Abnormal Pap Smear Management Guidelines

Alaska Native Medical Center

Update 1/2003

 

 

Our system for the prevention of cervical cancer in Alaska Native women
requires three elements working together.

-   •        Regular Pap screening of women at risk for the disease.

-   •        Medical evaluation and management of abnormal Pap results.

-   •        Tracking of Pap results and treatments with patient
    notification.

The first element was described in "Alaska Area Native Health Service
Cervical Cancer Screening" 12/06/00.  This will be updated in the to
include new recommendation from the US preventive Health Services Task
Force and the American Cancer Society and the American College of
Obstetrics and Gynecology when those groups complete their publications.

This document updates the management of the second element.

The system that is in place for tracking Pap smears and treatment has
worked well.  It will be challenged by changes in screening interval and
treatment recommendations and by new technologies including "thin prep"
and HPV testing.  Facilities and providers involved in women's health
will need to continue to work together to maintain the integrity of this
database that we all rely on to deliver quality care.

Management of vaginal infections found on Pap test are not addressed
here.

 

 

Background

-   -         Cervical cancer is now an uncommon disease, diagnosed in
    about 13,000 women in the U.S. and leading to 4500 deaths each year

-   -         Alaska Native women at one time had higher rates of cervix
    cancer than the general population.  More recent evaluations show
    the cervix cancer occurring no more frequently in Native women. 
    This change in cancer incidence most likely reflects historic lack
    of access to our utilization of preventive services (pap smears) and
    not a biologic difference. 

-   -         Cervix cancer remains the leading cause of cancer deaths
    for women in parts of the developing world where Pap screening is
    not available. This was also true in the US before Pap screening
    began 50 years ago.  Implementation of pap screening programs have
    produced an 80% to 90% decrease in cervical cancer incidence and
    mortality.

-   -         Cervical cancer screening has been very successful because
    there is a long pre-cancerous phase of disease (dysplasia) that can
    be detected and treated before actual invasive cancer develops.  We
    believe this phase typically lasts at least 5 years but as with any
    biological system there is wide variation.

-   -         Invasive cervical cancer is most commonly found in women
    who have not had pap screening for [many]{.underline} years.  Since
    our goal is to reduce the incidence of cervical cancer, the efforts
    that will have the greatest impact are those that target this group
    of women.

-   -         Historically cervical cancer was a disease of women in
    their 30's or 40's but the current average age at diagnosis is 56.
    This does not represent and actual increase in the incidence of
    disease in older women.  It does show that the prevention of
    cervical cancer has been more successful in younger women who are
    more likely to get regular pap screening.  After completing
    childbearing many women do not have regular contact with a medical
    provider even though they can be in the age range where screening is
    recommended.

-   -         The risk of invasive cervical cancer increases with
    persistent high-grade lesions.  This requires that we consider any
    history of dysplasia along with the current pap result in making
    triage and treatment choices.

-   -         Most of the abnormal Pap results we deal with will be
    Low-grade lesions found in young women (\<30).  This most likely
    represents recently acquired HPV infection.  The great majority will
    regress without treatment.

-   -         Low-grade lesions are less common in older women while
    high-grade lesions; glandular abnormalities and invasive cancer are
    all more common in this group.  This means that an abnormal Pap test
    is more likely to lead to a diagnosis of significant disease in an
    older patient.

 

Limitations of Pap Screening

-   -         Adenocarcinoma of cervix a separate disease from Squamous
    Cell carcinoma of the cervix that the Pap test is intended to
    prevent.  Adenocarcinoma does not have the same long pre-invasive
    period and it can arise high in the endocervical canal beyond the
    view of colposcopy.  This means that our screening program does not
    have the same reliability (negative predictive value) in excluding
    adenocarcinoma.  For this reason we apply separate guideline to
    glandular cell abnormalities and these do not include a
    "conservative management" option.

-   -         While we recommend pap testing it remains a woman' choice
    whether she wants a Pap smear or any other medical procedure.  Other
    health services such as birth control should not be withheld because
    of a lack of Pap screening.

-   -         Women who have had a hysterectomy for reasons not related
    to cervical dysplasia or cancer are very unlikely to develop a
    cancer that can be detected by Pap smear.  While vulvar and vaginal
    cancers are possible after a hysterectomy their incidence does not
    warrant regular screening without specific history. 

-   -         Gynecologic malignancies other than cancer of the cervix
    are sometimes discovered in evaluating a patient for an abnormal Pap
    smear.  These include endometrial cancer, fallopian tube cancer and
    ovarian cancer.  The pap smear is [not]{.underline} a good test for
    these malignancies and should not be used to evaluate for them.  A
    normal pap in no way excludes these conditions.  Surveillance for
    these malignancies will not be addressed in this guideline.

-   -         Since the Pap test is looking for pre invasive disease
    screening should focus on women in their 20's, 30's, 40's and 50's. 
    Screening women younger than twenty and over sixty-five has a much
    lower yield in finding dysplasia or cancer. 

 

 

 

A Few Words About HPV Testing

It has become clear that HPV (Human Papilloma Virus) infection has a
central role in the development of cervical dysplasia and cervical
cancer.  It is also clear that HPV infection is very very common and
usually harmless.  In the future we may have understanding or treatment
options that let us address HPV infection with real benefit to our
patients but we currently do not.  While it is tempting to try to treat
or test for HPV because it is the "cause" of cervix pathology, there is
no evidence that this approach can prevent cervix cancer.  The disease,
cervix cancer and it's precursors, has not changed, only our
understanding of HPV's role has.   While Pap screening and the treatment
of dysplasia may not look like the newest technology it has proven to
prevent greater than 90% of cervix cancer and we should not adopt new
technologies until they can demonstrate an improvement on that result.

Recently HPV testing, alone or in conjunction with Pap testing has
become widely available.   Testing for HPV high risks subtypes has been
advocated as part of a process to evaluate some patients with abnormal
pap smears.  Current evidence only supports using HPV studies to triage
patients who have Pap test results of ASC-US (about 4% of patients). 
There are three well-studied approaches to patients with an ASC-US Pap
result;

1.  1.      Repeat Pap smear in 4-6mo times 2, then colposcopy if the
    Paps remain abnormal.

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1.  2.      HPV testing with colposcopy for patients who test (+) for
    high-risk subtypes.

2.  3.      Colposcopy for all patients with ASC-US Pap results.

HPV testing has [not]{.underline} been shown to be better than the other
two approaches. 

 

For patients with an ASC-US Pap result HPV testing has been suggested by
two mechanisms -

-   -         The first is to have the patient with an ASC-US Pap result
    return for a pelvic exam with a swab for HPV.  The HPV result is
    then used to decide if the patient needs colposcopy.  Since this
    requires a pelvic exam where a Pap or a colposcopy could be done
    instead of the HPV test to acquire equivalent or definitive
    information we see no benefit to this approach.

-   -         The second method of using HPV typing is to collect a
    specimen at the time of routine Pap. (Thin prep or Co-collection)
    and then running the test [only]{.underline} if the Pap smear result
    is ASC-US.

Within the Indian Health System of Alaska we are not collecting Pap
tests in a way that makes after the fact HPV testing possible (like the
Thin-prep).  Changing to a system that would allow such testing would
add significant cost and inconvenience to every Pap smear and would
provide useful information to only about 2% of patients.  When the cost
or specimen handling issues change this issue will be revisited.

 

Also worth noting is the difference between high risk and low risk HPV
types. Low risk HPV types do not imply any increase risk of cervical
disease.  We recommend [never]{.underline} ordering testing for [low
risk HPV]{.underline} types. 

 

These Guidelines currently do not recommend using testing for high risk
HPV types to make treatment decisions.  This is an evolving topic and
will be reexamined regularly.

>  
>
>  
>
>  
>
>  
>
>  

Who Should Evaluate the Abnormal Pap Test

As with prior versions of these guidelines we recommend a two tiered
system of

Colposcopy privileging:

-   -         [Basic colposcopy privileges]{.underline} for providers
    trained in colposcopy but not expert in treatment of gynecologic
    disease. These providers could see patients in the low-risk group. 

-   -         [Full colposcopy privileges]{.underline} for providers
    with training in colposcopy [and]{.underline} the treatment of
    dysplasia and malignancy. These providers could see patients in the
    high-risk group. 

> Triage based on Pap result.
>
> Bethesda (2001) Classification
>
>  

*Low --Risk Group*

> ASC-US                Atypical Squamous Cells of Undetermined
>
> Significance
>
>  
>
> LSIL                     Low Grade Squamous Intraepithelial Lesion
>
>  

*High --Risk Group*

> ASC-H                  Atypical Squamous cells cannot exclude HSIL
>
>  
>
> HSIL                    High Grade Squamous Intraepithelial Lesion
>
>  
>
> Squamous Cell        Squamous Cell Carcinoma
>
> Carcinoma
>
>  

AGC                     Atypical Glandular Cells

> (specify cervical, endometrial, other)
>
>  
>
> AGC favor             Atypical Glandular Cells favor neoplastic
>
> Neoplastic
>
>  
>
> AIS                      Endocervical Adenocarcinoma In situ
>
>  
>
> Adenocarcinoma     Adenocarcinoma
>
>  
>
> Other Malignant     All other Malignant Cells (i.e. ovary)

Neoplasms

 

 

The 2001 Bethesda revision has fewer categories.  Hopefully this will
lessen confusion once we all adjust.  These ten categories easily break
into a low-risk and a high-risk group.

-   •        The first two categories (ASC-US and LSIL), the Low-Risk
    Group, will include most of the abnormal pap results and are
    unlikely to represent high grade or invasive disease.  Providers
    with basic colposcopy privileges can manage Pateints with results in
    these two categories. Management recommendations are sections A and
    B.

-   •        The remaining eight categories on the list, the High-Risk
    Group, are uncommon and are more likely to represent significant
    disease.  This group of patients will be older and complete
    evaluation of these results may require additional procedures beyond
    basic colposcopy.  For that reason we recommend that patients with
    results in these categories be evaluated by the Gynecologist or
    another provider with full Colposcopy privileges.

-   •        The High-risk group can be further divided into three
    subgroups.

1.  1.      Squamous dysplasia group;  HSIL and ASC-H.  Management
    recommendations are sections C and D respectively.

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1.  2.      Atypical glandular cell group;  AGC, AGC favor neoplastic
    and AIS. Management recommendations are sections E.

2.  3.      Invasive disease group;  Squamous Cell Carcinoma,
    Adenocarcinoma and Other malignant Neoplasms.  Management is prompt
    referral.

-   •        Finally management considerations for Special Circumstances
    are presented.

1.  1.      Adolescents; section F

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1.  2.      Post-menopausal women; section G

2.  3.      Immunocompromised; section H

3.  4.      Pregnant patients; section I

 

Adequacy of colposcopic exam

-   •        The provider performing the colposcopy should record a
    colposcopic impression using the histologic categories, (normal/no
    evidence of dysplasia,  CIN I, CIN II or CIN III ) along with a
    statement of satisfactory or unsatisfactory colposcopy, a drawing
    indicating the location of lesions and a listing of all biopsies
    taken.

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-   •        A [satisfactory]{.underline} colposcopy is defined as
    visualization of the entire transformation zone, including the
    squamo-columnar junction, and the limits of any lesion if present.

-   •        When the squamo-columnar junction or the limits of the
    lesion cannot be identified the colposcopy is described as
    [unsatisfactory]{.underline}.

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-   •        In the setting of an unsatisfactory colposcopy endocervical
    sampling is used to complete the evaluation.

-   •        Endocervical sampling can be obtained by ECC (endocervical
    curettage) for histology or by using a cytobrush to collect mucous
    from the endocervical canal for histology  (not cytology).

-   •        Endocervical sampling that finds no dysplasia is reassuring
    but an endocervical sampling that finds dysplasia of any grade is
    [not]{.underline} considered a complete evaluation.  This is because
    endocervical sampling is by definition a blind procedure.  Therefor
    an endocervical sampling that finds dysplasia is an indication for
    referral to GYN for consideration of an excisional procedure.

-   •        If the biopsy histology differs significantly from the
    colposcopic impression or the provider is not confident of the
    adequacy of evaluation with any colposcopy a referral should be made
    to the GYN specialist.

 

 

 

Section A: ASC-US  Atypical Squamous Cells of undetermined significance

 

ASC-US

![](media/image1.png){width="0.4270833333333333in"
height="0.3333333333333333in"}![](media/image2.png){width="0.4270833333333333in"
height="0.3333333333333333in"} 

 

Low risk Pap History                            History of dysplasia in
last 5yrs or

> ![](media/image3.png){width="0.14583333333333334in"
> height="0.5416666666666666in"}No history of regular pap screening

![](media/image4.png){width="0.3333333333333333in"
height="0.3333333333333333in"} 

 

![](media/image5.png){width="0.14583333333333334in"
height="0.4270833333333333in"}![](media/image6.png){width="0.8333333333333334in"
height="0.34375in"}![](media/image7.png){width="1.1354166666666667in"
height="0.3541666666666667in"}Pap in 6mo
                                                                             
Colposcopy     

![](media/image8.png){width="1.2291666666666667in"
height="0.90625in"}![](media/image9.png){width="0.4375in"
height="0.84375in"}                       

                                                            If
[\>]{.underline}ASC

![](media/image10.png){width="0.53125in"
height="0.3333333333333333in"}            If negative

> Pap in 6mo again

![](media/image5.png){width="0.14583333333333334in"
height="0.4270833333333333in"} 

                                                                                                                       
CIN found

                                                            No CIN
found                          (positive colposcopy)   

![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"}            If negative return to
                  (Negative Colposcopy)

![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"}            Annual
screening                                                                                                                                              
                                                                                   
Standard
RX                                                                Repeat
pap                                                 for CIN
grade                                                              12
months                               

           

ASC-US

-   •        This is the largest category of abnormal pap results.

-   •        The Bethesda 2001 update removes the category "ASCUS favor
    neoplasia". 

-   •        The category ASC-H is new and its evaluation is described
    separately (section C). 

-   •        We recommend evaluating these patients with 2 additional
    pap tests at 6month intervals.  If either of those tests is not
    normal the patient should go on to have colposcopy. 

-   •        We expect that about one half of these patients will need
    colposcopy.

-   •        Patients with a more concerning pap history should be
    considered for colposcopy as the first step.  This would include;

1.  1.      Any dysplasia in the last 5 years: LSIL, HSIL, ASC-H, AGC,
    CIN (any grade) etc.

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1.  2.      A history of not getting regular pap screening, at least two
    normal paps in the last five years.

-   •        We are not recommending HPV testing as explained above.

-   •        ASC-US is a common finding in the setting of atrophic
    vaginitis without actual dysplasia. This is addressed in section G.

 

 

 

 

 

 

 

Section B:  LSIL Low grade Squamous intraepithelial lesion

LSIL pap (Except special circumstances)

![](media/image12.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

![](media/image13.png){width="1.3333333333333333in"
height="0.4583333333333333in"}![](media/image14.png){width="1.0416666666666667in"
height="0.5416666666666666in"}Colposcopy

![](media/image12.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

Normal                         CIN
I                                       [\>]{.underline}CIN II

> No dysplasia or            Colposcopic impression           
> Colposcopic impression

Cancer found                and/or biopsy histology and/or biopsy
histology

![](media/image15.png){width="0.14583333333333334in"
height="0.34375in"}![](media/image16.png){width="0.14583333333333334in"
height="0.34375in"}![](media/image17.png){width="0.14583333333333334in"
height="0.65625in"} 

 

            F/u paps @ 6mo
                                                         Refer for
Excisional

interval
x2                                                                    
Procedure (LEEP/Cone)

![](media/image18.png){width="0.4270833333333333in"
height="0.3125in"}![](media/image19.png){width="0.34375in"
height="0.3125in"}                                                           
Risk Assessment

 

            Conservative management                                
Consider treatment if

            (appropriate for most patients)              -HIV (+)

![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"}                                                                                   
-Persistent dysplasia

                                                                                   
-Patient not able to comply

            F/u paps @ 6mo                                             
with follow up plan

![](media/image20.png){width="2.5416666666666665in"
height="0.46875in"}![](media/image21.png){width="0.7395833333333334in"
height="0.4270833333333333in"}            interval x2

![](media/image16.png){width="0.14583333333333334in"
height="0.34375in"} 

 

            Paps normal by             Abnormal at 12mo       
           \> LSIL at 6mo

                12mo[(Resolution)]{.underline}        
[(Persistent)]{.underline}                              
([Progression]{.underline})

![](media/image22.png){width="0.14583333333333334in"
height="0.21875in"}![](media/image23.png){width="0.14583333333333334in"
height="0.21875in"}![](media/image23.png){width="0.14583333333333334in"
height="0.21875in"} 

            Annual Paps                 Repeat
Colposcopy                  Repeat Colposcopy

 

-   •        The triage of LSIL is always Colposcopy (except special
    circumstances, see sec F&G)

-   •        The goal of colposcopy is to rule out high-grade dysplasia
    (CIN II/CIN III) before making a plan of care.

-   •        Once high-grade disease has been ruled out the plan of care
    for most patients should be conservative management.  This involves
    serial paps with the expectation that the disease will resolve
    spontaneously, usually within a year. 

-   •        With conservative management there is a small risk that the
    disease may progress.

-   •        The risk of progression from LSIL/CIN I to severe dysplasia
    or cancer is 2% at two years and 10% at ten years, assuming no
    treatment. These small risks warrant close follow up and should be
    considered when making a plan of care for a patient who will be
    unlikely to comply with follow up.

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-   •        Once a plan for conservative management is chosen there are
    three possible endpoints.

1.  1.      [Resolution of disease]{.underline} (the pap is normal at
    12mo): Then resume annual screening.

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1.  2.      [Persistence of disease]{.underline} (the pap is still
    abnormal at 12mo): This requires re-evaluation and repeat
    colposcopy.

2.  3.      [Progression of disease]{.underline} (either of the follow
    up paps show \>LSIL): This requires a change a management plan
    matching the advanced cytology.

Section C;  ASC-H  Atypical Squamous cells cannot exclude HSIL

 

ASC-H

![](media/image24.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

![](media/image25.png){width="1.4270833333333333in"
height="0.14583333333333334in"}Colposcopy                                         
Positive colposcopy and/or biopsy

![](media/image26.png){width="0.14583333333333334in"
height="0.3541666666666667in"}![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"}                                                           
(lesion found)

 

Negative colposcopy and                                  Plan based on
colposcopic/

biopsies  (no lesion found)                                 histologic
diagnosis

![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

Review of Materials

![](media/image27.png){width="0.84375in"
height="0.14583333333333334in"}(cytology and
histology)                        Change of cytology diagnosis on review

![](media/image16.png){width="0.14583333333333334in"
height="0.34375in"}![](media/image16.png){width="0.14583333333333334in"
height="0.34375in"} 

 

No change of diagnosis                         Plan based on new
cytology

![](media/image16.png){width="0.14583333333333334in"
height="0.34375in"} 

 

F/u paps @ 6mo interval x2

 

ASC-H

-   •        This is a new category and should not be confused with
    ASC-US.

-   •        Since the positive predictive value of this new category is
    similar to an HSIL result colposcopy is the first step in the
    evaluation. 

-   •        Two additional steps should follow up a negative
    colposcopic evaluation.

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-   -         A review of materials (both cytology and histology)

-   -         Follow up paps at 6mo intervals for one year.

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-   •        This plan is different from the HSIL plan in that it does
    not include an excisional procedure for diagnostic purposes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section D: High Grade Squamous Intraepithelial Lesion HSIL

HSIL Pap

> ![](media/image16.png){width="0.14583333333333334in"
> height="0.34375in"} 

Automatic Re-Read of Pap

![](media/image11.png){width="0.14583333333333334in"
height="0.3333333333333333in"}![](media/image28.png){width="1.1354166666666667in"
height="0.14583333333333334in"}and schedule colposcopy
                                 Cytology review does not concur with
HGSIL dx

![](media/image29.png){width="0.14583333333333334in"
height="0.3229166666666667in"} 

> HGSIL cytology confirmed      
>
> ![](media/image16.png){width="0.14583333333333334in"
> height="0.34375in"}                                                                       
> Plan per new cytology dx
>
>                                                

Visual inspection colposcopy

> ![](media/image30.png){width="0.8333333333333334in"
> height="0.5520833333333334in"}![](media/image16.png){width="0.14583333333333334in"
> height="0.34375in"} 
>
>  
>
> Same visit Excisional Procedure                        Cervical biopsy
> at colposcopy;
>
> for Diagnosis and Treatment                               base
> treatment  plan on histology
>
> ![](media/image31.png){width="1.9270833333333333in"
> height="0.14583333333333334in"}(LEEP/Cone)                                                  
> and colposcopic impression  
>
> ![](media/image11.png){width="0.14583333333333334in"
> height="0.3333333333333333in"}![](media/image32.png){width="0.14583333333333334in"
> height="0.2604166666666667in"} 
>
>                                                                                                
> \*

2.                    Follow up Paps every 4
    months                        Conservative management for

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2.                    x3  (if positive margins add
                                   selected patients after documented

> colposcopy  to 1^st^ f/u exam)                              discussion
> of risks and options
>
>  

 

-   •        HSIL should be a rare result (about 0.5%)

-   •        If HSIL is confirmed by histology ([\>]{.underline}CIN II)
    [or]{.underline} cytology, then an excisional procedure (LEEP or
    Cone) would be the recommended treatment.

-   •        If the colposcopy/histology does not confirm the cytologic
    diagnosis of HSIL then an excisional procedure is still the
    recommended treatment [unless]{.underline} a review of the cytology
    downgraded the diagnosis.

-   •        Since this is such a small number of cases and the cytology
    can determine treatment we are recommending that all HSIL paps be
    reviewed automatically and prior to the patient's scheduled
    colposcopy.  This will allow the provider performing the colposcopy
    to offer treatment at the same time rather than at a second visit.

-   •        If the colposcopy is unsatisfactory then an excisional
    procedure (leep or cone) is indicated for diagnostic purposes.

-   •        If for some reason the patient and the provider decide not
    to treat with an excisional procedure when there is a confirmed
    diagnosis of HSIL then the follow up plan would need to be
    individualized and discussion of risks and options documented.\*

-   •        The more conservative approach would be appropriate for
    young women (under the age of 25) who are likely to complete follow
    up.

-   •        The traditional approach of doing biopsies at the
    colposcopy before deciding on a treatment plan is of course
    acceptable so long as the provider and the patient understand that
    the biopsy results would not change the treatment recommendation in
    the setting of a confirmed HSIL cytology.

-   •        HIV screening should be offered to all patients with HSIL
    since HIV is

a risk factor for dysplasia and HIV infection would alter treatment
recommendations.

Section E: AGS Atypical Glandular Cell Group

 

This group breaks down into three subgroups with three different
management plans.

-   •        [Atypical Edometrial Cells;]{.underline} requires
    endometrial sampling by endometrial biopsy or hyteroscopy or D&C.

-   •        [Atypical Glandular Cells "favor neoplasia" and AIS
    Adenocarcinoma in situ]{.underline}; require a true work up that can
    start with colposcopy and endometrial sampling but that must
    continue until the abnormal cytology is fully explained or an
    excisional procedure is negative.

-   •        [Atypical Glandular cells (NOS)]{.underline} not otherwise
    specified; can be evaluated using the algorithm below and may not
    require surgical treatment.

1.  1.      Glandular cells are shed from the endocervix and the
    endometrium so assessment of AGS requires endocervical and possibly
    endometrial sampling.

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1.  2.      Endocervical sampling can be obtained with an ECC
    (endocervical curettage) or a cytobrush and histologic evaluation
    (not cytology).

2.  3.      Young patients (\<35yo) with regular menses are unlikely to
    have endometrial pathology and do not need endometrial sampling
    (Endometrial Biopsy).

>  

 

AGS (NOS)

![](media/image15.png){width="0.14583333333333334in"
height="0.34375in"} 

 

Assess Risk of Edometrial Disease

![](media/image33.png){width="0.3333333333333333in"
height="0.2604166666666667in"}![](media/image34.png){width="0.4375in"
height="0.2604166666666667in"} 

 

Age\<35 with normal menses                             Age\>35 or
abnormal bleeding

Low Risk                                                         High
risk

![](media/image35.png){width="0.14583333333333334in"
height="0.3333333333333333in"}![](media/image35.png){width="0.14583333333333334in"
height="0.3333333333333333in"}![](media/image35.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

Colposcopy with endocervical              Colposcopy with endocervical

> sampling                                   sampling [and]{.underline}
> endometrial biopsy
>
> ![](media/image35.png){width="0.14583333333333334in"
> height="0.3333333333333333in"}![](media/image36.png){width="0.14583333333333334in"
> height="0.4270833333333333in"}![](media/image37.png){width="0.14583333333333334in"
> height="0.53125in"}![](media/image38.png){width="2.03125in"
> height="0.6666666666666666in"}![](media/image39.png){width="1.9375in"
> height="0.6666666666666666in"} 
>
>  
>
>  

Normal colposcopy /histology               Abnormal colposcopy
/histology

![](media/image12.png){width="0.14583333333333334in"
height="0.3333333333333333in"} 

 

 

F/u paps @ 6mo interval x2                  Treatment plan based on
biopsy path

 

 

>  
>
>  

 

 

 

Section F;  Management of LSIL with special circumstance; Adolescents 

 

LSIL

![](media/image1.png){width="0.4270833333333333in"
height="0.3333333333333333in"}![](media/image2.png){width="0.4270833333333333in"
height="0.3333333333333333in"} 

>  

Low risk Pap History                                        History of
dysplasia in last 5yrs or

> ![](media/image3.png){width="0.14583333333333334in"
> height="0.5416666666666666in"}No history of regular pap screening
>
> ![](media/image40.png){width="0.14583333333333334in"
> height="0.84375in"} 
>
>  
>
> Repeat
> Cytology                                                          
>
> ![](media/image41.png){width="0.7395833333333334in"
> height="0.4479166666666667in"}(pap) in 6mo    
>
> ![](media/image42.png){width="0.14583333333333334in"
> height="0.6354166666666666in"}                                               
>
> ![](media/image43.png){width="0.6354166666666666in"
> height="0.14583333333333334in"}Negative                                  
> [\>]{.underline}ASC-US                    Colposcopy and management
>
> ![](media/image44.png){width="0.7395833333333334in"
> height="0.3229166666666667in"}                                                                                   
> As per section B
>
> Repeat
> Cytology                                                          
>
> (pap) in 6mo
>
> ![](media/image45.png){width="0.14583333333333334in"
> height="0.6458333333333334in"} 
>
> Negative
>
>  
>
> Routine Screening
>
>  
>
>  

-   •        ![](media/image15.png){width="0.14583333333333334in"
    height="0.34375in"}*Adolescents are at virtually no risk for having
    cervical cancer and have a very high incidence of transient HPV
    infection that presents as LSIL cytology.*

-   •        Aggressive management with colposcopy and possible therapy
    is unlikely to have any benefit and can cause significant fear and
    anxiety.

-   •        For patient who can comply with follow up, management based
    on repeat cytology (pap q 6mo X2) is a safe approach for this age
    group.

-   •        If either of the follow up paps is abnormal the patient
    should be scheduled for colposcopy.

```{=html}
<!-- -->
```
-   •        Patients with a more concerning pap history should be
    considered for colposcopy as the first step.  This would include;

```{=html}
<!-- -->
```
-   -         Any dysplasia in the last 5 years:  LSIL, HSIL, ASC-H,
    AGC, CIN any grade etc.

-   -         A history of not getting regular pap screening, (at least
    two normal paps in the last five years).

 

 

 

 

 

 

 

 

 

Section G:  Management of LSIL and ASC-US with special circumstance;
Post-menopausal Women not on Estrogen (ERT/HRT). 

 

ASC-US or LSIL

![](media/image46.png){width="0.4270833333333333in"
height="0.3229166666666667in"}![](media/image47.png){width="0.4270833333333333in"
height="0.3229166666666667in"} 

 

Low risk Pap History                            History of dysplasia in
last 5yrs or

> ![](media/image3.png){width="0.14583333333333334in"
> height="0.5416666666666666in"}No history of regular pap screening

![](media/image48.png){width="0.23958333333333334in"
height="0.4583333333333333in"} 

 

> Intravaginal Estrogen Therapy              
>
> ![](media/image49.png){width="1.1354166666666667in"
> height="0.53125in"}X3 weeks then Pap test in 1
> week                                            Colposcopy
>
> ![](media/image16.png){width="0.14583333333333334in"
> height="0.34375in"}![](media/image50.png){width="0.3333333333333333in"
> height="0.34375in"}![](media/image51.png){width="0.14583333333333334in"
> height="0.6354166666666666in"}![](media/image12.png){width="0.14583333333333334in"
> height="0.3333333333333333in"} 
>
>  
>
> Negative  (normal)                    [\>]{.underline}ASC-US
>
> ![](media/image52.png){width="0.6458333333333334in"
> height="0.3333333333333333in"}![](media/image53.png){width="0.14583333333333334in"
> height="0.4375in"}                                                                                   
>
>                                                                                    
> Management as outlined
>
> Repeat pap in
> 6mo                                                       in sections
> A and B
>
> If negative return to
>
> Routine screening
>
>  
>
>  

-   •        ASC-US or LSIL in a postmenopausal woman is often due to
    the effect of estrogen loss on the epithelium rather than HPV
    infection.

-   •        A short course of vaginal estrogen to treat vaginal atrophy
    followed by a repeat pap test is a practical option for patients who
    have no contraindication to estrogen therapy.

-   •        If the pap doesn't normalize with treatment then colposcopy
    should be scheduled

-   •        Rx: Conjugated estrogen cream (Premarin) 1gm vaginally qHS
    X 3wks then repeat cytology (pap) in 1wk.

```{=html}
<!-- -->
```
-   •        Patients with a more concerning pap history should be
    considered for colposcopy as the first step.  This would include;

2.  3.      Any dysplasia in the last 5 years:  LSIL, HSIL, ASC-H, AGC,
    CIN (any grade) etc.

3.  4.      A history of not getting regular pap screening, (at least
    two normal paps in the last five years).

 

 

 

 

 

 

 

 

 

> Section H:  Special circumstances HIV
>
>  

-   •        The recommendations for HIV-positive women with an abnormal
    Pap test are for the most part the same as those for HIV-negative
    women.

-   •        While cervical cancer is a diagnostic criterion for AIDS
    and cervical cancer is more common in HIV-positive women it is
    rarely a cause of death for these patients.

-   •        Published reports indicate that HIV-positive patients with
    abnormal pap tests are more likely to progress or recur than
    HIV-negative patients.  In light of this increased risk management
    of these patients should be more cautious.  This includes:

```{=html}
<!-- -->
```
-   -         Even minor pap test abnormalities (like ASC-US) should be
    evaluated by colposcopy rather than repeat pap tests

-   -         When a diagnosis of dysplasia/CIN is made these patients
    should consider excisional treatment rather than observation. 

-   -         HIV-positive patients should not be considered for long
    screening intervals. Patients with significant immunocompromise or a
    history of significant dysplasia may choose to maintain a 6-month
    screening interval.

-   -         After evaluation or treatment for an abnormal Pap test
    HIV-positive patients should have at least two normal pap tests six
    months apart before resuming annual screening. 

 

Section I :  Special circumstances Pregnancy

 

-   •        The indications for colposcopy are not changed by
    pregnancy.

-   •        We recommend that only providers with full colposcopy
    privileges perform colposcopy for pregnant patients. 

-   •        Cervical biopsies are safe in pregnancy and should be done
    for lesions suspicious for high-grade disease or invasion. 
    Endocervical sampling or curettage should not be done.

-   •        Since unsatisfactory colposcopy may become satisfactory as
    the pregnancy progresses, it is recommended that women with an
    unsatisfactory colposcopy undergo a repeat exam in 6-12 weeks.

-   •        The increased vascularity of the cervix in pregnancy may
    accentuate colposcopic findings.

-   •        For pap results including ASC-US and LSIL a single
    colposcopic exam that rules out a high-grade lesion is sufficient
    evaluation during pregnancy.

-   •        For patients with HSIL or colposcopic findings of
    high-grade dysplasia a second Pap test and colposcopy should be
    performed in three months to look for progression of disease. 
    Repeat biopsies should be obtained if visible lesions appear to have
    progressed or if the cytology suggests invasion. 

-   •        Unless invasive disease is identified treatment in
    pregnancy is unacceptable.

-   •        If a lesion persists after pregnancy treatment can be
    performed at that time.  The post-partum exam should include a Pap
    test and a colposcopy for patients who had dysplasia during the
    pregnancy.