214 Indian J Dermatol Venereol Leprol - March-April 2009 - Vol 75 - Issue 2

PAP SMEAR of 21 or within 3 years of the onset of sexual activity and it
can stop at the age of 70 years if there has been no abnormal

DEFINITION Pap test result in the past 10 years.[3]
A Pap smear, also known as Papanicoloau smear, is a A Pap test should be performed during the second half of the
microscopic examination of cells scraped from the cervix menstrual cycle (Day 14). Sample collection usually begins
and is used to detect cancerous or pre-cancerous conditions with appropriate instruction to the patient. Patients must
of the cervix or other medical conditions. It was named after abstain from sexual intercourse and avoid using any vaginal
Dr. George N. Papanicoloau, who first described it in 1928 medication or contraceptives 48 h before sample collection.
and since its introduction, the Pap smear has helped reduce The patient is placed in lithotomy position and the cervix is
cervical cancer incidence and mortality rates by 75%. The visualized by means of a speculum. The smaller end of the
Pap smear is a screening tool that looks for changes in the Ayre s spatula is introduced through the external os and the
transformation zone of the cervix, which most often are squamocolumnar junction is scraped by rotating the spatula
caused by HPV. to 360 . The scraping is then evenly spread onto a glass
slide, which is immediately fixed using 95% ethyl alcohol
METHOD OF SAMPLE COLLECTION and ether to avoid air drying artifacts.[4]
The cervix is composed of columnar epithelium, which lines WHAT IS AN ADEQUATE SMEAR?
the endocervical canal, and squamous epithelium, which
covers the exocervix. The point at which they meet is called An adequate smear is the one with the following features:
the squamocolumnar junction. Metaplasia advances from the 1. Adequate numbers of squamous epithelial cells present.
original 2. Evidence that the transformation zone was sampled (i.e.
the presence of endocervical cells on the smear).
ea called the transformation zone. It is this area that the 3. Spread in a relatively even monolayer.
sample is taken from for the Pap smear. Screening with 4. Epithelial cells not obscured by blood, inflammatory
conventional Pap testing should occur every year. If liquid- cells, or foreign material such as lubricant or talc.
based cytology (LBC) is being used, screening can be 5. Appropriately preserved.
extended to every 2 years. Screening should begin at the age
How to cite this article: Mehta V, Vasanth V, Balachandran C. Pap smear. Indian J Dermatol Venereol Leprol 2009;75:214-6.
Received: July, 2008. Accepted: September, 2008. Source of Support: Nil. Confl ict of Interest: None declared.
214 Indian J Dermatol Venereol Leprol | March-April 2009 | Vol 75 | Issue 2

Mehta et al. Pap smear
INTERPRETATION OF A NORMAL PAP SMEAR PAP SMEAR REPORTING
The following three types of cells are seen in a normal Pap The Pap smear reporting classification has evolved and been
smear: refined over time. The current reporting system is the
1. Cells from the basal layer, which are small, rounded and Bethesda system, which was introduced in 1988 [6] and later
basophilic with large nuclei,[5] updated again in 1999 [Table 1].[7]
2. Cells from the intermediate layer, which are basophilic
with vesicular nuclei[5] and Patients with abnormal Pap smear who do not
3. Cells from the superficial layer, which are acidophilic
with pyknotic nuclei.[5]
In addition, endometrial cells, histiocytes, blood cells and

bacteria may also be seen. The presence of atypical cells
indicates an abnormal Pap smear, which could be a result of
either inflammation caused by an infection or cervical atypia
[Figure 1].
squamocolumnar junction cannot be visualized, a cervical
cone biopsy or HPV DNA test is performed.
LIMITATIONS OF PAP SMEAR
1. Inadequate samples constitute about 8% of the

specimens received.
2. False-negative results as high as 20-30% have been
reported, which occurred due to clumping of cells when
the cells are not uniformly spread on the glass slide.
3. Sometimes, other contents of the cervical specimen such
as blood, bacteria and yeasts contaminate the sample and
prevent the detection of abnormal cells.
4. If exposed to air for too long before being fixed on the
Figure 1: Clinical photograph of a normal pap smear slide, cervical cells can become distorted.
have a gross cervical lesion are usually evaluated by 5. Human error is probably the primary threat to accurate
colposcopy- and colposcopy-directed biopsy. Colposcopy interpretation. An average Pap smear slide contains
can detect low- and high-grade dysplasia but does not detect 50,000-300,000 cells that must be examined and if the
microinvasive disease. Colposcopy is the study of cervical sample contains only a few abnormal cells within a
morphology using stereoscopic binocular magnification crowded background of healthy cells, the abnormal cells
provided by the colposcope. This instrument provides a 3- may be missed.
dimensional image of the examined tissue surfaces and its
use is now routinely recommended for the evaluation of NEWER TECHNIQUES
abnormal Pap smears. In screening programs aimed at
detecting and eliminating cervical cancer and pre-cancer,
A conventional Pap smear has a sensitivity ranging from 47
colposcopy plays an important adjunctive role with cytology
to 62% and a specificity of 60-90%. In
and histology. If no abnormalities are found or if the entire
Table 1: Bethesda Classifi cation for cervical squamous cell dysplasia

Smear fi ndings Interpretation
Negative for intra-epithelial lesions or malignancy Normal smear
Atypical squamous cells of undetermined signi cance (ASCUS) Abnormal squamous cells but do not meet the criteria for a squamous
intra-epithelial lesion
Low-grade squamous intra-epithelial lesion (LSIL) Mildly abnormal cells, changes attributable to HPV
High-grade squamous intra-epithelial lesions (HSIL) with features Moderate to severely abnormal squamous cells
suspicious for invasion
Carcinoma The possibility of carcinoma is high enough to warrant evaluation
Indian J Dermatol Venereol Leprol | March-April 2009 | Vol 75 | Issue 2 215
Mehta et al. Pap smear
order to minimize the number of false-negative results, LBC CONCLUSION
is now the preferred method of sample collection where a
cervical brush is used to collect the specimen, which All sexually active women must have a Pap smear
provides almost twice as many epithelial cells. The samples examination annually to detect cervical cancer. If the smear
are collected directly in a preservative solution and slides are is abnormal, it is repeated at 3-6 monthly intervals. Three
prepared meticulously avoiding any uneven manual abnormal results in a row is a definite indicator for further
smearing and thus reducing human error while evaluation.
interpretation. LBC has got a higher sensitivity and REFERENCES
specificity than Pap smear as the cellular structure is better
preserved because the cells are fixed immediately.[8] Another 1. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA,
way to improvise the Pap smear diagnosis is by using stains Shah KV, et al. Human papillomavirus is a necessary cause of invasive
cervical cancer worldwide. J Pathol 1999;189:12-9.
to detect the HPV antigens.[9]
2. Sitas F, Carrara H, Terblanche M, Madhoo J. Screening for cancer of 6. Solomon D. The 1988 Bethesda system for reporting cervical/ vaginal
the cervix. S Afr Med J 1997;87:620-2. cytologic. JAMA 1989;262:931-4.
3. Saslow D, Runowicz CD, Solomon D, Moscicki AB, Smith RA, Eyre 7. Solomon D, Davey D, Kurman R, Moriarty A, O Connor D, Prey M,
HJ, et al. American Cancer Society guidelines for the early detection et al. The 2001 Bethesda System: Terminology for reporting results of
of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342-62. cervical cytology. JAMA 2002;287:2114-9.
4. Suresh B. Cervical smear collection procedures. In: Gynaecological 8. Mahboobeh S, Diane S, Philip EC. Cervical cancer prevention:
cytology cervix. 1st ed. New Delhi: Interprint; 1996. p. 141-52. Cervical screening. Obstet Gyneacol Clin 2007;34:739-60.
5. Howkins, Bourne. Gynaecological diagnosis. In: Padubidri VG, 9. Eileen MB. Human papillomavirus and cervical cancer. Clin Microbiol
Shirish ND, editors. Shaw s textbook of gynaecology, 13th ed. Noida: Rev 2003;16:1-17.
Elsevier; 2004. p. 68-81.
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PAP SMEAR of 21 or within 3 years of the onset of sexual activity and it

can stop at the age of 70 years if there has been no abnormal

214 Indian J Dermatol Venereol Leprol | March-April 2009 | Vol 75 | Issue 2

In addition, endometrial cells, histiocytes, blood cells and

LIMITATIONS OF PAP SMEAR

1. Inadequate samples constitute about 8% of the

Table 1: Bethesda Classifi cation for cervical squamous cell dysplasia

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