Pap Smears

A Pap smear involves the painless removal of cells from the cervix. It is a screening test for cervical cancer. The cervix is the lower part of the uterus and the entry to the birth canal. Despite what most women think few women die in the United States each year because of cervical cancer. You may know a friend who had a pap smear showing a pre-cancerous condition of the cervix, known as dysplasia. You may even know a woman who had a condition called carcinoma in situ of the cervix, but these abnormalities are not life threatening as long as a woman is under a doctor’s care and doesn’t ignore the condition.

The Pap smear was developed by Dr. George Papanicolaou in 1954. This painless technique has been responsible for saving tens of millions of lives world-wide since its use became popularized. The Pap smear is nothing more than an exam, by a health care provider, that involves the gentle brushing and removal of cells from the cervix to be examined under the microscope by a trained cytologist.

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If you’re reading this you may be a woman trying to learn more about Pap smears or you might be someone who recently found out that she has an abnormal pap smear. Before we get started let’s put things into perspective about cervix cancer. In year 2005 the American Cancer Society reported that 662,870 women in the United States died of all forms of cancer. It breaks down as follows:

Lung cancer deaths 79,560
Colon cancer deaths 56,660
Breast cancer deaths 40,410
Rectal cancer deaths 16,810
Ovarian cancer deaths 16,210
Pancreatic cancer deaths 16,080
Leukemia deaths 10,030
Lymphoma deaths 9,680
Uterine cancer deaths 7,310
Multiple myeloma deaths 5,640
Stomach cancer deaths 4,780
Kidney cancer deaths 4,640
Bladder cancer deaths 4,210
Cervical cancer deaths 3,710
Esophageal cancer deaths 3,300
Melanoma deaths 2,860

For more information on the risk of various cancers in women visit

You can plainly see that although many women are afraid of cervical cancer very few women, comparatively die of this diseaser. That’s why the National Institutes of Health lists cervical cancer as a rare disease (remember I’m not talking about carcinoma in situ which is almost 100% curable, and is different from invasive cervical cancer!).

This is wonderful news and it means that visiting your health care provider regularly is tremendously important. Most of the women in the US who die of cervical cancer did not get regular pap smears! So, before you read any further understand that the Pap smear, which has been around for over 50 years, has made invasive cervix cancer a rare disease and death from cervical cancer rarer still!

The last point I’d like to make about Pap smears is that they are a screening test and not a definitive diagnosis. Pap smears help the health care provider determine which women need specific diagnostic tests such as colposcopy and cervical biopsies. If a pap smear indicates need to that a woman needs further diagnostic tests the actual diagnosis will require a biopsy.


The cervix is the lowest portion of the uterus. It can be seen through the vagina with the use of a vaginal speculum. During pregnancy the cervix acts as a valve and keeps the uterus from opening until a child is mature enough to be born. During labor the cervix opens to about 10 cms (4 inches) and allows the baby to enter the birth canal.

The cervix is covered with a thin skin called “epithelium”. It is a smooth surface very similar to the type of tissue that covers the inside of your lip.

The cervix represents an area where two types of epithelium (think of this as similar to skin cells) join. The “skin” of the cervix is covered with cells called squamous cells.

Squamous cells look like “omelets” stacked up 6 or 8 deep. The “skin” of the inside of the uterus is made up of columnar cells (think of these as being arranged like a column of beer cans). The cervix contains a vulnerable area where these two cells types join. This area is called the squamo-columnar junction or transition zone (T-Zone) and represents the changeover from one cell type to another. THE IMPORTANT PART to know is that it is specifically in the squamo-columnar junction or transition zone that cancer occurs.


The American College of Obstetricians and Gynecologists most current guidelines are:

  • Cervical cancer screening should start at age 21 year
  • Women aged 21-29 years should have a Pap test every 3 years.
  • Women aged 30-65 years should have a Pap test and an HPV test (co-testing) every 5 years (preferred). It is acceptable to have a Pap test alone every3years.
  • Women should stop having cervical cancer screening after age 65 years if they do not have a history of moderate or severe dysplasia or cancer and they have had either three negative Pap test results in a row or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past 5 years.

How common are Pap smear abnormalities?

About 55 Million Pap smears are performed in the United States each year. 3.5 Million of these Pap smears or 6% are abnormal and will require medical follow up. So just to put things in perspective remember that there are approximately 3700 cervical cancer deaths in this country each year. So, for every death attributed to cervix cancer there are 1000 abnormal pap smears! Calm down….you’re not alone if you have an abnormal pap smear.


The major risk factors for Pap smear abnormalities are:

  • Having sex at an early age (before 18)
  • Having sex with multiple sexual partners
  • Having sex with someone who has had multiple partners
  • Having sex with uncircumcised men
  • A history of Chlamydia infection
  • Obese women
  • Multiple pregnancies
  • Smoking
  • The HPV Virus
  • A family history of cervical cancer


Pap smear abnormalities cover a range from the very mild to those that are of far greater concern. Before we can discuss pap smears, however, we need to discuss (a) the range of cervical cell abnormalities and (b) what these abnormalities look like on a tissue biopsy.

The Pap smear is NOT a biopsy, however. Instead, it takes a sample of cells that are normally shed by the cervix and let’s the health care provider know when a biopsy might be necessary. The definitive diagnosis of an abnormality is made with a biopsy. Now here’s a photomicrograph of what a cytologist might see when looking at an abnormal cell.

ASCUS on Pap Smear

ASCUS (Atypical Squamous Cells of Undetermined Significance)

The very mildest abnormalities detected on Pap smear are referred to as ASCUS (atypical typical squamous cells of undetermined significance). This term is used for reporting Pap smear findings and indicates that some flat (squamous) cells look unusual and may or may not be pre-malignant. Of all Pap tests that reveal ASCUS reading, 80-95% are caused by benign conditions, chiefly infections. The remaining 20% prove to be precancerous when further testing, such as a colposcopy is performed.

In general, women and their gynecologists find this category the most annoying. The vast majority of these are “it’s probably normal but I want to keep an eye on things”. Women become concerned that they’re harboring invasive cancer—which is virtually never the case. Gynecologists would rather tell a woman “it’s completely normal and you can return next year”. Most women whose Pap smear reveals ASCUS are best managed by repeating the smear in 3-6 months or performing an additional test called a colposcopy (See below). In general, the best treatment for ASCUS is observation combined with colposcopy, since most of these lesions will spontaneously disappear without treatment. Some cases that co-exist with a vaginal or cervical infection will require antibiotic treatment.

As I’ve already stated, a pap smear that reveals ASCUS should not be ignored as some of them, on closer examination will reveal a more significant lesion. However, once that additional test has been performed, and dysplasia has been ruled out, this abnormality can be safely watched with repeat pap smears and occasional colposcopies—they do clear up given a little time and patience.

One of the “dangers” of ASCUS is that it tends to make women anxious and they often lose sleep—especially after talking to a friend whose well-intended advice often amplifies her anxiety. Unfortunately, many women hear the words “you have an abnormal pap smear” and insist on aggressive surgery. This is generally not recommended and often produces more problems that it solves.

The Dysplasias (Cervical Intraepithelial Neoplasia)

“Plasia” means growth. Dysplasia refers to the disorganized growth of cervical epithelial cells. But before we discuss disorganized growth we should look at what “organized” or “normal” growth looks like. If we look at the left hand portion of the accompanying picture, we can see that the bottom layers of cells are plump and contain nuclei. The top layer of cells is flat (like an omelet) and contains either small or no nuclei. Additionally, the cells are small and do not take up much stain.

The middle portion of the drawing reveals the appearance of dysplastic cells.

Diagram of normal healthy cervix cells.
Graphics provided by Dr. Paul D. Indman

Notice that the cells at the bottom are darker (they take up more stain) and the nuclei are very large compared to the cytoplasm of the cell. This is disordered (or dysplastic) growth and can be categorized as “mild” “moderate” or “severe”. When the disordered growth occupies the lower third of cervical “skin” or epithelium we consider it “mild”. It is considered moderate when dysplasia occupies the lower half of the epithelium and when dysplasia occurs in the full thickness of the cervical epithelium we call it carcinoma in situ (CIS).

Diagram of severe dysplasia or carcinoma in situ in cervix cells
Graphics provided by Dr. Paul D. Indman

Many women in the U.S. have carcinoma in situ (or severe dysplasia). However this is almost 100% curable and is not the same as invasive cervical cancer, which is very dangerous and fortunately very rare.

In carcinoma in situ (CIS) the full thickness of the epithelium has abnormal cells but they do not invade into the underlying tissue.

Invasion into the surrounding tissue is what defines a true cervical cancer.

To try and get an understanding of this try rubbing the skin on the back of your hand and notice that it is free of the underlying muscle and tendons—it moves freely with only gentle rubbing.

If the entire thickness of that skin were affected with abnormal cells it would be called CIS. If the entire thickness of that skin were rubbed and found to be attached to underlying muscle and tendons that would be an example of invasive cervix cancer.

Diagram of invasive cancer in cervix cells
Graphics provided by Dr. Paul D. Indmane

What is colposcopy?

A colposcopy is nothing more than a procedure where the cervix is viewed through a magnifying lens after being stained with a dilute vinegar (acetic acid) solution. It is a painless procedure.

The photograph below reveals the cervical “os” or opening of the cervical canal. There are several areas of the SCJ or squamo-columnar junction that are visible. This is precisely where one type of epithelium, squamous (think omelets), transitions to another type of epithelium—columnar (think beer cans). Occasionally an abnormal area shows up as unusually “white”. These areas are called “aceto-white” epithelium or AW. These AW areas are often where dysplasia can be found.

Appearance of the cervix before the application of a mild vinegar sollution (5% acetic acid).Moderate Dysplasia: The appearance after the cervix has been washed with a mild vinegar solution (5% acetic acid).

What is a LEEP or a LLETZ Procedure?

LEEP stands for Loop Electrosurgical Excision Procedure. Some doctors use the term LLETZ (Large Loops Excision of the Transformation Zone) which is an identical procedure.

This procedure is done, following a colposcopy which tells the physician exactly how large and where the lesion is located. The tissue is then submitted to a pathologist who examines the entire lesion looking for the presence of dysplasia and cancer. Additionally, the pathologist can tell if the entire lesion has been removed.

Although the LEEP procedure is a surgical procedure it is safely performed in our office. Many patients are given a combination of medications that result in conscious sedation—a type of “twilight sleep”.

Halfway through the LEEP procedure. Notice that the specimen includes the abnormal-appearing tissue.Appearance of the cervix at the end of the LEEP procedure. Note that the tissue removed is sent for analysis.Appearance of the cervix 6 weeks postoperatively.

During this procedure an electrical energy generator is attached to a fine wire loop that when energized, functions as a precise and rapid surgical tool. This instrument is then directed toward an abnormal area on the cervix and may be used quickly, effectively and painlessly to remove the abnormal tissue. The procedure takes about 15 minutes to perform and you may expect to spend another 40 minutes in the office as your medications wear off.


Most women return to work in 1-3 days. You should avoid heavy lifting for 3-4 weeks afterwards. You should avoid intercourse for a full 6 weeks postoperatively.


LEEP is extremely effective, with a 90% success rate; however, there are cases in which the procedure has to be repeated.


The risks and consequences are rare, but an LEEP can cause damage to the other pelvic organs or the wall of the vagina. There can be excessive bleeding or pelvic infection (particularly if you have sex before the recommended 3-6 weeks for the cervix to heal.) There also can be a reaction to the local anesthesia. Another rare consequence is the risk of preterm birth in some pregnancies. However, the likelihood of these complications is quite small—especially in experienced hands.

If I have a LEEP Procedure how often will I need to be followed? Your doctor will request frequent check ups and pap tests following this procedure. This may be as often as every 3 months during the first postoperative year.