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Cervical smear tests

VOL: 96, ISSUE: 42, PAGE NO: 7

Katherine Franklin, SRN, DipN, is a gynaecology nurse specialist, colposcopy clinic, Watford General Hospital

Cervical screening aims to prevent cancer of the cervix by detecting and treating precancerous changes in its cells. The first step in this process is a smear test, the taking of a sample of cells from the neck of the uterus. Microscopic examination of this sample can reveal abnormal cells which, if left untreated, could develop into invasive cancer.

Cervical screening aims to prevent cancer of the cervix by detecting and treating precancerous changes in its cells. The first step in this process is a smear test, the taking of a sample of cells from the neck of the uterus. Microscopic examination of this sample can reveal abnormal cells which, if left untreated, could develop into invasive cancer.

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All women aged between 20 and 64 are eligible for a free cervical smear test at least once every five years (NHS Cancer Screening Programmes, 1999), with some health authorities offering them every three years. If women fail to respond to such invitations, opportunistic screening may be offered whenever they visit their GP surgery.

The environment

A smear test involves an intimate examination and most women find it mildly uncomfortable. Nurses should therefore show sensitivity and ensure privacy by providing:

- A warm, quiet room with a door that can be secured;

- A modesty blanket;

- A screened changing area.

Efficiency is also important and all the necessary equipment should be arranged close at hand, on a work surface or trolley next to the examination couch. This includes:

- An adjustable lamp;

- Cervical smear request forms;

- Information leaflets;

- Specula - assorted sizes;

- Gloves;

- Water-based lubricant;

- Samplers - cervical spatulas

endocervical brushes;

- Fixative;

- Slides;

- Slide transporter;

- A bag or bowl for disposal.

Patient assessment

Explain the procedure and the reason for taking a smear, answering any questions to allay anxieties and fears. If an opportunity to discuss the woman’s lifestyle arises, it may be appropriate to offer advice on high-risk practices such as smoking and unprotected sex. Record details of any previous smears and take a contraceptive, menstrual and gynaecological history, noting any:

- Abnormal bleeding;

- Postcoital bleeding;

- Postmenstrual bleeding;

- Intermenstrual bleeding.

Make sure that the smear request form is completed accurately, giving the correct name, address and date of birth, and double-check that the correct patient identifiers are on the slides.

Tell the patient how long it will take to get the results, how she can obtain them and from whom. Stress that there is an 84% chance of a normal result and make sure that she realises that this indicates a low risk of developing cervical cancer, rather than no risk. Explain the implications of an abnormal result, and back this up by offering information leaflets that outline all possible consequences of an abnormal result.

Taking the smear

The speculum should be at body temperature and can be warmed or cooled under running water. Warm water is often all that is needed as a lubricant, but if not apply a water-soluble jelly only to its sides.

Place the speculum against the woman’s inner thigh so she is aware that you are about to perform the procedure. Then insert it with the blades closed, directing it downward, and rotate it when it is half way into the vagina so that the blades are in a horizontal position.

Keep talking to the patient throughout the procedure and allow time for her to relax before opening the speculum. Visualise the cervix and inspect what you can see of it, looking for suspicious lesions, bleeding, polyps or a discharge. Place a cervical spatula in the os and rotate it in a 360-degree sweep, applying pencil pressure.

An endocervical brush can be used in conjunction with the spatula, but not alone. Separate slides may be necessary if you are using spatula and brush smears, so check with your local cytology laboratory.

Transfer the cells by stroking the spatula straight across the slide. The aim is to spread a thin film of cells across the glass.

Fix the cells on to slide by gently flooding it with fixative. Keeping it horizontal, allow it to dry for about five minutes before placing it in a transporter case.

Withdraw the speculum gently with the blades slightly open to prevent it from catching vaginal skin or pubic hairs.

Practice points

- Women should be advised to abstain from sexual intercourse or using a condom for 24-48 hours before a smear test;

- Smears may not be necessary in those who have never been sexually active;

- Women should not apply oestrogen cream on the day the smear is taken;

- The best time to take a smear is in the middle of the menstrual cycle;

- The left lateral position can be used in some women;

- If contact bleeding occurs, one full sweep of the cervix is enough but this should be documented on the smear request form;

- A one-finger vaginal examination may help to locate the cervix, but take care not to disturb the surface epithelial cells;

- Cervical mucus can be moved gently away from the os with the blunt end of the sampler;

- Be aware of normal variations in the cervix but seek medical opinion if it looks unhealthy;

- An unhealthy looking cervix is enough reason to refer a women for colposcopy;

- Forge close links with your local cytology laboratory and colposcopy clinic;

- Vault smears are not part of the screening programme but there may be a local policy on disease follow-up;

- It is best practice to keep an audit of smears for self-evaluation and half a day of update training every three years is recommended.

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