2a Sampling the Cervix for HPV Testing and/or Cytology

Please refer to Chapter 3, Colposcopy and the Transformation Zone for a detailed discussion on the transformation zone, the target area for sampling.

As the vagina is a closed virtual space, the vaginal walls are collapsed, and the mucosal surfaces of the vagina, fornices and cervix are in contact with each other. So visualisation of the cervix requires insertion of a speculum to expose the face and the cervix and the os, so that the cervix can be inspected and the sampler can be inserted and rotated in the os.  
Adequate sampling requires a cellular sample, ideally free from excess mucus, blood and exudate. The sample should be collected using the Cervex-Brush® (endocervical broom Fig. 2.08) which is designed to pick up cells from both the endocervical canal and ectocervix simultaneously. The brush is made up of semi-circular soft, flexible hairs. The hydrophobic material of the brush facilitates the release of the cell material into the sample vial fluid.

The primary objective is to obtain and endocervical or immature metaplastic cell component in the sample (i.e. a TZ component) indicating the TZ has been sampled. The presence of endocervical cells in the LBC indicates the SCJ has been crossed (where squamous epithelium abuts with endocervical epithelium) and the TZ has been sampled. The presence of an immature metaplastic component only, also indicates the TZ has been sampled, but the SCJ, has not necessarily been crossed, to pick up endocervical cells.
Women who have a closed or stenosed cervical os on speculum examination, or a Type 2 or Type 3 TZ (refer to Chapter 3) may benefit from the additional use of an endocervical brush, to facilitate reaching higher into the endocervical canal to obtain a TZ component. Similarly, women referred to colposcopy, requiring an additional LBC sample being collected at colposcopy for an endocervical component, may benefit from use of an endocervical brush, illustrated left (Fig 2.09). This may be used in conjunction with the Cervex-Brush®, or as the sole collection device at recollection.
The endocervical brush is not recommended as the routine sole sampling device because the bristles clearly do not cover the area around the os and onto the face of the cervix.

2b. Vaginal Self-Collect CST

In July 2022 the vaginal self-collect CST was introduced as a screening option. Self-collection offers a private, non-confronting, comfortable, alternative screening option for a significant proportion of eligible women who would otherwise not come forward for screening. Personal barriers deterring women from screening include concerns about personal discomfort, body image, previous unpleasant experience, prior sexual abuse, cultural, religious and linguistic barriers.
The test is as accurate as clinician-collected samples for detecting high-risk human papilloma virus and has become a widely acceptable method of collection and testing for many women. 
In early 2025 49% of all CSTs done in Australia (NCSR data 2026) were vaginal self collects, suggesting it is becoming the preferred option for routine screening.

The vaginal self-collect CST is collected by the patient, using a swab (dry Copan FLOQSwabs®), which is only inserted a few centimetres into the vagina (Fig 2.10). No speculum is required, and the cervix is not seen or sampled, therefore no LBC can be made from that collection. 
Women presenting with symptoms or in follow-up for cervical or endometrial malignancy, AIS or DES exposure are not eligible for the vaginal self-collected CST. These women are recommended to have a clinician collected CoTest (or LBC only in the case of a history of endometrial cancer) according to the NCSP Guidelines.

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