Pap Smear (cont.)
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What are the possible recommendations for follow-up after a Pap smear?
Once the final diagnosis has been made, the follow-up recommendation informs you what the
appropriate next step(s) might be. For example, if the final diagnosis states
that the smear was "within normal limits," the appropriate follow-up might be
"recommend routine follow-up."
An abnormal Pap smear is one in which the laboratory interprets the cellular
changes to be different from those normally seen on a healthy cervix. There are
a number of possible follow-up scenarios for an abnormal Pap smear.
Absence of endocervical cells on the Pap smear: There is a particular area
wherein the cells lining the vagina change to the endocervical cells that
characterize the inside of the cervix. This is called the "transition zone" and
is the target of the endocervical sample. However, it may be so far up inside
the cervix that the Pap smear sampling instrument simply cannot reach that high.
To further complicate the situation, the transition zone in a woman migrates
(changes its position) at different times in her life and under different
conditions. Sometimes, the transition zone may be less accessible to the Pap
brush or the cervical os (opening to the cervix) cannot be seen well enough to
obtain an adequate sample. Sometimes, the reason for the absence of endocervical
cells on the Pap smear is simply not evident.
Regardless, if the cause of the absent endocervical cells is known or unknown,
the situation must be evaluated by the physician. In everyday practice, an
appropriate response to the absence of endocervical cells is to redo the Pap
smear, but also to take the woman's prior history into account in determining
the timing. If the woman has had regular Pap smears, has never had an abnormal
one, and does not have an added risk factor for an abnormal Pap smear, then the
clinician will often wait a year before repeating the smear. If the woman does
have risk factors, the clinician will often elect to repeat the smear sooner.
Unreliable Pap smear due to inflammation: If severe inflammation is present, its cause(s) must be investigated. The physician's goals are to identify the cause
of inflammation and to treat and resolve the condition, if possible. Untreated
inflammation can have consequences for the woman as well as her sexual partner(s).
Sometimes, the woman's medical history will shed light
on the cause of inflammation. For example, a woman may complain of irritation,
dryness, or pain
in her vaginal area. The inflammation can then be verified by the physician
during a pelvic exam. The vaginal irritation may be caused by a lack of
estrogen, such as
occurs after menopause when the ovaries stop producing this
hormone. This lack of estrogen tends to make the vaginal walls irritated and
red. If a woman has this condition and it is related to an estrogen deficiency
(called "atrophic vaginitis" and
usually described on the Pap smear report as "atrophic changes"), her physician
may recommend a trial of topical (locally-
applied) vaginal estrogen (cream, vaginal estrogen tablets, vaginal estrogen
ring) to hopefully heal the inflammation. The Pap smear is then repeated.
In summary, the physician will use clinical judgment in terms of the specific
follow-up after a Pap smear that reports inflammation.
Atypical squamous cells of undetermined significance (ASCUS): Sometimes,
atypical squamous cells of undetermined significance (also called "ASCUS"), is
the determination written on the Pap report. This is the mildest form of
cellular abnormality on the spectrum of cells ranging from normal to cancerous.
ASCUS means that the cells appear abnormal but are not malignant.
"Of undetermined significance" means that the
atypical-appearing cells may be the end result of a number of different types of
injuries to the cervix. For example, the human papilloma virus (HPV) could be
the cause of ASCUS. Most instances of ASCUS (80%-90%) resolve spontaneously (by
themselves without specific medical intervention or treatment). This is the
reason why many women with ASCUS readings will be asked to simply have a repeat
Pap smear in 4 to 6 months. The expectation is that regardless of the original
cause of the ASCUS, it will be resolved by the time the Pap smear is repeated.
If not, the cause of the ASCUS can still be identified and treated if ASCUS is
again observed on the repeat Pap smear 4 to 6 months later. This standard
recommendation of serial Pap smears - repeating the Pap smear in 4 to 6 months -
is made unless the physician has a concern that the woman is not willing or able
to return for a repeat Pap smear. In these cases, a colposcopy (see below) may be done without waiting to
repeat the Pap smear.
The third approach to ASCUS (besides serial Pap testing
and immediate colposcopy) is called reflex HPV testing. Reflex HPV testing refers to a process in which
the HPV test is only performed if the Pap smear result is abnormal. If the Pap
smear result is normal, it is not performed. For reflex testing to be possible,
a liquid-based Pap testing kit is required, which allows the lab to store the
sample until the Pap smear result tells them whether the HPV test will be
necessary or not. Not all facilities have access to liquid-based cytology kits.
If repeat smears are to be done for monitoring, the testing needs to be done
every 4 to 6 months for 2 years until there have been three consecutive normal
smears, at which time routine screening can be resumed. The Pap smears, however,
must not only be negative, but also satisfactory for interpretation, according
to National Cancer Institute Workshop Guidelines.
The irritation of the genital area that accompanies menopause can trigger ASCUS
by causing inflammation. If the physician suspects that this is the cause of
ASCUS, he or she may prescribe intravaginal estrogen (local estrogen, such as a
vaginal ring, vaginal cream, or vaginal estrogen tablets) and repeat the Pap
smear in 4 to 6 months to confirm that the inflammation is resolved. If the
inflammation persists, colposcopy will be necessary. Sometimes, the ASCUS
reading is accompanied by a comment to the effect that the Pap smear reader
thinks there may be a suggestion of dysplasia (abnormally dividing or abnormal
appearing cells), often worded as "favor dysplasia." In this case, the ASCUS is
generally not monitored over time but rather treated as if it is dysplasia (see
discussion below). Similarly, a woman who has a suppressed immune system is not
a good candidate for serial Pap smear tests because she is at higher risk of
serious abnormalities. Therefore, she should undergo colposcopy instead of
serial Pap smears. It is evident from this discussion that many factors go into
a physician's decision regarding which of the three treatment options to recommend
to an individual woman.
Low-grade squamous intraepithelial lesion (LSIL): A more serious cellular
abnormality is low-grade squamous intraepithelial lesion (LSIL). A reading of
LSIL is a reason for immediate further investigation because it is more abnormal
than ASCUS. Fifteen to 30% of women who have this abnormality on Pap testing will have a more serious abnormality on
biopsy of the cervix. Thus, all women with LSIL are recommended to undergo
colposcopy. On the brighter side, even LSIL spontaneously returns to normal
without therapy in many women within several months. For that reason, if the
initial colposcopy and biopsy results are favorable, serial Pap smears every 4
to 6 months may be recommended, after which a return to normal screening is
possible if there are three negative, consecutive, satisfactory Pap smears.
High-grade squamous intraepithelial lesion (HSIL): The most severe cellular
abnormality that is not actually cancer is high-grade squamous intraepithelial
lesion (HSIL). A finding of HSIL unquestionably requires prompt treatment.
Women with HSIL have a 70%-75% chance of having a more serious abnormality (CIN
2,3 see below) on biopsy of the cervix, and a 1%-2% chance of having actual
cervical cancer on biopsy of the cervix. Therefore, colposcopy is undoubtedly
the routine recommendation for all women with HSIL.
Cervical intraepithelial neoplasia (CIN): This is the most severe form of
high-grade squamous intraepithelial lesion (HSIL). A neoplasia is within the
realm of cancer. Type 1 CIN is "low grade," or less serious than Type 2, 3 CIN
(high-grade). The diagnosis of a cervical intraepithelial neoplasia (CIN) on a
woman's Pap smear means that she needs to be evaluated and treated as soon as
possible by a qualified physician.
Carcinoma in situ: This diagnosis is also a form of high-grade squamous intraepithelial lesion
(HSIL). A reading of "carcinoma in situ" on a Pap smear
report means there is cervical cancer present. However, the cancer is "in situ," which
means that it appears to be limited to the cervix and not to have invaded other
tissues.
Next: What treatments are available if a Pap smear is abnormal? »
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