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A Cytologic Examination (Papanicolaou Smear)
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Screening should begin within 3 years of the onset of sexually activity or at age 21 Testing should be done annually for 3 years and then at least every 3 years if no abnormality is detected After age 65 or 70, if there have been no abnormalities on the last 3 cytologic tests, screening may be discontinued With liquid-based cytology (LBC), the initial interval may be increased to every 2 years Specimens should be taken from a nonmenstruating patient, spread on a single slide, and fixed or rinsed directly into preservative solution if LBC is to be used A specimen should be obtained from the squamocolumnar junction with a wooden or plastic spatula and from the endocervix with a cotton swab or nylon brush Cytologic reports from the laboratory may describe findings in one of several ways (see Table 17 2) While use of class 1 5 is now rare, the CIN classification continues to be used along with a description of abnormal cells, including evidence of HPV The Bethesda System uses the terminology squamous intraepithelial lesions (SIL), low-grade or high-grade Cytopathologists consider a Pap smear to be a medical consultation and will recommend further diagnostic procedures, treatment for infection, and comments on factors preventing adequate evaluation of the specimen Reflex testing for highrisk HPV types with thin layer cytologic smears is useful for triage of atypia (atypical squamous cells of unknown significance; ASC-US) The routine use of combined cytologic screening and high-risk HPV testing is appropriate in women over the age of 30 who are being screened no more frequently than every 3 years Women who have undergone hysterectomy for benign disease do not need to be screened
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When to Refer
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All patients with a history of DES exposure should be monitored by an experienced colposcopist
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Tedeschi CA et al Six cases of women with diethylstilbestrol in utero demonstrating long-term manifestations and current evaluation guidelines J Low Genit Tract Dis 2005 Jan;9(1): 11 8 [PMID: 15870516]
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CERVICAL INTRAEPITHELIAL NEOPLASIA (DYSPLASIA OF THE CERVIX)
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ESSENTIALS OF DIAGNOSIS
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The presumptive diagnosis is made by an abnormal Pap smear of an asymptomatic woman with no grossly visible cervical changes Diagnose by colposcopically directed biopsy Increased in women with HIV
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B Colposcopy
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Women with ASC-US and a negative HPV screening may be followed-up in 1 year If the HPV screen is positive, colposcopy should be performed If HPV screening is unavailable, repeat
General Considerations
The squamocolumnar junction of the cervix is an area of active squamous cell proliferation In childhood, this junction is located on the exposed vaginal portion of the cervix At puberty, because of hormonal influence and possibly because of changes in the vaginal pH, the squamous margin begins to encroach on the single-layered, mucus-secreting epithelium, creating an area of metaplasia (transformation zone) Factors associated with coitus (see Prevention, below) may lead to cellular abnormalities, which over a period of time can result in the development of squamous cell dysplasia or cancer There are varying degrees of dysplasia (Table 17 2), defined by the degree of cellular atypia; all types must be observed and treated if they persist or become more severe Table 17 2 Classification systems for Papanicolaou smears
Numerical 1 2 3 3 3 4 Dysplasia Benign Benign with inflammation Mild dysplasia Moderate dysplasia Severe dysplasia Carcinoma in situ Invasive cancer Invasive cancer Invasive cancer CIN Benign Benign with inflammation CIN I CIN II CIN III Bethesda System Normal Normal, ASC-US Low-grade SIL High-grade SIL
Clinical Findings
There are no specific symptoms or signs of CIN The presumptive diagnosis is made by cytologic screening of an asymptomatic population with no grossly visible cervical changes All visibly abnormal cervical lesions should be biopsied
CIN, cervical intraepithelial neoplasia; ASC-US, atypical squamous cells of undetermined significance; SIL, squamous intraepithelial lesion
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