Manisha Patel, MD
• A 19yof presents to your office for an annual exam. She has never been sexually active.
The current American Cancer Society guidelines on cervical cancer screening recommend beginning screening within 3 years after the onset of vaginal intercourse or no later than age 21. Although the cervix is especially vulnerable to HPV infection during adolescence when the squamous metaplasia is most active, most of the infections are cleared by the immune system within 1-2 years without producing neoplastic changes. Screening less than 3 years after the onset of vaginal intercourse may result in over diagnosis of cervical lesions. The risk of neoplastic transformation increases in those women whose infection persists. Also the risk of squamous cell cervical cancer in the first two decades of life is exceedingly rare. Adolescents still need to be seen for gynecology care especially for preventive measures and counseling on areas such as STDs, contraception, immunization, diet, exercise.
• A 32yo married woman with 3 documented consecutive normal pap smears.
Annual screening should be recommended for women younger than age 30. Women aged 30 and older who have 3 consecutive cervical cytology results that are negative for dysplasia/cancer may be screened every 2-3 years unless the patient is a high risk patient (HIV, immunosuppressed such as renal transplant patients, exposure to DES, women treated for CIN 2 or 3 in the past or cancer). High risk patients need to continue annual screening. Also, a patient over the age of 30 with both negative cervical cytology and high risk HPV types can be rescreened every 3 years.
• A 50yof had a TAH/BSO one year ago and prior normal pap smears.
According to the ASCCP, after a patient has had a TAH with no prior history of high grade CIN, screening may be discontinued. If a patient had a high grade CIN lesion prior to TAH, she can still develop recurrent dysplasia/malignancy at the vaginal cuff. These patients need screening annually after the TAH until 3 consecutive negative pap smears and screening may be discontinued.
• A 80yof presents for annual exam.
Controversial regarding age to discontinue pap screening. American Cancer Society: discontinuing pap smears after the age of 70 in low risk women, U.S. Preventive Service Task Force: age 65 is the upper limit of screening, ACOG: no recommendations regarding age cut-off but if suggests re-assessment of risk factors during each annual examination to determine if reinitiating screening is appropriate.
A review of the pap smear, colposcopy, histology with the pathologist needs to be done to ensure that the initial interpretation is accurate. If the interpretation changes, then the patient needs to be managed per the ASCCP guidelines of the changed diagnosis. If the diagnosis does not change, the patient needs to have repeat cytology in 6 and 12 months or HPV testing in 12 months.
Colposcopy and endometrial sampling. Endometrial sampling should be done if the patient is greater than age 35 or having abnormal bleeding.
If cervical biopsies and endometrial sampling show no invasive disease, what is your step?
The next step in the evaluation depends on the intial pap smeaer.
If the initial pap smear was AGC-NOS, these patients can followed with repeat cytology at 4-6 month intervals for four times. If any of these repeat paps are significant for ASC/LSIL then colposcopy should be performed. If any of these repeat paps are significant for HSIL/AGC then a diagnositic excisional procedure such as cold knife cone should be performed. If the initial pap smear was AGC-favor neoplasia, then a diagnostic excisional procedure (CKC) should be performed.
Three possible options are available. You can give the patient a course of intravaginal estrogen therapy and repeat a pap smear one month after completion of therapy or you can repeat a pap smear in 4-6 months after the index pap smear: at that time if the pap is ≥ASC she should have colposcopy. Third option would be to get HPV testing 12 months after index pap and if HPV+ then colposcopy should be done.
Three possible options depending on the reliability of the patient. If the pt is not reliable, proceed with colposcopy. If the lesion at time of colposcopy is CIN I (if the pt has CIN II and reliable, you can also proceed with expectant management). If the patient is reliable you can repeat cytology 6 and 12 months after index pap or get HPV testing 12 months after index pap smear.
Colposcopy preferably by clinician experienced in the colposcopic changes induced by pregnancy. Biopsy of lesions suspicious for high grade disease or cancer is preferred. Bx of other lesions is acceptable. ECC is not acceptable. If colposcopy is unsatisfactory, repeat colposcopy in 6-12 weeks. A diagnostic excisional procedure is recommended only if invasion is suspected.
References: www.asccp.org and ACOG Compendium