At Women's Health Network we believe that by knowing
more, women find they can worry less. We want you to know what to expect if you
are anticipating your first pelvic exam and Pap smear, or to understand better if
you’ve never really been told what’s being done to you each year —
or why! — during your routine Pap and gynecologic exam.
We think being well informed can help you understand the value of regular pelvic
exams and Pap smears. We feel this information can help you become your own best
advocate, and to comprehend why this is all necessary, so you can feel comfortable
with the process.
Routine Pap testing and pelvic exam
The Pap test process is rather fast and takes only minutes, so if this is your first
Pap smear and pelvic exam, don’t let the lengthy explanation put you off!
First, a woman sits at the edge of an exam table. Then, when instructed, she places
her feet in the stirrup-style foot rests and lies back on the table (like the women
in labor so stereotypically depicted on TV or movies). The clinician will usually
ask her to separate her thighs and remain calm so the muscles are relaxed. The more
relaxed and dropped apart her legs remain, the more comfortable the woman will be
and the faster the process will go. (Wriggling the toes can be a great way to reduce
tension in the legs, groin, or buttocks.)
The examiner usually touches the outside of the vulva with a gloved hand to separate
the labia and view the external genitalia for normalcy. A speculum, which is like
a tampon applicator with a handle, is then gently inserted into vagina to widen
the opening. Different sizes and styles of speculums are used for different women.
The speculum allows the clinician to view the vaginal walls and the cervix. The
cervix is found high up in the vagina. It looks like a mini bagel projecting into
the vagina, and feels like a firm, nose-like projection if you were to touch it
with your finger. The cervix is occasionally positioned so it is hard to visualize,
but a skilled clinician can usually find it with some gentle shifting about of the
Once the speculum is in place, the clinician can collect a sample of tissue from
the outside of the cervix (ectocervix) with a spatula, then another from
the cervical canal to the womb (endocervix) with a cytobrush. Several types
of devices are used to collect samples, the most common being a contoured plastic
spatula similar to a tongue depressor. A small mascara-like brush is used to swish
the inside of the cervical canal, and a small plastic broom-like brush is also frequently
used. All these devices are gentle but can feel a bit funny to the patient when
used. Many women have a more fragile cervix that bleeds a bit when scraped, but
this is generally not a serious concern. And some women are more sensitive than
others, which is also perfectly understandable.
Nowadays it is pretty standard for the clinician to place the collected samples
in a liquid-based container, but in some settings the samples are still smeared
onto glass slides and a fixative applied.
Chlamydia and gonorrhea testing is done separately, before or after the
Pap. If there is vaginal fluid of concern, the clinician may use a Q-tip to swab
the vaginal walls and will check the sample under a microscope for signs of a vaginal yeast infection
or other types of infection.
The speculum is then removed, at which point the clinician will typically perform
a quick bimanual examination, where she feels the uterus and ovaries as best she
can with her skilled hands — placing two fingers of one hand inside the vagina
and the other hand on the lower belly. Then the clinician will press a little to
feel what cannot be seen.
The Pap sample is sent to a pathology lab for the technician to review the cells
under a microscope, checking for normal and
abnormal features. An HPV DNA analysis can also be done at that time if
requested, to determine whether a high-risk strain is detectable, particularly when
the patient indicates she may be at risk or her practitioner notes genital warts
(condylomata). When the analysis is complete a report is sent to the practice.
The clinic will usually send you a notice that all is well or will call you if anything
requires follow-up. Some clinics have a policy of contacting you only if further
follow-up is needed, so if you want to be notified of the findings regardless of
their nature, be sure to ask them to clarify their policy.
The new ThinPrep Pap smear — liquid-based technology
Originally the Pap test consisted of using a small wooden spatula to sample the
outermost cell layer of the cervical os (the opening to the womb inside
the vagina), then smearing the sample onto a glass slide for a pathologist to examine
(hence Pap smear). The technology and research have changed tremendously
over the past ten years, to include both liquid-base Pap tests and human papilloma
virus (HPV) DNA typing to assist in the interpretation and management of abnormal
With the new “liquid-based” Pap tests (i.e., ThinPrep®
and SurePath®), the cell sample is placed in a jar of liquid fixative
for rinsing and transport to the lab for further processing and review. This method
provides a cleaner, easier-to-read sample and has proven to have a significantly
lower margin of error.
You can now have HPV DNA testing from that same sample. If you do learn that you
have been exposed to a high–risk HPV strain, don’t be alarmed —
it just means that you will be best served by close monitoring and follow-up over
time to ensure your lifelong cervical health.
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