Overview of the Pap Smear Procedure

A Pap smear (or Pap test) is a quick, painless procedure that screens for cervical cancer. It involves examining cells taken from the cervix under a microscope. The test looks for abnormal cervical changes (cervical dysplasia)—precancerous or cancerous cells that could indicate cancer. If any are found, further testing, such as a colposcopy or biopsy, will be done in order to diagnose cancer.

The test is named after George Papanicolaou, the Greek doctor who invented the procedure in the early 1940s.

Purpose of Test

A Pap smear is meant to detect abnormal cervical changes that, in some cases, may suggest that cancer is likely to develop or that cancer has already developed. In many cases, it is possible to identify and treat developing cancer before it has a chance to spread beyond the cervix. Pap smears usually are done as part of regular pelvic exams.

For certain women, cells taken during a Pap smear are also tested for high-risk strains of human papillomavirus (HPV), which can cause various cancers. There are more than 100 strains of the virus, but not all cause the disease. (Around 70 percent of cervical cancers are caused by HPV 16 and HPV 18, with another 20 percent of cervical cancers being related to infection with HPV 31, 33, 34, 45, 52, and 58.)

Screening Guidelines

Because the Pap is a screening test, there are specific guidelines regarding who should have one, at what age, and how often based on age and risk factors. These are the current recommendations for cervical cancer screening and HPV screening from the American College of Obstetricians and Gynecologists (ACOG):

• Women ages 21 to 29 should have a Pap test alone every three years (but should not be tested for HPV).
• Women ages 30 to 65 should have a Pap test and an HPV test (this is called co-testing) every five years. It also is acceptable to have a Pap test alone every three years, although ACOG prefers the five-year co-testing schedule.

After age 65, ACOG says a woman can safely stop having Pap smears if she does not have a history of moderate to severe abnormal cervical cells or cervical cancer and she has had either three negative Pap tests in a row or two negative co-test results in a row within the past 10 years, with the most recent test done within the past five years.

Although these recommendations refer to all women, there are some risk factors for cervical cancer that may make it prudent to have more frequent Pap smears. These include:

• Having a family history of cervical cancer
• A diagnosis of cervical cancer or a Pap smear that showed precancerous cells
• Infection by the human immunodeficiency virus (HIV)
• Weakened immune system due to many factors, such as organ transplant, chemotherapy, or corticosteroids
• Early onset of sexual activity (intercourse)
• Multiple sexual partners
• A sexually transmitted infection, such as genital herpes or chlamydia
• Previous cancer of the genital tract
• Smoking
• Exposure to diethylstilbestrol (DES) before birth: DES is a drug that was often used to prevent miscarriage until research showed that women born to mothers who took DES were at an increased risk of cancer. In 1971, the U.S. Food and Drug Administration advised healthcare providers to stop prescribing it during pregnancy.

If you've had a hysterectomy, you still may need to have Pap tests. This depends on why you had the hysterectomy, whether your cervix was removed (because cervical cells can remain at the top of the vagina after surgery), and if you have a history of moderate to severe cervical changes or cervical cancer, in which case you should continue to have Pap tests for 20 years after your surgery.

Risks and Contraindications

There really are no physical risks associated with having a Pap smear. The test is very safe, even if you're pregnant. You might experience a bit of spotting due to the swab scraping the cervix.

Before the Test

Family practice providers, gynecologists, internal medicine physicians, and clinics all offer Pap smears. If the time slots for routine testing and other preventive services at your provider of choice tend to fill up quickly, you may want to schedule your test way in advance. (Your healthcare provider's office manager can advise you about this.)

The timing of a Pap smear is important if you're menstruating. When you have your period, the blood and other tissue can interfere with the results of the test. Unless your provider advises otherwise, it's best to schedule a Pap smear for one to two weeks after you expect your period, or, according to the American Cancer Society, five days after your period ends.

If your cycle is unpredictable and you start your period when it will coincide with your appointment, call your healthcare provider's office as soon as possible. You may be advised to reschedule, although some healthcare provider will go ahead with a Pap smear if a patient's flow is very light.

Besides menstrual blood and tissue, there a number of other things that can interfere with the accuracy of a Pap test by masking abnormal cells. These are:

• Sexual intercourse: Do not have sex during the 48 hours prior to your appointment.
• Spermicides (foams, jellies, or other birth control products): If you aren't having sex, it's unlikely you'll be using a spermicide, but it bears mentioning that you should not do so for 48 hours before your Pap smear.
• Vaginal lubricants: Do not use a lube for at least 48 hours before having a Pap smear.
• Tampons: Do not insert a tampon for 48 hours before your Pap.
• Vaginal douches: In general, it's not advisable to douche at all, but if it's something you do, stop for at least three days before your appointment.

If you forget these guidelines and have intercourse, douche, or use anything in the vagina in the two days before your appointment, call your healthcare provider or nurse to see whether you can reschedule. If you have to keep the appointment, tell your healthcare provider about the mix-up.

Timing

Although a Pap smear takes only a minute or two, the total amount of time you're at your appointment will be a bit longer—particularly if, as is typical, you'll be having the test as part of your regular gynecological check-up. An hour is typically a sufficient amount of time to block off.

If this will be your first visit to this particular provider, you may be asked to arrive 15 minutes or so ahead of time to fill out new patient forms, have your health insurance card photocopied for your files, and take care of your co-pay if you have one.

Location

Your Pap test will take place in an exam room at your healthcare provider's office, hospital, or other medical facilities. The room will feature a gynecological exam table—one that can be lowered or raised to allow you to sit up or lie back—that has devices called stirrups attached at the foot end. The stirrups are there to allow you to comfortably rest your feet during your exam.

There also will likely be other medical equipment in the room, such as a blood pressure cuff and a scale.

What to Wear

Because you will need to remove all clothing from the waist down for a Pap smear, you might consider wearing a dress or skirt so that all you have to take off is your underwear and shoes, but this is purely a personal preference. It may be just as easy for you to slip out of a pair of jeans, slacks, or sweatpants. Exam rooms can be chilly; you might want to wear or bring a pair of socks.

Cost and Health Insurance

Most private insurance companies will cover a Pap smear with no out-of-pocket cost. Check with your provider for details.

Medicare will cover a Pap smear every 24 months or, if you had a previous Pap smear that was abnormal or you're at high risk for cervical cancer, Medicare will pay for a Pap test every 12 months.

If you do not have insurance, you still have options:

• Free or low-cost screening through the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program (NBCCED): This supports women with a yearly income at or below 250 percent of the federal poverty level. The CDC has an easy-to-use, interactive map showing programs by state, as well as specific services for Native Americans.
• Your local or county health department: Both likely offer free or low-cost Pap smears to low income and/or uninsured women.
• Planned Parenthood: If your income level exceeds the allowable amount at your county health department, you may be able to have a Pap test at your local Planned Parenthood for less than it would cost to pay a healthcare provider.

What to Bring

You should have your health insurance card and your co-pay, if one will be expected at the time of your appointment, with you.

If you have any specific questions about the test, write them down and bring your list so you don't forget them. Your healthcare provider will need to know the first day of your last period if you've had known exposure to HPV, and if any health issues have come about since your last exam such as infections, unusual discharge, or pain. Consider bringing related notes so you're sure to mention these things as well.

Likewise, if you had previous Pap smears, colposcopies, or biopsies that are not reflected in your medical record (because, for example, you're a new patient), bring copies of your results if you have them. The same goes for treatment records.

During the Test

At your appointment, you will interact with an office receptionist who will check you in, a nurse who will guide you through getting ready for your Pap smear, and with the healthcare provider—probably a gynecologist—who will perform the Pap test.

Pre-Test

There likely won't be any test-specific paperwork to fill out, but you may need to submit new-patient forms if this is your first visit.

Once a nurse has escorted you to an exam room, you will need to undress from the waist down. You can leave your socks on if you're wearing them, especially if the room is chilly. The nurse will give you a paper drape to place across your middle and upper thighs. (If you'll be having a full gynecological check-up that includes a breast exam, you may have to take off all your clothes and put on a hospital gown with the opening in the front.)

Throughout the Test

When you've been given enough time to undress, the healthcare provider or nurse will knock on the door to make sure you're ready. If you are, they will come into the exam room. A nurse or other authorized person also may be present during your exam, per recommendations by the American Medical Association.

When the healthcare provider arrives, she may ask if you have any questions about the Pap smear, want to hear about any issues you may have been having, or inquire about any abnormal Paps you've had in the past that she may not be aware of. She also may engage you in friendly chit-chat to help you relax.

To set up for the test, the exam table will be tilted back so that you are lying on your back. You will bend your knees and place your feet in the stirrups on either side of the foot end of the table. This will make it easier for you to keep your knees apart while the prctitioner takes the sample. You will be asked to scoot your buttocks down to the very edge of the exam table.

In order to access your cervix, they will insert an instrument called a speculum made either of metal or plastic into your vagina to hold the walls of your vagina open. If it's a metal speculum, it may be warmed up. The practitioner will apply a lubricant to the speculum regardless of which type it is so that it slides in and out easily.

Once in, you may feel some pressure as the speculum is adjusted to allow a clear view of your cervix. You may hear a clicking sound as the practitioner widens the speculum. This may feel a little strange or uncomfortable, but should not hurt. Taking deep breaths can help you relax.

If the speculum does cause pain, don't hesitate to speak up. It may be possible for the practitioner to use a smaller one that will be more comfortable for you.

When the speculum is in place, the practitioner will insert a tiny swab or a brush that resembles a mascara wand into your vagina. Once the instrument, which has a long handle, reaches your cervix, your practitioner will gently rub its lining to collect a sample of cells. You may feel a bit of discomfort or you may feel nothing at all. If your practitioner wants to test for HPV as well, a second or the same swab may be used for this purpose.

Regardless, it will take just a few seconds a sample to be retrieved and a total of just a few minutes to do the complete test.

To prepare the cell sample for the pathology lab, your healthcare provider will then either spread the sample onto a conventional slide or preserve it in a liquid, a method called liquid-based cytology. With the latter, cervical cell samples can be washed of blood or other substances that might obscure abnormalities. Research suggests both methods are equally accurate, but liquid-based cytology allows for the testing of cells for HPV viruses.

Finally, the healthcare provider will gently slide the speculum out.

Post-Test

If you are only having a Pap smear, you will be able to take your feet out of the stirrups. The exam table may be adjusted to make it easier for you to sit up.

You may be given tissues or wipes so that you can remove any leftover lubricant from around your vagina before you get dressed. The healthcare provider and nurse will leave the room so that you can do this in private.

Once you're dressed, you can leave the exam room. You may need to stop by the desk on your way out, or you may be able to leave straight away. Ask a nurse or other office worker if you aren't sure.

You also might ask how and when you'll be notified of the results of your test if the healthcare provider or nurse didn't tell you voluntarily.

After the Test

After a Pap smear, you can resume your normal activities. If you have any spotting, it will be slight: A light-flow maxi pad should be sufficient to absorb it.

Interpreting Results

According to the Office on Women's Health, part of the U.S. Department of Health and Human Services, it usually takes from one to three weeks to get the results from a Pap test.

Negative results mean that there is no sign of cervical dysplasia; positive results mean that abnormal cells were detected.

Healthcare providers typically share results via phone call, mail, or portal. Some will not contact you at all if the results are normal. If you don't remember what the office's policy is in this regard, call and ask. Do not just assume that "no news is good news."

It's important to know that an abnormal Pap result does not always mean a woman has cancer. Remember, this test is a screening test, not a diagnostic procedure. In fact, most abnormal Paps are not due to cancer.

Positive (Abnormal) Results

One in 10 Pap smears come back showing some type of abnormality, according to the American Pregnancy Association. There are four types of abnormal Pap smear results and the one that applies to you, if your results are positive, determines next steps.

• Atypical squamous cells of undetermined significance (ASCUS): These results indicate slightly abnormal squamous cells—thin, flat cells that grow on the surface of the cervix. Changes in these cells don't clearly suggest precancerous cells are present. With the liquid-based test, your healthcare provider can reanalyze the sample to check for the presence of viruses known to promote the development of cancer, such as some types of HPV. If no high-risk viruses are present, the abnormal cells found as a result of the test aren't of great concern. If worrisome viruses are present, you'll need further testing.
• Squamous intraepithelial lesion: This term indicates that the sample cells may be precancerous. If the changes are described as low-grade squamous intraepithelial lesions (LSILS), it means the size, shape, and other characteristics suggest that if a precancerous lesion is present, it's likely to be years away from becoming cancer. High-grade squamous intraepithelial lesions (HSILS) may develop into cancer sooner. Additional diagnostic testing is necessary.
• Atypical glandular cells (AGC): Glandular cells produce mucus and grow in the opening of the cervix and within the uterus. Atypical glandular cells may appear to be slightly abnormal, but it's unclear whether they're cancerous. Further testing is needed to determine the source of the abnormal cells and their significance.
• Squamous cell carcinoma or adenocarcinoma cells: This result means the cells collected for the Pap smear appear so abnormal that the pathologist is almost certain a cancer is present. Squamous cell cancer refers to cancers arising in the flat surface cells of the vagina or cervix. Adenocarcinoma refers to cancers arising in glandular cells. If such cells are found, your healthcare provider will recommend a prompt evaluation.

False Results

False positive and negatives are possible with any test, so that's why it's important to get routine testing. There is also a diagnosis called "unsatisfactory." This could happen because:

• Too few cells were collected
• You have only a small number of abnormal cells
• Blood or inflammatory cells in the sample hid the abnormal ones

If you get n "unsatisfactory" result, the recommendation is to repeat the Pap test in two to four months.

Women who get false-negative results may end up not getting follow-up tests to confirm cervical cancer or treatment for it. It also is possible for Pap results to be false-positive, in which case unnecessary tests and even treatment may be performed.

The important thing to know about these risks of getting inaccurate Pap test results is that cervical cancer is a very slow-growing condition. It takes a long time to develop.

That's why screening guidelines recommend a Pap test every three years which, the National Cancer Institute says, minimizes "the harms caused by treating abnormalities that would never progress to cancer while also limiting false-negative results that would delay the diagnosis and treatment of a precancerous condition or cancer." So, essentially, if HPV and/or abnormal cells are missed once, it's very likely that they will be caught the next time around and that disease, if present, will still be treatable.

Follow-Up

If the results of your Pap smear are abnormal, your healthcare provider may want to repeat the Pap test or do another type of test, depending on the specific findings. Further testing may include:

• HPV Test: If an HPV test was not done at the time of your Pap, your healthcare provider may order one as a follow-up test.
• Colposcopy: A colposcopy is an in-office exam that allows the healthcare provider to view the cervix more closely with a colposcope, a lighted instrument that magnifies the cervix. It is placed outside the vagina during the exam. The images seen from the colposcope may be projected onto a screen for a more detailed view and biopsy planning.
• Punch Biopsy: During a colposcopy, a healthcare provider may perform a cervical biopsy depending on what is found during the exam. This involves removing a small amount of cervical tissue to be examined under a microscope. Most often this is a punch biopsy, in which the healthcare provider uses a device similar to a paper hole punch to gather the tissue sample that will be sent to a pathology lab to be evaluated. This may be mildly uncomfortable but takes just a few seconds. Depending on the findings during the colposcopy, a few areas of the cervix may be biopsied.
• Endocervical Curettage (ECC): This type of biopsy also can be done during a colposcopy. The healthcare provider will use a small brush to remove tissue from the endocervical canal, the narrow area between the uterus and cervix, to be examined by a pathologist. Endocervical curettage can be moderately painful, like bad menstrual cramps.
• Cone Biopsy: This procedure may be done when a larger biopsy is necessary—either to diagnose cervical cancer or to remove tissue so that it does not become cancerous. During a cone biopsy, a cone-shaped piece of tissue is removed for evaluation. This procedure is done under general anesthesia.
• Loop electrosurgical excision procedure (LEEP): An alternative to cone biopsy, a loop electrosurgical excision procedure uses an electrically charged wire loop to remove a tissue sample. It's done under local anesthesia and is more commonly used to treat high-grade cervical dysplasia, rather than diagnose cervical cancer.  

Abnormal cells found during a colposcopy and biopsy may be described as cervical intraepithelial neoplasia (CIN).

A Word From Verywell

The Pap smear is the best way to screen for abnormal cervical cells that may be cancerous or precancerous and to detect the certain strains of HPV that are associated with cervical cancer. It's painless and has no serious risks.

However, because it requires exposing the vagina and inserting medical devices into this intimate part of the body, the prospect of having a Pap smear can be anxiety provoking, especially if you've never had the test before. Even women who've had Paps may dread them—not because of fear that it will hurt, but simply because getting into position for the test is awkward.

Fortunately, the procedure takes just a few minutes and only needs to be repeated every three years for most women. Both of these factors should help make the prospect of having this vital test less nerve-wracking.