W. David Stinson, MD    Obstetrics & Gynecology

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Pathology of an abnormal Pap smear

This is a pathology diagram of a Pap smear from normal to more severe dysplasia, from left to right.  As you can see, the cells get smaller and the depth of abnormality increases with worsening dysplasia (abnormal growth).  CIN stands for cervical intraepithelial neoplasia.  'Neo' means new, 'dys' means abnormal.  I would call it CID instead of CIN, but this nomenclature changes every few years anyway.


In Situ carcinoma is basically 'cancer sitting there.'  At the bottom right, the abnormal cells have grown through the basement membrane or floor, such that they can now invade a woman's body.   This is true cancer.  Everything else is precancerous.  No one should get cervical cancer because it can be reduced with Gardisil and prevented with yearly Pap smears and follow up.


If you have an abnormal Pap test, you may be asked to return for a colposcopy.  This is a simple office procedure in which your cervix is examined with a low power microscope called a colposcope.  Acetic acid, or vinegar is applied to the cervix.  This will cause any abnormalities to become white under the colposcope.  A very small biopsy of any abnormal area is done.  If the biopsy returns with dysplasia, the next step can be observation, cryotherapy, LEEP, or a cold knife cone (CKC), depending on your age and the severity of the dysplasia.


Something not on this diagram is a finding called ASCUS or atypical squamous cells of undetermined significance.  Basically, this means that the pathologist who reviewed the Pap is saying that the cells do not look normal, but that they do not appear to be dysplastic or potentially cancer producing.  Mild infections can cause this finding, or it may be that there are true concerning changes to the cervix that have not progressed enough to be identified as dysplastic.   ASCUS is a very common finding.  Until recently, most physicians would have a woman return in four to six months and repeat the Pap.  With the addition of HPV testing, things have changed some.  If I have a patient with an ASCUS Pap that also is positive for high risk HPV, I have the patient return for a colposcopy rather than waiting.


It is important to point out that testing positive for high risk HPV does not mean that you will get cancer of the cervix.  We cannot say that HPV causes cervical cancer any more than we can say riding in a car causes a car accident, but you cannot get cancer of the cervix without having HPV, just like you cannot have a car accident unless you are in a car.  In fact, it is estimated that as many as 80% of sexually active 18 year olds carry some form of HPV.  I do not want you to think that I am downplaying the role of HPV in cervical cancer.  Unfortunately, I  have seen a lot of women with cervical cancer, and with rare exceptions, it was in women who did not get regular Pap tests or those who did not return for follow up on an abnormal Pap test.  So please, get your yearly Pap done and tell me you hate it.  I will understand.


Would you like to take a medical HPV and cervical cancer quiz?  Click here for a Pap quiz