If all women had gynaecological examinations and Pap smears regularly, most pre-cancerous conditions would be detected and treated before cancer develops. That way, most invasive cancers could be prevented. Any invasive cancer that does occur would be found at an early stage with a much better chance for cure compared to advanced cancer.
During a gynaecological examination, the doctor checks the vagina, cervix, uterus, fallopian tubes, ovaries, and the bladder and rectum. The doctor feels these organs for any abnormality in their shape or size. A speculum is used to open the vagina so that the doctor can see the vaginal walls and the visible part of the cervix.
Taking a Pap smear is a simple, painless procedure to detect abnormal cells, which may be present on the cervical surface or inside the cervical canal. A woman should have this test when she is not menstruating; the best time is between 10 and 20 days after the first day of her menstrual period. However, if bleeding is prolonged or abnormal a Pap smear should be taken regardless of bleeding. The abnormal bleeding may be a sign of cervical cancer. For about two days before a Pap smear, she should avoid douching or using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a medical practitioner), which may interfere or mask the detection of any abnormal cells.
A Pap smear can be done in a doctor's office or at a health clinic. A wooden scraper (spatula) and/or a small brush is used to collect a sample of cells from the cervix, cervical canal and back wall of the vagina. The cells are placed on a glass slide, fixed with a fixative spray and sent to a laboratory to be examined for abnormal changes.
The way of describing Pap test results has changed over the years. The present method is called the Bethesda System, where changes are classified as low-grade or high-grade SIL. Many doctors believe that the Bethesda System provides more useful information than older classifications. Women should ask their doctor to explain the classification system used for their Pap smear interpretation.
If the smear is abnormal, a method called colposcopy is used to examine the cervix in detail. The doctor applies a vinegar-like solution to the cervix and then uses a magnifying instrument much like a microscope (called a colposcope) to look closely at the cervix. The vinegar solution (acetic acid) causes abnormal surface cells to turn white, which helps in the localisation of abnormal areas from which small pieces (biopsies) need to be taken. The doctor may also apply an iodine solution to the cervix (a procedure called the Schiller test). Healthy squamous epithelial cells turn brown; abnormal cells remain unchanged or may turn yellow. These procedures can all be done in the doctor's office.
The doctor may remove a small amount of cervical tissue (this procedure is called a biopsy) to be sent and examined by a pathologist. If the doctor can identify an abnormal lesion colposcopically, he uses an instrument to pinch off small pieces of cervical tissue. The biopsy is about the size of a normal freckle and may be slightly uncomfortable. Another method used to take a larger biopsy is called large loop excision of the transformation zone (LLETZ), or in America: loop electrosurgical excision procedure (LEEP). In this procedure, the doctor uses an electrical wire loop to slice off a larger piece of tissue. These types of biopsies may be done in the doctor's office using local anaesthesia.
These procedures for removing tissue may cause some bleeding or other discharge. It is advised to abstain from sexual intercourse until the cervix has healed. Women also often experience some pain similar to menstrual cramping, which can be relieved with simple pain killers like paracetemol.
Sometimes, colposcopically guided biopsies or electrical loop tests may not be feasible, for example due to anatomical or technical reasons. Or the tests may not show for sure whether the abnormal cells are present only on the surface of the cervix. Under these circumstances, the doctor will then remove a larger, cone-shaped sample of tissue by means of surgical excision. This procedure is called conisation or cone biopsy. It requires either local or general anaesthesia and is usually done in hospital. The obtained specimen allows the pathologist to see whether the abnormal cells have invaded the tissue beneath the surface of the cervix. Conisation may also be used as treatment for a pre-cancerous lesion. It is important to inform your doctor if you may be pregnant at the time of a biopsy. The biopsy should be delayed until after the delivery.
In a few cases it may not be clear whether an abnormal Pap smear or a woman's symptoms are caused by changes of the cervix or of the endometrium (the lining of the uterus). In this situation, the doctor may look inside the uterus (hysteroscopy). The doctor stretches the cervical opening and uses a special endoscope (a thin long camera lens) to assess the uterine cavity. The doctor can then take biopsies from any visibly abnormal area or use a curette to scrape tissue from the lining of the uterus (endometrium) as well as from the cervical canal. Like conisation, this procedure requires local or general anaesthesia and may be done in the doctor's office or in the hospital.
If facilities for hysteroscopy is not available a dilatation and curettage (D&C) may be done. The doctor stretches the cervical opening and uses a special instrument to scrape tissue from the lining of the uterus which is called the endometrium. This tissue is then sent for examinitation by a pathologist.
(Reviewed by Professor Lynette Denny, Gynaecology Oncology Unit, Department Obstetrics & Gynaecology, University of Cape Town/Groote Schuur Hospital)