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Management of the Abnormal Pap Smear 

Cervical cancer has an incidence of about 15,700 new cases each year (representing 6% of all cancers), and 4,900 women die of the disease each year. Those at increased risk of preinvasive disease include patients with human-papilloma virus (HPV) infection, those infected with HIV, cigarette smokers, those with multiple sexual partners, and those with previous preinvasive or invasive disease. 

    
  1. Screening for cervical cancer
    1. Regular Pap smears are recommended for all women who are or have been sexually active and who have a cervix.
    2.  Testing should begin when the woman first engages in sexual intercourse. Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at age 18.
    3.  Pap smears should be performed at least every 1 to 3 years. Testing is usually discontinued after age 65 in women who have had regular normal screening tests. Women who have had a hysterectomy, including removal of the cervix for reasons other than cervical cancer or its precursors, do not require Pap testing.
  1.  Management of minor Pap smear abnormalities
    1.  Satisfactory, but limited by few (or absent) endocervical cells
      1.  Endocervical cells are absent in up to 10% of Pap smears before menopause and up to 50% postmenopausally.
      2.  Management. The Pap smear is usually either repeated annually or recall women with previously abnormal Pap smears.
    2.  Unsatisfactory for evaluation
      1.  Repeat Pap smear midcycle in 6-12 weeks.
      2.  If atrophic smear, treat with estrogen cream for 6-8 weeks, then repeat Pap smear.
    3.  Benign cellular changes
      1.  Infection--candida. Most cases represent asymptomatic colonization. Treatment should be offered for symptomatic cases. The Pap should be repeated at the usual interval.
      2.  Infection–Trichomonas. If wet preparation is positive, treat with metronidazole (Flagyl), then continue annual Pap smears.
      3.  Infection--predominance of coccobacilli consistent with shift in vaginal flora. This finding implies bacterial vaginosis, but it is a non-specific finding. Diagnosis should be confirmed by findings of a homogeneous vaginal discharge, positive amine test, and clue cells on saline suspension.
      4.  Infection-herpes simplex virus. Pap smear has a poor sensitivity, but good specificity, for HSV. Positive smears usually are caused by asymptomatic infection. The patient should be informed of pregnancy risks and the possibility of transmission. Treatment is not necessary, and the Pap should be repeated as for a benign result.
      5.  Inflammation on Pap smear
        1.  Mild inflammation on an otherwise normal smear does not need further evaluation.
        2.  Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear should be done every 6 to 12 months. If no etiology is found, the Pap smear should be repeated in 6 months.
        3.  Persistent inflammation may be infrequently the only manifestation of high-grade squamous intraepithelial lesions (HGSIL) or invasive cancer; therefore, persistent inflammation is an indication for colposcopy.
      6.  Atrophy with inflammation is common in post-menopausal women or in those with estrogen-deficiency states. Atrophy should be treated with vaginal estrogen for 4-6 weeks, then repeat Pap smear.
  1.  Managing cellular abnormalities
    1.  Atypical squamous cells of undetermined significance (ASCUS). On retesting, 25%-60% of patients will have LSIL or HSIL, and 15% will demonstrate HSIL. In a low-risk patient, it is reasonable to offer the option of repeating the cervical smears every 4 months for the next 2 years--with colposcopy, endocervical curettage (ECC) and directed biopsy if findings show progression or the atypical cells have not resolved. Alternatively, the patient can proceed immediately with colposcopy, ECC, and directed biopsy. In a high-risk patient (particularly when follow-up may be a problem), it is advisable to proceed with colposcopy, ECC, and directed biopsy.
    2.  Low-grade squamous intraepithelial lesion (LSIL). The smear will revert to normal within 2 years in 30%-60% of patients. Another 25% have, or will progress to, moderate or severe dysplasia (HSIL). With a low-risk
    patient, cervical smears should be repeated every 4 months for 2 years; colposcopy, ECC, and directed biopsy are indicated for progression or nonresolution. In the high-risk patient, prompt colposcopy, ECC, and directed biopsy are recommended. 


Adequacy of the specimen

      Satisfactory for evaluation

      Satisfactory for evaluation but limited by... Specify reason

Unsatisfactory for evaluation: Specify reason

General categorization (optional)

      Within normal limits

      Benign cellular changes: See descriptive diagnoses

      Epithelial cell abnormality: See descriptive diagnoses

Descriptive diagnoses

      Benign cellular changes

      Infection

      Trichomonas vaginalis

      Fungal organisms morphologically consistent with Candida spp

      Predominance of coccobacilli consistent with shift in vaginal flora

      Bacteria morphologically consistent with Actinomyces spp

      Cellular changes associated with herpes simplex virus

      Other

      Reactive changes

      Inflammation (includes typical repair)

Atrophy with inflammation (atrophic vaginitis)

Radiation

Intrauterine contraceptive device

Epithelial cell abnormalities

Squamous cell

      Atypical squamous cells of undetermined significance (ASCUS): Qualify

Low-grade squamous intraepithelial lesion (LSIL) compassing HPV; mild dysplasia/CIN 1

High-grade squamous intraepithelial lesions (HSIL) encompassing moderate and severe dysplasia, ClS/CIN 2 and CIN

      Squamous cell carcinoma

Glandular cell

      Endometrial cells, cytologically benign, in a postmenopausal woman

      Atypical glandular cells of undetermined significance (AGUS): Qualify

      Endocervical adenocarcinoma

Endometrial adenocarcinoma

Extrauterine adenocarcinoma

      Adenocarcinoma, not otherwise specified

Other malignant neoplasms: Specify
    1. High-grade squamous intraepithelial lesions (HSIL), moderate-to-severe dysplasia, CIS 1, CIN 2, and CIN 3 Colposcopy, ECC, and directed biopsies are recommended.  
    2. Atypical glandular cells of undetermined significance (AGUS). One-third of those for whom the report "favors reactive" will actually have dysplasia. For this reason, colposcopy, ECC (or cytobrush), and directed biopsies are recommended. If glandular neoplasia is suspected or persistent AGUS does not correlate with ECC findings, cold-knife conization perhaps with dilatation and curettage (D&C) is indicated. D&C with hysteroscopy is the treatment of choice for AGUS endometrial cells.
    3.  Squamous cell carcinoma should be referred to a gynecologist or oncologist experienced in its treatment.
  1.  Management of glandular cell abnormalities
    1.  Endometrial cells on Pap smear. When a Pap smear is performed during menstruation, endometrial cells may be present. However, endometrial cells on a Pap smear performed during the second half of the menstrual cycle or in a post-menopausal patient may indicate the presence of polyps, hyperplasia, or endometrial adenocarcinoma. An endometrial biopsy should be considered in these women.
    2.  Atypical glandular cells of undetermined significance (AGUS). Colposcopically directed biopsy and endocervical curettage is recommended in all women with AGUS smears, and abnormal endometrial cells should be investigated by endometrial biopsy, fractional curettage, or hysteroscopy.
    3.  Adenocarcinoma. This diagnosis requires endocervical curettage, cone biopsy, and/or endometrial biopsy.
  1.  Colposcopically directed biopsy
    1.  Liberally apply a solution of 3-5% acetic acid to cervix, and inspect cervix for abnormal areas (white epithelium, punctation, mosaic cells, atypical vessels). Biopsies of any abnormal areas should be obtained under colposcopic visualization. Record location of each biopsy. Monsel solution may be applied to stop bleeding.
    2.   
    3.  Endocervical curettage is done routinely during colposcopy, except during pregnancy. 
  1. Treatment based on cervical biopsy findings
    1.  Benign cellular changes (infection, reactive inflammation). Treat the infection, and repeat the smear every 4-6 months; after 2 negatives, repeat yearly.
    2.  Squamous intraepithelial lesions
      1.  Women with SIL should be treated on the basis of the histological biopsy diagnosis. Patients with CIN I require no further treatment because the majority of these lesions resolve spontaneously. Patients with CIN II or CIN III require treatment to prevent development of invasive disease.

These lesions are treated with cryotherapy, laser vaporization, or loop electric excision procedure (LEEP).

  
Copyright © MD Milos Kupresak, 2007