CHAPTER 4: SCREENING FOR CERVICAL CANCER

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132 Chapter 5: Diagnosis and Management of Precancer5Chapter 5: Diagnosis and Management of PrecancerIndications for endocervical curettageEndocervical curettage should be performed in the following circumstances:• The patient has a positive Pap smear, but no abnormality is seen with colposcopy.There may be a precancer or cancer hidden inside the cervical canal, which can bedetected by examining tissue obtained by curettage.• The Pap smear revealed a glandular lesion. These usually arise from the columnarepithelium inside the canal. In this case, endocervical curettage must be performedregardless of the colposcopy findings.• Colposcopy was unsatisfactory because the transformation zone was not seen in itsentirety.Special considerations• The entire transformation zone is not visible. In this case, the colposcopy isunsatisfactory and an endocervical curettage should be done. If this is not possible,women should be referred for LEEP or cold knife conization. This is especiallyimportant if the screening test revealed a high-grade lesion.• The woman is pregnant. As discussed in Chapter 4, pregnancy is not the ideal timeto perform a screening test. However, if a test is done and is abnormal, or if a lesionis noted on speculum examination, the patient should be referred for colposcopy.Taking biopsies during pregnancy can be associated with significant bleeding.Therefore, if there is no colposcopic indication of invasive cancer, the patientcan be given an appointment to return at 12 weeks postpartum for colposcopicre-evaluation and possible biopsy. If cancer is suspected, she should be referredimmediately to a specialist.• The woman is postmenopausal. In many postmenopausal women, the entiretransformation zone is not visible. If an adequate endocervical curettage is notpossible, a cold knife conization should be done.• The woman is HIV-positive. Management of abnormalities, including colposcopyand biopsy, should not be modified on the basis of a woman’s HIV status. During thehealing process after any procedure, seropositive women might have increased virusshedding and, if re-exposed, might be more likely to acquire an additional virus load.Abstinence from intercourse until healing has occurred is most important.
Chapter 5: Diagnosis and Management of Precancer 133Follow-upThe patient should be asked to return in 2–3 weeks for the results of the biopsy.Treatment options, according to the severity and extent of the abnormality, should thenbe discussed with her. Women who do not return as requested should be contacted,given their results and advised about what treatment they need (see Chapter 4 forstrategies to ensure that women receive the information they need).TREATMENT OF PRE<strong>CANCER</strong>Patient management depends on the results of the colposcopy,biopsy and endocervical curettage, and should be in linewith national guidelines. The flowchart in Annex 5 indicatesmanagement options.Annex 5Flowchart precancerPrinciples of treatmentIn most cases, precancerous lesions can be treated on an outpatient basis usingrelatively non-invasive procedures, such as cryotherapy or LEEP. For lesions thatcannot be treated in this way, inpatient methods such as cold knife conization can beused. Hysterectomy, a highly invasive procedure with a risk of complications, suchas infection, haemorrhage and injury to adjacent organs, should not be used to treatprecancer, unless there are other reasons to remove the uterus. Desire for permanentcontraception on the part of the patient is not an acceptable concurrent reason forhysterectomy.5Chapter 5: Diagnosis and Management of PrecancerRECOMMENDATIONPrecancer should be treated on an outpatient basis whenever possible. Bothcryotherapy and LEEP may be suitable for this purpose, depending on eligibilitycriteria and available resources.
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Page 30 and 31: 108 PS 6: Obtaining Informed Consen
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Page 38 and 39: 116PS 8: Taking a Pap SmearPS 8PS 8
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Page 73 and 74: PS 12: Cryotherapy 151PRACTICE SHEE
Page 75 and 76: PS 12: Cryotherapy 153Figure PS12.2
Page 77 and 78: PS 13: Loop Electrosurgical Excisio
Page 83 and 84: PS 14: Cold Knife Conization 161PRA
Page 85 and 86: PS 14: Cold Knife Conization 163At
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CHAPTER 4: SCREENING FOR CERVICAL CANCER

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