Click here to view next page of this article
The American Cancer Society recommends annual Pap smears for women who are sexually active or who have reached the age of 18.
After three consecutive satisfactory, normal smears, testing may be performed less frequently, but it should be performed at least every 2-3 years. If a woman has had SIL on any previous Pap smear, annual smears should be performed throughout her life.
Management of Minor Pap Smear Abnormalities
Satisfactory, but Limited by Few (or absent) Endocervical Cells
Endocervical cells are absent in up to 10% of Pap smears before menopause and up to 50% postmenopausally.
Management. Either repeat Pap annually or only recall women with previously abnormal Pap smears.
Unsatisfactory for Evaluation
Repeat Pap smear midcycle in 6-12 weeks.
If atrophic smear, treat with estrogen cream for 6-8 weeks, then repeat Pap smear.
Benign Cellular Changes
Infection--Candida. Most cases represent asymptomatic colonization. Treatment is offered for symptomatic cases. Repeat Pap at usual interval.
Infection--Trichomonas. If wet preparation is positive, treat with metronidazole (Flagyl), then continue annual Pap smears.
Infection--Predominance of Coccobacilli consistent with Shift in Vaginal Flora
This finding implies bacterial vaginosis, but it is a non-specific finding.
Diagnosis should be confirmed by findings of a homogeneous vaginal discharge, positive amine test, and clue cells on microscopic saline suspension.
Infection-Herpes Simplex Virus
Pap smear has poor sensitivity but good specificity for HSV; positive smears usually are caused by asymptomatic infection.
The patient should be informed of pregnancy risks and the possibility of transmission.
No treatment is necessary. Repeat Pap as for a benign result.
Inflammation on Pap Smear
a. Mild inflammation on an otherwise normal smear does not need further evaluation.
b. Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear is done every 6 to 12 months. If no etiology is found. The Pap smear should be repeated in 6 months.
c. Infrequently, inflammation.
III. Management of Squamous Cell Abnormalities
A. Atypical Squamous Cells of Undetermined Significance (ASCUS)
1. ASCUS indicates cells with nuclear atypia, but not atypia caused by human papilloma virus (HPV).
2. A Pap smear should be obtained every 6 months for 2 years. Annual Pap smears may be instituted after 3 consecutive satisfactory, negative smears. A repeat ASCUS smear within 2-years requires colposcopic evaluation.
3. ASCUS associated with severe inflammation and an identifiable cause of infection can be managed by treating the infection and re-evaluating the patient in 4-6 months with a repeat Pap smear. If ASCUS persists, colposcopy should be performed.
4. ASCUS in a postmenopausal patient may be secondary to vaginal atrophy. The patient should be treated with intravaginal estrogen cream for four weeks, followed by a repeat Pap smear. Colposcopy should be performed if ASCUS persists.
5. ASCUS with a qualification favoring a neoplastic process (SIL) should be evaluated with colposcopy.
6. ASCUS in a noncompliant patient or in a patient with a history of SIL on a previous Pap smear should be evaluated with colposcopy.
B. Low-Grade Squamous Intraepithelial Lesions (LSIL)
1. LSIL includes HPV and CIN 1 (or mild dysplasia). Koilocytotic atypia is indicative of HPV.
2. A Pap smear should be repeated.
IV. Management of Glandular Cell Abnormalities
A. Endometrial Cells on Pap Smear
1. When a Pap smear is performed during menstruation, endometrial cells.
B. Atypical Glandular Cells of Undetermined Significance (AGUS)
1. A colposcopic examination, repeat Pap smear, and endocervical sampling should be performed.
V. Colposcopically Directed Biopsy
A. Liberally apply a solution of 3-5% acetic acid to cervix, and inspect cervix for abnormal areas (white epithelium, punctation, mosaic cells, atypical vessels). Biopsies of any abnormal areas should be obtained under colposcopic visualization.
VI. Treatment Based on Biopsy Findings
A. Benign Cellular Changes (infection, reactive inflammation). Treat infection. Repeat smear every 4-6 months; after 2 negatives, repeat yearly.
B. Treatment of Squamous Intraepithelial Lesions
1. Condyloma Acuminata. Use either cryotherapy or electrosurgical loop excision.
2. Low Grade Squamous Intraepithelial Lesions (LSIL)
a. Conservative Approach. Since the risk of progression is 20% and the lesion is not dangerous until it progresses, these lesions may be followed with repeat Pap smear at 4-6 month intervals.
3. High Grade Squamous Intraepithelial Lesion
a. Ablative therapy should be completed to destroy the entire transformation zone.
b. Ablation is appropriate if the entire lesion and transformation zone are seen and the endocervical curettage is negative. After ablation, Pap smears should be scheduled at 3-month intervals for 1 year.
C. Electrosurgical Loop Excision (LEEP) is used for cervical ablation because it is more effective than cryotherapy, fast, and well tolerated.
D. Cryotherapy Double Freeze