Explaining Your Cervical Smear Results
Author – Kalyani Shinkar Editor – Mohona Sengupta
Last updated 26/05/24
Table of Contents
Introduction
The cervical smear test, also known as a Pap smear or Pap test, is a screening test used to detect abnormal cells on the cervix. Explaining an abnormal cervical smear test is a common OSCE scenario that requires effective communication and sensitivity to the patient’s emotional state and level of understanding. This article provides a detailed step-by-step guide on how to convey all the necessary information to patients about an abnormal cervical smear test.
Steps
- Introduce yourself, confirm patient details, and gain consent to speak to the patient.
- Read the exam instructions carefully before entering the station. If the station requires you to take a history, important questions you can ask the patient include:
- “When did you have the smear test?”
- “Have you had a smear test before? If so, what were the results of those tests?”
- “Are you vaccinated against HPV?”
- Take a sexual history (e.g. “Are you sexually active? How many sexual partners do you have? Do you use contraception? If so, what type of contraception do you use?”) https://mlamedics.com/contraception-counselling/
- Past Medical History – “Do you have any past medical history?”
- Drug History – “Are you on any medications?”
- Family History – “Do you have any conditions that run in the family, such as cancer?”
3. Check the patient’s baseline understanding of smear tests
- “Do you know the reason for carrying out a smear test?”
- “Do you know what the smear test looks for?”
4. ICE the patient:
- Ideas – “Do you know what a smear test is and what it shows?”
- Concerns – “Are you worried/concerned about anything in particular?”
- Expectations – “What were you hoping to get out of today’s consultation other than discussing your smear test results?”
5. Explain the purpose of a smear test and what it looks for
- “The smear test is a screening test used to detect abnormal cells in the neck of your womb (cervix).
- “It involves taking a small sample of cells from the neck of your womb and testing the cells to see if you have HPV infection or not”
- “HPV is a common sexually transmitted infection that is often harmless. However, there are some types that can cause cancer”
- “If the cells test positive for HPV, the cells get looked at closely under a microscope to see if there are any changes to the cells”
- “If there are changes and the cells are abnormal, this can increase your chance of developing cervical cancer. The good news is we can remove these abnormal cells and prevent cervical cancer from developing”
- “The smear test does not test for cancer, but detects abnormal cells, which could go onto become cervical cancer if left untreated. An abnormal test result does not mean that you have cervical cancer or that you will definitely go onto have cervical cancer”
6. Explain the next steps (colposcopy)
- “We have referred you for a procedure called colposcopy, which involves using a microscope (colposcope) to have a closer look at your cervix. The procedure is often done using local anaesthetic, which numbs the cervix, but can sometimes be done under general anaesthetic. Similar to a smear test, the doctor will ask you to lie on a bed with your legs out to either side of you, and a speculum will be inserted. A speculum is a small, thin plastic tube that is inserted into the vagina to visualise the cervix. The doctor will use an instrument called a colposcope (type of microscope), which will be placed close to your vagina through which the doctor will examine the cervix. They will use a special dye (acetic acid) to visualise the cells more clearly and may take tissue samples (biopsies) from any suspicious areas. This should not be painful, but you may experience a stinging sensation when the dye is applied. You may also experience a small pinch or scratching sensation when the biopsy is taken. The biopsy will then be sent to a lab for analysis. In some instances, the biopsy may be used as treatment to remove the abnormal cells.”
Image 1: Abnormal cells appear white following the application of acetic acid. These areas are more likely to be precancerous.
- “Depending on what the results of the biopsy show, your doctor will discuss what will happen next. You may require additional tests or you may be referred back to the regular cervical screening programme.”
- NB – If the patient’s biopsy shows CIN2 or CIN3, the abnormal cells will need to be removed with a LLETZ (large loop excision of the transformation zone) procedure or cold coagulation. LLETZ is more commonly performed and uses a thin wire to cut away abnormal cells. Cold coagulation involves burning away the abnormal cells with a heated probe. The patient will then be invited for a follow-up screening test 6 months after treatment, usually at their GP practice, which involves having a cervical smear test to check that the abnormal cells have been removed.
Image 2: Summary of Management Steps after an Abnormal Cervical Smear Test
7. Explain what happens after having colposcopy
- “After the procedure, you will likely be able to go home straight afterwards”
- Potential side effects – “You may experience some mild pain or bleeding for a few days after the procedure, especially if a tissue sample (biopsy) was taken. You can take some pain relief medication to help manage the pain.”
- Safety netting – “The procedure is safe, but there is a small risk of infection and you may experience heavy bleeding afterwards. If this happens, please contact the colposcopy team looking after you immediately.”
8. Closing the consultation
- If there is time left at the end, you can summarise what you have discussed and ask if the patient has any questions. “We have discussed the purpose of a cervical smear test and talked about your test results, including what the next steps are. Does that all make sense? Do you have any questions for me?”
- You can encourage preventative measures e.g. attending regular cervical screening appointments, HPV vaccination (if relevant), and practising safe sex.
- Provide them with a leaflet or signpost them to useful resources (e.g. NHS website)
General Tips/Advice
- During your explanation, remember to ‘chunk and check’ to facilitate patient understanding
- Provide support and reassurance throughout the discussion and encourage the patient to ask questions if they have any. They may feel anxious and think they are being diagnosed with cervical cancer following an abnormal cervical smear test result. It’s therefore important to offer reassurance and clarify their test result does not imply a diagnosis of cervical cancer.
Viva Questions
What is HPV and what is its association with cervical cancer?
Human papillomavirus (HPV) is a virus that infects the skin and mucous membranes of humans. There are several different types of HPV, which can be categorised into low-risk and high-risk types based on their association with cancer:
- Low-risk HPV: These types (e.g. HPV-6 and HPV-11) are associated with benign conditions such as genital warts.
- High-risk HPV: These types (e.g. HPV-16 and HPV-18) are associated with the development of cancers, including cervical cancer.
There is a well-established link between high-risk HPV types and cervical cancer, with persistent infection with high-risk HPV types being the leading cause of cervical cancer.
HPV is transmitted through sexual contact, and the majority of sexually active individuals will be infected with HPV at some point in their lives. Most HPV infections, however, will be cleared by the body’s immune system without causing any problems. In a minority of cases, the infection can persist and cause dyskaryosis, which can develop into cervical cancer if left untreated.
What is dyskaryosis?
Dyskaryosis is a term used in cytology and refers to the presence of abnormal (pre-cancerous) changes in squamous epithelial cells lining the ectocervix. Dyskaryotic cells can vary in severity and are often categorised into mild (low-grade), moderate (high-grade), or severe (high grade).
What is CIN1/2/3?
Cervical intraepithelial neoplasia (CIN) refers to abnormal changes in the cells of the cervix, similar to dyskaryosis. In contrast, CIN is detected on histology (not on cytology) and is determined through examination of cervical tissue obtained through colposcopy-guided biopsy. CIN is often categorised into 3 grades based on the severity of cell abnormalities:
- CIN1 (equivalent to mild dyskaryosis)
- Refers to low-grade changes in cervical cells. Only a small proportion of cervical tissue contains abnormal cells, and the changes are often considered low risk for progression to cervical cancer
- Many cases of CIN1 resolve on their own and do not require further treatment. Regular monitoring, however, may be required.
- CIN2 (equivalent to moderate dyskaryosis)
- Refers to moderate changes in cervical cells. A larger proportion of the cervical tissue contains abnormal cells compared to CIN1.
- Treatment is often required.
When are people invited for cervical cancer screening?
- From 25-49 every 3 years
- From 50-64 every 5 years