Abnormal Pap Smear

Objectives
Abnormal Pap Smear
2006 ASCCP guidelines review
Patricia Adam MD MSPH
Patricia Fontaine MD MS
University of Minnesota Department of
Family Medicine and Community Health
5/08
• At the conclusion of this workshop, audience
will:
• Know basic abnormal pap smear management,
including the roles of repeat pap, HPV testing, and
colposcopy.
• Recognize that adolescent, pregnant, and post-
menopausal women require special management
strategies
• Have practiced abnormal pap smear management by
working through cases
The evidence
• American Society for Colposcopy and Cervical
Pathology (ASCCP at asccp.org)
• 2006 Consensus Conference held at NIH
• Strength of recommendations: A, B, C, D, E
• Quality of evidence:
• I – at least one RCT
• II – one trial or cohort or case control
• III – expert
• Recommended, preferred, acceptable, unacceptable
The Basics
Pap management basics
Pathology basics
• Pap:
• Primarily a screening tool in women without known
disease
• Adjunct when known CIN and following it
• Colposcopy
• Diagnostic test to determine histology
• 50% - 67% sensitive
A
S
C
-
U
S
A
S
C
-
H
Cytology
(pap)
Histology
(biopsy)
LSIL CIN 1
Mild dysplasia
HSIL
CIN 2 Moderate dysplasia
CIN 3 Severe dysplasia
CIS
Cancer

Abnormal pap smear
management – general
Likelihood of
CIN 2 or CIN 3
General
Management
ASC-US
7 – 12% HPV, pap x2,
colpo
ASC- H 26 - 68% Colposcopy
LSIL 12 – 17% Colposcopy
HSIL 84 – 97% Colposcopy
Special
populations
Yes
No
Yes
No
Principles of Treatment
• Prevent CIN from progressing to cervical cancer
• without increasing complications from over-
treatment
• Decision to treat based on
• Biopsy Diagnosis
• Correlation with Pap smear and Colp findings
• Patient age
• Consensus guidelines and clinical judgment
Wright, TC. J of Lower Genital Tract Dis. 2007
Case 1
Cases
• An 18 year old woman presents to your office
with questions about birth control.
• She has been sexually active for three years,
without consistent birth control.
• She has never had a Pap smear. She denies
symptoms of sexually transmitted infection.
Case 1
Case 1: Pap smear
1. Is a Pap smear indicated, based on screening
recommendations?
A. Yes
B. No
“LSIL consistent with CIN 1/mild dysplasia with
features of HPV”

Case 1: Follow up LSIL Pap
The adolescent: LSIL or ASC- US
Which next steps would be appropriate for
management?
5. Colposcopy
Yes No
6. Repeat Pap in 6 months Yes No
B II
7. Repeat Pap in 12 months
Yes No
8. Perform HPV in 12 months Yes No
LSIL
Special populations: adolescents
• Defined by ASCCP as under 21
• High prevalence of HPV: 25- 30 %
• Risk for dysplasia increases with early sexual activity,
but risk of cancer is very low – CIN 2/3 has a much
higher rate of regression
• So, recommend:
• NOT to test for HPV
• Delay screening
• Delay colposcopy
• Delay treatment (LEEP increases risk of PTD)
The adolescent: LSIL or ASC- US
Case 1: 12 months later
2 years
No HPV !
• Patient follows up and Pap smear is read as
LSIL
• Appropriate next steps in management are
9. Perform reflex HPV testing now Yes No
10. Repeat Pap in another 12 months Yes No
11. Recommend colposcopy Yes No

Case 1: 24 months later
• The patient returns a year later and her Pap
smear is ASC-US.
• Appropriate next steps in management are?
Case 1: Cervix following application
of acetic acid
12. Perform reflex HPV testing now Yes No
13. Repeat Pap in another 12 months Yes No
14. Recommend colposcopy Yes No
Case 1: Colposcopic Findings
14. Colposcopic exam suggests a high grade
abnormality.
Y N
15. Endocervical curettage and cervical biopsy
should be performed.
Y N
Case 1: Biopsy Results
• Cervical biopsy shows CIN 1
• Endocervical curettage is negative for abnormal
cells
Case 1: Follow-up CIN 1
CIN I Adolescent
• Appropriate next steps in management are:
15. Repeat Pap in 12 months Y N
16. Recommend cryotherapy Y N
17. Recommend LEEP Y N
A II

Case 1: different scenario
• What if her biopsy came back CIN II
• Appropriate management options are:
The adolescent: CIN II/III
Can
observe
18. Repeat Pap in 12 months Y N
19. Repeat Pap and colpo in 6 months Y N
16. Recommend cryotherapy Y N
17. Recommend LEEP Y N
BIII
Adolescent summary
• Age less than 21
• LSIL, ASCUS and CIN 1 are all followed with
repeat pap smears at 1 year x 2.
• Colposcopy for abnormal pap is only done
when:
• HSIL paps
• 24 months of < HSIL paps and no colposcopy
• Allow for TIME to repair the transient HPV
changes before doing colposcopy
• HPV is no longer recommended for adolescents
Adolescent summary
• CIN I – follow with pap (

Case 2: Follow-up for ASC-H H Pap
17. Which next step is appropriate for
management?
A. Repeat Pap @ 6 and 12 months
B. Perform “reflex” HPV testing
C. Recommend colposcopy
D. All 3 are acceptable, but HPV testing is preferred
E. All 3 are acceptable, but colposcopy is preferred
Case 2: colposcopy
• On colposcopy they noted a low grade
appearing lesion, biopsied it along with 2
random biopsies. Colposcopy exam was
adequate.
• Targeted biopsy: metaplasia
• Random biopsies: CIN I, chronic cervicitis
Case 2: ASC-H H management
18. Appropriate management at this point would
include
A. Repeat HPV in 1 year
B. Referral to gyn for cone since the likelihood of
hidden high grade disease is significant
C. Repeat colpo and pap smear in 6 months
Case 2: ASC – H/CIN I mgmt
BII
Case 3
• A 25 year old woman presents to your office for a
routine pap smear. She is a G1 P0010, and has had two
normal Pap smears in the past. She uses the
contraceptive patch for birth control, smokes 1 pack of
cigarettes per day, drinks 6-86
8 beers per weekend, and
admits her diet consists of a lot of “junk food.”
• Pap smear is read as “ASC-US.
US.”
• Reflex HPV is positive for high grade types

Case 3: Biopsy Results
• Cervical biopsy @ 0900 CIN 2, moderate
dysplasia
• Cervical biopsy @ 1200 CIN 1,
mild dysplasia
• Endocervical sampling normal
Case 3: Follow-up CIN 2
19. Appropriate recommendation for this
25 year old is:
A. Recommend observation with follow-up Pap
and colposcopy in 6 months
B. Recommend treatment with cryotherapy
C. Recommend treatment with LEEP
D. Any excisional or ablation treatment is
acceptable, since satisfactory colp with neg ECC
CIN II treatment
Follow-up for CIN-2,3
(with satisfactory colposcopy)
AI
AII
• First time abnormality cryotherapy, laser,
LEEP are all acceptable
• Recurrent CIN 2, 3 excisional procedure is
preferred
• If colposcopy is unsatisfactory need a
diagnostic excisional procedure
• LEEP or cold knife cervical conization

Case 4
• 34 year old presents for annual pap which
returns as HSIL. You recommend she have
colposcopy. Colposcopy was satisfactory
although only a low grade lesion was found.
Random biopsies were done and exam of the
vagina was negative.
• Targeted biopsy: CIN 1
• Random biopsies: CIN 1 and cervicitis
• ECC: negative
Case 4
20. Appropriate management of HSIL with only
CIN 1 on biopsy is:
A. Cone or LEEP since there is lack of correlation
with pap and biopsies.
B. Review with the pathologist the pap smear and the
biopsies
C. Since colpo was satisfactory, ECC was negative
you will observe with 6 month pap and
colposcopies x 2.
D. All of the above
BIII
BII
BIII
CIN 1 preceded by HSIL
Case 5
• 26 year old G3P0002 has her first OB visit. Her
pap returns as LSIL.
• Appropriate management of LSIL in a pregnant
woman is:
21. Colposcopy now Y N
22. Colposcopy post partum Y N
^ except in special populations, + review of pap, colpo and biopsies, * only if satisfactory/ECC neg
Pregnancy and LSIL
Special populations: pregnancy
BII
B III
• Dysplasia is never treated in pregnant women unless
there is cervical cancer with invasion
• Pregnancy does not increase the risk of dysplasia
progression
• Vaginal delivery will often improve mild dysplasia
• May delay colposcopy in pregnant women with ASC-
US +HPV or LSIL until > 6 weeks post partum
• Repeat colposcopy in women with < CIN 2, 3 is not
acceptable

Case 6
• Eunice is a 58 year old woman, with history of
normal pap smears, whose recent pap returned
as LSIL. She is now 3 years postmenopausal
and notes vaginal dryness.
• Appropriate management of LSIL in a
postmenopausal woman is:
23. Colposcopy now Y N
24. Reflex HPV, if +, then colpo Y N
25. Repeat pap in 6 months x 2 Y N
Postmenopausal women
• HPV and CIN 2, 3 much less common
• Pap false positive rate higher with atrophy
• Colposcopy is difficult and uncomfortable
• In low risk women, , it is reasonable to do reflex
HPV testing for LSIL and only perform
colposcopy on those with + HPV.
• If history of abnormals, , the risk of cancer is
much higher and colposcopy should be done
Summary
• Management of abnormal pap smears is changing
– more evidence based
• Likelihood of CIN 2 or 3 informs the abnormal
pap smear management strategy
• General population:
• LSIL, ASC-US +HPV, ASC-H H and HSIL: colpo
• Adolescents:
• HSIL and ASC-H:
colpo
• LSIL, ASC-US: pap in 1 year
Summary
• Pregnant women
• LSIL and ASC-US: may defer colpo until after delivery
• Postmenopausal women
• LSIL: may do HPV testing in low risk women to select
those requiring colposcopy
Summary
• Treatment aimed at preventing cervical cancer
without over treatment
• CIN 1
• Don’t t treat (adol(
follow paps, , non-adol
follow HPV)
• CIN 2 and 3
• Treat with LEEP or cryo
• Adolescents: observe CIN 2, treat CIN 3
• HPV – in non adolescents
• ASC-US triage
• For following CIN 1