Normal cervix after application of acetic acid Cervical Ectropian Nabothian follicles The Post Menopausal cervix Cervical Polyp Cervical Warts Satisfactory With evidence of TZ sampling TZ – Squamous Metaplastic cells Transformation zone Acute Herpes Infection Herpes Simplex Strawberry Cervix Trichomonas Vaginalis Candida infection Actinomyces Threadworm ova Fibroid polyp Unsatisfactory smears • 2% • Can we reduce the incidence? Unsatisfactory • Scanty cellular material • Heavy blood staining • Cellular material obscured by debris or polymorphs • Lubricating gel in excess • Patient identity problem • Progesterone only contraception • Thin Prep pot past expiry date SMEAR TAKING • Always employ good technique • The cervix must be visualised • Any specimen with abnormal cells is by definition satisfactory for evaluation Bacteria and debris Mucus Atrophy • Range of speculum sizes available • Possible to give topical vaginal oestrogen for a week or two before attempting repeat smear if atrophy and dryness a problem Lubricant • Lubricants containing carbomers or carbopol polymers are prone to interfere with liquid based cytology • BSCC Guidelines recommend that if lubrication of the speculum is required a little warm water should be adequate. • Only use a small amount of a water soluble lubricant if absolutely necessary Lubricant Lubricant Lubricant Lubricant Lubricant • Patient Identity Problem automatically returned as unsatisfactory Risk factors for cervical neoplasia • Human Papilloma Virus especially oncogenic strains eg HPV 16,18,32 • Smoking • Multiple sexual partners • Sexual encounters at a young age • Immunosuppression (HIV positive) Borderline change in squamous cells • From April 2013 what used to be called Borderline with Koilocytic (i.e. HPV changes) is now reported as Low Grade Dyskaryosis. • Borderline now reflects inflammatory changes and interpretation difficulties – allows the cytologist to request a repeat sample Borderline Outcome 70 60 50 40 3-D Column 1 30 3-D Column 2 3-D Column 3 20 10 0 Neg HPV CIN1 CIN2 CIN3 Low Grade Dyskaryosis Koilocytes – HPV infection Koilocyte CIN 1 CIN 1 Management of CIN 1 • CIN 1 has low rate of progression • 50% can regress over 2 years • Kept under surveillance • Annual smear • Treated at progression or if changes persist at end of surveillance period Low Grade Dyskaryosis Outcome CIN 1 600 500 400 300 200 100 0 Neg HPV CIN1 CIN2 CIN3 High Grade squamous dyskaryosis (moderate) CIN 2 CIN 2/HPV High Grade Dyskaryosis (Moderate) Outcome 200 180 160 140 120 East 100 West 80 North 60 40 20 0 Unsat Neg HPV CIN 1 CIN 2 CIN 3 High Grade squamous dyskaryosis (severe) CIN 3 CIN 3 CIN 3 in glands High Grade Dyskaryosis (Severe) Outcome 250 200 150 East West 100 North 50 0 HPV CIN 1 CIN2 CIN3 CIN 3 LETZ BIOPSY FROM COLPOSCOPY LETZ CAREFULLY SLICED AND KEPT IN ORDER & INKED Results of Treatment • 95% success rate in all methods at first treatment • Recurrences occur primarily in 1st and 2nd years • Until now follow up has been 2 smears 6 months apart then if negative yearly for next 4years return to Routine Recall • Now the first post treatment smear at 6 months has cytological assessment and is tested for high risk HPV • If both Negative return to Routine Recall Squamous carcinoma Colposcopy Cervical cancer • The screening programme was designed to pick up squamous lesions • Endocervical glandular epithelium also undergoes premalignant change-Cervical Glandular Intraepithelial Neoplasia (cGIN ) • The malignant change from glandular epithelium is Adenocarcinoma Glandular abnormality • Endometrial Abnormalities can be picked up on smear. • Post menopausal bleeding should always be referred to Gynaecology for Endometrial biopsy. • Endometrial cells on a smear will be commented on after the age of 40. Is Screening Working? • Cervical screening, for all its imperfections, prevents a lot of cancers and saves a lot of lives. Is screening working? • The biggest risk factor is not attending for a smear test. • A single screen at the age of 40 reduces the cumulative incidence of cervical cancer by 20% • 5 yearly screening (20 – 64) reduces the cumulative incidence of cervical cancer by 83.6% • 3 yearly screening (20 –64) reduces the cumulative incidence of cervical cancer by 91.2% • At the end of 2015 screening is likely to start at 25 yrs. • HPV testing as a primary screening tool is under discussion at government level and is likely to be implemented but probably not before 2017. .