Cervical cytology. Cytological examination of the cervical canal or pap test in women. Indirect signs of some STDs in cytology

Cervical tests are the main method for diagnosing the condition of the female genital organs. Currently, the main laboratory methods for diagnosing the condition of the female genital organs are cytology analysis, as well as a biopsy.

Cytological analysis

A smear for cytology is one of the simplest and most accurate methods of gynecological examination, which allows you to determine the condition of the tissues. Cytological analysis of the cervix also makes it possible to identify abnormal (atypical) cells, which can later degenerate into malignant ones. A smear is an absolutely painless and safe procedure that is prescribed to all women who are sexually active. Women from 21 to 49 years of age should be examined every three years, and women over 50 years old - once every five years.

Currently, cytological analysis is the most affordable way to diagnose cancer and cervical dysplasia. This study must be carried out regularly by women suffering from the human papillomavirus and genital warts, as they may be prone to malignant degeneration.

A smear is taken strictly according to the rules, the main of which are:

Smear sampling is not carried out during menstruation, as well as immediately after the end.
A smear is not taken from patients suffering from inflammatory diseases of an infectious origin.
Sexual abstinence is required for 2 days before the test.
For two days, the patient is obliged to stop using intimate hygiene products, vaginal tablets, suppositories and sprays, and also to refuse douching.

A smear for cytology is taken during a gynecological examination. Using a cotton swab, the gynecologist cleans the upper part of the cervix from secretions. Using a special brush, the doctor takes the material and applies it to a glass slide, which is then sent to the laboratory. The results of the cytological analysis are usually ready seven to ten days after the smear is taken.

For eight to twelve days after taking a smear, patients should refrain from sexual intercourse. Also, douching and the use of vaginal tampons are prohibited.

If we talk about the results of the above study, then there are pathological and normal smear results. Normal ones indicate the absence of a pathological process in the mucous membrane of the cervix, and pathological ones indicate changes that can provoke cancer in a woman.

The poor results of this study should not be regarded as a verdict. If some deviations from the norm are detected, the doctor prescribes additional tests for cervical cancer (for example, colposcopy, biopsy, etc.).

Biopsy

A cervical biopsy is a cutting (excision) of a tissue fragment of this organ for microscopic examination. Today, a distinction is made between therapeutic and diagnostic biopsy. A biopsy gives more reliable results than a cytology test. With the help of a colposcope, the doctor finds the affected areas, from which he takes material for examination.

A biopsy of the cervix is performed in the following ways:

radio wave;
plucked;
conization.

The radio wave method consists in the use of radio wave therapy. This procedure is bloodless. Seven days after sampling, patients may experience bleeding.

The pinch method is the most informative and less traumatic biopsy method. It is made with special biopsy forceps.

Conization is the excision of a piece of tissue in the shape of a cone. This biopsy method is used for both diagnosis and removal of the affected area. This procedure is carried out on the fourth or fifth day after the end of menstruation. Before performing a biopsy, the patient must take a blood test for syphilis, HIV infection and hepatitis.

A biopsy of the cervix for analysis is carried out both in stationary conditions and on an outpatient basis. Since the material is taken for examination under anesthesia, the patient should not eat for twelve hours before the procedure. After ten to fourteen days, the results of the analysis are usually ready. After a biopsy, spotting is observed for some time, as well as pain in the lower abdomen.

Within seven to eight weeks after the biopsy, women must adhere to the following rules.

The study of the material obtained from the cervix allows you to determine the features of the cellular structure of this anatomical region, identify pathological changes and confirm or refute the proposed diagnosis.

The most common type of cytological analysis in gynecology is the PAP test, or Papanicolaou study. It was developed back in the early twentieth century for early diagnosis oncological diseases cervix, and it continues to be used today. Also in this area there are the latest methods - ThinPrep, or liquid cytology. This technique significantly increases the efficiency of diagnostic search and allows timely diagnosis and effective treatment.

Indications for cytological examination

The main goal of the implementation of the analysis for the cytology of the cervix is the early detection of cancer. Timely detection of atypical cells in the biomaterial is necessary for the possibility of blocking the cancer process. Cervical cancer is one of the most common oncological pathologies among women. Its danger lies in the asymptomatic course, which is why research is so important.

Pap smear analysis is an accurate and fast way to obtain reliable data on the presence or absence of atypical cells with precancerous or cancerous changes. In addition, the technique allows to identify some background diseases, the etiology of which is not tumor.

Cytological examination of cervical smears is the standard for detection and follow-up of the following pathological conditions:

the presence of pathogenic microflora;
violations of the cycle of menstruation (duration, intensity);
viral diseases (genital herpes, human papillomavirus infection - HPV);
infertility (impossibility of conception);
erosive changes in the cervical epithelium;
pathological discharge from the vagina.

A cytology smear is also necessary as a screening test in such cases:

Planning for pregnancy.
Several births in a row.
Early age of a woman during first birth.
Frequent change of sexual partners.
Postmenopause.
Planning for the placement of an intrauterine device.
Visible pathological changes when examining the cervix in the mirrors.
A burdened family history (cases of cervical cancer and other oncopathologies among relatives).
long-term hormone therapy.
A long time ago the previous study on cytology.

Cytological examination of cervical smears is recommended to be carried out annually for preventive purposes, and if any pathological abnormalities are detected, at least twice a year to monitor the effectiveness of therapy.

Preparation for the procedure for taking biomaterial

In order for the result of cervical cytology to be reliable, it is necessary to take into account the rules for preparing for biomaterial sampling. They are as follows:

Exclusion of hygiene procedures in the form of douching (sanation).
Abstinence from sexual activity for three days before the procedure.
Temporary refusal to use tampons, vaginal suppositories, tablets, creams and gels.
Abstinence from urination two hours before sampling.

In addition, you need to be aware of such nuances:

obtaining a smear from the cervical canal is possible only outside of menstrual bleeding, the optimal period is 10-12 days of the cycle;
smear cytology will not be reliable in the acute phase of an infectious disease, therefore it is carried out after a course of therapy;
intravaginal administration of any kind of medication should be stopped in agreement with the attending physician at least five days before the material sampling procedure.

Additional conditions and rules that the patient must take into account must be checked with the gynecologist.

Material sampling technique

To obtain material that will be subjected to cytological examination, the doctor makes a scraping from the exocervix - the outer part of the cervix - and from the mucous lining of the vagina using an Eyre spatula. To obtain a scraping and subsequent examination of a smear from the cervical canal, a special probe is used - endobrush. Its use allows obtaining biomaterial in sufficient quantity for analysis.

A gynecologist's tool kit for obtaining material may include:

Eyre spatula;
spirette - a tool for aspiration of material from the endocervix;
endobrush;
tweezers;
gynecological mirror;
Volkmann spoon.

The sequence of actions during the procedure includes:

Gynecological examination of the cervix in the mirrors. At the same time, the walls of the vagina are expanded and scrapings are performed, which can cause a feeling of slight discomfort.
At the same time, material is taken for analysis of microflora.
The resulting biomaterial samples are applied to the glass and fixed, then labeled and transferred to the laboratory for analysis.

A smear for the degree of purity in women: transcript

The time of the procedure for obtaining biomaterial is no more than 15 minutes.

Interpretation of study results

The normal balance of microflora and the absence of pathological changes in the analysis of a smear for cytology confirm the healthy state of the cervical canal. The cells in the smear during the study are compared with the morphological standards of the norm, that is, their size, shape, structure should not have abnormal deviations.

The doctor confirms the compliance of the results of the study with a healthy state in the following cases:

A smear for cytology includes epithelial cells of a cylindrical single-layer type.
When taking a smear from the transition zone or the vagina, the detection of stratified epithelial cells is also normal.

Even minor deviations in cell morphology are reflected in the laboratory report. Changes may confirm inflammatory diseases or the presence of benign anomalies. Most often noted:

inflammatory atypia;
atypia due to the presence of HPV;
mixed atypia;
atypia of unclear etiology, which require further diagnostic appointments.

What causes changes in the epithelium of the cervix?

Deviations in a cytology smear from normal values can provoke such pathologies and conditions:

Human papillomavirus infection.
herpetic infection.
Trichomoniasis.
Candidiasis.
Prolonged use of medications, in particular antibiotics.
The use of hormonal contraceptives.
Installation of an intrauterine device
Pregnancy.

What changes are possible?

Benign changes may include:

Detection of Trichomonas, Candida fungi, anomalies caused by infection with the herpes virus.
Cellular atypia provoked by inflammatory reactions: metaplasia, keratosis.
Atrophic changes in epithelial cells in combination with inflammation: colpitis, metaplasia.

Dysplastic changes and atypia suggest the following conditions:

Atypia of unknown origin (ASC-US).
High risk of the presence of cancer cells in the material (HSIL).
Precancerous atypia: different degrees of dysplasia.

If cancer cells are detected, it is necessary to prescribe additional methods of examination and the subsequent course of therapeutic correction (conservative or surgical treatment) with constant cytological control.

Mixed flora: a variant of the norm or a violation?

Labeling of cytology results

Changes in the results of cytological analysis of the designations presented in the table below.

Any degree of dysplastic changes is a signal confirming the need for further research and the appointment of adequate therapy.

Degrees of dysplasia

There are such degrees of dysplastic changes in the epithelium of the cervix:

Light. Confirms the beginning of an active inflammatory process.
Moderate. It speaks of a high risk of developing oncological pathologies.
Heavy. Precancerous.

Timely detection of dysplasia contributes to greater effectiveness of therapy, since it is still possible to prevent oncopathology.

Atypical cells detected: what does this mean for the patient

Regular medical consultations are the key to the effectiveness of both treatment and prevention.

The gynecologist should conduct a detailed consultation, during which he will tell what it is in a particular case, explain the advisability of conducting an additional examination. Additional diagnostic search methods will allow you to correctly determine the most effective course of therapy.

For diagnosis when atypical cells are detected during a cytological examination in gynecology, the following are additionally prescribed:

repeated cytological analysis of the epithelium of the cervix;
biopsy;
general and biochemical blood test;
human papillomavirus test.

It is important to follow all medical recommendations and prescriptions, this will allow you to identify and correct the pathological process in a short time. The effectiveness of the course of treatment should be regularly monitored by cytological examination. Therapy will be considered completed when the results of cytology confirm the healthy state of the cervical epithelium.

The study of scrapings from the cervix is an important diagnostic procedure that should be carried out regularly for preventive monitoring of the woman's health. An annual visit to the gynecologist for examination and diagnosis of possible pathologies should be the rule of life for everyone, because early diagnosis of any disease is the key to the timely start of treatment and its high efficiency.

Description

Method of determination Microscopy

Material under study See in the description

Home visit available

The vaginal part of the cervix - ectocervix is lined with stratified squamous non-keratinized epithelium. In women of reproductive age, it is constantly rebuilt by proliferation-maturation-desquamation and is completely replaced by a new population of cells every 4 to 5 days.

Normally, the squamous epithelium is represented by the following types of cells: cells of the superficial layer, cells of the intermediate layer, and cells of the basal-parabasal layer. The cellular composition depends on the presence / absence of the menstrual cycle and its phase. The squamous epithelium performs a protective function.

The cervical canal - endocervix - is lined with a cylindrical mucus-producing epithelium. Cyclic changes in the epithelium of the endocervix are poorly expressed. The main function of the cylindrical epithelium is secretory.

The transformation zone is the junction of the stratified squamous and columnar epithelium in women of reproductive age, which basically coincides with the area of the external os. Depending on age and hormonal balance in the body, it can also be located on the vaginal part of the cervix. In women of older reproductive and postmenopausal age, the boundary line is actually localized within the external pharynx. According to statistical data, precancer occurs from the zone of transformation.

Material for research. In the direction for the cytological examination of biological material, clinical data, diagnosis, features and place of obtaining the material, data on the menstrual cycle must be indicated.

Swabs are taken prior to bimanual examination and colposcopy. The instruments used must be sterile and dry, as water and disinfectant solutions destroy cellular elements.

During a preventive examination (cytological screening) of women, it is advisable to obtain cell material from the surface of the vaginal part of the cervix (ectocervix) and the walls of the cervical canal (endocervix), in the presence of pathological changes in the cervix aimingly.

Modified Eyre-type spatulas or Cervix-Brash, Papette brushes are used as a tool for taking material from the cervix during a preventive examination of women. For diagnostic purposes, the material is obtained separately with spatulas from the ectocervix, brushes such as Cytobrash from the endocervix.

Material for cytological diagnostics is obtained different ways: aspiration and scraping of the contents of the posterior fornix of the vagina, cervix or obtaining a smear-imprint. The resulting biological material is applied in a thin layer on a glass slide and dried in air. The glass must be marked with not only the last name / code, but also the place where the cell material was taken (cervix, cervical canal). The markings on the slide and in the direction for cytological examination must correspond to each other.

Please note that in children under 16 years of age, gynecological tests are taken only in the presence of parents. Medical offices do not do cervical scrapings and swabs for pregnant women 22 weeks or more, as this procedure can cause complications. If necessary, you can contact your doctor to take the material.

Literature

Petrova AS Cytological diagnosis of tumors and pretumor processes. Medicine, 1985. - p. 296.
Prilepskaya VN Diseases of the cervix, vagina and vulva. - M.: MEDpress, 1999. - p. 406.
Shabalova IP Cytological atlas. Moscow, 2001. p. 116.

Training

Preparation conditions are determined by the attending physician. In women of reproductive age, smears should be taken no earlier than on the 5th day of the menstrual cycle and no later than 5 days before the expected start of menstruation. You should not take cell material for research within 24 hours after sexual intercourse, sanitation of the vagina, introduction of medications into the vagina.

Indications for appointment

Cytological smears should be taken from all women over 18 years of age, regardless of clinical data, once a year. In the presence of clinically pronounced pathological changes in the cervix, the cellular material is taken aimingly. The frequency of cytological examination is determined by a gynecologist (at least 2 times a year). (Order No. 430 "On the approval of instructive and methodological guidelines for the organization of the work of the antenatal clinic" dated April 22, 1981 of the USSR Ministry of Health).

The cytological method of research occupies one of the important places in the diagnosis of diseases of the cervix. Due to its high accuracy, it is one of the leading research methods in the diagnosis of background, precancerous and cancerous processes of various localization.

Advantages of the method:

painlessness and safety of obtaining cellular material;
the possibility of studying the pathological focus in dynamics;
the possibility of diagnosing a malignant neoplasm in the initial stage of development;
small financial costs.

Disadvantages of the method:

the impossibility of establishing signs of infiltrative growth (cell, not tissue material is examined).

The specificity of this screening method is 69%. The rate of false-negative smears ranges from 5 to 40%. Inadequate sampling from the endocervix is the most important factor in causing false negative results.

The effectiveness of the cytological research method largely depends on the preanalytical stage: how correctly the cellular material is taken and the smears are prepared.

Interpretation of results

The interpretation of test results contains information for the attending physician and is not a diagnosis. The information in this section should not be used for self-diagnosis or self-treatment. An accurate diagnosis is made by the doctor, using both the results of this examination and the necessary information from other sources: history, results of other examinations, etc.

It should be remembered that the cytological method of research, like any other laboratory research method, does not always provide comprehensive information for making a diagnosis. Only a clinician has the right to make a final diagnosis (based on the study of anamnesis, observation of clinical manifestations and data from the histological method of examination).

The result of a cytological examination of the obtained biomaterial (smears-imprints) can be presented by a cytologist in the form of: - description of the cellular composition; - descriptions of the cellular composition and conclusions; - descriptions of the cellular composition and conclusions in a hypothetical form; - descriptions of the cellular composition and recommendations.

The form of the answer depends on a number of reasons: the adequacy of the cellular material (few cells, many elements of blood, mucus), an incorrectly completed referral for a cytological examination: the reason for the examination (clinical diagnosis) was not indicated, the presence / absence of menstruation; it is not indicated where the material came from, the marking in the direction does not correspond to that on the glasses, etc.

Result interpretation

Possibilities of cytological diagnosis of certain diseases of the cervix and options for interpreting the results of a cytological study:

Endocervix. Normally, with correctly obtained cellular material from the transformation zone (ZT) - the junction zone of the squamous and columnar epithelium - cells of the squamous and columnar epithelium are present in the smear without changes. Cytological conclusion: cells of squamous and cylindrical epithelium without features were found in the obtained material. The presence of a small number of metaplastic epithelial cells is an indication that the material was obtained from ST. In the absence of the above description, the swab was not taken from ST and the patient cannot be said to be at no risk of cervical cancer. Such swabs are commonly seen in postmenopausal women and patients who have undergone cervical treatment that has moved the borderline into the cervical canal. Depending on the patient's history, this may be a reason for re-sampling the material.

Clinical diagnosis in the direction of the polyp of the cervical canal, and the corresponding cytological picture allow the cytologist to conclude that the cytogram corresponds to the clinical diagnosis of the polyp of the cervical canal. If there is no clinical diagnosis, and the cellular composition is represented by large clusters of cells of the columnar epithelium, the cytologist gives a descriptive answer with the assumption of hyperplasia of the cells of the columnar epithelium or a polyp of the cervical canal.

Ectocervix. In reproductive age, the normal cellular composition of imprints from the vaginal part of the cervix is represented by squamous epithelial cells, predominantly of a superficial or intermediate type. The wording “in the obtained material cells of the squamous epithelium of the surface layers without features are noted” indicates that the obtained biological material consists of cells of the squamous epithelium of the surface and intermediate layers in various combinations in accordance with the phase of the cycle. At the beginning of postmenopause (normal), cells of the squamous epithelium of the intermediate layer are noted in the smear. In some women, during the whole subsequent life, an intermediate type of smear (squamous epithelial cells of the intermediate layer) is observed, sometimes with the presence of cells of the surface layer, which is apparently associated with the function of the adrenal glands, an active sexual life. The presence in the preparation of cells of the squamous epithelium of the surface layer (estrogenic type of smear) in the first 5 years of menopause should be alarming in relation to neoplasms of the ovaries, uterine fibroids. Postmenopause is characterized by the presence of cells of the basal-parabasal layer (i.e., deep layers).

Erosion (ectopia) of the cervix. The concept of cervical erosion (true erosion) involves a defect in the cervical mucosa caused by various diseases (syphilis, traumatic injuries, the effects of radiation therapy, cervical cancer, etc.). The term cervical ectopia (pseudo-erosion) means the displacement of a high cylindrical epithelium on the vaginal part of the cervix. Provided that there is a clinical diagnosis of "erosion / ectopia of the cervix" in the direction and the correct sampling of biomaterial from the ectocervix (cellular material is represented by squamous epithelial cells of all layers in various combinations, clusters of cylindrical epithelium cells, elements of inflammation), the cytological conclusion has the following form of answer: the cytogram corresponds (does not contradict) the clinical diagnosis - erosion of the cervix.

Cytological conclusion: the cytogram corresponds (does not contradict) the clinical diagnosis of cervical ectopia suggests the presence in the obtained material of squamous epithelial cells of the surface layers, clusters of cylindrical epithelium cells.

Conclusion: a cytogram of endocervicosis occurs if the clinical diagnosis of erosion/ectopia of the cervix is not indicated in the referral for cytological examination, and morphologically, cells of the squamous epithelium and clusters of cells of the cylindrical epithelium are noted.

It is not always possible to make a cytological diagnosis between superficial endocervicosis (ectopia of the cervix) and proliferating endocervicosis. A descriptive cytological response occurs when: - cells of the squamous epithelium and single clusters or single cells of the cylindrical epithelium are found in the material obtained from the ectocervix; - cellular material obtained from ecto- and endocervix and presented in one mixed smear; - smears are not smeared.

With healing endocervicosis, a large number of cells of metaplastic epithelium are found in smears (metaplasia is the replacement of one type of epithelium with another). Metaplastic epithelium is a target for human papillomavirus exposure - an area for the development of precancerous conditions. The presence in smears from the cervix of a small number of cells of metaplastic epithelium is an indicator of a normal physiological process.

Histogenetic mechanisms of replacement of the columnar epithelium by squamous: - progression of squamous cell transformation - direct ingrowth of the native epithelium under the columnar. As the squamous cells develop and mature, the endocervical cells move upward, degenerate, and eventually slough off. A similar process is observed during re-epithelialization of true cervical erosion healing; - squamous metaplasia - proliferation of undifferentiated reserve cells of the endocervical epithelium and their partial transformation into a fully mature squamous epithelium. The first stage of the process is the appearance of reserve cells, then comes reserve cell hyperplasia, followed by differentiation into immature squamous epithelium, and at the final stage mature squamous epithelium is observed.

Leukoplakia of the cervix. With the cytological method for diagnosing simple leukoplakia (a benign lesion of the cervix, a background disease), hyperkeratosis is detected, i.e., in the material obtained from ectocervix, layers (clusters) of squamous epithelium scales were found (there is no nucleus in the cytoplasm of the cell), separately lying squamous epithelium scales, dyskerocytes . If there is a clinical diagnosis of "leukoplakia of the cervix" - in the cytological report it is noted that the picture does not contradict the clinical diagnosis - leukoplakia of the cervix. In the absence of a clinical diagnosis of cervical leukoplakia, depending on the available material, the cytologist gives a descriptive answer, possibly with a recommendation to exclude cervical leukoplakia. Single scales of squamous epithelium have no diagnostic value. Leukoplakia with atypia - a cytological method of research is not always possible to identify, which is explained by the presence of squamous epithelium scales on the surface of the stratified squamous epithelium, which prevent the receipt of cellular elements. It is necessary to conduct a morphological study of the biopsy of the cervix.

Dysplasia of the cervix. Dysplastic changes occur in the stratified squamous epithelium of both exocervix and endocervix. As a rule, changes begin at the junction of the squamous and columnar epithelium. Dysplasia can simultaneously develop in several areas of the cervix and cervical canal, often changes are expressed to varying degrees. Spectrum dysplasia (CIN) is not a single disease. There are two biological essences of the process: a productive human papillomavirus infection and a cancer precursor.

Dysplasia-I (mild dysplasia, CINI) is one of the least reproducible cytological diagnoses. Dysplasia-I is often difficult to differentiate from reactive epithelium. It is not always possible to make a differential diagnosis between dysplasia III (severe dysplasia, CIN-III) and intraepithelial cancer by cytological examination.

Cytological conclusion: Dysplasia - I (weak, CIN-1); Dysplasia -II (moderate, CIN-II); Dysplasia -III (severe, pronounced, CIN-III). If there are cells with signs of malignancy in the obtained material, the cytologist gives a conclusion on the cytogram of the malignant neoplasm and, if possible, specifies the form of cancer.

Inflammatory processes of the cervix. Inflammation - a cellular reaction (in the focus) - is represented by a degeneratively altered epithelium, proliferative changes of a reparative, protective nature, and inflammatory atypia. In an acute nonspecific inflammatory process, a pronounced leukocyte infiltration (many neutrophilic leukocytes), incomplete phagocytosis is noted in the smear. The composition of the cell population of the epithelium may change. Cytological conclusion: cytogram of ecto-/endocervicitis. In subacute and chronic inflammation, eosinophils, lymphocytes, macrophages/cells such as foreign bodies (multinuclear macrophages) join - cytological conclusion: cytogram of chronic ecto-/endocervicitis. Acute inflammatory processes are more often observed in age group 20 - 24 years old, chronic processes and their consequences occur in women 25 - 34 years old.

Infectious lesions of the cervix. Cytological features of smears for infectious lesions of the cervix depend on the pathogen and the duration of the inflammatory process.

Mycoplasmas, ureaplasmas and corynobacteria as the cause of inflammation are observed in a group of young women (up to 20 years old). In the age group over 30 years, anaerobic microorganisms occupy the first place among the causative agents of inflammatory processes in the genitals. Mixed infection increases the pathogenicity of each of the pathogens. In such cases, inflammation causes a pronounced tissue reaction, accompanied by damage to the epithelium, destruction and dysplasia. This leads to the development of not only colpitis, endocervicitis, but can play a significant role in the formation of cervical ectopia. Incomplete phagocytosis is noted (phagocytic activity of leukocytes is suppressed). The cytological conclusion indicates the type of flora with a recommendation to exclude a certain type of infection.

Bacterial vaginosis (BV) - (clinical diagnosis). In cytological preparations, BV is represented by key cells. If the key cells are not found, and the flora is cocco-bacillary, it is recommended to exclude the presence of gardnerella (ureaplasma) in the cytological response; in the presence of mobiluncus bacilli, a recurrence of the pathological process after the treatment is possible.

Genital herpes - the herpes simplex virus has a high tropism for epithelial and nerve cells. Relapses are mainly due to the persistence of infection in the nerve ganglion. In the cytological examination of the obtained material, changes in the cells of the squamous epithelium, specific for their defeat by this species, may be noted. viral infection: multinucleated cells of the "mulberry" type. Form of cytological response: signs of a viral infection were found in the material obtained. It is recommended to exclude the herpes simplex virus.

Papillomavirus infection of the genitals. The human papillomavirus is able to persist for a long time in the basal layer of the squamous epithelium, which causes a high frequency of recurrence of the process. The frequency of coincidence of cytological and histological diagnoses in condyloma was 42%: CIN-I - 56%, CIN III 74%. False-negative cytological responses are explained by the consequence of incorrect material sampling - 90%, incorrect interpretation - 10%.

In addition, underdiagnosis in cervical smears may be due to the presence of koilocytes in the deeper layers of the squamous epithelium or the presence of a large overlap of inflammatory elements and flora. Cytological conclusion: the obtained material showed signs of a viral infection. It is recommended to rule out the human papillomavirus. Indirect changes characteristic of a viral infection: an increase in the size of the nucleus, nonspecific multinucleation. The form of the cytological response: the obtained material shows indirect signs of a viral infection. It is recommended to exclude the herpes simplex virus, human papillomavirus.

Trichomoniasis. An inflammatory reaction develops in the presence of a large number of protozoa. Proper preparation of the patient is essential for the quality of the study. Termination of the use of trichomonocidal drugs for 5-7 days before taking the material. In the cytological preparation, there are signs of an acute/chronic inflammatory process, mixed flora, Trichomonas. Cytological conclusion: trichomonas colpitis.

Chlamydial infection. Chlamydia are tropic to columnar epithelium. Often found in women with cervical ectopia. In pregnant women and menopausal women, signs of infection may be observed in the squamous epithelium. They can also be found in macrophages. Cytologically, the presence of intracellular specific inclusions is determined, which are more often detected with a fresh or untreated infection. Cytological forms of response: cells with cytoplasmic inclusions morphologically similar to chlamydial infection were found. It is recommended to exclude the presence of chlamydial infection.

Squamous intraepithelial lesions (SIP) of the cervix are associated with significant qualitative and quantitative changes in the vaginal microflora. Deficiency of lactobacilli is observed in all patients with PIP, there is an increase in representatives of opportunistic flora. In the cytological conclusion, changes in the flora are indicated, if possible, a representative of the opportunistic flora is characterized. The presence of nonspecific vaginosis is noted.

A smear for cytology (oncocytological smear, Papanicolaou test, PAP test) is a laboratory test, the object of which is the epithelial cells of the cervix. During the Pap test, the size, shape and location of epithelial cells are studied.

A cytological examination of a smear makes it possible to identify pathological changes in the epithelium, the presence of atypical cells and cellular anomalies, as well as to detect precancerous and cancerous cells in the mucous membrane of the cervical canal. This ability to quickly and inexpensively diagnose oncological processes in the early stages has made the PAP test a mandatory procedure for all women.

The reliability of a cytological smear in pathological processes in the epithelial tissue of the cervix reaches 80%. Since the development of cancer is long and takes from 5 to 15 years, the regular PAP test makes it possible to timely detect the deviation of the mucosa from the norm.

With identified pathologies, dysplasia, microcarcinoma, a more accurate invasive biopsy method and histology of the obtained tissues of the reproductive organs are used.

Indications for analysis

Depending on the age of the woman, it is necessary to conduct a routine cytological analysis of the smear with the following regularity:

at 21-49 years old - 1 time in 3 years;
at 50-65 years old - 1 time in 5 years.

In addition to a routine examination, an analysis to prevent cervical cancer is prescribed in such cases:

erosion;
infertility;
herpes infection in the vagina;
diabetes;
human papillomavirus (HPV);
with vaginal discharge;
violation of the menstrual cycle;
when planning a pregnancy;
before installing the spiral (Navy);
1-3 months after birth.

Contraindications

It is contraindicated to take biological material for cytological studies in such cases:

during pregnancy, especially after the 20th week, a cytological smear is not performed, since intervention in the cervix can adversely affect the condition of the fetus;
with menstrual bleeding;
with cervicitis;
in the presence of colpitis (vaginitis) - inflammation of the mucous membrane of the vagina.

The results of a cytological analysis study made during inflammatory processes of the genital organs may show a false positive or false negative result of oncocytology.

Preparation for the procedure

For the reliability of the results of the PAP test by the cytological method, it is necessary to adhere to some rules for preparing for the procedure.

First of all, the violation of the microflora of the vagina is excluded 48 hours before the smear. To do this, you should stop using intimate hygiene products, preparations for vaginal use (candles, douching), and also exclude sexual contact. Immediately before the procedure, visits to the toilet are excluded for 2-3 hours.

As a rule, cytological analysis is performed after treatment of bacterial infections. If a gynecological examination or colposcopy was performed the day before, then a smear for cytology is performed no earlier than 2 days later.

How to take a swab

When conducting a smear for cytology, the gynecologist's immediate object of attention is the cervical canal - the mucous part of the internal reproductive organs that connects the uterine cavity and the vagina.

The length of the cervical canal, on average, is 3-4 centimeters, while the canal is conditionally divided into 3 zones:

external pharynx or ectocervix - goes into the vagina and is covered with squamous epithelium cells;
internal pharynx or endocervix - located on the side of the uterus, covered with glandular epithelium;
transitional, inner part of the channel.

There are two ways to carry out the procedure:

1. Standard smear for cytology. With the help of special tools (Eyre's spatula, Volkmann's spoon), the gynecologist takes swabs from the vagina, the external os of the cervix and directly inside the cervical canal. For this, a special cervical brush is used, which does not injure the narrow canal and does not cause any discomfort during the procedure.

Biological material is placed on sterile glass, fixed with a special solution and dried, after which it is sent to the laboratory.

2. Method of liquid cytology (LBC, Liquid Based Cytology). A more modern and accurate way to study the mucous membrane of the cervical canal.

To obtain biological material, the gynecologist uses several types of brushes (endocervical, Wallach's brush), after which the tips are removed from the used instruments. Next, the brushes are placed in a bottle (vial) with a special liquid for preserving biological material.

The vial is labeled and sent to the laboratory. The method of liquid cytology allows you to get more accurate results and the ability to conduct additional examinations of the epithelium, if necessary.

Deciphering a cytological examination of a cervical smear

First of all, the decoding of cytological analysis consists in assessing the biological material (normal or poor quality). If a poor smear quality is noted, then the reason is indicated on the form. As a rule, this may be the presence of additional impurities (escudate, blood, sperm). In this case, you should take a second smear for cytology.

There are 2 types of classifications used in evaluating the results of a cytological examination of a smear: the Papanicolaou classification and the Bethesda system. On the smear form, the designations of both systems may be present, as this increases the diagnostic capabilities of the PAP test.

Papanicolaou classification

The classification of the results of the analysis, developed by Georgis Papanicolaou, consists of 5 classes, each of which has its own assessment of the number of identified atypical cells.

Class	Characteristic
1	The results of cytological studies are normal
2	Changes in cell morphology (damage to the structural, membrane apparatus, enzyme system) due to inflammatory processes in the reproductive organs of a woman, then treatment and a repeated PAP test are carried out
3	A small number of abnormal cells with a disturbed structure of nuclei and cytoplasm are found. Further biopsy and histology are used
4	Signs of malignant changes (anomalies of the cytoplasm, an increase in nuclei) were found. Consultation and examination by an oncogynecologist is required
5	A large number of cancer cells were detected, which indicates cancer

Bethesda System Classification

The classification of the Bethesda System cytological examination is used in the CIS countries in parallel with the Papanicolaou classes, while the analysis form indicates the smear score for both classifications. The advantage of the new system is that there are more detailed descriptions of cellular changes in all parts of the cervical canal.

Name	Decryption
NILM	The smear corresponds to the norm: there are no changes and malignant cells in the biological material
ASC US	The squamous epithelium of the smear contains atypical cells
ASC-H	High probability of malignant processes that led to a change in the structure of cells. Extended colposcopy is used
L-SIL	There were not numerous benign changes in squamous epithelial cells with a low probability of developing cancerous processes. Requires colposcopy, HPV test, and repeat Pap test after one year
H-SIL	A few changes in malignant cells caused by dysplasia. For additional analyzes, a biopsy or excision followed by histology is used, it is also necessary to conduct a Pap test every 6 months for 2 years to further monitor the dynamics of the development of malignant processes
Squamous cell carcinoma	Squamous cell carcinoma
AGC-US	The smear revealed cellular pathologies of the glandular epithelium of unknown origin
AGCfavorneoplastic	A significant number of anomalies of the glandular epithelium, dysplasia is suspected. Requires colposcopy, HPV test
AIS	Endocervical carcinoma was found early stage tumors of a malignant nature. Colposcopy, diagnostic excision, curettage should be performed
Adenocarcinoma	Cancer of the glandular epithelium

The results of cytological analysis also indicate the presence of microorganisms present in the smear. At the same time, the microflora in cytology is not the object of detailed study, therefore, if there are violations, additional analyzes are required.

The results of a Pap smear test of the cervix may indicate the presence of the following microorganisms:

herpes virus of the reproductive organs;
Trichomonas (Trichomonas vaginalis);
chlamydia;
bacteria that cause actinomycosis (Actinomyces spp.);
coccal flora in bacterial vaginosis;
thrush.

Also, in the analysis form for oncocytology, such a result as dysplasia (neoplasia) of the cervix can be indicated - a change in the structure, size and multilayering of squamous epithelium cells. Another name for the pathology is cervical intraepithelial neoplasia (CIN).

There are three degrees of severity of neoplasia:

CIN I (mild) - pathological changes are mild and are observed in the first third of the epithelium, while the surface and intermediate layers are not changed;
CIN II (moderate) - a pathology with more pronounced cellular changes affecting the second third of the epithelial tissue;
CIN III (pronounced form) - the entire thickness of the epithelial layer is affected and significant structural changes in cells are observed.

When cervical intraepithelial neoplasia is detected, it must be remembered that only CIN III is considered a precancerous condition, in which additional studies and treatment are mandatory.

As a rule, pathological changes in CIN I and CIN II do not require treatment if the woman has no human papillomavirus, genitourinary infections and complaints, and the vaginal microflora is normal.

In half of the cases of mild to moderate neoplasia, the cervical epithelium returns to normal within two years. At the same time, a cytology smear should be performed every 3-6 months to monitor the dynamics of neoplasia.

All women 21 years of age and older, or no later than within the first three years after the onset of sexual activity, should take a Pap smear of the cervix with subsequent cytological examination and undergo an annual gynecological examination, in accordance with the recommendations of the Institute of Obstetrics and Gynecology.

Annual screening should be done until age 30. If the last three tests by this time were negative, screening is possible once every 2-3 years (at the discretion of the treating person). When performing a Pap smear of the cervix, it is necessary to take material from the cervical canal and ectocervix.

The number of false-negative Pap test results with highly differentiated intraepithelial changes reaches an average of 20%, but with glandular changes and invasive cancer, their number is even higher.

To reduce the number of false negative results, new technologies for cytological examination of cervical smears have been developed, for example, the use of liquid slides for material preparation. In this case, the stick with the material is placed in a fixative solution on a glass slide, and not on a dry glass. Blood, mucus and inflammatory cells are removed, and a monolayer of epithelial cells is automatically prepared by the machine. Special processors select the most atypical smear cells. This helps to increase the sensitivity of the test, reduce the time required for the cytologist to analyze, and thus increase the efficiency of the test.

The effectiveness of this test alone or in combination with cervical cytology in women over the age of 30 is currently under discussion. The HPV DNA test is more sensitive but less specific than the cytological test.

Regular screening is necessary, even among vaccinated women, as the vaccine does not protect against all types of HPV.

Classification of positive results of cytological examination of smears of the cervix according to Papanicolaou

In 1988, a meeting was held on the basis of the National Institute of Oncology, at which issues of existing terminology and methods for describing cytological studies were discussed. As a result, the Bethesda system was developed, which takes into account:

- the quality of the material taken for the study;
- options for establishing a diagnosis (there are changes or not);
descriptive diagnosis.

This system, revised and supplemented in 2001, is presented below.

Abbreviated Bethesda classification of pathological cytological changes in the cervix

By the quality of the drug:

- the drug is suitable for assessing changes (there is no tissue of the transformation zone);
- the drug is not suitable for the study (specify the reason);
- the drug was not given for research (specify the reason);
- the drug has been studied, but the results are unreliable for assessing the degree of changes in the mucous membrane of the cervix.

General classification:

- with no intraepithelial lesion or malignancy;
- with violation of the structure of epithelial cells;
- other.

Interpretation of the results of a cytological examination of a cervical smear

Tumors with no intraepithelial lesion or malignancy:

- caused by microorganisms (for example, Trichomonas vaginalis);
- reactive changes in the mucous membrane caused by inflammation, radiation, the use of intrauterine contraceptives;
- atrophic changes.

Tumors with a violation of the structure of epithelial cells.

Squamous cell tumors:

- the presence of atypical squamous cells of undetermined origin (ASCUS) does not exclude the existence of high-stage squamous intraepithelial formation (ASC-H);
- the initial stages of squamous intraepithelial formations (LSIL), including HPV lesions, moderate dysplasia, SHIN I;
- late stages of squamous intraepithelial formation (HSIL), including moderate or severe dysplasia, cancer in situ, SHIN II and SHIN III;
- squamous cell carcinoma.

glandular cells:

- atypical glandular cells of the endocervix, endometrium or other localization;
- atypical neoplastic glandular cells (especially endocervix or unspecified origin);
- endocervical cancer in situ (AIS);
- adenocarcinoma;
- others (for example, endometrial cells in the cervix in women older than 40 years).

Evaluation of positive Pap smears

All patients with visible changes in the mucous membrane of the cervix, regardless of the results of a cytological examination of Pap smears of the cervix, should be biopsied

If a small number of atypical cells are detected in a smear (ASCUS), the test is repeated after 6 months. It is also possible to perform a virological study aimed at detecting herpes viruses (HPV). In 6-10% of patients with questionable Pap smear cytology results, a high grade of SPIN is found on colposcopy. In 90% of women, using genetic research, particularly pathogenic types of herpes viruses are detected.

The colposcopic sign of cervical neoplasia is a well-defined white line on the surface of the epithelium after treatment with acetic acid. This effect is due to the fact that under the action of acetic acid, cell dehydration occurs and cells with a higher nucleus density appear lighter. In addition to epithelial cells white color an atypical vascular pattern may or may not be present.

Vascular changes in SPIN involve two phenomena: punctate changes and mosaicism. Point changes are caused by the formation of single spirally twisted capillaries inside the papillae of the subepithelial layer, which then go to the surface of the epithelium and appear as dots. Mosaicism occurs as a result of the formation of a network of capillaries located parallel to the surface of the epithelium. Both phenomena can be found in the same area of the cervix. The wider the capillaries, the more atypical the pattern, and the greater the distance between the capillaries during examination, the higher the degree of tissue atypia. The whiter the epithelium during colposcopy, the higher the degree of dysplasia.

With microinvasive point vascular changes and mosaicism are expressed to a large extent. With invasive cancer, these changes are even more amplified. The tortuosity of the course of the vessels, the change in the shape, width and location of the terminal vessels are combined with much more serious changes in the architectonics associated with the formation of twisted, dilated and blindly ending vessels in the form of a comma.

The article was prepared and edited by: surgeon