Papanicolaou tests are basic procedures in a woman’s preventive care. Cervical screening is meant to evaluate recognizable precancerous lesions that are treatable if detected early. It is recommended that all sexually active women be initially screened annually for 3 normal results, then every 3 years until 3 normal results are obtained after menopause.
Problem
Fear of pain has been found to bar adolescent women from attending for a Pap test.1 It is important to make patients feel as comfortable as possible for what can be an intrusive and uncomfortable procedure.
Question
It has long been taught that lubricant should not be used to gather the specimen, as lubrication was thought to interfere with the quality of the specimen. It was recommended that the speculum be warmed and lubricated with water only.2 However, it has been the experience at our clinic that metal speculums without lubricant increased the patient’s discomfort. A straw poll revealed that most of the clinic’s physicians had begun using small amounts of lubricant despite what they had been taught. None of them had had specimens returned as being unsatisfactory because of this practice. As such, we reviewed literature to find support for what had become our standard of care. Does lubrication interfere with the quality of the specimen?
Literature review
We found 4 studies in the literature that supported our practice and none that did not. Patients were randomized in 1 study to either gel or water at the time of presentation.3 In a Texan study, speculums were lubricated depending on the month,4 which was randomly selected. In another study, different clinics were randomized to use gel or water as a lubricant.5 One study left the choice of lubrication to the attending physician.6 A recent study examined the specimen quality with gel versus water, as well as patient discomfort.7 In all studies, the pathologists were blinded to whether gel or water was being used.
The number of slides analyzed varied: 182 (Harer et al),3 3460 (Griffith et al),4 8534 (Amies et al),5 615 (Tavernier et al),6 and 70 (Gilson et al).7 No study found any differences in the slide results. In addition, the study by Griffith et al looked at the result of testing for Chlamydia trachomatis and Neisseria gonorrhea. No difference was found for C trachomatis results. Unfortunately, the numbers for N gonorrhea were too small to analyze.
In the study by Gilson et al, the only paper that looked at discomfort levels,7 no difference was found in discomfort scores with the use of gel. However, the numbers were low in this study and the Pap test was performed twice, initially with water only and then the patients were examined again with gel or water as a lubricant. As well, there were small numbers of postmenopausal patients.
Conclusion
Both our experience and the literature support lubricating speculums with a dime-sized spot of gel in the performance of Pap tests. While it is our feeling that this practice decreases discomfort for the patient, a recent paper found that the use of gel did not reduce discomfort or pain during the procedure. Further study needs to be done. However, clinicians can be reassured that the use of gel does not adversely affect specimen quality.
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