Pearls of Wisdom: Pap Testing

Question: Samantha is a 35-year-old woman who has strayed well beyond the recommended interval for pap testing. She said that at her last examination 7 years ago, insertion of the speculum was so painful that she was reluctant to return.

A scanty amount of post-insertion bleeding that occurred after the last examination resolved within 24 hours, but she was left with vaginal soreness and dyspareunia for almost 1 week. You have been warned that the use of lubricant can contaminate Pap smears and make the cytology difficult to interpret.

Which is the best lubricant for vaginal speculum examinations?

1. No lubricant is necessary.
2. Water, because it is the most comfortable.
3. Water, because it does not confound interpretation of the cytology.
4. Lubricants (eg, K-Y jelly) because it is both the most comfortable and does not confound cytology interpretation when properly applied.

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

Answer: Lubricant, such as K-Y jelly, because it is both the most comfortable and does not confound cytology interpretation when properly applied.

The literature indicates that women are much more compliant with recommendations for health maintenance interventions than men; more than 80% of women with access to care comply with recommendations for Pap screening.¹ However, unpleasant experiences with the speculum or bimanual examination certainly may contribute to reticence.

Speculum Exams: Standard Dogma²

Steps to increase the comfort of women during speculum examinations include so-called vocal anesthesia—talking a woman through the process as you perform it to reassure and orient her to the process as you do it— as well as utilization of an appropriately-sized speculum, warming of the speculum if it is metal, and adequate lubrication.

Concerns of Contamination

If lubricant is applied to the upper and lower blades of the speculum, and the speculum is at least partially open prior to accessing the cervix, there is usually no concern that lubricant from the speculum blades will come in contact with the cervix. Note: The lubricant facilitates speculum insertion much more comfortably than does water.

After decades of practice during which I had never received a Pap result termed unsatisfactory due to obscured detail from use of lubricant, I was heartened to see that the literature confirms the propriety of common lubricants.  

Research

A study of 182 women presenting for routine Pap testing compared the quality of Pap smears when water or lubricant was used. The number of unsatisfactory Pap tests was identical with either form of lubrication. Since standard lubricant provides easier, more comfortable examination, it should be preferred.

Lubricating the Pap Speculum²

What’s the “Take Home”?    

The textbooks were incorrect. Lubricant (eg, K-Y jelly) provides more comfortable speculum insertion and does not compromise Pap cytology interpretation. Hence, it should be preferred.

References:

1. Breen N, Wagener D, Brown M, et al. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health interviews surveys. J Natl Cancer Inst. 2001;93(22):1704-1713.
2. Harer WB, Valenzuela G Jr, Lebo D. Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears. Obstet Gynecol. 2002;100(5 Pt):887-888.