title: Order of endocervical and ectocervical cytologic sampling and the quality of the Papanicolaou smear.
abstract: OBJECTIVE
  To determine whether the order of cell collection, endocervical or ectocervical cells first, has an effect on the quality of the Papanicolaou smear.
  
  
  METHODS
  One thousand smears were obtained using an Ayre spatula and an endocervical brush. In 500 cases the endocervical brush was used first, and in 500 cases the spatula was used first. All Papanicolaou smears were collected by resident physicians in our university hospital gynecologic clinics. A smear was considered limited for interpretation for the following reasons: 1) lack of endocervical component, 2) obscured by blood, 3) obscured by inflammation, 4) drying artifact, and 5) too thick.
  
  
  RESULTS
  The brush-first group had 405 (81%) adequate smears compared with 410 (82%) adequate smears in the spatula-first group. More smears were obscured by blood when the brush was used first (22 or 4.4% compared with three or 0.6%, P < .001). No endocervical component (ie, metaplastic cells, endocervical cells, or mucus) was found in 29 (5.8%) smears from the brush-first group compared with 45 (9.0%) of the spatula-first group, an insignificant difference. More squamous intraepithelial lesions were found when the spatula was used first (55 or 11% compared with 35 or 7.0%, P < .05).
  
  
  CONCLUSIONS
  The quality of the Papanicolaou smear can be improved by using the Ayre spatula first followed by the endocervical brush. Fewer smears will be obscured by blood, which could result in more squamous intraepithelial lesions being detected.
authors.affiliation: Department of Obstetrics and Gynecology, Allegheny University of the Health Sciences, MCP-Hahnemann School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: D
authors.initials: D
authors.lastname: Eisenberger
authors.forename: E
authors.initials: E
authors.lastname: Hernandez
authors.forename: T
authors.initials: T
authors.lastname: Tener
authors.forename: B F
authors.initials: BF
authors.lastname: Atkinson
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D065006:Papanicolaou Test; D012680:Sensitivity and Specificity; D013048:Specimen Handling / Q000379:methods; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000453:epidemiology; D014626:Vaginal Smears / Q000379:methods* / Q000592:standards; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000453:epidemiology