PAP SMEARS - Full extract 

Gloria is in her early 50s and has worked in a city department store since finishing school. Her husband left many years ago, just after her daughter was born.

She keeps very well and I see her only occasionally. Over the years, I've suggested many times that she have a Pap smear. "No way," has been the standard response. "If I had something wrong, I wouldn't want to know about it anyway."

When she came in last year with bronchitis, I gave her a booklet about having a Pap smear. "Great," she said. "I'll put this with my other light reading."

To my surprise, a few months later she booked in for a full check-up and a Pap smear. Everything seemed in good order. "In for a penny, in for a pound," she said. "I'm going to have one of those free mammograms next."

When she rang a few days later, I was able to tell her that her Pap smear was completely normal. I couldn't resist asking why the sudden change of attitude. "My daughter got married last month," she said. "I'm making it my business to be around for my grandchildren."

Most younger women seem to have got the message about the importance of Pap smears. However, there is a large group of women over the age of 40 who have not had one for many years, or who have never had one at all. Yet it is these women who are most at risk, and who should be having regular Pap smears.

There are about 1000 new cases of cancer of the cervix each year in Australia and about 400 people die from the condition. A viral infection called HPV (Human Papilloma Virus) is thought to be a significant factor in causing this type of cancer.

If cancer of the cervix is detected at the earliest stage, it can be completely cured with simple treatment to the cervix itself. Later stages require more involved treatment such as hysterectomy and radiotherapy. Although there has been news of promising research into a vaccine against HPV, the main approach for many years will continue to be early diagnosis and treatment.

The only way this can be achieved is with two-yearly Pap smears for all women - from the ate of first intercourse right through until the age of 70 years.

The Pap smear is a screening test, in that vast numbers of healthy people with no symptoms at all are screened to pick up a small number of people with abnormal cells. These abnormalities can range from the signs of HPV infection and milder abnormalities called dysplasia, right through to the various stages of cancer of the cervix.

It helps to understand what happens when a Pap smear is done. The cervix is the lowest part of the uterus and can be felt as a firm protuberance at the top of the vagina. It has a small central opening and a canal that opens into the uterine cavity. The aim of the Pap smear is to take a good sample of cells from the surface of the cervix and from the canal.

With the patient in a comfortable position, an instrument called a speculum is inserted into the vagina to allow a good view of the cervix. A thin wooden spatula, rather like an icy-pole stick, is inserted and the end moved across the surface of the cervix to collect mucous-like material. The spatula is withdrawn and wiped on to a glass slide. A tiny disposable brush is then inserted into the opening of the cervix and rotated a few times to collect cells from the canal. This is also wiped on to the glass slide, which is then sprayed with an alcohol fixative. Sometimes an extra specimen of mucus is placed into a special fluid and sent for an additional test.

Next the doctor does a vaginal examination to check the size and shape of the uterus and surrounding pelvic structures, like the ovaries and fallopian tubes. The slide is then packed and labelled for sending to the pathology centre with an accompanying request slip. There, the slide is processed and examined under a microscope to see if there are any abnormal cells, or signs of cancer.

The patient's name is automatically placed on the Victorian Cytology Register for later recalls and reminder cards if necessary. The pathologist's report is typed and sent back to the referring doctor who will either notify the patient or wait for the patient's call.

There is a lot involved in having a Pap smear and there are several areas where human error can occur. Most of the time it works very well. However, like any other screening test, it is not infallible. About 90 per cent reliability is generally accepted for smears done in larger centres. This means there could be a 1 in 10 chance of a very early cancer going undetected. This reduces to 1 in 100 for consecutive Pap smears, hence the importance of having regular two-yearly tests

The Pap smear is a very useful screening test, but is not a diagnostic test. Symptoms like abnormal bleeding should always be discussed with your doctor, even if there has been a recent normal Pap smear. Referral to a gynaecologist for further investigation is likely to be required.

Health Tip:
* Make sure you obtain the results of each Pap smear. If you do not receive a report from your doctor, phone the clinic to discuss your result.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001