Procedures for Gynecologic Specimen Collection

General Information for all Gynecologic Collections

The adequacy of the cervical screening specimen is determined by:

  1. The presence of an adequate squamous component.
  2. The presence of an adequate endocervical component (in premenopausal females with a cervix).
  3. The absence of obscuring entities, including inflammation, blood, and contaminants such as talc or lubricant.
  4. Adequate cellular preservation.

General patient instructions:

  1. In premenopausal patients, obtain specimens during the second half of the menstrual period to avoid contamination by obscuring blood.  However, menstrual bleeding is not a contraindication to cervical screening.  The problem of blood obscuring the cellular field is significantly reduced by the use of the liquid-based thin-layer specimen.
  2. The patient may be instructed not to douche or engage in sexual intercourse within 24 hours of the procedure.  This may improve the cellular yield and reduce the potential for obscuring elements.  Again, the use of the liquid-based, thin-layer specimen significantly reduces the potential for interference in the quality of the specimen.

General procedural instructions (see below for specific instructions)

  1. The cervical screening specimen should be collected  prior to bimanual examination.
  2. Care should be taken to avoid contamination of the sample with lubricant jelly.  The vaginal speculum should be inserted with warm water as a lubricant.
  3. Ideally the entire portion of cervix should be visible when the specimen is obtained.
  4. Vaginal discharge or secretion, when present in large amounts, should be removed before obtaining the cervical sample so as not to disturb the epithelium. Small amounts of blood will not interfere with cytologic evaluation; however, large amounts of blood as present during menses may interfere with cytologic interpretation because of obscuring blood. If the patient has no sign of symptoms of a cervical disorder, consideration may be given to treating the vaginitis first. Use of the thin layer specimen minimizes the interference from these factors.
  5. If testing for sexually transmitted disease is indicated, the cervical screening specimen should be taken first, followed by tests for gonococcus and chlamydia.
  6. Clinical history and findings are also very important for proper interpretation; for example: past history of dysplasia of cervix treated with laser, cryosurgery, LEEP, etc.; presence of cervix ectropion, polyp, etc.
  7. It is extremely important to enter all information on the cytology request form. This includes age of the patient, date of last menstrual period, pre- or postmenopausal status, use of and type of contraception, use of hormone replacement therapy (estrogen and progesterone), whether the patient received chemotherapy or radiation therapy.

SurePath™ Preparations

Indications: Cervical screening for the detection of premalignant or malignant lesions of the cervix which can be eradicated thus reducing the occurrence of invasive carcinoma of the cervix. The use of the thin-layer/liquid-based collection procedure is intended to replace the conventional Pap smear
Specimens Required: Cervical sample from the junction of the ectocervix and the endocervix (transition zone).
Supplies: SurePath®™ Preservative Fluid Collection Vial
Broom-type sampling device (Cervex-Brush™ )RECOMMENDED
OR Brush Spatula
Collection
Method:		 Properly fill out a Cytopathology Requisition with appropriate Patient demographics, pertinent clinical information, and relevant history,  Label SurePath™ Preservative Fluid Collection Vial with correct patient name and medical record number.  Collect a sample with a broom-type (Cervex-Brush™) sampling device using the following procedure:
  1. Adequately visualize the cervix with the speculum inserted using warm water as the lubricant. (The speculum exam should precede bimanual examination.)
  2. Once the cervical os is adequately visualized insert the central long tines of the Broom-type device (Cervex-Brush™) into the cervical os. As these are being inserted the device should be slowly twisted.
  3. Twist the Broom (Cervex-Brush™) five times in clockwise direction. 
    NOTE: Direction must be consistent. Continue all five times in the clockwise direction, DO NOT alter or vary the direction of the Broom during sampling.
  4. Transfer the sample to the collection vial by gently popping the broom tip off the handle and dropping the tip into theSurePath™ preservative fluid (THE BROOM TIP MUST BE SUBMITTED IN THE VIAL).
    NOTE    : The Cervex-Brush™ is the recommended collection device for the SurePath™ Pap Preparations. A spatula/brush combination can be used to collect the specimen. The spatula/brush tips are scored and should be snapped off into the vial and submitted for processing.
  5. Cap vial securely so that the fluid does not leak from the vial.
  6. Send the appropriately labeled vial containing the broom tip and the requisition to the laboratory.

Reflexive HPV-DNA Testing on SurePath™ Specimens with ASCUS Diagnosis
Indications: Human Papilloma Virus DNA (HPV-DNA) testing is available for those patients with the diagnosis of Atypical Squamous Cells of Undetermined Significance (ASCUS). Those patients in whom Atypical Squamous Cells of Undetermined Significance (ASCUS) are detected should have a HPV-DNA (Hybrid Capture 2) test performed. This test is most cost-effective when performed on the original liquid-based thin-layer specimen in which the ASCUS was identified.  Patient management can then be based on an algorithm using the results of these combined tests.
Specimens
Required:		 Liquid-Based Thin-Layer specimen
Supplies: SurePath™ Preservative Fluid Collection Vial
Broom-type sampling device (Cervex-Brush™ )
Supplies may be obtained by calling Client Services at 1-866-869-1334.
Collection Method:
  1. Collect Thin-layer specimen for gynecologic cytology following SurePath™ Preparation collection method (see above).
  2. Select or provide handwritten instructions on the Cytology requisition for :"Thin-layer With Reflex HPV if ASCUS"  (Recommended Standard of Care).   HPV-DNA Testing results will appear as a Procedure/Addendum to the original Gynecologic Cytology Report when Reflexive HPV Testing is completed.

Cytyc ThinPrep® Pap Preparations

Indications: Cervical screening for the detection of premalignant or malignant lesions of the cervix which can be eradicated thus reducing the occurrence of invasive carcinoma of the cervix. The use of the thin-layer/liquid-based collection procedure is intended to replace the conventional Pap smear.
Specimens Required: Cervical sample from the junction of the ectocervix and the endocervix (transition zone).
Supplies: Cytyc ThinPrep® PreservCyt Vial
Broom-type sampling device OR Endocervical Brush/Spatula
Collection
Method:		 Properly fill out a Cytopathology Requisition with appropriate Patient demographics, pertinent clinical information, and relevant history,  Label ThinPrep PreservCytCollection Vial with correct patient name and medical record number.  Collect a sample with a broom-type  sampling device or endocervical brush/spatula using one of the following procedures:
 

Broom-like Device Collection:

Recommendation: Do not recommend using lubricant as it interferes with the processing of the specimen and may result in an inadequate slide. If lubricant has to be used in collection of specimen, suitable lubricants include KY Jelly (non sterile or sterile), Surgilube, or Astroglide. Other lubricants interfere with specimen and should not be used.

  1. Label ThinPrep® PreservCyt vial with patient name and MRN.
  2. Obtain sample using broom-like device.
  3. Insert central bristles into the endocervical canal deep enough to allow the shorter bristles to contact the ectocervix.
  4. Push gently and rotate CLOCKWISE five times.
  5. Rinse the broom immediately in the PreservCyt vial by pushing the broom into the bottom of the vial 10 times forcing bristles apart.
  6. Swirl brush vigorously in solution.
  7. Discard brush- DO NOT submit brush in vial.
  8. Tighten cap on vial until torque line on cap passes torque line on vial.
  9. Transport to laboratory for processing.
 


Endocervical Brush/Spatula Collection:

Recommendation: Do not recommend using lubricant as it interferes with the processing of the specimen and may result in an inadequate slide. If lubricant has to be used in collection of specimen, suitable lubricants include KY Jelly (non sterile or sterile), Surgilube, or Astroglide. Other lubricants interfere with specimen and should not be used.

  1. Label ThinPrep® PreservCyt vial with patient name and MRN.
  2. Obtain a sample from the ectocervix using a plastic spatula.
  3. Rinse the spatula into the PreservCyt vial by swirling vigorously in the vial 10 times.
  4. Discard the spatula.
  5. Obtain a sample from the encodervix using an endocervical brush.
  6. Insert brush in to the cervix until only the bottom fibers are exposed.
  7. Slowly rotate 1/4 to 1/2 turn in one direction.
  8. DO NOT OVER ROTATE.
  9. Rinse the brush quickly in the PreservCyt vial by rotating he device in the solution 10 times while pushing against the vial wall.
  10. Swirl vigorously to further release material.
  11. Discard brush-DO NOT submit in vial.
  12. Tighten cap on vial until torque line on cap passes torque line on vial.
  13. Transport to laboratory for processing.

Reflexive HPV-DNA Testing on ThinPREP® Specimens with ASCUS Diagnosis

Indications: Human Papilloma Virus DNA (HPV-DNA) testing is available for those patients with the diagnosis of Atypical Squamous Cells of Undetermined Significance (ASCUS). Those patients in whom Atypical Squamous Cells of Undetermined Significance (ASCUS) are detected should have a HPV-DNA (Hybrid Capture 2) test performed. This test is most cost-effective when performed on the original liquid-based thin-layer specimen in which the ASCUS was identified.  Patient management can then be based on an algorithm using the results of these combined tests.
Specimens
Required:		 Liquid-Based Thin-Layer specimen
Supplies: Cytyc ThinPrep® PreservCyt Vial
Broom-type sampling device OR Endocervical Brush/Spatula
Collection Method: 1. Collect Thin-layer specimen for gynecologic cytology following Thin-layer (ThinPrep®) Preparation collection method (see above).

2. Select or provide handwritten instructions on the Cytology requisition for :"Thin-layer With Reflex HPV if ASCUS"  (Recommended Standard of Care).   HPV-DNA Testing results will appear as a Procedure/Addendum to the original Gynecologic Cytology Report when Reflexive HPV Testing is completed.

Conventional Pap Smears

Indications Cervical screening for premalignant or malignant cervical lesions which can be eradicated to reduce the incidence of invasive cervical cancers.
Specimens Required: Cervical and endocervical samples.
Supplies: Vaginal speculum, wooden extended-tip spatula, cytobrush, fixative (spray fixative or 95% ethyl alcohol), clean glass slide (single end frosted), black lead lab pencil, request form. Spatulas, slides, fixative and slide mailers may be obtained from Client Services (1-800-695-6491).
Collection Procedure:
  1. Label one slide with the patient's name (prior to obtaining the specimen).
  2. Obtain specimen prior to bimanual examination.
  3. Use an unlubricated speculum (saline or warm water may be used). Adequately visualize the cervix.
  4. The exocervix is sampled first using the spatula. This is accomplished by inserting the tip of the spatula into the endocervical os and then scraping the entire cervix using a twisting motion 360 degrees. Remove the spatula and have an assistant hold the spatula.
  5. Insert the cytobrush into the endocervical canal so that the brush is completely into the canal (approximately 1.0cm). (Do not insert too deeply as lower uterine segment will be sampled.)
  6. Turn the cyto brush one quarter turn and remove gently. Excessive twisting and movement causes excessive bleeding.
  7. Quickly roll the cytobrush on one half of the labeled glass slide.
  8. Take the spatula and smear the spatula specimen on the other half of the slide.
  9. Spray-fix the slide immediately.*
  10. Send the labeled, fixed slide with the requisition to the laboratory.
*  The collected material should be applied uniformly to the slide, without clumping, and should be rapidly fixed to avoid air drying.  If spray fixatives are used, the spray SHOULD BE HELD AT LEAST 10 INCHES AWAY from the slide to prevent dispersal and destruction of the cells by the propellant.

OTHER COLLECTIONS:
DES Exposure Screening

Indications: Evaluation of potential changes associated with in utero DES exposure.
Specimens Required: Right and left lateral vaginal, anterior vaginal, posterior vaginal, cervical sample.
Supplies: Vaginal speculum, one or more cervical spatulas, one extended-tip spatula, cytobrush***, fixative (spray fixative or 95% ethyl alcohol), five clean glass slides (single-end frosted), black lead lab pencil, request form. SurePath Cytorich® Preservative Vial, broom sampling device (Cervex-Brush™), spatulas, slides, fixative and  slide folders may be obtained from Client Services (1-800-695-6491).
Collection Procedure: Label all slides with patient's name and specific site (anterior, posterior, right lateral, left lateral, cervical). Obtain specimens prior to bimanual examination. Use an unlubricated speculum (saline or warm water may be used). After visualization of the upper 1/3 of the vagina is accomplished, with the spatula scrape the upper 1/3 of either lateral vaginal wall. Withdraw the spatula and spread the material quickly and evenly onto the correctly labeled slide. Fix immediately (drop slide into fixative or spray with fixation, holding the spray bottle approximately 8 to 12 inches from the slide). Sample remaining specimen sites.  Perform the cervical sample as described above using either the thin-layer or conventional smear technique.  A liquid thin-layer screening is recommended for the cervical specimen.  Smear and fix slides appropriately. Complete the cytology request form, including relevant history. Submit the specimen along with the request form.

Vaginal Sampling

Indications: Vaginal sampling may be indicated in patients with prior history of cervical cancer or premalignant lesions which have been treated with hysterectomy and removal of the cervix. The vaginal cuff is the target of the sampling.
Specimens Required: Liquid-based thin-layer specimen or conventional smear
Supplies: Vaginal speculum, SurePath CytoRich® Preservative Vial and Broom (Cervex-Brush™)
Glass slide, cytobrush, spatula, and spray fixative.
Collection Procedure:
  1. Using the speculum lubricated with water, visualize the vaginal cuff.
  2. Brush the cuff with the broom (Cervex-Brush™).
  3. Place broom tip in the labeled SurePath CytoRich® preservative vial and send to the laboratory with the appropriate requisition.

*Alternatively the vaginal cuff can be brushed with the cytobrush and the specimen rolled onto the surface of a labeled glass slide. The slide should be spray fixed immediately and sent to the laboratory with the appropriate requisition.