Clinical Manual for Management of the HIV-Infected ... - myCME.com

Cervical Dysplasia
Background
Cervical dysplasia and cancer are associated with
human papilloma virus (HPV), a sexually transmitted
virus. Carcinogenic strains of HPV may, in conjunction
with other factors, cause dysplasia and cancer not only
of the cervix, but also of the vulva, vagina, and anus.
HIV-infected women have a higher prevalence of HPV
infection than HIV-uninfected women, and are 5 times
more likely to develop cervical dysplasia, or squamous
intraepithelial lesion (SIL), precursors to cervical cancer.
They may also have a higher risk of invasive cervical
cancer and tend to have more aggressive forms of
cervical cancer. Invasive cervical cancer is an AIDSdefining
illness.
The risk of high-grade cervical lesions appears to be
higher in women with advanced immunodeficiency than
in women with preserved CD4 cell counts. Other risk
factors for dysplasia and cervical cancer include African
American ethnicity, a history of smoking, younger age at
onset of sexual intercourse, and multiple sexual partners.
Effective antiretroviral therapy (ART) with immune
reconstitution has not been shown to prevent the
progression of dysplasia.
Screening for cervical dysplasia and appropriate
intervention in women with high-grade dysplasia
are effective in preventing cervical cancer. Frequent
monitoring and careful follow-up in women with lowgrade
lesions are essential for preventing progression
to invasive disease. Papanicolaou testing should be
performed routinely on all HIV-infected women, with
testing initiated at diagnosis, repeated 6 months after
the first test, then performed annually thereafter if
the results are normal. (See chapter Initial and Interim
Laboratory and Other Tests.) Because the risk of anal
dysplasia is also increased in HIV-infected women,
many experts recommend concurrent screening for anal
dysplasia. For further information, see chapter Anal
Dysplasia.
Prevention of HPV infection is difficult. Latex or
plastic barriers may be partially effective, although
infection may occur through bodily contact outside the
area covered by the barriers. A vaccine against certain
strains of HPV has been approved by the U.S. Food and
Drug Administration and others are expected to follow,
although their efficacy in HIV-infected women and
men is not yet known.
S: Subjective
Section 6—Disease-Specific Treatment | 6–13
Patients with cervical dysplasia or early cervical
cancer are usually asymptomatic and disease will not
be diagnosed unless screening is performed. Genital
condylomata (warts) indicate infection with HPV
and are typically associated with low-risk types of
HPV; however, women with genital warts may have
concurrent dysplasia. The classic symptom of early
invasive cervical neoplasia is intermittent, painless
bleeding between menstrual periods, which may present
initially as postcoital spotting. Late symptoms of
invasive cervical carcinoma include flank and leg pain,
dysuria, hematuria, rectal bleeding, and obstipation.
Ask all female patients about risk factors for, and
previous history of, cervical dysplasia and cancer,
including the following:
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Genital warts; previous or current HPV infection
Previous abnormal cervical Papanicolaou smear
Previous abnormal anal Papanicolaou smear
Previous cervical cancer; when and how treated
Sexual activity before age 20
History of multiple sexual partners
Cigarette smoking
CD4 count