Disclosure
Workshop: Case Management
of Abnormal Pap Smears and
Colposcopies
This speaker has no financial interests
or other relationships with industry
relative to the subject of this lecture
Rebecca Jackson, MD
Associate Professor
Obstetrics, Gynecology &
Reproductive Sciences and
Epidemiology & Biostatistics
Case Based Problems
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Emphasis on new 2006 guidelines by
ASCCP (American Society of Colposcopy and
Recommended Guidelines
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– For work-up of abnormal cytology:
Cervical Pathology)
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Changes for adolescents
Who needs colposcopy vs who can be
managed expectantly?
Next steps after colposcopy
Treatment options: cryotherapy, laser,
LEEP and cone biopsy
Post-treatment surveillance
ASCCP guidelines
http://www.asccp.org/pdfs/consensus/algorithms_cyto_07.pdf
And: AJOG 2007;197(4); 346-355.
– For treatment of CIN:
http://www.asccp.org/pdfs/consensus/algorithms_hist_07.pdf
And: AJOG 2007:197(4):340-345.
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SFGH 2008 guidelines in your syllabus
(developed by Dr. George Sawaya, very similar to
ASCCP)
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Case 1
Case 1: ASCUS, not adolescent
A 32 year old woman’
woman’s Pap smear comes back
“ASAS-CUS”
CUS”
3 equivalent options:
1. Repeat cytology at 6, 12 months.
Colpo if >ASC
2. Immediate colpo
3. Reflex HPV test.
What are your management options?
1. If negÆ
negÆrescreen in 12 months with
cytology.
2. If posÆ
posÆcytology
Case 2
Case 2: LSIL in adolescent
An 18 year old woman just began having
sexual intercourse two months prior to her
visit to you for birth control pills. Her Pap
smear comes back “LSIL.”
LSIL.”
She has a followfollow-up pap smear in one year
which also shows LSIL.
What are your management options?
What are your management options now?
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Case 3
Case 3--continued
A 19 year old Go woman, sexually
active since the age of 15, has a Pap
smear read as “ASCASC-H.”
H.”
Colposcopy is satisfactory and biopsybiopsyproven CIN 2 is diagnosed in a single
quadrant.
What are your management options?
What are your management options?
Case 3: CIN 2/3 in adolescents
Case 3:
CIN 2/3 management options in adolescents
• Treatment (excision or ablation) OR observation
• For CIN2—
CIN2—observation is preferred (as long as colpo is
What if her colposcopy had been unsatisfactory?
• ASCCP: diagnostic excisional procedure is the
preferred approach
satisfactory) if patient is reliable
•
•
Colposcopy and cytology at 6 month intervals for
up to 2 year
Treat only if cin2 persists for >2 yrs
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Case 4
A 78 year old woman who has
never had any abnormal Pap
smears now has a Pap smear read
as ASCASC-US. She has not been
sexually active for over 15 years.
A repeat pap in 6 months is also
ASCASC-US.
Case 4: continued
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Colposcopy reveals an attenuated,
flush cervix. Unsatisfactory. ECC
shows CIN 1.
Management options?
Options?
Case 5
Case 5 continued
A 43 year old woman has a Pap
smear read as AGC (atypical
glandular cells).
Colposcopy is satisfactory.
ECC is normal.
EMB is normal.
What are your management
options?
What are your management
options?
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Case 5 continued
Repeat Pap is AGC.
What are your management
options?
Case 6
An 18 year old is referred to you with a lab
report that reads “ASCASC-US with HPV DNA test
positive for a highhigh-risk type.”
type.” She undergoes
colposcopy, and she is satisfactory with no
lesions seen. Her repeat HPV test is still positive
at one year and her colposcopy is again
negative.
Next steps?
Case 7
Case 8
A 16 year old is pregnant within six
months of becoming sexually active. She
was late to care at 22 weeks at which
time she had a Pap smear that was read
as HSIL.
A 58 year old widow has a Pap smear
read as ASCASC-US and you send a test for
HPV. It is positive.
What are your management options?
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Case 8 continued
Case 9
Colposcopy is unsatisfactory.
ECC shows severe dysplasia (CIN 3)
cannot rule out invasion.
A 45 year old woman has biopsybiopsy-proven
CIN 3, a satisfactory colposcopy and a
negative endocervical curettage.
What are your management options?
What are your management options?
Case 10
A 20 year old woman has an HSIL Pap,
satisfactory colposcopy and a normal
endocervical curettage.
General rules
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What are your management options?
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Less is better for adolescents (less
aggressive workwork-up, less aggressive
treatment)
Don’
Don’t use HPV test in adolescents
AGC is worse than ASCUS. Requires
extensive workwork-up
Typically don’
don’t need to treat CIN1
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Final Thoughts
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Make sure women have adequate
education about HPV if HPV DNA
testing is used
Involve women in decisions when
uncertainty exists in guidelines
Stress smoking cessation
Consider HIV testing
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