UNIT

ONE: APPROACH TO THE PATIENT EDUCATIONAL TOPIC 3: PAP SMEAR AND DNA PROBES/CULTURES
Rationale: The Pap smear is one of the most effective screening tests used in medicine today. Proper technique in performing the Pap smear and obtaining specimens for DNA probes and/or microbiologic culture will improve accuracy. Intended Learning Outcomes: The student will demonstrate the ability to: Perform a Pap smear Obtain specimens to detect sexually transmitted infections Explain the purpose of these tests to the patient TEACHING CASE CASE: JA is a 21-year-old G0 female who presents for an annual exam. She had an abnormal Pap smear reading of ASCUS with + HPV 3 years ago followed by a colposcopy, but no biopsies were performed. Her follow-up Pap smears were normal and the last one was 1 year ago. She is currently sexually active with a new partner for the last 2 months, and has had four lifetime partners. She does not report any history of sexually transmitted diseases. She is currently using birth control pills for contraception. She is just finishing her menstrual cycle and is spotting; her periods are regular without problems. Her review of systems is negative. She smokes one pack of cigarettes per week; she does not drink and states that she has occasionally used marijuana. Her vitals and physical exam are normal. COMPETENCY-BASED DISCUSSION & KEY TEACHING POINTS: Competencies addressed: Patient Care Medical Knowledge Interpersonal and Communication Skills 1. What are the different techniques available to obtain a pap smear? Discuss conventional Pap smear and Thin Prep: Both collected from the endocervical canal and transformation zone with spatula and cytobrush or cytobroom. Thin prep is the most widely used technique. Do not use any gel prior to performing the Pap smear. Discuss the importance of properly labeling specimens and sending it off to the lab promptly. 2. In addition to performing a Pap smear, what cultures might you recommend for this patient, and how do you proceed in obtaining them?

Since the patient is sexually active with a new partner, you should offer her screening for sexually transmitted diseases including gonorrhea and chlamydia. All sexually active patients under the age of 25 should be screened annually for chlamydia. A patient who is between the age of 21- 30 only needs a pap test every two years. Screening for chlamydia need not involve a speculum exam as chlamydia testing can be performed via urine screen. One may consider annual pap tests for this patient due to her multiple risk factors for developing cervical cancer. After performing the Pap smear, you wipe any excess cervical mucous and you insert the cotton swab to collect the cultures or the DNA probe in the endocervical canal. 3. How often does this patient need to undergo a Pap smear? Patients who have had an abnormal Pap smear previously will need more frequent Pap smears based on the actual abnormality. For this patient, since it appears that she had normal follow-up, she needs to continue to have Pap smears every 2 years assuming this one is normal. 4. What risk factors does this patient have for cervical dysplasia and cancer? Multiple partners, sexual activity at an early age, history of abnormal Pap smear, smoking. 5. If while performing the speculum exam, you notice a gross lesion on the cervix, what would your next step in management be? Any gross lesion on the cervix will need to be directly biopsied as Pap smears have a false negative rate and cervical cancer might be missed. 6. What other counseling or advice you need to discuss with this patient? Discuss the importance of cervical cancer screening guidelines. Offer the patient blood testing for other sexually transmitted infections such as syphilis, HIV, and hepatitis B and C. Discuss the importance of safe sex practices.

REFERENCES Beckman CRB, et al. Obstetrics and Gynecology. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2009. Hacker NF, Moore JG, et al. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia: Saunders, 2010.

ACOG Practice Bulletin 109, Cervical Cytology Screening, December 2009.