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Will This Exercise Be Good Enough?

Professorial Obstetrics and Gynecology Unit
Peradeniya, Sri Lanka

A. A. Amarasinghe, MD

Private consultant
McDonough, GA

To the Editor: Since Papanicolaou showed that exfoliated cervical cells could be successfully used for identification of pathology of uterine cervix, speculum examination and obtaining a smear became a part and parcel of routine gynecological care.¹ Millions of females undergo this procedure due to better health care facilities, organizational commitment, screening programs, and patient awareness.²

The use of water-soluble gel as a lubricant was thought to affect the smear quality by altering the uptake of dye during staining. Evaluation of the quality of the smears so obtained was made by Gilson et al.³ This evaluation had its strengths and weaknesses. The striking positive feature was the involvement of each subject as her own control, when initial smear was performed on all subjects without gel and the second smear was performed with gel in half the patients and without gel in the other half. The procedure therefore allowed better assessment of discomfort level both within the groups as well as between groups while making sure that the patients would not require a second visit in case the gel obscured the cervical cytology. The major drawback of the exercise was the use of fewer patients compared with previous studies.⁴ Although the smaller sample size was shown to be sufficient enough by post hoc power analysis, this could affect the generalizability of the results to a larger population. The lack of uniformity within the study population was evident in the fact that it was primarily composed of premenopausal females who could produce biased results when inquiring the discomfort level. This could lead to type 11 error and jeopardize the correctness of the conclusions.⁵

The fact that the patients were kept blinded for the use of lubricant is questionable. It is practically difficult to conceal the use of a 2.7-g pack of lubricant gel from a female study subject! Further clarification is appreciated on the time and place of application of gel. However, the results obtained from this study may well divert our thinking pattern on the use of water-based lubricant during speculum examination for Papanicolaou smears.

Notes

Dr. M. Gilson and coauthors were shown this letter and declined to comment.

References

1. Papanicolaou GN, Traut HF. The diagnostic value of vaginal smears in carcinoma of the uterus. Am J Obstet Gynecol 1941; 42: 193–206.

2. Curtis P, Mintzer M, Resnick J, Morrell D, Hendrix S. The quality of cervical cancer screening: a primary care perspective. Am J Med Qual 1996; 11: 11–7.[Abstract/Free Full Text]

3. Gilson M, Desai A, Caedoza-Favarato G, Vroman P, Thornton JA. Does gel affect cytology or comfort in the screening Papanicolaou smear? J Am Board Fam Med 2006; 19: 340–4.[Abstract/Free Full Text]

4. Amies AM, Miller L, Lee SK, Koutsky L. The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis. Obstet Gynecol 2002; 100: 889–92.[Abstract/Free Full Text]

5. Guyatt G, Jaeschke R, Heddle N, Cook D, Shannon H, Walter S. Basic statistics for clinicians: 1. Hypothesis testing. CMAJ 1995; 152: 27–32.[Abstract]

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