Sampling problems
Common sampling problems have led pathologists to report on the adequacy of the specimen, in addition to the cytopathology. If the specimen is reported as unsatisfactory, the examination must be repeated. The specimen may be reported as unsatisfactory for several reasons:

• Improper labeling of the slide
• Inadequate number of cells collected or transferred onto the slide
• Poor fixation, which distorts cells (air drying artifact, for example)
• Contaminant (such as lubricant jelly)
• Blood obscuring the cells (avoid collecting a Pap smear during menses)
• Inflammation obscuring cells (treat cervical or vaginal infections with appropriate antibiotics before repeating the Pap smear)
• Cytolysis or autolysis (this is often seen in women who are pregnant or have a low vaginal pH)

(UNMC, Sanfilippo)

No endocervical component present
Interpretation of a Pap smear may also be problematic if the report states that the specimen is satisfactory for interpretation but lacks an endocervical component. This designation is used when cells from the squamocolumnar junction are not present on the sample. The Bethesda System classifies this as "less than optimal—no endocervical component present." The endocervical or transformation zone (TZ) component is defined either by endocervical glands or cells, or by metaplastic squamous cells. Obtaining cells from the transition zone is important because this is where most cervical dysplasia is seen. Several factors may affect the yield of endocervical cells:

• Sampling technique
• Prior cervical procedures
• Surgical absence of the cervix
• Oral contraceptives
• Hormonal status of the patient (The TZ in postmenopausal women may be high within the endocervical canal.)
• Pregnancy

(DiSaia, Appleby)

Experts disagree on the management of the patient who lacks endocervical cells on Pap smear, in part because of conflicting evidence regarding the importance of collecting endocervical cells. The Interim Guidelines for Management of Abnormal Cervical Cytology state that "the absence of a TZ component (endocervical cells or metaplastic squamous cells) should not be the only criterion for repeating the test." Cross-sectional studies report more abnormalities on smears containing endocervical cells than on smears without such cells. Yet, longitudinal studies do not report increased numbers of abnormalities on subsequent smears when endocervical cells were absent from the first smear. The 1992 National Cancer Institute (NCI) Workshop addressed these inconsistencies. The NCI Workshop recommends that routine follow-up at prescribed intervals is satisfactory without an endocervical component if:

• There is no suspicion of a premalignant lesion
• There is nothing of concern in the patient’s clinical history
• There is no abnormality identified on physical examination
• There is no previous abnormal smear
• There are no other clinical risk factors (O'Leary)

Miller et al state, "If no endocervical cells are present, the Pap smear may need to be repeated, depending on the patient’s risk factors. We believe that a repeat Pap smear is indicated if the first sample is inadequate in any patient with one or more of the risk factors" (Miller).

Complications of the Papanicolaou Smear

Doing a Pap smear seldom causes significant complications. The most common complication is minor bleeding from irritation of friable mucosa by the speculum or cervical sampling instruments. Patients should be warned that spotting is normal following the pelvic examination. There may also be mild discomfort, but this is short lived.