First, elevate the head of the exam table to 30 to 45 degrees and assist the patient in placing her heels in the footrests, adjusting the angle and length as needed.
Carefully cover the patient's abdomen and legs down to her knees with a sheet.
Ask patient to slide down to the edge of the table and relax her knees outward just beyond the angle of the footrests.
External inspection and palpation
Look for any redness, swelling, lesions or masses.
Inspect the labia, the folds between them, and the clitoris, paying attention to any redness, swelling, lesions, or discharge.
Use a warm and lubricated speculum for the examination. (There is some controversy about whether gel-based lubricants distort cytologic assessment. For this reason, the speculum is lubricated with warm tap water or a thin layer of gel lubricant, avoiding the tip of the speculum. You should know what is recommended by the laboratory in your area.)
Inform the patient that you are about to begin the speculum exam.
Expose the introitus by spreading the labia from below using the index and middle fingers of the non-dominant hand (peace sign).
Insert the speculum at a 45-degree angle, pointing slightly downward being careful to avoid contact with the anterior structures.
Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle is almost flush with the perineum.
Open the "bills" of the speculum 2 or 3 cm using the thumb lever until the cervix can be visualized between the bills.
In this example, the sample is obtained using an extended tip spatula and then a cytobrush. There are also several other collection devices commonly used in practice.
First, the spatula is rotated several times to obtain a sample from the ectocervix. The cytobrush is then inserted into the os and rotated 180 degrees.
Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell division and where dysplastic cells originate) is adequately sampled.
The sample is then placed into a liquid medium.
Using the liquid-based system over the conventional Pap smear technology allows for later testing of the sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal.
Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out which system is preferred.
Once the sample is obtained, let the patient know the speculum is about to be withdrawn.
Then, withdraw the speculum slightly to clear the cervix, loosen the speculum and allow the "bills" to fall together, and continue to withdraw while rotating the speculum to 45 degrees.
Two Methods of Obtaining Cytological Specimens
In a conventional Pap smear, cells are obtained from the ectocervix by using an Ayers spatula and the endocervix by using a cytobrush. The specimen is then rolled (cytobrush) and smeared (spatula) onto a slide and then rapidly fixed to prevent air-drying. A single slide is used for both the ectocervical and endocervical samples. In the newer liquid-based systems, the sample is collected in a similar fashion, except an extended tipped plastic spatula is recommended along with the cytobrush.
The sample is obtained using the broom-like device alone or both the extended tip spatula and then a cytobrush. The samples are then quickly placed into an alcohol based preservative solution. There are currently two liquid based systems approved by the FDA; the ThinPrep system and the Sure Path system. Both liquid based systems appear to be as good as, or better than, conventional technology in diagnosing intraepithelial lesions and for obtaining adequate specimens. The liquid-based technology has the advantage of being able to co-test for HPV.
Performing a Bimanual Exam
Screening for ovarian cancer with a bimanual exam is not recommended, however this is the technique you would use should you need to do the exam for a symptomatic patient.
First, explain to your patient what you are going to do.
Next, apply lubricant (e.g., K-Y jelly) to the index and middle fingers of your non-dominant gloved hand and insert them into the patient's vagina.
Move cervix side to side (laterally) to ensure that it is non-tender and mobile.
Place your non-gloved hand [I’d recommend wearing gloves on both hands] on the abdomen just superior to the symphysis pubis, feeling for the uterus between your two hands. This gives you an idea of its size and position.
Then, moving your pelvic hand to each lateral fornix, try to capture each ovary between your abdominal and pelvic hands. The ovaries are usually palpable in slender, relaxed women, but are difficult or impossible to feel in obese women.
Cervical Cancer Screening Guidelines
In 2012, the American College of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP) and USPSTF came to a consensus on cervical cancer screening.
The guidelines recommend that:
At age 21: cervical cancer screening should begin.
Between ages 21 and 29: screening should be performed every three years.
Between ages 30 and 65: screening can be done every five years if co-tested for HPV (preferred) or every three years with cytology alone (acceptable).
However, they stipulate that certain risk groups need to have more frequent screening. They include women with compromised immunity, who are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971).
Women older than 65 years who have had adequate screening within the last ten years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing.
Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.
Sexual behaviors associated with an increased cervical cancer risk include:
Early onset of intercourse
A greater number of lifetime sexual partners
Other risk factors include:
Diethylstilbestrol (DES) exposure in utero.
Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increasing the risk by up to fourfold.
Immunosuppression, which also significantly increases the risk of developing cervical cancer.
The Pap test generally shows one of the following:
-low-grade squamous epithelial cells (LSIL)
-high-grade squamous epithelial cells (HSIL)
-atypical glandular cells of undetermined significance (AGUS)
-atypical squamous cells of undetermined significance (ASC-US)
ASC-US is considered an inconclusive pap test result that requires follow-up testing to determine appropriate patient management. An ASC-US Pap test result is often triaged by HPV testing when using liquid-based cytology.
Reflex HPV testing is easily performed as a follow-up test by utilizing residual cells from the liquid-based Pap test vial to test for the presence or absence of high-risk HPV.
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