Guidance

Topics 7 and 8: anatomy, physiology, and taking cervical samples

Updated 14 September 2023

Applies to England

1. Topic 7: anatomy and physiology of the pelvic organs

1.1 Topic 7 learning objectives

The trainee should know about the structure and function of the female genital system including the:

• vulva
• vagina
• pelvic floor
• cervix uteri
• body of the uterus
• fallopian tubes and ovaries
• the position of the cervix
• the anatomy of the cervix and its cellular structure
• the transformation zone (TZ)
• the squamocolumnar junction (SCJ)

The trainee should understand:

• how age and pregnancy affect the position of the TZ and changes in cells
• the physiological changes of the female genital system throughout life
• the physiological processes which lead to the development of the TZ
• how to relate the structures of the female genital system to their functions
• the difference between the SCJ and the TZ
• the hormonal cycle and how this affects the epithelium of the cervix

The trainee will be able to

• apply knowledge and understanding of basic anatomy and physiology to recognise the features of a healthy cervix

Guidance for the trainer

Signpost the trainee to the cervical screening video resource containing:

• Module 1: Anatomy of the cervix
• Module 2: Human papillomavirus replication and cell cycle dysfunction
• Module 3: Cervical intraepithelial neoplasia
• Module 4: Invasive carcinoma

2. Topic 8: the practical aspects of taking cervical samples

2.1 Topic 8 learning objectives

The trainee should know about:

• the optimal environment for taking a cervical sample
• equipment required for taking cervical samples
• the minimum identifying requirements for taking a cervical sample
• taking a clinical history
• taking a screening history
• preparing the request form
• positioning the individual
• choosing the appropriate speculum
• common appearances of the cervix
• Nabothian follicles
• polyps
• bleeding on taking a sample
• clinical suspicion of malignancy
• fixing the sample
• ending the appointment
• completing the request form
• documenting the procedure
• sending the sample and accompanying documents to the designated laboratory for analysis
• infection control
• disposing of equipment and waste

The trainee should understand:

• the importance of communication in creating a positive experience for the person having screening
• how to prepare the person for the test
• how to visualise and assess the cervix and interpret what is seen
• how to sample the TZ
• the circumstances when additional samples can be taken
• how to identify and advise on common vulval, vaginal and cervical conditions
• how to make clinical assessments and decisions in complex situations
• how to communicate clear and accurate information
• how to engage in difficult conversations with individuals
• when to offer support and assurance to the person
• when to ask for and where to seek additional support
• when to initiate a safeguarding response
• relevant health and safety and infection control procedures in a clinical setting

The trainee will be able to:

• obtain a satisfactory cervical sample from people across the screening age range
• communicate clear and accurate information to the person, and offer support and reassurance where required

Guidance for the trainer

Refer to the ‘Cervix chart for sample takers in primary care’ (NHSCSP Publication number 25). This chart is available to order on a one per room basis.

Provide a choice of equipment (specula, broom and brush). Use a pelvic model to demonstrate the correct procedure to insert the speculum and visualise the cervix. Demonstrate the procedure in both the dorsal and left lateral positions. Allow sufficient time for trainees to practise on the pelvic model.

Assess the trainee’s communication skills and practical skills by observing them in a simulated clinical consultation.

Provide examples of case studies (these can vary in length and complexity). Assess how the trainee says they would approach and evaluate each situation and what action they would take in each case.

Signpost the trainee to further reading and resources on all topics in this section including:

• national cervical screening information leaflets for the NHS Cervical Screening Programme
• the invitation leaflet sent with or signposted to from all cervical screening invitations
• the colposcopy leaflet sent to all people referred for colposcopy after an abnormal cervical screening result
• information on cervical screening for lesbian and bisexual people
• easy read information about cervical screening, created with and for people with learning disabilities
• publication and infographic on the investigation and management of post coital bleeding

Teaching resource

Refer to PowerPoint presentation 8 for subject areas in Topic 8.

3. Preparing for taking a sample

The environment for sample taking should be:

• warm
• well lit
• private
• comfortable
• as relaxing as possible

3.1 Equipment for taking cervical samples

Equipment should include:

• an adjustable height examination couch
• a good light source
• specula of different sizes, reusable or once-only use
• sterilisation facilities if reusable specula are used
• disposable non-latex gloves
• information leaflets for people
• a supply of Cervex-Brush™ / brooms
• a supply of endocervical brushes
• a supply of fixative vials
• packaging for transporting samples to the laboratory

3.2 Checking the person’s identity

At least 3 legible and correct patient demographics are required to identify a person. This enables the laboratory to match with any existing record on the pathology system.

The minimum identifying requirements for carrying out cervical sampling are:

• the person’s full name including first name and surname
• the person’s date of birth
• ideally the person’s NHS number as a fourth identifier, or their home address

3.3 Providing information and answering questions

Communication is a vital skill for the sample taker and essential for creating a positive experience for the individual.

Sample takers should have highly developed personal skills to engage with people and be able to:

• communicate clear and accurate information
• offer support and assurance where required
• undertake health promotion in relation to cervical screening through the use of available resources

Sample takers should:

• use simple language to explain complex medical terminology
• speak at a measured pace to make sure the person can follow the conversation
• take time to ask the person if they have any questions
• respond clearly and check the person’s understanding

Sample takers should explain the purpose of cervical screening and what will happen at each step of the procedure. Check that the person attending screening understands:

• the purpose of cervical screening and its limitations
• the purpose of testing for human papillomavirus (HPV)
• the meaning of a normal test result (low risk, not no risk)
• the meaning of a negative HPV test with abnormal cytology
• the likelihood of an inadequate test and why this may happen
• the reasons for being referred following a test (normal or abnormal) which will include the HPV result
• how and when test results are made available
• the importance of contacting the sample taker if no result has been received within 2 weeks
• the importance of always reporting any abnormal bleeding or discharge to their doctor

Sample takers should explain to the person what they are going to do during the procedure, and what to expect. A person who is having a test for the first time may need a more detailed explanation, including looking at the speculum and the sampling device. The person needs to know they will have to remove their underwear and that the speculum will be inserted into their vagina.

The person demonstrates consent if they are willing to proceed with having screening. The sample taker must document that they gained consent for the procedure.

If a person chooses not to proceed with screening, or if distressed by the procedure, then the sample taker must recognise this as their valid choice not to have the test on that occasion. The sample taker may offer another date for the test.

Some people may wish to have a chaperone irrespective of the sex of the sample taker. The sample taker should offer the person a chaperone in accordance with local policies. If the person accepts or declines a chaperone, note this on record.

3.4 Taking and recording a clinical history

Ask questions and record responses in line with the sample request form, covering:

• the date of last menstrual period (LMP) if relevant
• any abnormal bleeding, such as intermenstrual, menorrhagia, post-coital, post-menopausal
• any unusual vaginal discharge
• contraceptive use (specify which type)
• use of hormone replacement therapy (HRT)
• retroviral infection (RVI)

Do not take a sample:

• during menstruation
• less than 3 months postnatally
• less than 12 weeks after termination of pregnancy (TOP) and miscarriage
• if there is a discharge or infection present (treat the infection first; if prescribing a pessary, refer to local clinical guidelines before taking a cervical sample)

There should be a 3-month gap after any clinical intervention, for example a hysteroscopy or the fitting or removing of a coil, to allow sufficient time for the cervical epithelium to regenerate.

Taking a sample when an IUCD is in situ

You may see the threads of an IUCD when taking a sample. Take care not to tangle the threads or remove the IUCD. If you inadvertently dislodge or remove the IUCD, refer to a clinician on site and provide the person with contraceptive advice.

Avoid cervical screening during pregnancy. We advise people to wait for 3 months after giving birth before taking a sample.

The screening test is not a diagnostic tool, and a normal test result could offer false reassurance. Refer people with symptoms of abnormal bleeding or persistent discharge, pelvic pain, bloating or urinary symptoms for further investigation without waiting for the test result.

3.5 Female genital mutilation (FGM)

FGM is mutilation of the labia majora, labia minora or clitoris. The practice is prevalent in many African countries, parts of the Middle East and Asia, and sometimes called ‘cut’, ‘circumcision’ or ‘female circumcision’. FGM has been illegal in the UK since 1985. There are 4 recognised types of FGM.

Type 1: Clitoridectomy: part or total removal of the clitoris.

Type 2: Excision: part or all of the clitoris and labia minora with or without excision of the labia majora.

Type 3: Infibulation: a narrowing of the vaginal opening with the creation of a covering seal formed by cutting and repositioning the labia minora and/or majora, with or without removal of the clitoris.

Type 4: Other: includes pricking, incising, scraping, or cauterising the female genital area for non-medical reasons.

Sample takers may have difficulty in passing the speculum in people who have undergone FGM.

Complications from FGM may include:

• difficulty passing urine and a history of recurrent or chronic urinary infections
• difficulty with menstruation
• superficial dyspareunia or apareunia
• recurrent abscesses or cysts particularly in the clitoral area
• complications in pregnancy and childbirth
• ongoing psychological trauma from the time of the initial FGM

If sample takers encounter medical complications, they should consider referral to a local FGM service to confirm FGM status and the possible need for de-infibulation. Alternatively, consider onward referral to specialist gynaecology and or counselling services.

The sample taker must be aware that a person who has undergone FGM may be a vulnerable adult. If the sample taker considers this to be the case, or if there may be a risk to other female family members, they should complete a safeguarding risk assessment or discuss the case with their safeguarding officer and share the information with multi-agency partners, for example, health visitors, school nurses or practice nurses, to initiate a safeguarding response.

Reporting FGM in people under 18 is mandatory (although out of scope of the screening programme) and the requirement to record data on FGM is set out in Department of Health (DH) guidance.

3.6 Checking a screening history

Check the person’s screening history, in particular:

• the date of their last test
• any abnormal test results

Establish that a person is eligible for a test (usually age 24.5 to 64 for routine tests) and that a test is now due (or overdue).

Some people outside the standard screening age range may be eligible for screening if:

• they have a routine recall date allocated as a result of a previous test
• they are under surveillance or follow up as a result of a previous abnormality
• they did not respond to their last invitation and now wish to be tested

If the person has had a previous abnormal result the sample taker should check:

• when
• where (the laboratory and colposcopy unit)
• the type of result
• if there was any treatment
• what (if any) follow up was undertaken

3.7 Preparing the request form

The sample taker should complete the following data items:

• surname, previous surnames, first names (check details, including spelling, with the person)
• a full postal address and postcode (check details, including spelling, with the person)
• date of birth
• NHS number
• name and address of sender if not GP
• name and address of GP
• GP code
• the person’s hospital registration number (if applicable)
• the source of the sample (type of organisation)
• the date of the test
• the first day of last menstrual period
• whether the person is pregnant, postnatal, has an intra-uterine contraceptive device (IUCD) fitted, or uses hormones
• the reason for the test
• any clinical information (completed after sample is taken)
• the sample taker’s pin number or code.

The sample taker must check the details recorded on the cytology request form and electronic record for accuracy.

3.8 Preparing the equipment for the test

Prepare the equipment needed for the test. Check the vial is in date and fully remove the seal and lid before taking the sample.

3.9 Preparing and positioning the individual

Invite the person to step behind the curtain. Ask them to remove their lower under garments and lie down on the couch. Tell them where to place any clothing once they have removed it. Consider any cultural factors when advising the individual on what clothing to remove. Advise the individual to remove only enough clothing and under garments necessary to complete the examination. Provide a modesty sheet to cover the pelvic area.

Refer to both the dorsal and the left lateral positions and let the individual choose which they prefer. The Programme does not advocate an ideal position for taking a sample.

3.10 Choosing the appropriate speculum

All sample takers should have a range of specula available including:

• very small
• small
• medium
• large
• broad / long

The equipment should include a long bladed narrow speculum such as the Winterton™ speculum, to enable better visualisation of the cervix when the vagina is long or the cervix is lying posteriorly.

Check the quality of the equipment selected. When using the speculum, the sample taker should:

• consider using a little water based and carbomer free lubricant (avoiding the tip of the speculum so as not to contaminate the cervix)
• warm or cool under running water to reach body temperature for a metal speculum (make it clear to the person what is being done)
• gently insert the speculum side-on, directing it downward using gentle, unhurried movements
• open and close the speculum slightly or change the angle of insertion to bring the cervix into view
• note that a common error is failure to insert the speculum far enough into the vagina
• allow time after inserting the speculum to allow the person to relax

4. Appearance of the cervix

The sample taker inserts the speculum to:

• visualise the cervix
• assess the cervix
• interpret what is seen

The following appearances of the cervix should be familiar:

Cervical epithelium
The cervical epithelium is of 2 kinds. The multi-layered squamous epithelium on the ectocervix appears pale pink, and the thinner columnar epithelium in the endocervix appears red.

Cervical eversion
This is a wide area of columnar epithelium, also known as ‘ectropion’. Opening the speculum exaggerates the appearance further. Cervical eversion does not require treatment unless the person is symptomatic. If symptomatic, refer the individual to colposcopy.

Laceration of the cervix
This is associated with childbirth, and exposes more of the canal lined by columnar epithelium.

Post treatment for CIN
You may see a central ‘rosette’ of reddened epithelium on the cervix which is asymptomatic and does not bleed to the touch. This represents an old area of healing.

4.1 Sampling the transformation zone (TZ)

The whole cervix must be visualised to obtain a satisfactory sample. Sample takers should note that:

• CIN can develop anywhere in the vaginally exposed columnar epithelium, so the whole TZ needs to be sampled
• the position of the TZ varies; the part of the TZ adjacent to the squamo columnar junction (SCJ) is the most vulnerable to CIN
• if the SCJ is visible, the sample must include the whole circumference of the SCJ and the adjacent 1cm of squamous epithelium
• if the SCJ is in the endocervical canal and not visible, the sample must include cells from the canal in addition to the ectocervix
• they must visualise the cervix at the time the sample is taken, and make sure the whole of the TZ has been sampled (the laboratory cannot be certain that the full circumference of the cervix has been sampled by the cellularity or cell content of the sample)
• if an experienced sample taker is unable to visualise the cervix, the person should be referred to a colposcopy clinic for investigation
• samples taken after treatment for glandular neoplasia, CIN 2 or CIN 3 are special cases, and sample takers should make sure that information about previous treatment is given on the test request form

Nabothian follicles

These are mucus-retaining cysts formed as islands of columnar epithelium covered by squamous epithelium. They are usually small (about 5mm in diameter), but occasionally may enlarge to 1 to 1.5cm. The cervix may have a knobbly appearance if several cysts are present. No treatment is required, and a sample can be taken as normal.

Polyps

The sample taker may take a sample as long as the polyp does not interfere with full 360 degree coverage. If in doubt, refer the person to gynaecology and then sample after treatment (3 months later).

Small ectocervical polyps where the base is visible and which are asymptomatic do not require referral for gynaecological opinion.

Large, symptomatic or endocervical polyps where the base is not visible should result in referral for a gynaecological opinion (although such polyps are usually benign).

People with 2 cervices

If a person has 2 cervices, the sample taker must:

• take a sample from each cervix
• put each sample into a separate vial
• label each vial and identify which cervix they have come from (use the person’s left and right)

4.2 Bleeding on taking a sample

Bleeding on taking a sample is not uncommon, especially from the columnar epithelium. If the cervix bleeds with no clinical suspicion of malignancy, sample takers should assess the amount of bleeding and consider possible causes. The sample taker should send the sample to the laboratory, and explain to the person that the sample may be inadequate (and they may need to have the test repeated).

If bleeding is a repeated problem and causes repeated inadequate samples, or if the person has post-coital bleeding, the sample taker should consider referral to a gynaecologist for further investigations.

4.3 Clinical suspicion of malignancy

Cervical cancer is rare in the UK. Many sample takers will never see a single case. Signs of malignancy include:

• an enlarged cervix where the surface is irregular and friable, crumbling to the touch (gross example)
• large blood vessels which bleed freely when rubbed by the end of the speculum
• an offensive, watery discharge may also be present

If the cervix bleeds with clinical suspicion of malignancy, and a clinician considers the cervical appearance is suspicious of malignancy, they must refer the person to a gynaecologist urgently through the cancer wait times (CWT) ‘2-week wait’ pathway. Do not take a sample.

Cervical screening is a screening test, not a diagnostic tool. If a person presents to their GP practice with cervical cancer symptoms, the GP should refer them to a gynaecologist.

In rare cases, hrHPV may not be present and a normal screening result may occur even though malignancy is present.

If the sample taker has any concerns about the person’s health when the cervix is visualised, they should seek appropriate clinical advice.

5. Taking the sample

Achieve a high cellular yield with correct use of the Cervex-Brush™ / broom.

1. Insert the central bristles of the Cervex-Brush™ / broom into the endocervical canal so that the shorter, outer bristles fully contact the ectocervix.
2. Using pencil pressure, rotate the Cervex-Brush™ / broom 5 times in a clockwise direction. In order to ensure good contact with the ectocervix, bevel the plastic fronds of the Cervex-Brush™ / broom for clockwise rotation only.

The trainee should take care to:

• make sure the Cervex-Brush™ / broom fronds are fully splayed
• apply firm pressure when taking the sample for the entire 5 clockwise rotations
• move the speculum around if necessary to view the cervix properly

5.1 Taking an additional endocervical sample

The endocervical brush should be used only in a very few circumstances, and always in conjunction with a Cervex-Brush™/ broom.

Consider taking a second sample using an endocervical brush only if:

• there is difficulty inserting the Cervex-Brush™ / broom into the os, for example if the os is narrow or stenosed
• the person is being followed up for previous borderline changes in endocervical cells
• the person is being followed up for a previously treated endocervical glandular abnormality (usually when the person has not had a hysterectomy or radiotherapy) when a previous sample was inadequate because of the absence of endocervical cells

Sample takers should take the endocervical sample after the Cervex-Brush™ / broom sample:

1. Insert the endocervical brush gently into the os, with the lower bristles remaining visible, and rotate clockwise through one whole turn.
2. Fix both samples in the same vial, and clearly note on the cytology request form the use of 2 sampling devices and the reason why.

5.2 Wide ectropion

If a wide ectropion is present use a Cervex-Brush™ / broom to collect the sample. If necessary, a use a second brush to sweep the transformation zone in accordance with the manufacturer’s instructions for users. Fix both samples in the same vial, and note this on the cytology request form.

6. Fixing the sample

Fix the sample immediately, without rushing the technique, using the instructions below.

1. Place the Cervex-Brush™ / broom as it is into the fixative.
2. Push the Cervex-Brush™ / broom into the bottom of the vial using a vigorous swirling motion. Do this at least 10 times, forcing the bristles apart. Firm pressure is necessary or the cells will cling to the Cervex-Brush™ / broom.
3. Inspect the Cervex-Brush™ / broom for any residual material and remove any remaining by passing the Cervex-Brush™ / broom over the edge of the fixative vial.
4. Make sure the material reaches the liquid to preserve it.
5. Tighten the cap so that the torque line passes the torque line on the vial.
6. Shake the vial if you wiped any material on the edge.
7. Label the vial.
8. If an additional sample has been taken with an endocervical brush, add it to the vial and rinse in the same way as for the sample brush.

If the laboratory requests a cyto brush sample, add it to the same vial in the same way as the Cervex-Brush™ / broom sample.

You must place the sample in the vial at once to achieve immediate fixation. Do this before removing the speculum.

7. Removing the speculum

Withdraw the speculum gently, with the blades apart until the cervix is no longer within the blades. Allow the speculum to close and continue to withdraw it until fully removed.

8. Ending the appointment

Allow the person time to dress before going on to complete the screening appointment.

Check that:

• you have recorded their name and date of birth on the vial
• you have completed the cytology request form
• the detail on the form and vial are correct and both match

Explain to the person:

• how and when they will receive their test result
• what the results may be
• what follow up may be relevant (as appropriate)

Check the person understands:

• they should see their GP if there is any abnormal bleeding or discharge
• they can return to the practice for further advice (consider providing an information leaflet)

9. Completing the request form

Complete the clinical data box by:

• indicating the type of specimen
• specifying if an additional sample (endocervical) was taken and sampling device used
• providing any information on current signs and symptoms
• detailing any problems with sampling the cervix
• providing all clinical details, such as unusual bleeding
• noting any issues regarding the appearance of the cervix

Also provide brief details of any significant history, including:

• abnormal cytology (with slide number) where available
• any previous diagnosis and treatment

This ensures that the laboratory has sufficient information to make an appropriate recommendation on the person’s future management.

Check that all the relevant boxes are complete and legible. Sign the form (electronic signature), and provide the sample taker pin code (if used locally).

10. Documenting the procedure

Document the details of the test in the person’s records using appropriate codes and templates. These details should include:

• confirmation that the cervix was fully seen
• confirmation of sampling from the transformation zone
• the date the sample was taken
• the sample taker’s details
• consent obtained
• other clinical information if applicable

Sample takers must record their actions clearly and accurately and use only recognised abbreviations.

As a failsafe measure, the trainee should keep a list of all samples sent, and correlate this with the results returned by the laboratory.

11. Sending the sample to the cervical screening laboratory

Send samples to the laboratory on the same day they are taken in order to achieve the programme standard 14-day turnaround for results.

Send the sample and the corresponding request form to the cervical screening laboratory, packed in accordance with local arrangements.

Make sure the vial lids are fitting correctly to prevent any leakage. Leaking vials could result in the laboratory rejecting the sample.

12. Infection control

Sample takers should follow local protocols for infection control.

13. Disposing of equipment and waste

Sample takers should dispose of equipment and waste safely in accordance with local protocols.