". Br J Cancer 89 = (1):=20 88=E2=80=9393. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1038%2Fsj.bjc.6600974"=20 rel=3Dnofollow>10.1038/sj.bjc.6600974. PMC 2394236. PMID 12838306. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D2394236. =20
^ = http://www.ourbodiesourselves.org/publications/cbclex5b.as= p=20
^ = Martin-Hirsch P, Lilford R, Jarvis G, = Kitchener HC.=20 (1999). "Efficacy of cervical-smear collection devices: a systematic = review=20 and meta-analysis". Lancet 354 (9192): = 1763=E2=80=931770. doi:<= A=20 class=3D"external text"=20 href=3D"http://dx.doi.org/10.1016%2FS0140-6736%2899%2902353-3"=20 rel=3Dnofollow>10.1016/S0140-6736(99)02353-3. PMID 10577637. =20
^ = "Pap Smear". http://www.emedicinehealth.com/pap_smear/article_em.htm. Retrieved = 2008-12-27. =20
^ = http://www.ncbi.nlm.nih.gov/pubmed/20196659=20
^ ^=
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c=20 DeMay, M. (2007). Practical = principles of=20 cytopathology. Revised edition.. Chicago, IL: American Society for = Clinical Pathology Press. = ISBN 978-0-89189-549-7. =20
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^ ^a=20 ^b=20 ^c=20 ^d=20 Coste J, Cochand-Priollet B, de = Cremoux P,=20 et al. (2003). "Cross sectional study of conventional cervical smear, = monolayer=20 cytology, and human papillomavirus DNA testing for cervical cancer=20 screening". BMJ 326 (7392): 733. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1136%2Fbmj.326.7392.733"=20 rel=3Dnofollow>10.1136/bmj.326.7392.733. PMC 152633. PMID 12676841. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D152633. ACP Journal Club=20
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^ ^a=20 ^b=20 ^c=20 ^d=20 ^e=20 ^f=20 Kulasingam SL, Hughes JP, Kiviat NB, = et=20 al. (2002). "Evaluation of human papillomavirus testing in primary = screening for cervical abnormalities: comparison of sensitivity, = specificity,=20 and frequency of referral". JAMA 288 (14): = 1749=E2=80=9357. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1001%2Fjama.288.14.1749"=20 rel=3Dnofollow>10.1001/jama.288.14.1749. PMID 12365959. =20
^=20 Cuschieri KS, Cubie HA, Whitley MW, = et=20 al. (2005). "Persistent high risk HPV infection associated with = development=20 of cervical neoplasia in a prospective population study". J. = Clin.=20 Pathol. 58 (9): 946=E2=80=9350. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1136%2Fjcp.2004.022863"=20 rel=3Dnofollow>10.1136/jcp.2004.022863. PMC 1770812. PMID 16126875. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=3D= pmcentrez&artid=3D1770812. =20
^ ^a=20 ^b=20 ^c=20 Cuzick J, Szarewski A, Cubie H, et = al.=20 (2003). "Management of women who test positive for high-risk types of = human=20 papillomavirus: the HART study". Lancet 362 (9399): = 1871=E2=80=936. doi:<= A=20 class=3D"external text"=20 href=3D"http://dx.doi.org/10.1016%2FS0140-6736%2803%2914955-0"=20 rel=3Dnofollow>10.1016/S0140-6736(03)14955-0. PMID 14667741. =20
^=20 Arbyn M, Buntinx F, Van Ranst M, = Paraskevaidis=20 E, Martin-Hirsch P, Dillner J (2004). "Virologic versus cytologic = triage of=20 women with equivocal Pap smears: a meta-analysis of the accuracy to = detect=20 high-grade intraepithelial neoplasia". J. Natl. Cancer Inst. = 96=20 (4): 280=E2=80=9393. doi:<= A=20 class=3D"external text" = href=3D"http://dx.doi.org/10.1093%2Fjnci%2Fdjh037"=20 rel=3Dnofollow>10.1093/jnci/djh037. PMID 14970277. =20
^ = Colposcopy and Treatment of Cervical Intraepithelial = Neoplasia: A=20 Beginner's Manual=20
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^ = [1], J Inflamm 2007;4.=20
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^ = DONALD G. McNEIL Jr. (April 6, 2009). "New=20 DNA Test Outperforms the Pap Smear". The New York=20 Times. http://www.nytimes.com/2009/04/07/health/07virus.html<= /SPAN>. =20
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^ = Sarah Boseley, health editor. "The Guardian - NHS under pressure for new cervical = cancer test=20 provision". Guardian. http://www.guardian.co.uk/science/2009/apr/02/cervical-can= cer-india-test-smear. Retrieved = 2010-08-29. =20
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^ = McNeil Jr, Donald G. (2009-04-07). "DNA Test Outperforms Pap Smear". The New York=20 Times. http://www.nytimes.com/2009/04/07/health/07virus.html?_r=3D= 2&em. Retrieved = 2010-05-21. =20
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^ = Willis BH,=20 Barton P, Pearmain P, Bryan S, Hyde C, "Cervical screening programmes: = can=20 automation help? Evidence from systematic reviews, an economic = analysis and a=20 simulation modelling exercise applied to the UK". Health Technol = Assess 2005=20 9(13).[2]=20
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^ = Sherris J.=20 et al. Evidence-Based, Alternative Cervical Cancer Screening = Approaches in=20 Low-Resource Settings. International Perspectives on Sexual and = Reproductive=20 Health. Volume 35, Number 3, September 2009=20
^=20 Sankaranarayanan R et al. A critical assessment of screening methods = for=20 cervical neoplasia. International Journal of Gynecology and = Obstetrics.=20 2005;89 Suppl 2:S4=E2=80=93S12.=20
^ = Luciani S,=20 Winkler J. Cervical Cancer prevention in Peru: Lessons learned from = the TATI=20 demonstration project. Washington, DC: Pan American Health = Organization; 2006.=20
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External = links

PapScreen - Australian information about Pap tests = (or Pap=20 smears)=20
Obtaining Pap Smear Video=20
Jo's Trust - UK's leading cervical cancer charity.=20
Imaginis - Pap Smear information=20
International Agency for Research on Cancer - = Resource about=20 screening, including that of Cervical Cancer. There are digital = atlases of=20 coloscopy, histology and cytology, the rationale of screening and = setting up=20 of a screening programme.=20
The Pap Test: Questions and Answers =E2=80=94 National = Cancer=20 Institute =E2=80=94 from the U.S.'s National = Cancer=20 Institute=20
Pap=20 Smear =E2=80=94 from eMedicineHealth=20
MedlinePlus: Cervical Cancer Prevention/Screening = =E2=80=94 from MedlinePlus=20
NCI Bethesda System Web Atlas, with 349 images of = different=20 Pap smear morphologic findings =E2=80=94 from the A= merican=20 Society of Cytopathology=20
Canadian Guidelines for Cervical Cancer Screening - = Society=20 of Obstetricians and Gynaecologists of Canada=20
The UK's National Association of Cytologists=20
British Society for Clinical Cytology=20
IBMS =E2=80=94 The Institute of Biomedical Science = on cellular=20 pathology=20
NHS=20 Cervical Screening Programme =E2=80=94 from the UK's National = Health=20 Service=20
EngenderHealth- Cervical Cancer Screening =

<= /TR>

v=20 =C2=B7 = = d=20 =C2=B7 = ePapillomavirus= =20 =E2=80=93 Human=20 papillomavirus

Related
diseases
Cervical=20 cancer =C2=B7
Factor=20 in other cancers= =20 (Anal, = Vaginal, Vulvar, Penile, = Head and=20 neck cancer (H= PV-positive=20 oropharyngeal cancer)) =C2=B7
Warts (genital, plantar, flat, Laryngeal = papillomatosis), Epi= dermodysplasia=20 verruciformis, Focal = epithelial hyperplasia, Papilloma

Vaccine HPV = vaccine (Cervarix, = Gardasil)

Screening<= /TD>
Pap test (stain) -=20 Cytopathology/Cytotechnology=20 results Bethesda=20 System
Experimental techniques (Speculoscopy,=20 Cervicography)

Colposcopy

Biopsy histology = Cervical=20 intraepithelial neoplasia (CIN) =C2=B7 Koilocyte =C2=B7 V= aginal=20 intraepithelial neoplasia (VAIN) =C2=B7 Vu= lvar=20 intraepithelial neoplasia (VIN)

Treatment Cervical=20 conization =C2=B7=20 = Loop=20 electrical excision procedure=20 (LEEP)

History Georgios=20 Papanikolaou =C2=B7 Harald zur=20 Hausen

M:=20 VIR

virs=20 (prot)

cutn/sy= st=20 (hppv<= /A>,=20 hiva,=20 infl,=20 zost,= =20 zo= on),=20 epon

drugJ(dnaa,=20 rnaa,=20 rtva,=20 vacc)

= v=20 =C2=B7 = d=20 =C2=B7 = eFemale genital surgical and = other=20 procedures (gynecological= =20 surgery) (ICD-9-CM=20 V3 65-71)

Adnexa

Ovary Oophorectomy=

Fallopian=20 tubes Salpingectomy&nbs= p;=C2=B7 Tubal=20 ligation =C2=B7 Essure =C2=B7 Tubal=20 reversal

Uterus
general: Hysterectomy = =C2=B7 Hysterotomy =C2=B7 Pelvic=20 exenteration =C2=B7 Uterine= =20 artery embolization =C2=B7 Hysterosalpin= gography

uterine=20 cavity: Hysteroscopy = =C2=B7 Vacuum=20 aspiration

endometrium:=20 Endometrial=20 biopsy =C2=B7 Endometrial=20 ablation

myometrium:=20 Myomectomy
cervix: = Colposcopy =C2=B7 Cervical=20 conization (= LEEP) =C2=B7 Cervical=20 cerclage =C2=B7 Pap test

Vagina Vaginectomy =C2=B7 Culdoscopy =C2=B7 Culdocentesis&nbs= p;=C2=B7 Hymenotomy =C2=B7 Colpocleisis = =C2=B7 Vaginal wet=20 mount

Vulva Vulvectomy =C2=B7 Female=20 genital cutting

M:=20 =E2=99=80 FRS

anat/ph= ys/devp

noco/cong/n= pls,=20 sysi/epon

= proc/asst,=20 drug (G1/G2B<= /A>/G3CD)

Retrieved from "http://en.wikipedia.org/wi= ki/Pap_test"

Categories: = Gynec= ological=20 cancer | Medical=20 tests | Papillomavi= rus

Hidden = categories: All=20 articles with dead external links | Articles=20 with dead external links from November 2010 | All=20 articles with unsourced statements | Articles=20 with unsourced statements from January 2009 | All = accuracy=20 disputes | Articles=20 with disputed statements from January 2009 | Articles=20 with unsourced statements from July 2007 | Articles=20 needing more viewpoints from September 2010

Pap test

Contents

Indications

Procedure

Results

Effectiveness

Types of = screening

Conventional=20 cytology

Liquid-based=20 monolayer cytology

Human = papillomavirus=20 testing

Testing in=20 resource-poor areas

Other = options

Automated = analysis

Practical = aspects

Experimental=20 techniques

Visual inspection = to detect=20 pre-cancer or cancer

Gallery

References

External = links

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