1. ANATOMIC FEMALE PELVIS AND THE UTERUS
“How is the correct way for best results to Pap smear and others methods on prevention”
Laura Fleider MD – Maldonado Verónica MD
Lower Genital Tract and Colposcopic Unit
Department of Obstetrics and Gynecology –
Hospital de Clínicas “José de San Martín”
University of Buenos Aires Argentina

2. ANATOMIC FEMALE PELVIS AND THE UTERUS
CLASSIFICATION OF THE FEMALES GENITAL ORGANS
External organs
Genital organs
Internal organs

3. ANATOMIC FEMALE PELVIS AND THE UTERUS
THE EXTERNAL FEMALE GENITALS
Vulva include:
The mons pubis.
Labia majora and minora
Clitoris
Vestibule with glands and urethral meatus
Vaginal orifice
The muscles and fascia surrounding these structures
Yavagal S,Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerationsSemin Plast Surg May;25(2):121-9,

4. ANATOMIC FEMALE PELVIS AND THE UTERUS
Anatomia genitales externos femeninos recursos.cnice.mec.es/biosfera/alumno/3ESO/apararep/anafem.htm

5. ANATOMIC FEMALE PELVIS AND THE UTERUS

6. ANATOMIC FEMALE PELVIS AND THE UTERUS
prepuce
Clitoris
Frenulum
Labia Majora
Labia Minora
Vaginal Orifice
Posterior Fourchette
Perineal Body

7. ANATOMIC FEMALE PELVIS AND THE UTERUS
MONS PUBIS:
The mons pubis is a triangular area of fatty tissue, covered with hair-bearing skin lying on top of the pubic bone
THE LABIA MAJORA:
The labia majora are prominent cutaneous folds located between the mons pubis and the perineum mainly consisting of adipose tissue, hair follicles, and sebaceous glands
THE LABIA MINORA:
The labia minora are folds of skin, devoid of fat, rich in sebaceous glands lying medial to the labia majora on each side immediately adjacent to the vestibule
THE CLITORIS:
The clitoris is a highly neurovascular erectile structure
Yavagal S,Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerationsSemin Plast Surg May;25(2):121-9,

8. ANATOMIC FEMALE PELVIS AND THE UTERUS
Neurovascular Supply of External Genital
Arterial supply of the vulva is derived from the external and the internal pudendal arteries on each side.
The pudendal nerve is the main sensory and motor nerve of the perineum.
Yavagal S,Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerationsSemin Plast Surg May;25(2):121-9,

9. ANATOMIC FEMALE PELVIS AND THE UTERUS
THE INTERNAL FEMALE GENITALS
Include:
Vagina
Uterus
Ovaries
Fallopian tubes
The connective tissue supports of the fascia, muscles, and ligaments

10. ANATOMIC FEMALE PELVIS AND THE UTERUS
VAGINA:
The vagina is a fibromuscular tubular structure that extends from the cervix to the vulva and measures 7–9 cm in length
UTERUS:
The uterus consists of the upper fibromuscular body and lower cervix, which primarily consists of fibrous connective tissue .
THE FALLOPIAN TUBES:
The fallopian tubes are tubular structures lined with ciliated columnar epithelium extending from the upper lateral end of the uterus to the ovary on each side.
OVARIES:
Each ovary consists of an inner medula, an outer cortex with follicles and stroma.
Yavagal S,Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerationsSemin Plast Surg May;25(2):121-9,

11. ANATOMIC FEMALE PELVIS AND THE UTERUS

12. ANATOMIC FEMALE PELVIS AND THE UTERUS
Adapted from Anatomia del aparato reproductor femenino; recursos.cnice.mec.es/biosfera/alumno/3ESO/apararep/anafem.htm

13. ANATOMIC FEMALE PELVIS AND THE UTERUS
Atlas digital Primal, corresponding to the female pelvic viscera, developed fron cuttings of RM, which allows, among other things,, rotation and image substraction. Distribuido en DVD-ROM (2008)

14. ANATOMIC FEMALE PELVIS AND THE UTERUS
Atlas digital Primal, corresponding to the female pelvic viscera, developed fron cuttings of RM, which allows, among other things,, rotation and image substraction. Distribuido en DVD-ROM (2008)

15. ANATOMIC FEMALE PELVIS AND THE UTERUS
“HOW IS THE CORRECT WAY FOR BEST RESULTS TO PAP SMEAR AND OTHERS METHODS ON PREVENTION”

16. ANATOMIC FEMALE PELVIS AND THE UTERUS
Correct value of the PAP test: we need to perform a “correct sampling of the cervix with appropriate equipment”
Women must be satisfied when we perform the Pap smear, and she may not feel pain
We must prepare all the equipment required for the examination before beginning it, to minimize the time that the woman spend in what some consider may be an embarrassing position.

17. ANATOMIC FEMALE PELVIS AND THE UTERUS
MATERIAL REQUIRED TO PERFORM A PAP SMEAR
Gloves
Light
Speculum
sampling devices (Ayre’s spatula , endocervical brush, cervical broom, fixative)
Pencil and slide carrier for conventional smears or
vials and a ballpoint pen where liquid-based cytology (LBC) is used
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer screening: recommendations for collecting samples for conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007* ,

18. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING DEVICES
Spatula : of wooden or plastic
Endocervical brush
Cervical broom
Fixative
Pencil and slide carrier for conventional smears or
vials and a ballpoint pen where liquid-based cytology
(LBC) is used

19. ANATOMIC FEMALE PELVIS AND THE UTERUS
ELEMENTS FOR GYNECOLOGY EXAMINATION

20. ANATOMIC FEMALE PELVIS AND THE UTERUS
ELEMENTS FOR CERVICAL SAMPLE

21. ANATOMIC FEMALE PELVIS AND THE UTERUS
ELEMENTS FOR THE COLPOSCOPIC EXAMINATION

22. ANATOMIC FEMALE PELVIS AND THE UTERUS
ELEMENTS FOR ENDOCERVICAL SAMPLE

23. ANATOMIC FEMALE PELVIS AND THE UTERUS
FACTORS ADVERSELY AFFECTING THE QUALITY OF A CELL SAMPLE ARE:
• menstruation, blood loss, breakthrough bleeding
• vaginal inflammation ⁄ infection
• sexual intercourse within 24 hours
• severe genital atrophy (menopause)
• pregnancy, postpartum period and lactation
• physical manipulation or chemical irritation such as: examination, disinfectant, cream or liquid, lubricating jelly, vaginal medication, vaginal douche or spermicidal jelly (less than 24 hours before), cervical surgery (less than 3 months before)
• radiotherapy

24. ANATOMIC FEMALE PELVIS AND THE UTERUS
PREPARING TO TAKE THE SAMPLE
Take woman’s identification data
Ask about her general health and whether she has any symptoms such as irregular bleeding
Ensure that the woman is lying comfortably on the examination couch in the dorsal or lateral position and position the light source so as to the cervix clearly
Select the largest speculum that can be inserted comfortably
Insert the speculum along the axis of the introitus

25. ANATOMIC FEMALE PELVIS AND THE UTERUS
THREE METHODS ARE RECOMMENDED FOR SAMPLING THE TRANSFORMATION ZONE USING
Cervical broom; or
Combination of a spatula for the ectocervical sample and an endocervical brush for the endocervical sample; or
Extended tip spatula alone

26. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING AND PREPARING A CONVENTIONAL SMEAR
CERVICAL BROOM:
Endocervical cells and ectocervical cells are sampled simultaneously
Rotate the brush five times over 360°
Sweep the broom lengthwise along the slide, turn over and repeat for the other side
Fix immediately
The fixative of choice is 95% ethyl alcohol but other appropriate fixatives may be used.
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer
screening: recommendations for collecting samples for
conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007* ,

27. ANATOMIC FEMALE PELVIS AND THE UTERUS
CERVICAL BROOM
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer
screening: recommendations for collecting samples for
conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007*

28. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING AND PREPARING A CONVENTIONAL SMEAR
SPATULA AND BRUSH:
Spatula Sampling
Rotate the spatula through more than one complete turn while maintaining firm contact with the cervix
Endocervical Brush Sampling
Insert the endocervical brush for two thirds into the endocervical canal, so that the lower bristles are still visible, and rotate gently 90°-180°
Roll (not wipe) the endocervical brush immediately over the outer third of the slide in the opposite direction from which it was collected.
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer
screening: recommendations for collecting samples for
conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007* ,

29. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING AND PREPARING A CONVENTIONAL SMEAR
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer
screening: recommendations for collecting samples for
conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007*,

30. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING AND PREPARING A CONVENTIONAL SMEAR
Cytobrush sampling, to obtain endocervical cells

31. ANATOMIC FEMALE PELVIS AND THE UTERUS
SAMPLING AND PREPARING A CONVENTIONAL SMEAR
M. Arbyn*, A. Herbert,European guidelines for quality assurance in cervical cancer
screening: recommendations for collecting samples for
conventional and liquid-based cytology.Cytopathology 2007, 18, 133–139 ª European Communities 2007* ,

32. ANATOMIC FEMALE PELVIS AND THE UTERUS
LIQUID-BASED CYTOLOGY SAMPLE
Alternative to improve to the extended conventional cervical screening
Objetive: to increase the sensitivity without decreasing specificity
FDA appoved the ThinPrep Pap test

33. ANATOMIC FEMALE PELVIS AND THE UTERUS
LIQUID-BASED CYTOLOGY SAMPLE
Step 2: place the brush into de liquid, stiming to release 10 times the cells learned
Step 3: discard the brush, send the sample closed and labeled to the laboratory
Step 1: sampling endoexocervical brush ( 5 turns clockwise)

34. ANATOMIC FEMALE PELVIS AND THE UTERUS
VISUAL INSPECTION ASISTED (VIA)
It permeates the cervix with acetic acid 3-5% for 1 minute and then displays it under a 100W light
Distinguish normal and abnormal cervical epithelium
Great variability in the Sensitivity and Specificity
In our area:
Sensitivity 38-44%
Especificity %
Yet to be found its role as a diagnostic method

35. ANATOMIC FEMALE PELVIS AND THE UTERUS
VIA: Normal Cervix

36. ANATOMIC FEMALE PELVIS AND THE UTERUS
VIA:Abnormal Cervix
(you can see an acetowithe epithelium)

37. ANATOMIC FEMALE PELVIS AND THE UTERUS
VIA:Abnormal Cervix
(you can see an acetowithe epithelium)

38. ANATOMIC FEMALE PELVIS AND THE UTERUS
ABNORMAL VISUAL INSPECTION
Exophytic lesion
Leukoplakia
Vaginal
condiloma
condiloma

39. ABNORMAL VISUAL INSPECTION NOT RELATED TO MALIGNANCY
ANATOMIC FEMALE PELVIS AND THE UTERUS
ABNORMAL VISUAL INSPECTION
NOT RELATED TO MALIGNANCY
Nabothian cysts
Atrophic

40. ANATOMIC FEMALE PELVIS AND THE UTERUS
HYBRID CAPTURE
HPV DNA is detected
Use long genomic probes and antibodies specific for RNA-DNA hybrids unleashing a high level "signal amplification" For each hybrid detected can join multiple signal-generating enzymes
It's fast, reliable and less expensive
Semiquantitative
High level of interlaboratory reproducibility
High sensitivity, but low specificity

41. ANATOMIC FEMALE PELVIS AND THE UTERUS
HYBRID CAPTURE

42. ANATOMIC FEMALE PELVIS AND THE UTERUS

43. ANATOMIC FEMALE PELVIS AND THE UTERUS
RECOMMENDATIONS FOR THE SCREENNING CERVICAL CANCER
1) AGE TO BEGIN SCREENING
Cervical cancer screening should begin at age 21, (women younger than 21 years should not be screened regardless of the age of sexual initiation or other risk factors).
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

44. ANATOMIC FEMALE PELVIS AND THE UTERUS
2) WOMEN AGED 21 TO 29 YEARS
Screening with cytology alone every 3 years is recommended.
Women 21 to 29 years with 2 or more consecutive negative cytology results, there is insufficient evidence to support a longer screening interval ( more than 3 years)
HPV testing should not be used to screen women in this age group, either as a stand-alone test or as a cotest with cytology
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

45. ANATOMIC FEMALE PELVIS AND THE UTERUS
3) WOMEN AGED 30 TO 65 YEARS
Women aged 30 to 65 years should be screened with cytology and HPV testing (‘‘cotesting’’) every 5 years (preferred) or cytology alone every 3 years (acceptable)
There is insufficient evidence to change screening intervals in this age group following a history of negative screens.
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

46. ANATOMIC FEMALE PELVIS AND THE UTERUS
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

47. ANATOMIC FEMALE PELVIS AND THE UTERUS
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

48. ANATOMIC FEMALE PELVIS AND THE UTERUS
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical CancerCA CANCER J CLIN 2012;62:

49. Many Thanks!!!! 49