Actinomycosis

Actinomycosis is a fungus that is occasionally identified on Pap smear and for the most part is an incidental finding, posing no threat to the patient.

Its’ clinical significance controversial. IUD users sometimes (but rarely) develop pelvic abscesses from this organism. For that reason, some physicians have recommended removal of the IUD in asymptomatic patients if Actinomyces are present. Others disagree, believing that removal of the IUD in patients with no symptoms is an over-reaction to a very small chance of a problem.

Atrophy

Atrophy is an expected finding in menopausal women not taking estrogen replacement therapy.

• If this is the only abnormal finding and the patient has no symptoms, it can be safely ignored.
• If the patient complains of vaginal dryness, irritation, painful intercourse, vaginal discharge, odor, or other symptoms, then the Pap finding of atrophic vaginitis is helpful in determining the cause.
• If the Pap smear has other abnormalities, treating the patient for 2-3 weeks with Premarin and then repeating the Pap will often result in the other abnormality disappearing.

Atypical Squamous Cells of Undetermined Significance (ASCUS)

ASCUS (Atypical Squamous Cells of Undetermined Significance) is the way the cytologist tells you that there is something on the patient’s Pap smear that is not perfectly normal, but they can’t tell with any certainty what it is or whether it is significant.

ASCUS smears are handled differently in different circumstances:

• If this is the first time any abnormality has been found on the patient’s Pap smears, most gynecologists recommend simply treating any coincidental infection (if present) and repeating the Pap in 6 months. Should the abnormality persist, then colposcopy is usually recommended for the persistent ASCUS result.
• If the patient has previously been evaluated for an abnormal Pap and found to have either mild dysplasia or HPV changes, the occurrence of an occasional ASCUS smear is not surprising and is often considered normal for that person. In higher risk circumstances, further colposcopy is sometimes undertaken to re-evaluate the cervix.
• A patient with (1) a past history of cervical dysplasia, who (2) has had many normal Pap smears following treatment, and who (3) develops ASCUS should probably be re-evaluated colposcopically if she has not had that procedure done recently, as this could represent the beginning of a new problem.

Candida (Monilia, Yeast)

Candida or yeast is occasionally identified on Pap smear and for the most part is an incidental finding, posing no threat to the patient.

If the patient is experiencing symptoms (itching, burning, or cheesy discharge), then she should be treated for a yeast infection.

If the Pap smear shows…

• Significant inflammation, or
• Reactive changes, or
• Reparative changes, or
• Class II or Class IIA category, or

…then some physicians favor treating the yeast infection (which makes the Pap smear easier to read) and then following up with another Pap smear. Other physicians feel that is not necessary so long as the patient continues to come in annually for a Pap smear. Any abnormality not seen because of an obscuring yeast infection, they reason, will be seen at the next Pap smear.

If you are preparing to investigate a more serious abnormality with colposcopy, then it is usually worthwhile treating the yeast to try to reduce the confusing picture of inflammation that may be present.

If the Pap smear is otherwise normal and the patient without symptoms, Candida appearing on the Pap smear can be safely ignored and the Pap repeated in 1 year.

Chlamydia

Chlamydia is a common sexually-transmitted illness. It can be found in 5-20% of asymptomatic women, depending on their sexual history. In the majority of cases, it causes no problems, but in some patients, it causes:

• PID (pelvic inflammatory disease)
• Infertility
• Cervicitis

Whenever chlamydia is suggested on a Pap smear, you have two alternative approaches:

• Assume chlamydia is present, treat the patient with Doxycycline (or erythromycin or Azithromycin), and then perform a chlamydia culture to insure it has been eradicated, or
• Bring the patient in for a chlamydia culture. If positive, treat it. But if the culture is negative, then ignore the Pap smear finding.

Coccoid Bacteria

The presence of these bacteria on an otherwise normal Pap smear is of no consequence.

If the Pap shows inflammation sufficient to obscure the reading and the cytologist asks for an earlier-than-normal repeat Pap, many physicians will treat the patient with a broad-spectrum antibiotic suitable for strep and anaerobic bacteria (Flagyl, Amoxicillin, etc.) before repeating the smear. Others will simply repeat the smear at a somewhat earlier than normal time.

If the Pap is otherwise normal, but the patient complains of symptoms of vaginal discharge, bad odor or irritation,

the presence of coccoid bacteria on the Pap smear is sometimes used as the basis for treatment using broad-spectrum antibiotics effective against strep and anaerobes.

In the absence of symptoms or other abnormality on the Pap, the presence of coccoid bacteria is not considered clinically significant and needs no treatment.

Condyloma

An abnormality in the appearance of the cells of the skin of the cervix which suggests the presence of condyloma (venereal warts). Condyloma are not by themselves dangerous, but require further investigation, because:

• Condyloma are caused by HPV, the same virus which is associated with cervical dysplasia and cancer of the cervix.
• The Pap changes which suggest condyloma have basically the same clinical significance as the changes suggesting low grade intraepithelial lesions (LGSIL), CIN I, and mild dysplasia.

Patients demonstrating condyloma on their Pap smears who previously had normal Paps are ideally evaluated with colposcopy and cervical biopsies to determine the precise diagnosis, extent of the problem, and rule out other, more significant illness.

Drying Artifact

The Pap smear must be sprayed with cytology fixative immediately (within seconds) of spreading the smear on the glass slide. The slide should be soaked so that the fixative will begin to fall off the slide if it is tilted (don’t tilt it to see as you may lose some cells).

Many physicians avoid the problem of drying by leaving the speculum in place while they obtain their specimen, spread it on the slide and immediately fix it with spray.

Endocervical Cells not Present

The presence of endocervical cells on a Pap smear is an indication that the smear included sampling of the cervical canal and, by inference, the squamo-columnar junction. If endocervical cells are not seen, it may mean:

• You did not sample high enough in the cervical canal.
• Your sampling was fine, but the cytologist didn’t recognize the cells.

Some physicians feel that any Pap without endocervical cells should be repeated. However, studies have demonstrated that Paps without endocervical cells are still very effective in detecting abnormalities.

Pap smears obtained at a 6-week postpartum visit often do not have endocervical cells present.

If your Pap smears consistently show “no endocervical cells,” you may wish to review your basic Pap smear technique to be sure you are taking a high enough sample.

Endometrial Cells are Present

If the Pap smear says that endometrial cells are present, this means that endometrial cells, which are normally located inside the uterus, have been shed and are appearing at the mouth of the cervix.

This is a normal finding in women of childbearing age, particularly if they are close to starting or just finishing their menstrual period. Menopausal women taking estrogen replacement therapy may also normally show a few endometrial cells on their Pap smears from time to time.

In menopausal women not taking estrogen replacement therapy, the presence of endometrial cells is an abnormal finding and should be followed up with further study, such as an endometrial biopsy, or sonohysterogram, to try to determine the reason for the presence of these cells.

Estrogen Effect

Estrogen has a predictable effect on the cells of the cervix and the absence or presence of estrogen can be determined on the Pap smear.

In women of childbearing age, or menopausal women taking estrogen replacement therapy, the Pap would be expected to show an “estrogen effect,” and its’ absence would be a curiosity, though not dangerous.

In menopausal women not taking estrogen replacement therapy, the presence of detectable “estrogen effect” would suggest some non-ovarian source of estrogen and the long-term effects of unopposed estrogen should be considered.

Gardnerella

The presence of Gardnerella on an otherwise normal Pap smear in a patient without symptoms is of no consequence.

If the Pap shows inflammation sufficient to obscure the reading and the cytologist asks for an earlier-than-normal repeat Pap, many physicians will treat the patient with Flagyl before repeating the smear. Others will simply repeat the smear at a somewhat earlier-than-normal time.

Herpes

If the Pap smear demonstrates giant cells with intranuclear inclusions, the cytologist may report “possible herpes virus.”

In the asymptomatic patient with an otherwise normal Pap smear, this is of no clinical significance. Some physicians will bring the patient back for a herpes culture (if her history is negative for herpes), while others will ignore this finding.

If the Pap shows significant degrees of inflammation, the presence of herpes virus may explain the inflammation. A follow-up Pap avoiding any time of herpes recurrence may give more reliable information. In patients suspected of having herpes, a herpes culture is ideal for confirming the diagnosis.

HPV

If HPV is described in the Pap results, it represents an abnormality in the appearance of the cells of the skin of the cervix which suggests but does not confirm the presence of human papilloma virus (HPV).

This finding is often based on the presence of “koilocytes,” having enlarged nuclei, surrounded by a clear “halo” of cytoplasm. Koilocytes often (but not invariably) point to the presence of virus in the cells.

Patients demonstrating these changes who previously had normal Paps are ideally evaluated with colposcopy and cervical biopsies to determine the presence or absence of HPV.

Inadequate Smear

An inadequate smear means the quality of the Pap smear is not sufficiently good to give a reliable interpretation. The smear may be inadequate because:

• An insufficient number of cells were present.
• The slide had too many RBCs on it.
• The slide had too many WBCs on it.
• The cells had dried out before fixative was applied to the slide.

An inadequate smear should be repeated, using good technique and fixing the slide with appropriate spray immediately after the cells are smeared on the glass. Before repeating the Pap, you may want to treat any infection that is present (to eliminate the WBCs) and make sure the patient is not on her period (to eliminate the RBCs).

Inconclusive Smear

An inconclusive smear usually means that there are too few cells to be certain of the diagnosis, or there are confusing findings and the cytologist is warning you not to rely too strongly on this smear.

It is wise to repeat “inconclusive” smears. Before repeating the Pap, treat any infection that may be present, avoid her menstrual flow, get a good, representative sample, and apply the fixative immediately.

Inflammation

Inflammation merely means the cervix is irritated for some reason. In the absence of any symptoms or any other significant abnormality on the Pap, it can be safely ignored.

If inflammation is severe enough, it may interfere with the ability of the cytologist to accurately read the Pap. Inflammation by itself need not be treated. If other abnormalities are identified in addition to the inflammation, you may treat the other problems and the inflammation will probably go away.

IUD Changes

These are minor changes seen on the Pap smears of some women with IUDs. It is of no clinical significance.

Koilocytosis

A distinctive abnormality in the appearance of the cells of the skin of the cervix, in which some of the nuclei are surrounded by tiny “halos.”

Most commonly, these changes occur in the presence of HPV (Human Papilloma Virus) but occasionally are associated with more serious problems such a cervical dysplasia or even early malignancy.

Patients demonstrating koilocytosis who previously had normal Paps are ideally evaluated with colposcopy and cervical biopsies to determine the source of the koilocytes.

Leptothrix

This curious bacterium is occasionally found in large numbers in the vagina and cervix. It apparently causes no harm and is not considered a pathogen. It would not be worth noting except for two characteristics:

• It can live comfortably with Trichomonas.
• It can resemble yeast on a wet mount.

It may safely be ignored.

Nuclear Atypia

An abnormality in the appearance of the nuclei of the cells of the skin of the cervix.

Most commonly, these changes occur in the presence of HPV (Human Papilloma Virus) but occasionally are associated with more serious problems such a cervical dysplasia or even early malignancy.

Patients demonstrating nuclear atypia who previously had normal Paps are ideally evaluated with colposcopy and cervical biopsies to determine the source of the atypia.

Reparative and Reactive Changes

Changes in the skin cells of the cervix which suggest that a healing process is underway or that the cervix is reacting to the presence of a virus or bacteria.

While these changes are not dangerous, their presence often provokes gynecologists to repeat the Pap smear at a sooner-than-expected time (such as 6 months, rather than 1 year after the previous Pap). The reasons for this increased surveillance are:

• Reactive or Reparative changes make the Pap more difficult to interpret, so that the clinician cannot be as reassured by this Pap as he/she would by a Pap without these changes, and
• Distinguishing between reactive/reparative changes and early dysplasia is difficult and the Pap interpretation may be incorrect.

Other gynecologists feel that in a patient with previously normal Pap smears, the first appearance of reactive/reparative changes is not cause for alarm and they will repeat the Pap at the next annual examination. They reason that should there be an underlying dysplastic process, the progression of dysplasia is usually so slow that there is no particular advantage to repeating the smear sooner than the annual exam.

SIL (Squamous Intraepithelial Lesion)

This is a general term for dysplasia.

Low grade SIL (LGSIL) includes mild dysplasia, HPV changes, and CIN I. These are considered “low grade” because the risk of progression to malignancy is small (10% or less).

High grade SIL (HGSIL) includes moderate dysplasia, severe dysplasia, carcinoma in situ, CIN II and CIN III. These are considered “high grade” because many of them (although not all) will progress ultimately to invasive cancer of the cervix if not treated.

Squamous Metaplasia

This is an innocent finding that represents the normal squamous epithelium of the face of the cervix overgrowing the columnar epithelium of the cervical canal. Squamous metaplasia need not be treated.

Trichomonas

This microorganism is usually treated when identified on Pap smear. Trichomonas causes substantial inflammation of the cervix and makes the job of interpreting the Pap smear more difficult.

After treating the patient with Flagyl, the smear should be repeated in about 3-6 months…long enough to allow complete resolution of any lingering inflammation, but sooner than 1 year.

If there is other evidence of a significant cervical lesion (dysplasia) then the Pap may be repeated sooner after treatment.