Master the board step 3

Gynecology
When is screening started?
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Age 21, regardless of the onset of sexual activity
What screening is used?
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Conventional method: 50 percent sensitivity
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Liquid-based prep: Sensitivity is increased to 75–80 percent
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HPV DNA testing: Useful in management of ASCUS
What is the frequency of screening?
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If < 30 years old and average risk, every 3 years with cytology only.
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If > 30 years old and average risk, every 3 years with cytology only or every
5 years with co-testing (cytology + HPV).
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If HPV tested concomitantly, can do Pap every 5 years.
Cervical cancer screening
guidelines per the USPSTF:
• Pap screening not
recommended for
women > 65 with recent
normal Pap smear.
• Pap smear not
recommended for
women with total
hysterectomy for benign
disease.
• HPV testing alone is not
sufficient for screening.
A 35-year-old woman is referred because of a Pap smear reading of ASCUS. The
patient states that her last Pap smear, done approximately 1 year ago, was negative.
She has been sexually active, using combination oral contraception pills for the last
4 years. A repeat Pap smear after 3 months again reveals ASCUS. Which of the following
is the next step in evaluation?
a. Endocervical curettage
b. Colposcopy and biopsy
c. HPV DNA typing
d. Repeat Pap smear in 6 months
e. Repeat Pap smear in 12 months
Answer: B. ASCUS is most commonly found in women with inflammation due to early
HPV infection. Approximately 10–15 percent of patients with ASCUS have premalignant
or malignant disease. Two Pap smears revealing ASCUS must be followed up with
colposcopy and biopsy.
Management of abnormal Pap smears is a commonly tested exam topic.
Management
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If the case describes a patient with atypical squamus cells of undetermined
significance (ASCUS) on the Pap smear and follow-up is certain, repeat the
Pap smear in 3–6 months and order HPV DNA typing. If the result is
negative, follow-up is routine. If the repeat Pap smear is again ASCUS, or
HPV 16 and 18 are found, then order colposcopy and biopsies.
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If the case describes a patient with ASCUS on Pap smear and follow-up is
uncertain (i.e., patient is not reliable to return for follow-up), order colposcopy
and biopsies.
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