The Truth... What is it?





An abnormal Pap smear is not a medical emergency!

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As to this file/page, you have been directed to & now @ Dr. Shaw's personal website

(much more Pap smear information...here)


Since Pap smear screening is not a medical emergency (or even medically urgent), interest in getting a result quickly makes much less sense than an intense focus on optimizing the detection of cervical cancer. However, many patients are anxious and hyperdemanding. So, turn-around-time (TAT) [check out TAT factors] has become a competitive factor.

Here is the so-called progression possible with Pap smears from perfectly normal to cancer (the KEY reason for Pap smears is to detect cancer & lesser reason to detect abnormalities that COULD (but not inevitably so) indicate the woman is MAYBE on a "road" that could end up with cancer.

In most Pap cases, cells are perfectly normal, then start to find some "atypical" cells [cells that "aren't just right"], then start to find some "mild dysplasia" cells, then start bto find some "moderate dysplasia" cells, then start to find some "severe dysplasia" cells, then find some malignant [cancer] cells. For sampling reasons, one could seem to skip a step in the next Pap smear or go back to all perfectly normal cells. The cases that more commonly eventually become cancer are positive for the HPV virus. I would bet that at least 50% of women sooner or later get a Pap smear that is not perfectly normal.

The vast majority of abnormal Pap smear situations are worked out deliberately, methodically, and without haste. For legal reasons...and so that illustrative materials might be used to help you understand any potential problems...you will nearly always be asked to come in to the doctor's office in order to discuss the situation in person.

Used to the fullest, the Pap smear can reveal cancer, pre-cancer, irritative changes, abnormal populations of organisms (bacteria [fishy-smelling gardnerella "bacterial vaginosis"; streptococcal overgrowth], fungi [candidiasis], viruses [HPV, herpes, CMV], or parasites [trichomonas or chlamydia]...the Pap will not detect gonorrhea or syphilis), or female hormone depletion...even when you have not had any complaint. These discussions may relate to organisms and sexually-transmitted disease (STD) and their potential effects on you, a sex partner, or on an unborn baby (all of these STDs can be transmitted the same as HPV...see below). So, you may be called in to discuss any of these things; but, most commonly it will be due to problems in deciding whether your Pap smear shows reactive/irritative changes or pre-cancerous change.

Much of the terminology used in Pap smear reports is essentially government-mandated. Words, from better to worse, such as: atypia (reactive/reparative; ASCUS/SAUS; AGCUS/AGUS), dysplasia (LGSIL [HPV/koilocytotic atypia and/or mild dysplasia] or HGSIL [moderate or severe dysplasia], CIS (carcinoma in-situ), or "cancer" are used to communicate the concerns of the diagnostic cytopathologist physician (who "reads" your abnormal Pap smear) to your treating doctor or nurse. We use Bethesda terminology and fully use Bethesda 2002  since our update to the CoPath LIS at the end of August of 2002. None of these updated, advanced nomenclature systems has turned out any better AT ALL than the old Class I-V sytem that I learned in the early 1970s!

If the terms used indicate very mild concerns [example], you may only be asked to have a repeat Pap smear following a shorter-than-normal period of time [less than the usual annual Pap smear], with or without some type of medical treatment in the meantime. HPV tests might be done.

If the terms used indicate higher concern, you may be asked permission for either a cervical biopsy (take a small piece of cervix tissue) or a cone (a larger "surgical" piece of cervix tissue..."cold-knife" cone or LEEP cone) to be performed by your treating doctor. The cone can also be the treatment; but cones can lead to an incompetent cervix in a patient desiring further child-bearing. That sample will be sent for microscopic analysis by a surgical pathologist physician. These procedures are often (but not always) done in conjunction with "colposcopy"...a high-magnification exam of your cervix surface with an instrument inserted into your vagina. Even tiny abnormal areas can be seen, thereby, so that the biopsy or cone actually samples the abnormal area. The results of the tissue exam are usually available in less than a week. It is a very helpful advantage when the surgical pathologist is able to diagnose the piece of cervix tissue along with examining the current or previously abnormal Pap smear slides (that is, it is best if all are diagnosed by pathologists in the same lab). Treatment is by way of cervical cone (above) or cryosurgery (freezing of the cervix); freezing almost always causes the target-zone for follow-up Pap smears (the squamo-columnar junction) to retract down into the endocervical canal where it becomes impossible to see and difficult to sample.

 

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(posted 1 December 1998; 1st update 6 July; 2nd, 5 Oct. 1999; 3rd, 18 June; 4th, 13 Dec. 2000; 5th, 17 Feb.; 6th, 30 April 2001; latest update 4 August 2003)