1. Sample Taker Training Cervical Cytology & Management of Abnormalities

2. Cervical Cytology Results Negative Negative with infection Unsatisfactory Abnormal

3. Types of Cells Seen

4. Mature Cell Pattern Pre-menopause HRT Oestrogen cream Tamoxifen Obese women

5. Immature Cell Pattern – Oestrogen Deficient Post menopausal Post-natal Depoprovera

6. Evidence of Transformation Zone Sampling Endocervical Cells and/or Metaplastic Cells

7. Background Blood Cells Polymorphs Red Blood Cells A lot of the blood is removed during processing but occasionally may be noticeable in the background of the sample

8. Endometrial Cells These come from the womb lining May be shed during menstruation together with blood

9. Late Menstrual Cycle Cells break up & some detail is lost

10. Best time to take a smear? Menstruation – no (Days 1-5) Proliferative phase – OK Ovulation – OK Avoid the later days of the cycle if possible

11. Infections Candida Trichomonas (TV) Herpes Rarely worm eggs may be seen = contaminant

12. Unsatisfactory Samples Reason for unsatisfactory given in report –May help when taking repeat sample e.g. treatment of infection or topical oestrogen treatment Repeat in 3 months (minimum) After 3 unsatisfactory samples – refer to colposcopy

13. Abnormal Results

14. Cervical Abnormalities May be squamous or glandular in origin Non-cervical abnormalities including metastatic cancer may be seen (rare)

15. Abnormalities That May Be Seen On Cervical Samples Squamous Abnormalities - CIN (Cervical Intraepithelial Neoplasia) Endocervical Abnormalities (Glandular Neoplasia) Glandular Neoplasia (non-cervical) – cells may shed but NOT directly sampled

16. Squamous Dyskaryosis Cytological term meaning abnormal nucleus

17. Progression of CIN Normal Cells Low grade dyskaryosis Borderline changes Moderate dyskaryosis Severe dyskaryosis Cancer Treatment Normal If left untreated (36%) HPV / Smoking etc.

18. Squamous Abnormalities Borderline Changes Mild dyskaryosis Moderate dyskaryosis Severe Dyskaryosis Severe/?invasive carcinoma Low Grade High Grade

19. Borderline Changes Minor changes seen but not dyskaryotic

20. CIN 1CIN 2CIN 3 mildmoderateseverenormal

21. CIN1 CIN2 CIN3 (in a crypt) CANCER MILD DYSK MODERATE SEVERE SEV/?INV Basement membrane

22. Cervical Cancer - Squamous

23. Management Low grade High grade Severe dyskaryosis / ?invasion HPV test to decide management Colposcopy referral URGENT colposcopy referral

24. Glandular Abnormalities That May Be Seen On Cervical Samples Endocervical Abnormalities (Glandular Neoplasia) Glandular Neoplasia (non-cervical) – cells may shed but NOT directly sampled

25. Glandular Abnormalities Borderline Changes ?Glandular Neoplasia (Cervix) ?Glandular Neoplasia (Other) HPV Test to decide management Urgent referral to colposcopy Urgent referral to gynae

26. Do not delay referrals if clinical symptoms A negative cervical sample does NOT exclude a non-cervical abnormality e.g. womb cancer, ovarian cancer Post menopausal bleeding – refer to gynae If cervix looks suspicious refer to colposcopy Don’t wait for cytology result

27. Malignant looking cervix

28. Summary of Management Low grade abnormalities HPV test High grade dyskaryosis Colposcopy Glandular abnormalities Cervical Non-cervical +ve -ve Routine Recall Gynae

29. Early Repeat Tests If HPV testing is not performed early repeat tests may be requested. –Repeat interval indicated on report –Patient recalled by letter

30. Early Repeat Samples - HPV Test NOT Performed Low grade abnormalities –6 or 12 month repeat samples (3 negative results before return to routine recall) High grade abnormalities after treatment –12 month repeat samples (10 annual repeats before return to routine recall)

31. Management after Hysterectomy NOT followed up by the CERVICAL screening programme – cease recall –Follow up is the responsibility of the Gynaecologist