Smear tactics: A more comfortable Papanicolaou test

Vol 53: may • mai 2007  Canadian Family Physician•Le Médecin de famille canadien

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Smear tactics

A more comfortable Papanicolaou test

Nicole Tsang

MD

W.E. Osmun

MD CCFP

P

apanicolaou tests are basic procedures in a woman’s  preventive care. Cervical screening is meant to evalu- ate recognizable precancerous lesions that are treatable if  detected early. It is recommended that all sexually active  women be initially screened annually for 3 normal results,  then  every  3  years  until  3  normal  results  are  obtained  after menopause.

Problem

Fear  of  pain  has  been  found  to  bar  adolescent  women  from  attending  for  a  Pap  test.¹  It  is  important  to  make  patients feel as comfortable as possible for what can be  an intrusive and uncomfortable procedure.

Question

It has long been taught that lubricant should not be used  to  gather  the  specimen,  as  lubrication  was  thought  to  interfere with the quality of the specimen. It was recom- mended  that  the  speculum  be  warmed  and  lubricated  with  water  only.²  However,  it  has  been  the  experience  at  our  clinic  that  metal  speculums  without  lubricant  increased the patient’s discomfort. A straw poll revealed  that  most  of  the  clinic’s  physicians  had  begun  using  small amounts of lubricant despite what they had been  taught.  None  of  them  had  had  specimens  returned  as  being  unsatisfactory  because  of  this  practice.  As  such,  we  reviewed  literature  to  find  support  for  what  had  become our standard of care. Does lubrication interfere  with the quality of the specimen?

Literature review

We  found  4  studies  in  the  literature  that  supported  our  practice  and  none  that  did  not.  Patients  were  random- ized  in  1  study  to  either  gel  or  water  at  the  time  of  pre- sentation.³  In  a  Texan  study,  speculums  were  lubricated  depending on the month,⁴ which was randomly selected. 

In  another  study,  different  clinics  were  randomized  to  use gel or water as a lubricant.⁵ One study left the choice  of lubrication to the attending physician.⁶ A recent study  examined the specimen quality with gel versus water, as  well as patient discomfort.⁷ In all studies, the pathologists  were blinded to whether gel or water was being used. 

The  number  of  slides  analyzed  varied:  182  (Harer  et  al),³  3460  (Griffith  et  al),⁴  8534  (Amies  et  al),⁵  615  (Tavernier et al),⁶ and 70 (Gilson et al).⁷ No study found  any  differences  in  the  slide  results.  In  addition,  the  study  by  Griffith  et  al  looked  at  the  result  of  testing  for 

Chlamydia trachomatis and Neisseria gonorrhea. No differ- ence was found for C trachomatis results. Unfortunately,  the numbers for N gonorrhea were too small to analyze.  

In the study by Gilson et al, the only paper that looked  at discomfort levels,⁷ no difference was found in discom- fort  scores  with  the  use  of  gel.  However,  the  numbers  were  low  in  this  study  and  the  Pap  test  was  performed  twice, initially with water only and then the patients were  examined again with gel or water as a lubricant. As well,  there were small numbers of postmenopausal patients. 

Conclusion

Both  our  experience  and  the  literature  support  lubricat- ing speculums with a dime-sized spot of gel in the per- formance  of  Pap  tests.  While  it  is  our  feeling  that  this  practice  decreases  discomfort  for  the  patient,  a  recent  paper  found  that  the  use  of  gel  did  not  reduce  discom- fort or pain during the procedure. Further study needs to  be done. However, clinicians can be reassured that the  use of gel does not adversely affect specimen quality. 

Dr Tsang wrote this article while working with Dr Osmun and is now a resident in psychiatry at the University of British Columbia in Vancouver. Dr Osmun is an Assistant Professor in the Department of Family Medicine at the University of Western Ontario and practises at the Southwest Middlesex Medical Clinic in Mount Brydges, Ont.

References

1. Kahn JA, Chiou V, Allen JD, Goodman E, Perlman SE, Emans SJ. Beliefs about  Papanicolaou smears and compliance with Papanicolaou smear follow-up in  adolescents. Arch Pediatr Adolesc Med 1999;153(10):1046-54.  

2. Hacker NF, Moore HJ, Gambone JC. Essentials of obstetrics and gynecology. 4th  ed. Philadelphia, Pa: WB Saunders Ltd; 2004. p. 14.

3. Harer WB, Valenzuela G Jr, Lebo D. Lubrication of the vaginal introitus and  speculum does not affect Papanicolaou smears. Obstet Gynecol 2002;100:887-8.

4. Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrica- tion and its effects on cervical cytology and microbiology. Contraception  2005;72(1):60-4.

5. Amies AE, Miller L, Lee S, Koutsky L. The effect of vaginal speculum lubrica- tion on the rate of unsatisfactory cervical cytology diagnosis. Obstet Gynecol  2002;100:889-92.

6. Tavernier LA, Connor PD, Gates D. Water vs gel lubrication for cervical   cytology specimens. J Fam Pract 2003;52(9):701-4.

7. Gilson M, Desai A, Cardoza-Favarato G, Vroman P, Thornton JA. Does gel  affect cytology or comfort in the screening Papanicolaou smear? J Am Board Fam Med 2006;19(4):340-4.

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Practice Tips can be submitted on-line at http://mc.manuscriptcentral.com/cfp or through the CFP website www.cfp.ca under “for authors.”

FOR PRESCRIBING INFORMATION SEE PAGE 955

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