Pap Smear (cont.)
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What treatments are available if a Pap smear is abnormal?
If a Pap smear is interpreted as abnormal, there are a number of different
management and treatment options including colposcopy, conization,
cryocauterization, laser therapy, and large-loop excision of the transformation zone.
All of these procedures have essentially the same
overall cure rate of over 90%.
However, the procedures do vary considerably in a number of other respects and
so will be discussed separately.
Colposcopy: Colposcopy is a procedure that allows the physician to take a closer
look at the cervix. The colposcope is essentially a magnifying glass for the
cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the
whole transformation zone (the transition between the vagina-like lining and the
uterus-like lining), must be seen.
During colposcopy, the cervix is cleaned and soaked with 3% acetic acid. This
acid not only cleans the surface of the cervix but it also allows cellular
abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).
If suspicious areas of cervical tissue are seen during colposcopy, a biopsy
(tissue sampling) is often done. The sample is sent to the laboratory for
analysis by a pathologist and the biopsy results determine the next step in the treatment.
The procedure is essentially painless and quite simple, usually taking only
several minutes to perform. Generally, the woman is instructed not to have
intercourse, douche, or use tampons for about a week afterwards if a biopsy is
done. Pregnancy is not a contraindication to colposcopy. Colposcopy can
adequately evaluate 90% of women who have abnormal Pap smear results.
In unusual circumstances, colposcopy does not allow an adequate view of the
cervix and another procedure called conization is necessary in order to obtain a
tissue biopsy.
Conization: This is still the standard method to which all other methods are
compared. Conization allows the entire area of abnormal tissue to be removed and
provides the maximum amount of cervical tissue for laboratory evaluation to rule
out the presence of invasive cancer. After the cervical area is visualized,
generally by colposcopy, a cone-shaped specimen of tissue (perhaps 1/2-1 inch
long and 3/4 inch wide) is taken from around the endocervical canal.
Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching and using tampons and refrain from sexual
intercourse.
Cure rates close to 100% are achieved with conization as long as the cells along
the margins of treatment are normal.
With conization, there are associated risks from anesthesia and postoperative
hemorrhage (bleeding-in about 10% of cases) as well as possible future adverse
effects on fertility. Conization is generally performed only on women who have
had unsatisfactory colposcopy results, have adenocarcinoma in situ (a diagnosis
of cancer) already, or whose Pap smears suggest they may have some invasion of
cancer into the nearby tissue.
Hysterectomy (surgical removal of the uterus and the cervix) for non-cancerous
abnormal Pap smears is now rarely done. A hysterectomy is appropriate only for
those women who are finished with childbearing and have severe pre-cancerous
abnormalities that have persisted despite other treatments. It may also be
appropriate for women with certain specific findings after conization.
Cryocauterization: Cryocauterization is a simple and safe procedure. A probe,
called a cryoprobe, is first cooled by carbon dioxide and then touched to the
abnormal cervical area. This freezes and kills the cells, resulting in the
sloughing of the abnormal tissue.
A woman undergoing cryocauterization can expect a watery
vaginal discharge for
several weeks after the procedure.
Laser therapy: Laser therapy
makes use of the principle that laser light can be produced by electricity
running through gas. In the treatment of cervical lesions, the gas is usually
carbon dioxide. This type of laser can instantly boil water and therefore can also be used to kill and vaporize cells.
When a laser beam (using a tiny wand called a
micromanipulator) is directed into the cervix at an area of abnormal cervical
tissue, the light energy is converted to heat, which in turn causes cell death, as occurs with cryocauterization.
However, the laser apparatus is expensive, and its use requires more skill than
other treatment options, such as cryocauterization. The procedure is also
painful and generally requires general anesthesia.
The benefit of laser therapy is that it may cause less cervical scarring as
compared to cryocauterization. This in turn may mean that, should the woman need
colposcopy in the future, the chances of adequately viewing her cervix may be
better after laser therapy.
Large-loop excision (LEEP) of the transformation zone:
Large-loop excision of
the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a
thin-wire loop to administer electrocautery. It allows samples to be collected
for additional tissue analysis and can be performed in the office under local
anesthesia.
Specialized (more frequent) follow-up is necessary after LEEP. This follow-up
includes Pap smears, colposcopy, and sometimes other techniques. When there is
no more evidence of abnormal cervical tissue, it may be possible to resume
annual screening Pap smears.
Next: What is the follow-up after treatment for an abnormal Pap smear? »
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