Smear test is a special cervic screening test performed women to evaluate the cervix and check it both for cancer and conditions that are precursors of cancer. Smear test (pronounced as “Smir”)are also known as spreading a thin layer sample (from the cervix) onto glass, taking a wipe swab from the cervix, CVS (Cervico-Vaginal Smear Test), PAP test or PAP smear test.

Why is the Smear Test (PAP Test) Performed?

The main aim of this test is the early recognition especially of cervix cancers and precancerous lesions. The test has recently become a routine part of gynecological examinations and gynecological conrols.

How is Smear Test (CVS, Cervicovaginal Smear Test) Performed?

Cells inevitably come off from surfaces due to constant renewal of body tissues. Collection of the cells that come off and examination of them under a microscope after undergoing special processes is called “a cytologic examination (a cellular examination)”.

Cytologic examination is best performed on samples collected from the cervix. Such collection of cervical cells is called “smear” (spreading, swab).

Smear test is also called as “PAP Smear” as a tribute to the Greek scientist “George Papanicolaou” as the test was first performed by him in the 1930s.

Is PAP Smear Testing (CVS) A Painful Procedure?

No. Smear test is a part of routine gynecological examinations and you do not feel pain at all while smear is being taken during your gynecological examination.

What is the Importance of the Smear Test?

Smear test is life-saving. Yes, there are two very important tests, which are considered as life-saving and life-extending for women and for women, and the efficacy of which has been proven: the smear test and mammography.

Cervical cancer, which is the second most prevalent cancer among cancers relating to the female reproductive system following breast cancer, is a condition that results in full recovery when diagnosed in an early period.

As is the case in all cancers, cervical cancer appears after a larval period that lasts for many years.

In cervical cancer, the disease has unfortunately spread to the body when the symptoms finally appear. For this reason, several tests have been developed to recognize cancers in the early period.

The most significant test in the early diagnosis of cervical cancer is the smear test.

Samples taken through smear are pathologically examined searching whether there are cancer cells or cells that are precursors of cancer cells.

How is Swab (Smear) Taken?

Smear taking is an extremely simple and painless method. The cervix is rendered visible after a device called “speculum” is attached to the vagina during gynecological examination.

A thin layer of the material taken is spread onto a glass called “microscope slide” and fixed by spraying alcohol or hair lacquer. This is called “thin spread”.

Which Information is Required by the Pathologist for Smear Test Results?

Duly prepared smear preparate on the microscope slide is sent to the pathologist. While investigating the preparate, the pathologist (pathology expert) needs some information about the patient. These are:

• Patient’s age
• Patient’s complaints
• Date of last menstruation and normal menstrual cycle
• Presence of pregnancy, number of previous pregnancies
• Whether the patient uses birth control pills or other hormonal medications
• Whether the patient uses an intra uterine device (spiral)
• The reason why smear is requested
• Clinical referral diagnosis

Smear is a quite effective screening method. Thanks to this method, abnormal cells are detected in extremely early periods and their progresses towards advanced cancer can be prevented via proper treatment methods.

A study carried out in the USA identified that deaths due to cervical cancer decreased by 72% as a result of the widespread use of smear test.

As well as providing information on the hormonal condition and infections of the woman, the smear test also plays a significant role in the early detection of relapses after cancer treatment.

Who Must Get a Smear Test?

Since cervical cancer is one of the most prevalent cancers and a sharp decrease is detected in the prevalence of the disease and cervical cancer induced deaths thanks to the screening test, all women must get a smear test.

However, it is obvious that it would be irrational to scan everybody with the same frequency. Therefore, research as to the age woman must start getting the screening test and the frequency in which each woman will be scanned has been carried out and the need for detecting individuals who are at high and low risk of cervical cancer arose. Whereas 35 was previously considered as the critical age for starting getting screening tests, American Cancer Society accepted to divide women into two categories, namely high-risk and low-risk, and to determine the method of screening in 1988.

The society emphasized the fact that the time when sexual activity begins, rather than the age of 35, must be taken as a basis.

Who are in the High-risk Group for Cervical Cancers?

High Risk Group for Cervical Cancers:

First screening: At the age of 18 or at the beginning of sexual activity

Once a year in the high risk group

Every three months in the first 2 years following cancer treatment, every six months in the following 3 years and once a year afterwards

What Does Smear Show?

Cellular condition, hormonal condition and microbiological condition of a patient can be evaluated in preparates prepared by taking cervico-vaginal smear.

Vaginal infection factors such as cervical and vaginal cells, bacteria, trichomonas, candida, blood elements and sperms might be found in smear preparates.

Whereas the structure of cervical and vaginal cells provide information about cancer and lesions thaa are precursors of cancer, the number of these cell types reflects the hormonal condition. Therefore, smear images obtained from women in the reproductive age and women in menopause are different from each other.

How is the Evaluation Carried Out?

Direct observation of factors causing vaginitis in the microscopic investigation is quite helpful in the diagnosis of infection. However, especially trichomonas infections can be misdiagnosed as malign.

Results of the smear test are classified as several different schools. “Papanicolaou Classification” is the most frequent one.

“Bethesda Classification” which is much more detailed than the Papanicolaou Classification has gained popularity over the latter in the recent years.

Bethesda classification was modified in 1991. According to this classification which is gaining wide currency day by day, smear test is not a tool of diagnosis, it is just a medical consultation.

Bethesda Classification

Frequently reported definition in the presence of abnormal smear is “cervical intraepithelial neoplasia (CIN)”.

In this finding which is briefly referred to as CIN; CIN 1 defines dull dysplasia, CIN 2 defines mild dysplasia and CIN 3 defines severe dysplasia.

According to the Bethesda classification, on the other hand, CIN 1 is equal to LSIL and CIN 2 and 3 are equal to HSIL.

Whether the preparate prepared and the number of cells available in this preparate are sufficient for cytologic diagnosis must be specified.

What does Atypical Squamous Cells of Undetermined Significance (ASCUS) mean and what must be done?

In this case, some changes have been identified in the cells that form the epithelium that covers the uterine cervix as a result of the smear investigated. These changes are neither as insignificant as “reactive changes” we mentioned above nor as serious as squamous intraepithelial lesions (SIL). This means cellular changes that cannot be classified are observed.

Smear test for a case, the smear result of which is ASCUS, must be repeated every 3-6 months for 2 years.

Follow-up must continue until three normal smear test results are obtained in succession.

Furthermore, proper treatment must be administered during this period if infection or menopause-induced changes are detected in the cervix.

In the monitoring of ASCUS cases, it has been identified to a great extent that a significant lesion was not found and that repeated smear or colposcopic biopsies were normal.

However it has been observed that the ratio of development of squamous intraepithelial lesion (SIL) is higher when the second smear test appears to be ASCUS within two years or if another results is ASCUS during annual follow-ups.

Therefore, the HPV DNA test must be performed in these cases for colposcopic evaluation or HPV typing. 

Squamous Intraephitelial Lesions (SIL)

These lesions define observation of some changes that might become cancerous in cells forming the epithel lining the cervix. They are divided into 2 groups, namely Low Grade-LSIL and High-Grade-HSIL.

According to the former classification, LSIL defines CIN 1 cases and HSIL defines CIN 1 and CIN 2 cases.

What is LSIL?

Probability of these lesions to lead to cancerous changes is very low. Development of cervical cancer is a process. There is not a direct transformation from LSIL to cancer. It first progresses to a more advanced lesion after a certain time passes and then cancerous changes take place.

This process takes for about 15-20 years.

LSIL cases might regress of their own Accord, stay as they are or progress to a higher degree lesion.

However, the lesion regresses of its own Accord in 75% of LSIL cases.

Therefore, monitoring of the patient is a method that is preferred more frequently in these cases.

Only 1% of LSIL lesions progress towards cancer.

How is LSIL Treated?

Colposcopy must certainly be performed in all these cases.

Smear follow-up in 4-6 month intervals for 2 years will be sufficient in young patients with small lesions detected in colposcopy or in patients in which lesions cannot be detected or patients who have low risk factors.

The patient will be monitored with normal annual controls if negative smear results are obtained 3 times in succession.

Such surgical interventions as conization or LEEP might be preferred in cases holding high risk factors if colposcopy is not sufficient and if the lesion cannot be seen as a whole.

The lesion regresses by its own accord without performing any procedures in a very large part of the cases monitored.

What is HSIL? How it is Treated?

When HSIL is detected, it is thought of as a lesion that can lead to real cancer. Therefore,  treatment is a must in these cases.

The only exception to this rule is pregnancy and in this case, treatment must be postponed to postpartum period. The treatment is the excision of the lesion.

LEEP, conization and hysterectomy are treatment methods that will be decided upon considering the patient.

What is Colposcopy?

Investigation of the tissue under an optical system by way of making it bigger to a certain extent and performance of a biopsy in suspicious areas are possible thanks to the optical system called colposcopy. A colposcopy device and a gynecologist that is experienced on this field are needed to carry out this procedure.

Experience in the field of colposcopy is a must. This is because evaluation of the image obtained requires experience.

Is Smear Test Performed During Pregnancy?

It is ideal to go through a general examination when you decide to fall pregnant and have the smear test performed at this stage. However, in cases when this is not possible, your doctor ask you when you had your last smear test during your first pregnancy control. If it has been a long time since you had your last smear test, the doctor will perform a smear test. There are no reservations to having a PAP smear test during pregnancy.

Furthermore, although pregnancy reduces the risk of uterine, breast and ovarian cancers that might be experienced in an individual in advanced ages, it increases the risk of cervical cancers. Therefore, a routine smear test is performed by most doctors in the first three months of pregnancy.

Points That Must be Taken into Consideration Before the Procedure

Lack of sexual intercourse for a period of 24 hours before smear samples are taken will render the results more reliable.

No vaginal creams or medications must be used and vaginal shower must not be taken for a period of minimum 72 hours before smear samples are taken.

The ideal time for having the test is the period starting 10 day after your menstrual bleeding stops and ending in your following menstrual period.

Smear samples can be taken in the presence of bleeding if your bleeding is not too heavy and if it is considered necessary.

Another significant point is that the pathologist that will assess the smear must be experienced in this field.

How Reliable is the Smear Test?

Probability of obtaining a negative result, which is false, in smear screening is about 25%. That is, the probability that the result of the smear test turns out to be normal although the smear is clinically malignant is 25%. Many factors ranging from the mistakes in the smear sampling technique to the experience of the pathologist play a role here.

• Smokers
• Female Polygamists (women with more than one partners), OR women whose partners are polygamists
• Individuals having their first sexual experience in young ages
• Individuals carrying Human Papilloma Virus (HPV) infection
• Individuals taking birth control pills
  • Satisfactoriness
  • Satisfactory, Limited, Unsatisfactory
  • Definition
  • Normal
  • Benign
  • Epithelial cell abnormality
  • ASCUS (Atypical Squamous Cells of Undetermined Significance)
  • LSIL (Low grade squamous intraepithelial lesion)
  • HSIL (High grade squamous intraepithelial lesion)
  • Glandular cellular abnormality
  • AGUS (atypical glandular cells of undetermined significance)
  • Adenocarcinoma (cancer)