Oklahoma State Department of Health
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      A.    Cervical cancer screening is used to detect cervical abnormalities for diagnosis and
            treatment to prevent cervical cancer. Screening is done to identify individuals with cervical
            dysplasia who may be at increased risk of developing cervical cancer and individuals with
            the disease who have not been previously evaluated or diagnosed. Screening should be
            focused on women in the priority populations. The priority populations are comprised of
            women who are of racial, ethnic, and/or cultural minorities (such as American Indians/Alaska
            Natives, African Americans, Hispanics, Asians, Pacific Islanders, and lesbians), women with
            disabilities, women who have not been screened for cervical cancer in the past 5 years and
            women who live in geographically or culturally isolated communities in urban and rural

      B.    Cancer of the cervix has traditionally been squamous cell carcinoma, but now 25% of
            cervical malignancies are adenocarcinoma. Cervical cancer may originate on the exocervical
            surface, the transformation zone, or in the canal (os). The principal pattern of growth is one
            of local extension. This may take the form of disease growth onto the vaginal epithelium or
            growth out into the parametria, the uterine ligament. Lymph node metastasis is common.


      A.    Etiology: The main causative agent for cervical cancer is Human Papillomavirus. The high-
            risk types of HPV (HPV types 16, 18, 31, 33, 35, 39, 45, 51, 56, 58, 59, 68) are present in
            most cases. There are also important co-factors including genetic and behavioral/lifestyle
            factors. Also see the OSDH HIV/STD Service Manual-Section IV, C. Genital Warts.

      B.    Epidemiology: The incidence of cervical cancer has decreased significantly overall, however
            it may be rising slightly among young women. The main method for early detection of
            cervical cancer is cervical cytology screening.

            1.      The incidence of cervical cancer is highest in women who:
                    a.      have experienced Human Papillomavirus infection (HPV);
                    b.      have experienced any sexually transmitted diseases;
                    c.      smoke;
                    d.      have experienced vaginal intercourse before age 18;
                    e.      have had more than one sexual partner or whose partner had more than
                            one partner;
                    f.      have multiple pregnancies;
                    g.      fail to seek screening services;
                    h.      are of lower education and income levels;
                    i.      have immune disease (HIV).

            2.      Although commonly found in women throughout their lifetime, the average age of a
                    woman with cancer of the cervix is 50 years - which means that half of the women
                    who have this cancer are diagnosed before menopause.

      C.    Thin Prep Pap Test Guidelines for Clinical Services provided through County Health
            Departments, OSDH programs, clinics, and providers

            1.      Women under age 21 who have been sexually active for three or more years should
                    begin annual Pap testing.
            2.      Women who have reached age 21 should begin annual Pap tests.
            3.      Women over the age of 26 who have never had cervical cancer screening or have
                    not had cervical cancer screening in the past 5 years should receive high priority in
                    screening recruitment.

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             4.      Women age 30 and older that have had three documented consecutive normal
                     annual Pap tests may receive a Pap test only every three years as long as the Pap
                     test remains normal. These women should continue to have annual pelvic, vaginal,
                     and vulvar examinations.
             5.      Women who have undergone a hysterectomy without removal of the cervix should
                     continue cervical cancer screening until at least age 70.
             6.      Discontinue cervical cancer screening in women age 70 or older that have had 3 or
                     more normal consecutive Pap tests and no abnormal Pap tests in the prior 10 years.
             7.      Women who have had hysterectomies with a positive history of cervical malignancy
                     or dysplasia may receive an annual Pap smear.
             8.      Women who have had hysterectomies including removal of the cervix and who have
                     no history of cervical dysplasia or malignancy may receive a Pap test once
                     postoperatively.      If no abnormality is detected, repeat Pap tests are not
                     recommended through any county health department clinic. These women should
                     continue to have annual pelvic, vaginal, and vulvar examinations.
             9.      Women who have changed partners, have multiple partners, or whose partner(s)
                     have multiple partners should have an annual Pap test. Women with risk factors
                     such as HIV infection or a weakened immune system should be screened annually.
             10.     Women that are post dysplasia should have a Pap test every 6 months times two
                     tests. If all results are normal, then Pap testing should be done according to age

       D.    When To Screen

             1.      Women enrolling in at any County Health Department, OSDH program, clinic, or
                     provider that includes Pap testing should receive screening within the contents of
                     these guidelines.
             2.      Women enrolling at any County Health Department, OSDH program, clinic, or
                     provider, who have had a Pap test in the previous 9 months from another provider
                     should present a copy of that report.
                     a.       If the report is normal, follow routine Pap testing guidelines.
                     b.       If the report is abnormal, and the client has not had any treatment since the
                              test, follow guidelines in PHN GUIDELINE: DYSPLASIA (CERVICAL)
                     c.       If a copy of the report cannot be obtained, and it has been more than four
                              months since the previous Pap, repeat the Pap test.
                     d.       If it has been more than 9 months since the previous Pap test, repeat the
             3.      Collection of a Pap test should not be repeated in less than 4 months to allow
                     cervical cells to regenerate.
             4.      The above three statements also apply to pregnant women.


       A.    Signs and Symptoms: Cervical dysplasia has no signs or symptoms, therefore routine Pap
             tests are very important for healthy asymptomatic women. Cervical cancer patients may or
             may not have abnormal vaginal bleeding, post-menopausal bleeding, post coital bleeding, or
             abnormal discharge. Women with the onset of unexplained vaginal bleeding/discharge, or
             persistent, or non-cyclic vaginal bleeding should be referred for gynecologic evaluation.

       B.    Laboratory Studies: The Pap test is a collection of scraped shed cells placed in a liquid
             based medium that is sent to a laboratory for processing, microscopic review, and reading.
             (See “Thin Prep  Pap Test  Endocervical Brush/Spatula Protocol” located in Procedure
             Manual 2.2.

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      C.   Documentation: Indicate on the lab slip if client has douched, had vaginal intercourse, or
           used vaginal medications or lubricants within the previous 48 hours. Advise her a repeat Pap
           test may be indicated because of insufficient cells.


      A.   Visual inspection of the cervix, vagina and vulva (See “Female Pelvic Exam” located in
           Procedure Manual 2.5).

           1.      Observe symmetry of shape, color, size, and texture of the surface of the cervix and
                   cervical os.
           2.      Observe for lesions, polyps, cysts, friability, and/or presence of discharge.
           3.      Collect specimens as appropriate.

      B.   Documentation of Physical Findings

           1.      Describe location of findings in relation to a clock face (i.e. “Nabothian cyst at 2
           2.      Terms used to describe visible findings:
                   a.       firmness – soft, firm, hard
                   b.       shape – round, irregular, pedunculated
                   c.       texture – smooth, rough
                   d.       discharge present – clear, yellow, green, white, milky, frothy, mucopurulent,
                   e.       eversion – transition zone is visualized
                   f.       erosion – ulceration or breakdown of the normally smooth surface of the
                   g.       friable – bleeds easily when touched by swab, scraper or brush
                   h.       polyp – pedunculated, soft, smooth, reddish piece of fleshy tissue usually
                            protruding from the cervical os
                   i.       stenotic os – cervical os is scarred from previous medical procedures,
                            transition zone is inside os making it difficult to obtain specimen
                   j.       Nabothian cyst – endocervical glands filled with secretions. Appear as hard,
                            yellow, rounded lesion. Requires no treatment.

      C.   Treatment: See document: Cervical Cytology Protocol: Detection, Referral and Follow-up,
           attached to PHN GUIDELINE: DYSPLASIA (Cervical)

      D.   Patient Education

           1.      Women should be counseled about risk factors for cervical cancer and the need for
                   a routine Pap test. Provide women with clinically accurate, culturally sensitive, and
                   literacy appropriate education materials such as the OSDH prepared pamphlets
                   about Pap testing’ abnormal Pap tests and HPV located in shipping and receiving.
           2.      Women should be given information about positioning and the Pap test procedure.
           3.      Women should be informed about the optimal time within their menstrual cycle for
                   obtaining a Pap test. The optimal time is 10 to 17 days from start of last menstrual
                   cycle. Pap tests may be done during menses, although heavy bleeding may
                   obscure the cells. Advise the woman repeat Pap testing may be indicated if cells
                   are obscured by blood.
           4.      Women should be instructed not to douche, have vaginal intercourse, or use vaginal
                   medications or lubricants 48 hours before Pap test. If the woman has douched, had
                   vaginal intercourse or used vaginal medications or lubricants, advise her a repeat
                   Pap test may be indicated because of insufficient cells.
           5.      Women should be informed of the results of their Pap smear result within an
                   acceptable period of time. (See Consultation and Referral for further instructions).

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       E.      Consultation/Referral

               1.      Women with Pap test results “suspect vaginal infections” should be referred for
                       diagnosis and treatment. If the client was seen in Family Planning or Maternity
                       Clinic, a wet prep and appropriate treatment may have already been provided as a
               2.      Women with Pap test results indicating infection should be referred for diagnosis
                       and treatment.
               3.      Women with abnormal results should be notified of their abnormal Pap test result
                       within an acceptable period of time. See document: “Cervical Cytology Protocol:
                       Detection, Referral and Follow-up”, attached to PHN GUIDELINE: DYSPLASIA.
                       Laboratory results are reported using the Bethesda System. Women should be
                       informed of the need for follow-up evaluation procedures. Determine if she is
                       eligible for the Oklahoma Cares Program (866-550-5585). If she is ineligible for the
                       Oklahoma Cares Program, contact the Take Charge! Patient Navigator at 405-271-
                       6912 to determine eligibility for OU Dysplasia Clinic. If she is not eligible for either
                       program, refer her to a private physician’s of her choice by completing referral form
                       399. Document counseling in the client record.


American Cancer Society, CA Journal, 11-2003.
American College of Obstetrics and Gynecology, Report of Task Force on Routine Cancer Screening, 1994
American College of Obstetricians and Gynecologists(ACOG). Cervical cytology screening. Washington
     (DC): American College of Obstetricians and Gynecologists (ACOG); 2003 Aug.11p. (ACOG practice
     bulletin; no. 45, [79 references]
American Journal of Obstetrics and Gynecology, 2006 Consensus Guidelines for the Management of
     Women with Abnormal Cervical Cancer Screening Tests October 2007 346-355

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                                Pap Test Decision Tree

           AGE                        QUALIFYING              FREQUENCY OF PAP
                                      TREATMENT                   TESTING

    Less than 21 years
 with less than 3 years of                                               NO Pap
      sexual activity

    Less than 21 years
with sexual activity for 3 or                                            Annual
        more years

      Age 21 years
  regardless of years of                                                 Annual
     sexual activity

       Age 30 years
with 3 documented normal                                      Every 3 years as long as
     annual Pap tests                                                  normal

                                                               Discontinue screening if
   Age 70 years or older                                      has 3 or more normal Pap
                                                              tests and no abnormal in
                                                                    prior 10 years.

                                  for cervical dysplasia or   Annual until age 70 then
                                           cancer              follow age guideline

                                      Hysterectomy,            Pap once post surgery
                                   no cancer, no cervix         and then no further
                                                                  testing required

                                       any reason,             Follow age guidelines
                                    cervix still present

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     1.    Cervical smear (Liquid based Pap Smear).

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  Cervical Cytology Screening - 8

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