Cervical Screening Test (Smear Test) – OSCE Guide

Cervical screening (previously known as a smear test) frequently appears in OSCEs, and you’ll be expected to demonstrate excellent communication and practical skills. This guide provides a step-by-step approach to performing cervical screening in an OSCE setting, with an included video demonstration.

Cervical screening involves an initial test for the human papillomavirus (HPV). If HPV is detected on the cervical screening sample, cytology is performed to assess for dyskaryosis. For more information, see the Geeky Medics guide to cervical cancer and cervical intraepithelial neoplasia (CIN).

Gather equipment

Gather the appropriate equipment:

• Gloves
• Speculum
• A light source
• Endocervical brush
• Sample pot (liquid-based cytology)
• Paper towels
• Lubricant*

*Use of lubricant should be avoided when taking a cervical smear sample due to the risk of contamination. However, if lubricant is required, only a carbomer-free product that is recommended by the manufacturer of the cervical screening kit should be used (e.g. OptiLube Zero a.k.a. CerviLube for Hologic ThinPrep).¹⁰

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain what the procedure will involve using patient-friendly language: “Today I need to perform a cervical screening test. This looks for the presence of a virus called HPV (human papillomavirus). If HPV is found, the lab will perform another test on the sample (cytology) to look for any abnormal cells caused by the virus. If abnormal cells are seen, you may need further investigations.

The procedure will involve me inserting a small plastic device called a speculum into the vagina. This will allow me to visualise the neck of the womb (your cervix). I will then place a very small brush into the vagina and take a sample of cells from the neck of the womb. It shouldn’t be painful, but it will feel a little uncomfortable. You can ask me to stop at any point. You may experience some light vaginal bleeding after the procedure.”

Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”

Gain consent to proceed with the examination: “Do you understand everything I’ve said? Do you have any questions? Are you happy for me to carry out the procedure?”

Ask the patient if they have any pain or if they think they may be pregnant before proceeding with the clinical examination. Establish their last menstrual period (cervical screening is not recommended during menstruation). 

Provide the patient with the opportunity to pass urine before the examination.

Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided.

Provide the patient with privacy to undress and check whether it is okay to re-enter the room before doing so.

Preparation

1. Wash your hands

2. Open the speculum packaging whilst avoiding touching the speculum or the inner surface of the packaging

3. Open the lubricant (if being used) onto the inner surface of the speculum packaging

Position the patient

1. Re-check consent and that the patient is happy to proceed with the procedure: “I’m going to move on and examine your genitals. Are you happy for me to do this?”

2. Position the patient in the modified lithotomy position: “Draw your ankles up towards your buttocks, keep your feet flat on the bed, and then let your legs fall open”

Vulval inspection

It is good practice to inspect the vulva for any abnormalities

1. Don a pair of non-sterile gloves and an apron

2. Expose the patient’s external genitalia and ensure there is adequate lighting

Inspect the vulva

Inspect the vulva for abnormalities:

• Ulcers: typically associated with genital herpes
• Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea
• Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (scarring with associated abnormal architecture)
• Vulvovaginal atrophy: most commonly occurs in postmenopausal women
• White lesions (leukoplakia): may be patchy or in a figure-of-eight distribution around the vulva and anus, associated with lichen sclerosus
• Other lesions: causes include folliculitis, molluscum, genital warts and vulval malignancy
• Masses: causes include Bartholin’s cyst and vulval malignancy
• Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy)
• Female genital mutilation: total or partial removal of the clitoris and/or labia and/or narrowing of the vaginal introitus

Inserting the speculum

Warn the patient that you are going to insert the speculum and ask if it is still okay for you to do so.

If the patient consents to continuing the procedure, prepare to insert the speculum. If using an approved lubricant (see equipment section for details), apply a small amount of product over the exterior sides of the speculum only, taking care to avoid the tip. This is to avoid contaminating and invalidating the sample.

Then, proceed to insert the speculum:

1. Carefully separate the labia using the thumb and index finger of your non-dominant hand

2. With the blades closed, gently insert the speculum. Usually, the speculum is inserted with the handle pointing sideways (at 9 or 3 o’clock)

3. Once inserted, rotate the speculum so that the handle is facing upwards

4. Open the speculum blades until an optimal view of the cervix is achieved

5. Tighten the locking nut to fix the position of the blades

Inspection of the cervix and vaginal walls

Inspect the cervix for:

• The cervical os: if open and the patient is pregnant, this may indicate an inevitable or incomplete miscarriage
• Erosions around the os: most commonly associated with ectropion; however, early cervical cancer can have similar appearances
• Cervical masses: typically associated with cervical malignancy
• Scarring: from a previous colposcopy procedure (e.g. LLETZ)

Inspect the cervix and vagina for:

• Ulceration: most commonly associated with genital herpes
• Atrophy: in post-menopausal patients
• Foreign body: for example, a retained tampon or condom
• Abnormal discharge: several possible causes, including bacterial vaginosis, vaginal candidiasis, trichomonas, chlamydia and gonorrhoea

Cervical screening sample

1. Insert the endocervical brush through the speculum into the endocervical canal, avoiding touching the sides of the speculum with the brush

2. Rotate the brush 360 degrees, in a clockwise direction, 5 times

3. Remove the endocervical brush, avoiding touching the speculum as you do so

4. Immediately transfer the sample to the liquid-based cytology container (follow local cytology guidelines for transferring the sample from the brush into the container)

5. Label the sample 

Removing the speculum

1. With your non-dominant hand, hold the blades of the speculum whilst you loosen the locking nut with your dominant hand. This ensures the blades do not snap shut when the locking nut is loosened.

2. Gently remove the speculum whilst slowly closing the blades and inspecting the walls of the vagina

3. Cover the patient with the sheet, explain that the procedure is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves.

4. Dispose of the used equipment into a clinical waste bin

To complete the procedure…

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Complete the cytology request form.

Discuss the results process with the patient, including the average wait time for results and how the results will be communicated.

Document the procedure in the medical notes, including the details of the chaperone.

Summarise your findings.

Further assessments and investigations

Further assessments and investigations are not usually performed following routine cervical screening. If the cervix appears suspicious for cervical cancer, the patient must be referred urgently for assessment without waiting for the cervical screening results.

If the patient has specific symptoms, they will require further assessment. This may include:

• Urinalysis: including β-HCG to rule out pregnancy
• Bimanual vaginal examination: to palpate for masses and cervical motion tenderness
• Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial/viral)
• Ultrasound abdomen and pelvis: to further investigate pelvic pathology

Reviewers

Dr Ashley Jefferies

Community Sexual and Reproductive Health Registrar

Mr Isaac Magani

Consultant Obstetrician and Gynaecologist

References