You are often alarmed hearing you have an abnormal smear test. Though understandable, in most cases there is no need for concern, and further research will be performed at Gynaecologie Amsterdam.  We can see you within a few days.  

Cervical cancer is diagnosed in about 700 women each year. For prevention, selective HPV vaccination of young girls has been included in the National Vaccination Programme. In the Netherlands a routine population screening program is aimed at early detection of abnormal PAP smears to prevent cervical cancer. Women receive an invitation for screening at the GP, and the possibility to self-test as from their 30th birthday. The smear is first examined for the presence of the human papillomavirus (HPV). Only when this virus is present, the smear will be assessed for abnormal cells. When there are abnormal cells, you are referred to Gynaecologie Amsterdam for colposcopic examination. 

See also the video at Abnormal smear and colposcopy | The Gynecologist

What are we looking for in a smear test?

The cervix is lined with two types of cells, squamous cells and cylinder cells. Squamous cells are flat cells that line the outside of the cervix, and the wall of the vagina. Cylinder cells are high cells that line the canal in the cervix and make mucus. The transition area from squamous cells to cylinder cells is called the transformation zone. With an abnormal smear, the cells usually originate from this transformation zone. 

The sensitivity of the cervix to HPV infections is explained by the specific transition between the squamous cells in the mucous membrane on the outside of the cervix and the cylinder cells in the mucous membrane on the inside of the uterus (mouth). If the HPV virus is present and you have an abnormal smear, you will be referred to Gynaecologie Amsterdam for further examination. 

PAP results and abnormal pap smear

PAP is an abbreviation of Papanicolaou, the name of the person who established this classification of the results of smears. The Pap results range from 1 to 5. 

PAP 1 smear means that the cells in the smear are completely normal. If HPV is found in the smear but no abnormal cells, you will be invited 6 months later for a check-up smear at the GP.

PAP 2 smear: This is an abnormal smear and some cells of the smear look different than normal. However, the deviation is not clear. You will be referred for a colposcopy if HPV is also present. In case of PAP 2 without HPV, you will be advised to repeat the smear.

PAP 3a smear: The result shows abnormal cells. You will be referred for a colposcopy. In some 50%, after the colposcopy (with biopsies), it appears that treatment is not necessary.  

PAP 3b smear: The cells of the cervix are more abnormal than in a PAP 3a. After colposcopy with biopsies, the chance of a loop excision is greater than with a PAP 3a. 

PAP 4 smear: The cells deviate more than with a PAP 3a or a PAP 3b. In general, treatment is necessary. 

PAP 5 smear: The cells in the cervix are very different. It is essential to have yourself examined by a gynecologist at short notice. There might be cervical cancer. 

Colposcopy

(See also the video at Abnormal pap smear and colposcopy | The Gynecologist)

In this follow-up examination, the gynecologist looks at the cervix with a microscope. This is called colposcopy. The gynecologist places a speculum in the vagina. To assess the tissue, the gynecologist applies a vinegar solution to the cervix. This can sting for a while. The gynecologist looks at the cervix with the microscope and examines the transition zone. She assesses the squamous cells and cylinder cells and takes pictures of the transformation zone. Please advise beforehand if you are frightened or distressed. At Gynaecologie Amsterdam you can review the photos taken. 

In case of abnormalities, the gynecologist takes some tissue samples from the cervix, by one or more biopsies (3-4 mm small pieces of tissue). The samples are assessed by the pathologist. Taking a biopsy may be perceived as painful. If needed, you can ask for local anesthesia. When a biopsy is taken, the wound is treated with silver nitrate to alleviate the bleeding. You might experience some light menstrual cramps. Usually the bleeding is very light and a sanitary napkin is sufficient. The blood loss usually disappears within a few days. If it takes longer or is more prolific than a menstruation, please contact us. 

Result biopsy

The pathologist examines the biopsies with a microscope, the results of which will be available within 7-10 days.  The result will be e-mailed to you or discussed by telephone or in the clinic, depending on your preferences. 

The pathologist uses the CIN classification (I, II or III). CIN is an abbreviation of Cervical (from the cervix) Intraepithelial (in the superficial layer) Neoplasia (new tissue). 

The term dysplasia if the tissue is abnormal. This is a possible pre-stage of cancer and not cervical cancer itself! 

In CIN I, so-called mild dysplasia, the tissue shows slight abnormalities. 60% Of the CIN I disappears spontaneously, 30% remains stable, 10% progresses to CIN III and in 1% of the CIN I becomes cancer. The policy is to repeat the PAP smear (cells) plus HPV after 12 months or earlier if you have symptoms. 

In CIN II, moderate dysplasia, the abnormalities are more pronounced. In CIN II, 40% decreases, 40% remains stable, 20% evolves into CIN III and 5% becomes cancer. The policy is to repeat the PAP smear plus HPV after 6 months and depending on these results a new colposcopy or repeat the PAP smear and HPV after some time. 

In CIN III, severe dysplasia, there are stronger abnormalities of the tissue, and this is a pre-stage of cervical cancer.  In CIN III about 50% progresses to cervical cancer. CIN III is always treated with a loop excision or alternatively with local Imiquimod application for 16 weeks. 

A loop excision also called a LLETZ (Large Loop Excision of the Transformation Zone) is a treatment in which the gynecologist removes a piece of tissue from the cervix with a loop. The procedure is an outpatient procedure. 

The cervix is anesthetized with a very thin needle. For electric safety reasons a sticker is stuck on your thigh. Vinegar is applied to identify the abnormal tissue and the gynecologist removes this abnormal tissue by using a thin metal loop, which is heated. Then the wound is treated with diathermy to stop the bleeding. You hardly feel anything of the procedure itself, but it can give unpleasant sounds and smells. The treatment takes about half an hour. Afterwards, you may have bloody, brownish, sometimes foul-smelling discharge for several weeks. This is normal. If you still have pain after returning home, you can take Paracetamol or Ibuprofen. These can be purchased at the drugstore and pharmacy without a prescription. After returning home you can take a shower. Bathing and swimming is not recommended until 4 weeks after the procedure. Intercourse is not recommended until 4 weeks after the procedure. You will receive more detailed information at Gynaecologie Amsterdam, including the usefulness of vaccination with Gardasil 9 against the HPV virus. 

The pathologist examines the tissue of the loop excision. The treatment will be successful in 80-90% of the cases. In 10-20% of the cases the CIN III recurs. To increase the success rate, we advise you to take the vaccination of Gardasil 9 in addition to the loop excision to increase the success rate to 90-95%. 

The local application of Imiquimod on its own has a success rate of around 60%.

In case of precancer of the cylinder cells (AIS) or in case of cervical cancer you will be referred to the hospital for further treatment, e.g., a conization. 

Note: If you smoke, you are more likely to have a permanent HPV infection. So, to quit smoking is also important!

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