Disclosure Workshop: Case Management of Abnormal Pap Smears and Colposcopies Rebecca Jackson, MD Associate Professor Obstetrics, Gynecology & Reproductive Sciences and Epidemiology & Biostatistics This speaker has no financial interests or other relationships with industry relative to the subject of this lecture Case Based Problems Emphasis on new 2006 guidelines by ASCCP (American Society of Colposcopy and Cervical Pathology) 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 Recommended Guidelines ASCCP guidelines For work-up of abnormal cytology: 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. SFGH 2008 guidelines in your syllabus (developed by Dr. George Sawaya, very similar to ASCCP) 1
Case 1 A 32 year old woman s s Pap smear comes back AS-CUS Case 1: ASCUS, not adolescent 3 equivalent options: 1. Repeat cytology at 6, 12 months. Colpo if >ASC 2. Immediate colpo 3. Reflex HPV test. 1. If neg rescreen in 12 months with cytology. 2. If pos cytology Case 2 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. Case 2: LSIL in adolescent She has a follow-up pap smear in one year which also shows LSIL. What are your management options now? 2
Case 3 A 19 year old Go woman, sexually active since the age of 15, has a Pap smear read as ASC-H. H. Case 3--3 --continued Colposcopy is satisfactory and biopsy- proven CIN 2 is diagnosed in a single quadrant. Case 3: CIN 2/3 in adolescents Case 3: CIN 2/3 management options in adolescents Treatment (excision or ablation) OR observation For CIN2 observation is preferred (as long as colpo is 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 What if her colposcopy had been unsatisfactory? ASCCP: diagnostic excisional procedure is the preferred approach 3
Case 4 A 78 year old woman who has never had any abnormal Pap smears now has a Pap smear read as ASC-US. She has not been sexually active for over 15 years. A repeat pap in 6 months is also ASC-US. Case 4: continued Colposcopy reveals an attenuated, flush cervix. Unsatisfactory. ECC shows CIN 1. Management options? Options? Case 5 A 43 year old woman has a Pap smear read as AGC (atypical glandular cells). What are your management options? Case 5 continued Colposcopy is satisfactory. ECC is normal. EMB is normal. What are your management options? 4
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 ASC-US with HPV DNA test positive for a high-risk 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 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. Case 8 A 58 year old widow has a Pap smear read as ASC-US and you send a test for HPV. It is positive. 5
Case 8 continued Colposcopy is unsatisfactory. ECC shows severe dysplasia (CIN 3) cannot rule out invasion. Case 9 A 45 year old woman has biopsy-proven proven CIN 3, a satisfactory colposcopy and a negative endocervical curettage. Case 10 A 20 year old woman has an HSIL Pap, satisfactory colposcopy and a normal endocervical curettage. General rules Less is better for adolescents (less aggressive work-up, less aggressive treatment) Don t t use HPV test in adolescents AGC is worse than ASCUS. Requires extensive work-up Typically don t t need to treat CIN1 6
Final Thoughts 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 7