Gynecology

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THE PAP-TEST

The Pap test is a screening test, which is carried out even in healthy women, without any sign of possible disease, to detect early cervical cancer or alterations that over the years could become. Its introduction has contributed significantly to the reduction of mortality due to cervical cancer (also known as cervical cancer). It could also be useful for giving indications on a woman‘s hormonal balance and allowing the recognition of bacterial, viral or fungal infections.

The examination is carried out during a normal gynecological examination, during which it is applied speculum, an instrument that slightly dilates the vaginal opening to highlight the cervix on which the operator performs a delicate removal using a special spatula, Ayre spatula, and a soft toothbrush, Cytobrush, which are used to collect small amounts of mucus from the cervix and cervical canal, respectively. On this sample, in the laboratory, the cells exfoliated by the tissue will be searched, so that they are examined with special coloring methods and a thorough computerized examination.

According to European guidelines and the National Oncology Commission, in the age group between 25 and 65 it would be advisable to carry out the test at least every three years. In the United States it is performed every 12 months.

Even menopausal women must continue to undergo the examination, at least up to 65 years of age, even if they no longer have sexual relations

The only trick in the execution of the examination is not to perform it during the menstrual flow, so it would be good to fix the appointment at least three days from the end of the menstruation and one week before the next cycle is expected to take place, since the presence of blood can obscure the field of vision and make the reading of the exam inaccurate. Pregnancy, the use of contraceptives and the presence of an intrauterine spiral do not represent a contraindication to the investigation.

Virgin women, who have never had complete sex, can still try to take the exam. The doctor or midwife, properly informed, will use a special tool to dilate the opening of the vagina. Depending on the anatomical characteristics of the woman, in these cases it could however be difficult to be able to take the sample of mucus to be examined from the cervix. The result may therefore not be as reliable.

Despite these difficulties, adult women should still undergo the investigation because, although the risk of cervical cancer is very low in a virgin woman, there are rare forms that develop independently of the transmitted papilloma virus (HPV) infection from a partner.

It should also be clarified that, while it is true that cervical cancer depends almost entirely on viral infection, most HPV infections on the other hand resolve spontaneously and, even when this does not happen, they will not necessarily give rise to a cancer. Vaccination against HPV infection does not currently exempt you from taking the test. The protection does not ensure total coverage and is aimed only at the most common viruses, but not at all types of viruses.

Women who have undergone hysterectomy in the past should consult their doctor to find out whether they should continue screening or not. In general it is however considered appropriate to repeat the exam if the uterus has been removed due to a tumor or a pretumoral form, while it is not necessary if it has been removed for other reasons, for example due to abundant bleeding.

In the two days before a Pap test, it is better to avoid products of spermicides, lavages, creams, gels, ovules or vaginal foams of any type, because they could eliminate or hide abnormal cells.

The results could also be altered by sexual intercourse, from which it would be better to abstain in the two days before the exam

The cells are then colored according to the Papanicolau method and examined under the microscope by a cytologist or pathologist who will arrange to produce a report.

The report is communicated with a brief description of the state of the cells. In Italy the recommended and most frequently used classification is the 2001 Bethesda System (TBS 2001) which divides the test results into:
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[av_table purpose=’tabular’ pricing_table_design=’avia_pricing_default’ pricing_hidden_cells=” caption=” responsive_styling=’avia_responsive_table’ av_uid=’av-je5iq’]
[av_row row_style=” av_uid=’av-ijtme’][av_cell col_style=’avia-highlight-col’ av_uid=’av-i6616′]Negative[/av_cell][av_cell col_style=” av_uid=’av-heabu’]no evidence of intraepithelial or neoplastic lesion[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-gz0my’][av_cell col_style=’avia-highlight-col’ av_uid=’av-gl8hu’]LSIL[/av_cell][av_cell col_style=” av_uid=’av-g27um’]low grade squamous intraepithelial lesion, including HPV / mild dysplasia, CIN1[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-f1fba’][av_cell col_style=’avia-highlight-col’ av_uid=’av-ehxb2′]HSIL[/av_cell][av_cell col_style=” av_uid=’av-dybd6′]high grade squamous intraepithelial lesion, including moderate and severe dysplasia, carcinoma in situ / CIN2, CIN3[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-d9qsq’][av_cell col_style=’avia-highlight-col’ av_uid=’av-co6eq’]AIS[/av_cell][av_cell col_style=” av_uid=’av-18b3e’]suspected glandular cells for in-situ adenocarcinoma of the cervix[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-bn6ru’][av_cell col_style=’avia-highlight-col’ av_uid=’av-ayabm’]Carcinoma[/av_cell][av_cell col_style=” av_uid=’av-a7bvi’]squamous carcinoma cells[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-a2wje’][av_cell col_style=’avia-highlight-col’ av_uid=’av-92nr6′]ASC-US[/av_cell][av_cell col_style=” av_uid=’av-8kuxq’]atypical squamous cells, not further classifiable[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-88fva’][av_cell col_style=’avia-highlight-col’ av_uid=’av-7f8pm’]ASC-H[/av_cell][av_cell col_style=” av_uid=’av-6p4wa’]atypical squamous cells, an HSIL is not excluded[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-637ry’][av_cell col_style=’avia-highlight-col’ av_uid=’av-k6t2′]AGC[/av_cell][av_cell col_style=” av_uid=’av-54lk2′]atypical glandular cells, specifying whether endometrial, endocervical, glandular or otherwise not specified[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-4a0mq’][av_cell col_style=’avia-highlight-col’ av_uid=’av-44lna’]Adenocarcinoma[/av_cell][av_cell col_style=” av_uid=’av-3il4q’]Adenocarcinoma: endocervical, endometrial, extrauterine or not otherwise specified[/av_cell][/av_row]
[av_row row_style=” av_uid=’av-2n5yi’][av_cell col_style=’avia-highlight-col’ av_uid=’av-7x2a’]CTM[/av_cell][av_cell col_style=” av_uid=’av-1q2lm’]Malignant tumor cells not otherwise specified[/av_cell][/av_row]
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The different responses reflect different probabilities of developing or already presenting a cervical cancer. In general, in the case of a “non-negative” test a diagnostic in-depth analysis (colposcopy and possibly biopsy) or a short-term repetition of the test, possibly associated with biomolecular techniques such as HPV typing, is indicated. In other cases, a repetition of the examination is due simply to an insufficient quantity of the cells taken or to an inflammation that can prevent the correct interpretation of the examination.

THE TEST FOR HPV

The HPV test consists in taking a small amount of cells from the cervix that are subsequently analyzed to check for the presence of Papillomavirus DNA. Infections caused by this very common virus are responsible for cervical cancer. The examination, whose methods of execution are similar to those of the Pap test, can be performed by all women, provided that there is no menstrual flow, however, the opportunity to perform it is still subject to evaluation.

The HPV test is more sensitive than the Pap test: it is, in other words, more effective in detecting lesions that could develop into tumors. However, it is less specific, meaning that it also identifies infections that could regress spontaneously.

For this reason it is recommended that a positive HPV test be followed by a Pap test confirming the real positivity.

HPV test positivity does not necessarily mean the presence of a tumor; the HPV test must be performed at longer intervals (at least five years) compared to the three years required for the Pap test and finally, for the Early diagnosis of cervical cancer should not be used before the age of 30-35, since before this age HPV infections are very frequent, but regress spontaneously and almost never develop into cancer.

What is HPV?

HPV, or human papilloma virus, is a common viral infection, predominantly sexually transmitted. Most people are carriers of HPV without even knowing it.

We know about 100 types of HPV; 13 of these can cause cervical cancer. Some types cause genital warts (known as “warts”), which, although not linked to cancer, make it advisable to check for the presence of an HPV infection in the cervix.

What are the risks of HPV?

In most cases, when it comes into contact with HPV, the body gets rid of the virus within a few months. However, in a small percentage of women, the virus is not eliminated; in these cases the risk of developing cervical abnormalities that can develop into a tumor increases. The lesions that develop are initially low-grade (LSIL) and evolve only in 15% of cases towards high-grade lesions (HSIL), given the high frequency of spontaneous regression, also depending on the state of the woman’s immune defenses.

What is the HPV test (DNAPAP) for?

The DNAPAP test detects the presence of high-risk HPV types before cervical cells show visible changes.

The test therefore allows the identification of women potentially at risk of cervical cancer.
To carry out this test, just take a sample of cells from the cervix in the same way as for the Pap test.

Is it useful to do both the Pap test and the HPV test (DNAPAP)?

In women aged 30 and older, performing a Pap smear (and if possible thin-layer cytology) together with the HPV test is the most effective method to prevent cervical cancer. This combined approach can in fact detect 97% of high-grade cervical diseases. The HPV test makes it possible to distinguish, among the anomalies highlighted by the Pap test, those that will regress by themselves from those that will turn into a more serious disease.

If both tests are negative, the risks of developing cervical cancer are very minimal.
The test also, according to the guidelines of the Italian Society of Colposcopy and other international companies, should always be performed for the control after treatments for precancerous lesions of the cervix and for all cases of doubtful Pap-Test (ASCUS).

We remind you that:

• The HPV is a very common virus, one should not be alarmed if the test is positive;
• cervical cancer is a very rare disease, thanks also to the preventive measures that can be activated (Pap-Test, cytology on a thin layer, DNAPAP);
• if the anomalies are detected early, the treatment is 100% successful.

The thin layer Pap test

Relative new in the diagnosis of cervical disease, the material collected, instead of being crawled on a slide, is inserted into a vial containing a liquid that allows the “washing” of the cellular material and therefore the separation of the cells from blood, mucus, etc. The end result is a much “cleaner” slide that allows more reliable diagnoses.

Furthermore, if lesions were found on the cervix referring to the HPV virus, it will be possible to request the test for the relative research.

The test for HPV research can always be requested in association with the Pap test: recent studies indicate that in this way it is possible to obtain the best prevention, particularly in women over 30 years of age.

TRANSVAGINAL GYNECOLOGICAL ECOGRAPHY

Transvaginal ultrasound is a diagnostic investigation system often used in gynecology and obstetrics. Compared to trans-abdominal pelvic ultrasound (in which the ultrasound probe is placed on the lower abdomen) it allows a better visualization of the uterus, endometrium, uterine cervix, fallopian tubes, ovaries and the para-uterine space, including the parieto-colic and of Douglas cable.

The probe coated with disposable material and small (just over 1 cm in diameter), is inserted into the vagina with the aid of the ultrasound gel, allowing an easy and painless entry; emits ultrasounds that are reflected differently from different tissues. These signals are recognized by a computer that reconstructs images of the pelvic organs on a monitor, and the doctor can record them individually or as a whole.

Transvaginal ultrasound is performed by the gynecologist or other competent medical personnel; the patient is invited to urinate before the exam and, once the bladder is empty, is laid out in a bed for gynecological examination. The examination is completed in a few minutes if no further investigation is needed.

Transvaginal ultrasound is performed in different cases, including the suspicion of pathologies affecting thefemale genital apparatus (Endometrial hyperplasia, Uterine leiomyomatosis, a nickname and endometriosi, ovarian masses and other pathological conditions of the adnexa, abscesses or localized infectious processes, cervico-endometrial neoplasms, endometrial polyps or cervical, extrauterine pregnancy) or early visualization of gestational chamber in suspected patients pregnancy.

The investigation can also be performed at any stage of the menstrual cycle. In virgin women the gynecologist can evaluate with the visit whether the hymen is sufficiently elastic to allow the test to be performed. Otherwise you can decide to use trans-rectal ultrasound.

The transvaginal examination is performed with an empty bladder, but sometimes it is required to have it full (and therefore to drink and not to urinate in the hour preceding the survey) to carry out the external pelvic ultrasound first. At the time of the investigation one must undress from the waist down and place on the couch in a gynecological position. No other test preparation is required.

WHAT IS SONO HYSTEROSALPINGOGRAPHY?

The Sonohysterosalpingography (SHSG: Sonohystero-Salpingography or Hy-Co-Sy: Hystero-salpingo-Contrast Sonography) with contrast medium is an ultrasound method for the evaluation of tubal patency, or the possible opening of one or both uterine tubes.

It is proposed as a non-invasive alternative to hysterosalpingography (radiological method) and to chromosalpingography during laparoscopy (laparoscopy is a real intervention, although not very invasive, which is performed by practicing only three small holes in the abdomen). These last two techniques we have mentioned are still considered the best methods for studying tubal patency.

The Sonoisterosalpingografia is proposed as a first level diagnostic test in the initial assessments for couple sterility, in these cases it is generally associated with the evaluation of the uterine cavity with Sonoisterografia and with the study of uterine morphology with 3D Transvaginal Ultrasound.

The second indication of Sonoisterosalpingografia is to verify the presence of endocavitary uterine pathologies (fibroids, synechia polyps, etc.).

CONTRAINDICATIONS

Absolute

• Pregnancy or suspected pregnancy
• Acute adnexal inflammatory pathology
• Genital blood loss
• Malignant tumors of the genital system
• Cardiac or respiratory disorders

Related

• Acute gynecological inflammations: vaginitis, cervicitis, endometritis
• Cervical stenosis

HOW DO YOU DO IT?

The examination is performed in the ambulatory, in the first phase of the cycle (between the 5th and 12th day) without using local anesthesia; it may be useful to perform a premedication with antispasmodics about an hour before the exam.

After disinfecting the uterine cervix, a catheter with a balloon is introduced into the uterus, and positioned so that the balloon occludes the internal uterine orifice. This operation serves to prevent the spillage of the contrast liquid that must be introduced to perform the examination.

At this point, while performing the transvaginal ultrasound, sterile physiological solution and air are injected into the catheter and air bubbles pass through the uterine cavity, at the level of the tube and around the ovary. If the passage happens without obstacles it means that the tubes are open. It can also happen that inside the tubes there is a mucus deposit, which in this case, when the jet of air and water passes, is removed. And therefore the diagnostic examination also has a “curative” effect.

The use of color Doppler, which shows a strong increase in color when the contrast medium passes, can be used as an additional criterion for the diagnosis of tubal patency. Finally the survey of a fluid flap in the peritoneal cavity after the examination further confirms that the tubes are open.

SIDE EFFECTS

The examination can cause, albeit in a small percentage of cases, some side effects such as pelvic pain, sweating, nausea, vomiting, bradycardia, lipotimia and vaginal blood loss.

Pelvic infection and peritonitis. The percentage of this complication is less than 0.1%; it manifests itself with fever and abdominal pain and may require home antibiotic therapy and, in the most serious cases, hospitalization. Rarely, to resolve this pathological picture, surgery (laparoscopic / laparotomic) may be necessary.

ASSESSMENT CRITERIA FOR THE EXAM

Tubal patency criteria are considered:

• Visualization of the passage of air and physiological solution through salpingi
• The positivity of the Color-Doppler signal of the passage of the physiological solution
• Visualization of the periovaric diffusion of air bubbles and injected liquid
• The display of the free liquid in the Douglas cable

Criteria for tubal imperviousness are considered:

• Failure to visualize the passage of air and physiological solution through salpingi
• Failure to visualize the perovenous diffusion
• Failure to display free liquid in Douglas cable

METHOD SUCCESS

From the literature data the investigation cannot be carried out up to 10% of cases due to severe cervical stenosis (it is the most frequent cause, especially in nulliparous patients), excessive cervical canal overflow that does not allow a correct filling of the uterine cavity and passage of the liquid in the salpingi, uterine pathologies that prevent the correct insertion of the catheter (fibroids, polyps, etc.), onset during the examination of pelvic pain or other conditions that lead to suspending the examination.

DIAGNOSTIC ACCURACY IN THE EVALUATION OF PIPELINES

The results of this method are generally compared with those obtained by salpingocromoscopy during laparoscopy (agreement in 75-90% of cases) and with hysterosalpingography (agreement in 85-100% of cases). The SNG can therefore be considered a valid first level test for the determination of tubal patency and, as a first approach, can replace hysterosalpingography. The method is certainly valid for documenting tubal patency, while it is not as safe to diagnose a tubal occlusion. The examination is certainly accurate when the passage of the micro-bubbles of air in the tubes and in the peritoneal cavity is highlighted, while its accuracy is reduced when this passage cannot be assessed so clearly. In these cases the tubal occlusion must not be given as a conclusive finding but it is necessary to perform second-level examinations (Hysterosalpingography or Chromosalpingography) that allow a definitive diagnosis.
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