Dale Akkerman
Ob/Gyn, Burnsville office

• Goal of cervical cancer screening program is to detect neoplasia to allow intervention to prevent early invasive cervical cancer and to reduce mortality
• Goal is not to prevent any or all abnormal cytologic reports

• No screening before age 21 regardless of age of onset of sexual activity
• Screening every two years between ages of 21-29 and every three years after age
30 after three consecutive normal Pap tests.
• Stop screening between ages 65-70 if no abnormal Pap tests in 10 years.

• Does not apply to women who are immunosuppressed, HIV positive, have been exposed to DES in utero, or have prior history of CIN 2/3+
• Source: American Cancer Society and
ACOG

• Definitive reference for abnormal Pap smear management is ASCCP (American
Society for Colposcopy and Cervical
Pathology). May download guidelines at asccp.org
• Simplification found in Initial Management of Abnormal Cervical Cytology. May download at icsi.org

• CIN (cervical intraepithelial neoplasia) is a histologic, not cytologic diagnosis
• Various cytologic reports are meant to convey more accurately the cytopathologist’s concern that a patient’s lesion has risk of CIN-2, CIN-3, AIS, or cervical cancer

• This significant risk is referred to as
CIN-2/3+
• Screening results which suggest a high probability of CIN-2/3+ should alert the clinician the patient needs immediate and thorough evaluation to rule out gynecologic malignancy

• Presence of HPV+ DNA in an ASC cytology result carries an equivalent risk of
CIN-2/3+ as an LSIL cytology result
• Hence, these results should be managed similarly (colposcopy and ongoing followup for adult women)

• Only diagnosis which alters clinical management of the pregnancy is invasive cancer
• If screening suggests high risk for CIN-
2/3+, patient should undergo colposcopy without endocervical sampling
• If low risk for CIN-2/3+, either colposcopy as above or wait 8-12 weeks postpartum

• Spontaneous resolution of CIN-1 and CIN-
2 occurs at 70% and 50% rates
• Most HPV+ infections resolve within 24 months
• Risk of invasive cancer approaches zero
• For these reasons, no cervical cancer screening is recommended for patients age 20 or younger

ASCUS (Atypical Squamous Cells)
• Need to known HPV status
• Concern centers on high-risk subtypes
(HPV+)
• Risk of CIN-2/3+ is 5-10%

• This Pap smear is considered normal
• Repeat Pap smear in 12 months
• If persistent for two years, consider referral for evaluation of findings: source of inflammation or rare circumstance of HPV subtype not in current testing profile

• Colposcopy
• Endocervical sampling if no lesion visualized or if colposcopic exam is unsatisfactory

ASCUS and HPV+:
Colposcopy shows no CIN
• Cytology in 6 and 12 months OR
• Only HPV testing in 12 months
• If cytology ≥ ASC or HPV +, repeat colposcopy
• If cytology normal or HPV-, return to routine screening

• Colposcopy
• 15-30% risk CIN-2/3+
• 80% HPV+
• Endocervical sampling if colposcopic exam unsatisfactory except for pregnant patients

• Per ASCCP guidelines

• Cytology at 6 and 12 months OR
• Only HPV testing at 12 months
• If cytology ≥ ASC or HPV +, repeat colposcopy
• If cytology normal or HPV-, return to routine screening

• Colposcopy
• If no CIN-2/3+, manage as LSIL: no CIN-
2/3+
• If CIN-2/3+, manage as per ASCCP guidelines

• Preferably immediate colposcopy or defer at least 6 weeks after delivery (better 8-12 weeks postpartum)
• If colposcopy during pregnancy shows no
CIN-2/3+, do follow-up screening postpartum

• Up to 95% risk for CIN-2/3+
• Either colposcopic exam or immediate
LEEP are acceptable options
• No LEEP for pregnant women

• If unsatisfactory colposcopy, perform diagnostic excisional procedure (LEEP)
• If satisfactory, may observe with colposcopy and cytology at 6 and 12 months OR perform diagnostic excisional procedure (LEEP)
• If negative cytology X 2, routine screening
• If HSIL, needs diagnostic excision (LEEP)

• Several subtypes for this cytologic class
• Also includes AIS (adenoca in situ)
• For any subtype, need colposcopy; HPV testing; endocervical and endometrial sampling
• ICSI guidelines streamline ASCCP recommendations

Subsequent Management for AGC
• Numerous arms and options
• Refer to ASCCP guideline for particular plan of action based on initial cytology report: AGC favor neoplasia, AGC (NOS),
AGC favor endometrial origin, AGC favor endocervical origin, AIS

• Only reported if patient age 40 or older
• Determine if patient has irregular bleeding, risk factors for endometrial cancer, or if patient is postmenopausal
• If “yes” for any of these categories, patient needs endometrial sampling
• Otherwise repeat cytology in 12 months

• Tamoxifen or other SERM use
• Family or personal history of ovarian, breast, colon or endometrial cancer
• Chronic anovulation
• Obesity
• Prior endometrial hyperplasia

• Patient ≥ 30 years old
• Cytology must be negative and no recent change in sexual partner
• If HPV-, routine screening not needed for at least 3 years
• If HPV +, repeat cytology and HPV testing in 12 months

• If both repeat cytology and HPV-, routine screening no sooner than 3 years
• If cytology negative and HPV+, needs colposcopy
• If cytology abnormal, follow usual category algorithm

• Minimum age is 9 years old
• There is a quadrivalent vaccine (HPV4) for prevention of cervical, vaginal and vulvar cancer and genital warts
• There is a bivalent vaccine (HPV2) for prevention of cervical cancer
• Best administered before exposure to HPV from sexual contact

• Typically administer first dose to females at age 11 or 12
• Second dose 1-2 months after first dose and third dose 6 months after first dose
(minimum of 24 weeks between first and third dose)
• Can administer to females between ages of 13 and 18

• Can do catch-up immunization to age 26
• Relatively older females typically have only one strain of HPV and will benefit from the vaccination series
• HPV4 can be administered as a threedose series to males aged 9 to 18 to prevent genital warts

• If pregnancy occurs during series, postpone subsequent doses until after pregnancy completed
• No evidence of increased fetal abnormalities or fetal wastage from exposure

• Alum agent causes 85% to complain of pain and 25% to have redness at site
• Syncopal episodes not greater than for other vaccinations in same age group
• 70% of syncopal episodes occur in first 15 minutes; patient should recline for than span of time
• Source: icsi.org