Also Known As
Pap Test
Cervical Smear
Cervical/Vaginal Cytology
Formal Name
Papanicolaou Test
This article was last reviewed on
This article waslast modified on September 28, 2018.
At a Glance
Why Get Tested?

To screen for cervical cancer and certain vaginal or uterine infections

When To Get Tested?

For women age 21 or older, once every 3 to 5 years depending on your age, risk factors, use of other screening tests, and your healthcare provider's advice

Sample Required?

Cells from the cervical area

Test Preparation Needed?

You may be instructed not to douche or tub bathe for 24 hours before the Pap test is to be performed. You may also be asked to refrain from sexual intercourse for 24 to 48 hours before the test. Do not use any vaginal creams or foams for 48 hours prior to the exam and do not schedule the test during your menstrual period.

You may be able to find your test results on your laboratory's website or patient portal. However, you are currently at Lab Tests Online. You may have been directed here by your lab's website in order to provide you with background information about the test(s) you had performed. You will need to return to your lab's website or portal, or contact your healthcare practitioner in order to obtain your test results.

Lab Tests Online is an award-winning patient education website offering information on laboratory tests. The content on the site, which has been reviewed by laboratory scientists and other medical professionals, provides general explanations of what results might mean for each test listed on the site, such as what a high or low value might suggest to your healthcare practitioner about your health or medical condition.

The reference ranges for your tests can be found on your laboratory report. They are typically found to the right of your results.

If you do not have your lab report, consult your healthcare provider or the laboratory that performed the test(s) to obtain the reference range.

Laboratory test results are not meaningful by themselves. Their meaning comes from comparison to reference ranges. Reference ranges are the values expected for a healthy person. They are sometimes called "normal" values. By comparing your test results with reference values, you and your healthcare provider can see if any of your test results fall outside the range of expected values. Values that are outside expected ranges can provide clues to help identify possible conditions or diseases.

While accuracy of laboratory testing has significantly evolved over the past few decades, some lab-to-lab variability can occur due to differences in testing equipment, chemical reagents, and techniques. This is a reason why so few reference ranges are provided on this site. It is important to know that you must use the range supplied by the laboratory that performed your test to evaluate whether your results are "within normal limits."

For more information, please read the article Reference Ranges and What They Mean.

What is being tested?

A Pap smear (Pap test) is a screening test for cervical cancer. It is used to detect abnormal or potentially abnormal cells from the vagina and uterine cervix. Various bacterial, fungal, and viral infections of the uterus may also be detected using this test.

Cervical cancer is caused by the uncontrolled growth of cells in the cervix, the narrowed bottom portion of a woman's uterus. Cervical cancer begins slowly. The earliest, precancerous changes cause the cells lining the inside or outside of the cervix to appear different from normal cervical cells. These changes, when present on a Pap test, are called "atypical cells." However, atypical cells are not entirely specific for a precancerous condition and can temporarily appear in response to infections or irritation of the cervix lining. If precancerous, the atypical cells can become more abnormal in appearance over time and are more likely to progress to cancer if left untreated.

Pap tests, when performed routinely, have been a great help in the detection and treatment of areas of precancerous cells, which help to prevent cervical cancer from developing. In addition, the test can help detect cervical cancer in the early stages, when it is most treatable. The Pap test is also used to monitor any abnormalities or unusual findings. In many cases, these findings are part of the body's repair process and often resolve themselves without any further treatment.

Almost all cases of cervical cancer are caused by persistent infections with certain types of human papilloma virus (HPV). HPV types 16 and 18 account for about 70% of cervical cancers in the U.S. HPV tests detect the high-risk HPV types and are currently recommended along with a Pap test every 5 years for women age 30-65. HPV tests are not recommended for younger women because HPV infections are common in this age group and usually resolve without treatment. However, if a young woman has an abnormal Pap test, then HPV testing may be done.

In 2015, a panel of experts representing several major health organizations developed interim guidelines that say that HPV testing without a Pap test may be offered as an option for cervical cancer screening to women age 25 and older. (For more on this, see Common Questions below and the news item "Experts Offer Advice on hrHPV Testing as a Primary Screen for Cervical Cancer.")

How is the sample collected for testing?

The Pap test consists of sampling cells from the cervical area. For the more common liquid-based methods, the sample is obtained using a type of "spatula" swab or brush. The specimen is put into a special liquid preservative and sent to a laboratory, where the cell suspension is processed onto a glass slide, stained, and examined by a cytotechnologist and/or pathologist. An advantage of this liquid-based sample is that the cell suspension may also be used for HPV testing. For the older, traditional method, the sample is smeared on a glass slide and sent to a laboratory to be stained and examined under a microscope.

Is any test preparation needed to ensure the quality of the sample?

You may be instructed not to douche or tub bathe for 24 hours before the Pap test is to be performed. You may also be asked to refrain from sexual intercourse for 24 to 48 hours before the test. Do not use any vaginal creams or foams for 48 hours prior to the exam and do not schedule the test during your menstrual period.

Accordion Title
Common Questions
  • How is it used?

    A Pap test is primarily used to screen for cervical cancer. It is used to look for cervical and/or vaginal cells that are cancerous or that may be precancerous. A sample of cervical cells or cell suspension is placed on a glass slide, stained with a special dye (Pap stain), and viewed under a microscope by a cytotechnologist and/or pathologist. The Pap test can also be used to detect vaginal or uterine infections, such as trichomonas infections.

    Abnormal cells and infections can be present without causing any noticeable symptoms. In some cases, further testing and/or treatment may be required while in other cases, the healthcare provider may choose to monitor the person over time to see if the situation resolves on its own.

    Almost all cases of cervical cancer are caused by persistent infections with certain strains of human papillomavirus (HPV), a very common sexually transmitted viral infection. An HPV test may be done along with a Pap test for women age 30 to 65 every 5 years. Abnormal results on a Pap test may also be followed by HPV testing.

    Recent (2015) interim guidelines from a panel of experts representing several major health organizations say that HPV testing without a Pap test may be offered as a cervical cancer screening option for women age 25 and older. 

  • When is it ordered?

    The appropriate frequency of Pap testing is dependent on age, concurrent use of the HPV test, and risk factors (see Screening: Cervical Cancer (Young Adults), (Adults), (Adults 50 and Up)). The American College of Obstetricians and Gynecologists, the U.S. Preventive Services Task Force, and the American Cancer Society recommend the following:

    • Screening with Pap tests should begin no earlier than age 21.
    • Women between the ages of 21 and 30 should have a Pap test every 3 years.
    • Women between the ages of 30 and 65 should have both a Pap test and an HPV test every 5 years (preferable); a Pap test alone every 3 years is also acceptable.
    • After age 65, no screening is necessary if women have had adequate prior screening and no history of cervical cancer. This means that a woman who has had 3 consecutive negative Pap tests or 2 consecutive negative HPV DNA tests within the last 10 years, with the most recent within the last 5 years, no longer needs screening once she turns 65 years old.

    The recent interim guidelines on using HPV testing without a Pap test suggest that women who choose this option and have a negative result on an initial HPV test not be screened again for 3 years.

    Some women may need more frequent cervical cancer screening. Women with the following conditions and circumstances should discuss shorter screening intervals with their healthcare provider:

    • HIV infection
    • Suppressed immune system for other reasons, such as organ transplant
    • Exposure to DES (diethylstilbestrol) during their mothers' pregnancy
    • Previous treatment for cervical cancer or a condition called cervical intraepithelial neoplasia-2 or 3 (CIN 2, CIN 3)

    A health practitioner may also order a Pap test when a woman has multiple sexual partners, is pregnant, or has abnormal vaginal bleeding, pain, sores, discharge, or itching.

  • What does the test result mean?
    Slides showing possible Pap test results
    Various normal and abnormal cervical cells as seen under a microscope.

     

    A "negative" Pap test means the cells obtained appear normal or there is no identifiable infection. In some instances, the conventional Pap test may be reported as "unsatisfactory" for evaluation. This may mean that cell collection was inadequate or that cells could not be clearly identified. A summary of other reported results follows. [See below for Pap Test Terminology on the Bethesda System for classification of Pap test results.]

    • Unsatisfactory: inadequate sampling or other interfering substance
    • Benign: non-cancerous cells, but test shows infection, irritation, or normal cell repair
    • Atypical cells of uncertain significance: abnormal changes in the cells that cover most of the external part of the cervix (squamous cells-ASCUS) or in the cells that cover the lining of the uterus opening and canal (glandular cells—AGCUS) for which the cause is undetermined; an ASCUS test result is frequently followed up with HPV testing to identify the presence of a high-risk infection with HPV.
    • Low-Grade changes: frequently due to infection with HPV, which in some instances can be a risk for cervical cancer; this test result may be followed up with DNA testing to identify the presence of a high-risk HPV infection.
    • High-Grade changes: very atypical cells that may result in cancer
    • Squamous cell carcinoma or adenocarcinoma: terms used to identify certain types of cancer; in these cases, cancer is evident and requires immediate attention.
  • Is there anything else I should know?

    The Pap test is generally used as a screening test. A certain percentage of abnormalities in women may go undetected with a single Pap test, which is why it is important to have Pap test done regularly. A significant limitation of the test has to do with sample collection. The Pap test represents a very small sample of cells present on the cervix and in the vaginal area. Even for the most experienced health practitioner, sample collection can be occasionally inadequate and a repeat Pap may be required.

    If a woman douches, tub bathes, or uses vaginal creams 48 to 72 hours prior to the examination, the test results might be "unsatisfactory." Other factors that may alter results include menstrual bleeding, infection, drugs (such as digitalis and tetracycline), or having sexual relations within 24 hours prior to examination.

    In these cases, a repeat Pap test may be necessary, but it does not necessarily mean there is a significant problem. In some instances, the use of the liquid-based techniques may eliminate obscuring materials such as blood and mucus that may prevent a clear and uncluttered presentation of cervical cells. A second advantage is that the same sample may be used to perform additional testing for HPV, if appropriate.

  • What are the risk factors for cervical cancer?

    The most important risk factor for cervical cancer is infection with high-risk types of human papilloma virus (HPV). That is why HPV tests are now recommended in conjunction with a Pap test for women who are 30 to 65 years of age.

    According to the National Cancer Institute, additional factors can further raise cervical cancer risk after an HPV infection. These include having many children, long-term oral contraceptive use, and chronic inflammation.

    Increased risk is also associated with beginning sexual intercourse at an early age, having multiple sexual partners, infrequent Pap test, cigarette smoking, a history of DES exposure, previous diagnosis of cervical cancer, compromised immune system from organ transplant or HIV, and the presence of other sexually transmitted diseases such as herpes.

  • Do I need a Pap test if I have an HPV test done?

    You may be able to have an HPV test without a Pap test. The Food and Drug Administration recently approved an HPV test for use without a Pap test and recent (2015) interim guidelines from a panel of experts representing several major health organizations say that HPV testing without a Pap test may be offered as a cervical cancer screening option for women age 25 and older. Though the panel reviewed the evidence from several research studies to make their recommendations, it acknowledges that more studies are needed to further evaluate the HPV test and its role in cancer screening. For example, there are still questions about whether age 25 is the best age to start offering it as a primary screening option and how often women should be screened. (For more, read the news item "Experts Offer Advice on hrHPV Testing as a Primary Screen for Cervical Cancer.")

  • Do I need cervical cancer testing even if I've had the HPV vaccine?

    Because an HPV vaccine does not protect against all cervical cancers, women who have had the vaccine still need routine screening.

    The Food and Drug Administration has approved HPV vaccines for use in girls and women ages 9 to 26 to prevent cervical cancer. They protect against the high-risk types of HPV types that cause 70% of cervical cancers and the HPV types that cause about 90% of genital warts. Some HPV vaccines are also approved for boys and men to prevent cancers such as penile and anal cancer as well as genital warts. The vaccines are given in 3 doses over a period of 6 months. They are effective only if received before an initial exposure to the virus, so individuals should get them before becoming sexually active.

  • Does an abnormal Pap test always mean cancer?

    A single "abnormal" Pap test does not necessarily indicate that cancer is present. The membranes covering the cervix undergo constant changes and repair. While treatment may not be necessary, the situation should be monitored closely. This may require a repeat Pap test every three to six months until the situation is resolved.

  • Why do I need regular Pap test or HPV tests?

    Cervical cancer is a slow, progressive disease and may take years to advance beyond the cervix. Because of this fact, regular gynecologic examinations and screening tests are necessary to detect precancerous cells and allow removal of affected tissue. Regular exams can also detect cervical cancer early if it does develop. With early detection, cervical cancer is easier to treat. Left unchecked, however, it is almost always fatal. 

  • How is cervical cancer treated?

    Treatment of cervical cancer depends on the stage of the disease. When the cancer is either limited to the lining of the cervix or contained within the cervix, treatments generally include surgical removal of abnormal tissue, cryotherapy (freezing abnormal tissue), or laser technology.

    Interventions for more invasive cervical cancer may include surgery to remove the affected tissue and organs, such as the uterus (hysterectomy), radiation treatments to destroy any remaining cancerous cells, or chemotherapy.

    If you are diagnosed with cervical cancer, be aware that treatments for the disease are constantly evolving. Talk to your healthcare provider and a gynecologic oncologist (a doctor who specializes in cancer of the reproductive organs) to choose a treatment plan that is best for you.

View Pap Test Terminology

In 2014, a task force updated the classification system for reporting Pap test or smear results, called the Bethesda System. The Bethesda System terminology was originally developed in 1988. The 2014 review of the system incorporated minimal changes to the earlier version but refined some positions and content.

Bethesda System Terminology: 
Important Sections of the Report and the New Terminology

Specimen Adequacy: Each laboratory must report if the cervical sample obtained for the test was adequate and if the quality of the smear was satisfactory for examining under the microscope. Before looking at the results, one should always check to see if the smear has been marked "Satisfactory." If "unsatisfactory," the reasons will be given and the smear will have to be repeated in 2 or 3 months.

Interpretation/Results: This is the section where the important findings from looking at the cells are reported. There are four different sections:

  • Negative for intraepithelial lesion or malignancy
  • Other: Endometrial cells present in a woman age 40 or more
  • Epithelial Cell Abnormalities
  • Other Malignancies

Negative for intraepithelial lesion or malignancy:
This is the desired result and where a "normal" result is reported. There are two important subcategories, where abnormal findings not related to the risk of cancer are reported. These are:

  • ORGANISMS: This is where evidence of trichomonas, a fungal (yeast) infection, herpes, or some other infection is reported.
  • OTHER NON-NEOPLASTIC FINDINGS: This is where evidence of injury and response to injury, previously termed "Benign Cellular Changes," is reported.

Other: Endometrial cells present in a woman age 40 or more:
This section is used to alert the health practitioner that endometrial cells (cells from the lining of the uterus) are present when they normally should not be. This is a check on the status of the uterus and endometrium and not the cervix. When a woman is having monthly periods, endometrial cells are often present near the time of a period. After menopause, however, they should not be present. If you are still having periods even though you are over age 40, you and your healthcare provider can disregard this part of the report.

Epithelial Cell Abnormality:
This section is where abnormalities that are associated with the risk of developing cancer are reported. The abnormalities range from changes that are only slightly abnormal to definite cancer. There is a spectrum of change. There are two types of epithelial cells in the cervix (squamous and glandular) and changes in each are listed.

Squamous Abnormalities (cells that cover most of the external part of the cervix)

  • Atypical Squamous Cells: Unknown Significance (ASC-US) or Cannot exclude HSIL or high-grade changes (ASC-H)
  • Low Grade Squamous Intraepithelial Lesion (LSIL)
  • High Grade Squamous Intraepithelial Lesion (HSIL); one subcategory: "with features suspicious for malignancy"
  • Squamous Cell Carcinoma

The potential for malignancy increases as you move down the list to the last diagnosis of Squamous Cell Carcinoma, which is an invasive cancer.

Note: There are over 50 million Pap smears done in the U.S. each year and approximately 4,000 new cancers are reported. The odds of a positive Pap smear for cancer are quite small.

Glandular Abnormalities (cover the lining of the uterus opening and canal)

  • Atypical cells, not otherwise specified
  • Atypical cells, favor neoplastic
  • Adenocarcinoma in situ
  • Adenocarcinoma (can be endometrial (uterus), endocervical (cervix), extrauterine (origin from outside uterus and cervix), or the site of the malignancy cannot be determined based on the Pap smear))

Glandular abnormalities are much less common than squamous abnormalities. The list above is arranged so that the potential for malignancy increases as you move down the list. A diagnosis like adenocarcinoma in situ (a cancer limited to the surface that has not invaded) is one of the rarest diagnoses made on a Pap smear and frequently requires consultation among pathologists.

Other Malignancies:
Malignant tumors other than primary squamous carcinoma and glandular adenocarcinoma are occasionally seen on a Pap smear and they are reported here.

Reminder

It is important that if you do not understand your Pap smear results, you ask your healthcare provider for clarification. Ninety-nine percent of the abnormal findings reported on a Pap smear are either completely benign or completely reversible and treatable. However, annual Pap smear testing remains important to ensure that any potentially serious problems are detected promptly.

Article Source

Ritu Nayar, MD and David C. Wilbur, MD. The Pap test and Bethesda 2014. Article first published online: 1 MAY 2015. Cancer Cytopathology Volume 123, Issue 5, Pp. 271–281. Available online at http://onlinelibrary.wiley.com/doi/10.1002/cncy.21521/full through http://onlinelibrary.wiley.com. Accessed August 2015.

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