The Facts of Life: Examining Reproductive Health

Female Anatomy

Gynecological Exam

At a gynecological examination, a woman's medical history is taken. Then, her clinician will examine her breasts and perform a pelvic exam which includes a Pap smear, a bimanual exam and a recto-vaginal exam. Each of these provides the clinician with vital medical information about her patient. The exams are brief and for the most part, painless. Some women do experience slight discomfort, usually due to nervousness.

Recently, there has been some controversy about how often women should obtain Pap smears. Some medical experts have suggested that the exams be spaced every two to three years rather than annually. They believe that a woman who has had three or more consecutive, normal Pap smears no longer needs to be tested once a year. However, it is known that certain women are at increased risk of cervical cancer. For these women, annual exams may be lifesaving. Women with human papillomavirus (HPV) or human immunodeficiency virus (HIV), smokers, and women who have multiple sex partners (or whose sex partners have multiple sex partners) are at increased risk.

Essentially, the only women who are not at a somewhat increased risk of cervical cancer are those who have had sexual intercourse with only one partner in their lifetime and whose partner has had sex only with them. Thus, there are several factors to consider when deciding how often to seek gynecological assistance. If a woman has a history of sexually transmitted diseases, has had more than one sexual partner, and/or smokes, a pelvic examination every year may ultimately save her life.

The Breast Exam
A practitioner visually examines the surface of a woman's breasts for lumps, depressions, bulges, swelling, sores, and mole-like features. To perform a manual breast exam, the practitioner will ask her patient to lie down. Now, she will gently press down in a circular motion around the breasts and arm pits with the flat portion of her fingers. Any signs of lumps, dimpling, discharge from the nipples, or enlargement of the lymph nodes in the arm pits may indicate a problem. Following the exam, the patient may be taught how to check her breasts monthly, if she is not doing so already.

The Pelvic Exam
The pelvic exam begins with the external exam. The genital area is checked for any sores, rashes, or signs of other infections. An instrument called a speculum is then inserted into the vagina. The speculum enables the practitioner to view the patient's lower internal reproductive organs. The main reason for this exam is to collect a sample of cells from the cervix (passageway to the uterus) to be tested for cancer and other conditions. This test is known as the Papanicolaou or "Pap" smear. Another purpose of the speculum exam is to look for rashes or redness on the vagina or cervix. These may indicate sexually transmitted diseases (STDs).

The Bimanual Exam
Because the health care practitioner is able to view only a limited area, she must now "see" the internal organs through her sense of touch. First, she will insert two lubricated, gloved fingers into the vagina. While pressing down on the abdomen with the other hand, she is able to feel the size, shape, and consistency of the uterus, fallopian tubes, and ovaries. She will check for tumors, tenderness, and location of the organs.

Finally, a recto-vaginal exam is performed. The practitioner inserts a clean, lubricated, gloved finger into the patient's rectum while a gloved finger is in the vagina. Pressing down on the abdomen will enable the examiner to feel areas that cannot be reached with the other exams.

The Pap Test
Every year, thousands of new cases of cervical cancer are diagnosed in the United States, usually through the use of a Pap smear. Since the introduction of the Pap smear in 1943, the United States death rate from cervical cancer has been reduced by more than 70%. Pap smears enable the detection of pre-cancerous lesions, which can be treated before invasive cancer has time to develop. It is probable that, should all women obtain Pap smears regularly, cervical cancer could be eliminated as a cause of disease.

The Pap smear is named after Dr. George N. Papanicolaou, the physician who developed this test. A sample of cells from the cervix is obtained with a small brush and spatula. The cells are transferred to a glass slide and sent to a laboratory to be examined under a microscope for abnormalities.

Causes of incorrect readings
Douching and/or intercourse within 24 hours before the Pap test may cause an incorrect reading. Other kinds of sexual activity will not affect the reading. A fairly heavy menstrual flow may also cause an incorrect reading. Laboratory technologists and physicians study the cells to determine if they are normal. Most abnormal Pap smears are not cancer.

PAP Smear Q & A
What is a PAP smear?
The PAP smear is a way to examine cells collected from the cervix and vagina. It is a safe, effective and inexpensive way to check for cancer. It can show the presence of infection, inflammation, abnormal cells, or cancer. The PAP smear can detect abnormal cells at an early stage, before they become cancer. Therefore, the PAP smear is an important part of a woman's routine health care.

Information a woman should provide to her practitioner:
1. Age
2. Date of your last menstrual period
3. Current medications (birth control pills or other hormones)
4. Any history of abnormal PAP smears
5. History of a hysterectomy (having uterus removed)
6. Any abnormal bleeding or discharge

Remember, it is important not to douche before your appointment.

How often should a PAP smear be done?
Women who are, or have been sexually active, or have reached age 18, should have regular PAP smears (ask your clinician how frequently you should have them). There is no upper age limit for PAP smears. Older women should continue to have regular physical exams, including a PAP smear. A woman who has had a hysterectomy (removal of uterus) should continue to have routine PAP smears as well.

What will a PAP smear report tell me?
The main purpose of the PAP smear is to detect the presence of abnormal cells from the cervix and vagina which may but have not yet become cancer cells. The PAP smear can also be used to detect common infections of the cervix. Detecting these organisms is always important, but particularly during pregnancy, so that harm to the baby can be avoided. The PAP smear is not intended to identify all cancers of the female genital tract. Not all cancers shed cells into the area that the PAP smear samples. For example: Endometrial (cells that line the inside of the uterus) cancer may never discharge cells into the cervix (where the PAP smear is taken). But sometimes if the endometrial cancer gets large enough, it can shed cells into the area and they might be sampled. These cells may or may not be seen on the PAP smear depending on several factors. However, the PAP smear does a great job identifying those with cancer or pre-cancerous lesions that begin in the cervix or vagina.

What if I have an abnormal PAP smear?
An abnormal PAP smear report rarely means that you have cancer. Some abnormal PAP smears are due to infections which, when treated, return to normal. Other types of abnormal PAP smears show pre-cancerous changes. Several different terms have been used to describe the abnormal cells that may be seen in PAP smears. Pre-cancerous conditions are called low-grade and high-grade squamous intraepithelial lesion. Other terms sometimes used to describe these abnormal cells are cervical intraepithelial neoplasia (CIN) and dysplasia. The abnormal cells are often low grade lesions (mild dysplasia) and represent only slight pre-cancerous changes. They can progress into high grade (moderate and severe dysplasia and carcinoma in-situ), but if a low grade lesion is detected on your PAP smear, your doctor will probably choose to have you come in and repeat the PAP smear in shorter time intervals (three to six months) so that it can be watched closely. Other preventative measures may be performed to control the progression of the lesion. This is usually done in cases of higher grade lesions. The patient is closely monitored to make sure these changes do not return. Having PAP smears often can help your doctor detect cell changes at an early stage before they become cancerous.

What happens to my PAP smear after it is collected?
After your PAP smear is taken, your slide will be sent to a cytology laboratory (if your PAP smear is taken at the University of Iowa Hospital and Clinics, it will be sent to the cytology laboratory at UIHC for evaluation). Your cells will be stained with dyes so they can be viewed through a microscope by a laboratory specialist called a cytotechnologist ( a person who studies cells). A pathologist will examine any abnormal cells identified by the cytotechnologist. It is your right to question your doctor about the type of laboratory that evaluates your PAP smear. Both the cytotechnologist and the pathologist should be trained in viewing PAP smears so you can be assured of the most accurate diagnosis possible.

What is cytology?
Cytology is the microscopic diagnosis of cells for infectious, pre-malignant and malignant diseases. The use of cytology in the early detection of cancer has gained widespread acceptance, particularly with the techniques developed by Dr. George Papanicolaou. Since its inception 50 years ago, cytology has proven to be an essential tool in the early detection of cancer occurring in all body sites.

What is a cytotechnologist?
A cytotechnologist is literally "one who studies cells." Cytotechnologists are health professionals trained to detect changes in cells through microscopic evaluation. Some of these changes are the presence or absence of malignant cells (cancer), pre-malignant changes, viral changes or inflammatory processes. Cytotechnologists are responsible for providing the final diagnostic report on all negative gynecological (Pap) smears and a preliminary diagnosis in cases that require further evaluation by a pathologist. A cytotechnologist must acquire in-depth knowledge of both normal and abnormal cellular features of virtually every organ of the body to accurately interpret the various cytologic specimens.

Normal Squamous Cells These cells line the ectocervix and the vagina in a woman's genital tract. Their function is to protect the cervix. They have a centrally located nucleus (dark sphere that contains genetic material [DNA] and will determine the function the cell will play in the body) and abundant clear cytoplasm (substance that surrounds the nucleus made up of mostly water). 10.Normal squamous cells

Normal Endocervical Cells These are a different type of cell which lines the endocervix. They are known as columnar cells. Their function is to release secretions to keep the cervix moist. Some of the differences between these cells and squamous cells: endocervical cells are tall rather than round and the nucleus is placed to one side instead of in the middle. These cells must be present in pap smears to have an adequate sample, unless the patient has a hysterectomy (uterus removed). 11.Normal endocervical cells

Candida albicans This is a yeast/fungal infection. Candida is identified by its branching pseudo-hyphae with budding spores. (Looks somewhat like tree branches with fruit growing and falling off around them) 12.Candida albicans

Low Grade Squamous Intraepithelial Lesion (LGSIL) or Mild dysplasia These cells represent slight pre-cancerous changes in squamous cells. The nucleus is 3-4 times the size of a normal squamous cell and darker in color. The cytoplasm is similar in size to that of a normal squamous cell. Compare the cells in the middle of the picture which are mildly dysplastic to the cells around the edges which are normal. 13.Low grade lesion

High Grade Squamous Intraepithelial Lesion (HGSIL) or Moderate dysplasia These cells represent a more significant pre- cancerous change. The cells are somewhat smaller in size with a larger darker nucleus and less cytoplasm. The nucleus also has slightly irregular edges. 14.High grade squamous intraepithelial lesion (HGSIL) or moderate dysplasia
High Grade Squamous Intraepithelial Lesion (HGSIL) or Severe dysplasia These cells are from pre-cancerous lesion that is close to becoming cancer. The cells are similar to moderate dysplasia except there is even less cytoplasm and the nuclei are darker and more irregularly shaped. 15.High grade squamous intraepithelial lesion (HGSIL) or severe dysplasia

Squamous cells carcinoma (SCCa) or cancer of the cervix (at high magnification) The cell pictured here is extremely large. The cells can become quite bizarre looking. The cytoplasm is usually dense and "crisp" around the edges, sometimes said to look as if it were cut out with a cookie cutter. The nucleus is dark and can have a clumped appearance (dark in areas and light in others). 16.Squamous cells carcinoma (SCCa) or cancer of the cervix (at high magnification)