Colposcopy and Pap Smear Triage Guidelines September 5, 2003

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Colposcopy and Pap Smear Triage
GuidelinesSeptember 5, 2003
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• ASCUS PAP
• Recurrent ASCUS PAP
• ASC-H PAP
• AGC (AGUS)
• LSIL PAP
• HSIL PAP
• Guidelines for treatment of abnormal histology
• Biopsy Confirmed CIN 2 or 3
• Colposcopy in Pregnancy
• Immunosuppressed Patients

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ASCUS PAPAutomatically sent for HPV DNA
testingIndex Next Slide
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Positive ()
Negative (-)
Repeat Pap 12 mos.
Colpo
()
(-)
Routine Screening
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Colpo
CIN/CA Per ASCCP Guidelines
(-) Routine Screening
HPV DNA 12 Mos.
Normal
ACS or HPV Repeat Colpo

• For recurrent ASCUS with apparently normal colpo
  bring in for colpo of vagina and vulva, as well
  as looking carefully for vaginitis. Empiric
  treatment of vaginitis is not recommended.
• For postmenopausal women (even on HRT) with ASCUS
  can consider treating with estrogen vaginal cream
  for two weeks, then discontinuing one week prior
  to repeat pap smear. If negative, repeat pap
  again after estrogen treatment in 4-6 months. If
  negative again can resume routine screening.
  IfgtASC must send for colposcopy.
• Index Next Slide

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ASC-H PapIndex Next Slide
Colposcopy with ECC for all patients.
Biopsy confirmed CIN
No lesion identified
See following Guidelines
Ask pathologist to review all specimens
Change in Dx As per guidelines
No change HPV DNA _at_ 12 mos.
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AGC (AGUS)Index Next Slide
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AGUS pap
Colposcopy with ECC and EMB for all patients.
No invasive disease
Invasive disease approp referral
Initial pap AGC-favor Neopolasia or AIS
Initial pap AGC-NOS
Diagnostic excisional procedure (CKC preferred.
Neoplasia
No Neoplasia
Repeat colpo or refer
ASC or LSIL
Per following Guidelines
Repeat cytology _at_ 4-6 mo intervals X4
Diagnostic excisional Procedure or refer
HSIL or AGC
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LSIL PAPIndex Next Slide
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Colposcopy with ECC for all patients
No CIN/CA
CIN/CA
HPV testing at 12 Months
Manage as per Following Guidelines
gtASC or HPV
Negative
Recommend treating patients with persistent
histologically proven LSIL At 12 months unless
and adolescent (lt20 years old).
Recommend Following adolescents who are reliable
and can understand and accept Risk of possible
progression of disease for 24 months before
treating Persistent LSIL because of the higher
rate of spontaneous disease Clearance and lower
rate of progression to cancer in this
population. For post menopausal women with first
LSIL pap and suspected atrophy, Can treat in the
same manner as for post menopausal women
with ASCUS (see prior pages)
Repeat Colpo
Routine Screening
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HSILIndex Colposcopy and ECC for all patients
Next Slide
Satisfactory Colpo
Unsatisfactory Colpo
CIN of any Grade on bx
No lesion seen
No CIN or Only CIN 1
CIN 2, 3 On biopsy
See CIN 2, 3 Guidelines
Review of Material and colpo Of entire genital
tract
Review of Material and colpo Of entire
genital tract
See CIN 2,3 Guidelines
No change
Change Dx
No Change
Per Guidelines
Diagnostic Excisional Procedure
Per Guidelines
Diagnostic Excisional Procedure
Per Guidelines
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Guidelines for treatment of abnormal
histologyIndex Next Slide
Biopsy confirmed CIN 1 and satisfactory
colposcopy Follow up without treatment is
preferred (assuming no history of CIN and patient
agrees to follow up. Can offer patient treatment
at this time)
HPV testing at 12 Mos.
HPV positive
Negative
Repeat colposcopy
Persistent CIN 1
CIN 2,3
No CIN
Per Guidelines
Annual Screening
Consider treating patients With persistent
LSIL At 12 months
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Guidelines for treatment of abnormal histology
(Continued)Index Next Slide

• For adolescent patients (lt20 years old) with
  persistent CIN1 on colposcopy, consider watching
  for 24 months if patient is reliable to follow up
  and can accept to possible risk of progression of
  disease. This population of patients have a
  higher spontaneous clearance rate of CIN, and a
  lower rate of progression to cancer.
• Acceptable treatment options include cryotherapy
  or LEEP. Excisional methods are preferred for
  recurrent (as opposed to persistent) CIN1
• Biopsy confirmed CIN1 and unsatisfactory
  colposcopy
• Diagnostic excisional procedure is recommended.
• Exceptions Pregnant women (see following)
• Adolescents follow up without treatment is
  acceptable in a reliable patient. HPV typing
  and colposcopy at 12 months. If not resolved,
  perform diagnostic excisional procedure.

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Biopsy Confirmed CIN 2 or 3Index Next Slide
Satisfactory Colpo
Unsatisfactory Colpo
Excision or ablation of T-zone (ablation
for Small, lt2 quadrant Lesions only)
Diagnostic excisional procedure
HPV typing and Cytology in 6 mos.
Exceptions adolescents with CIN 2 with
satisfactory colposcopy who are reliable can be
followed for 12 months for spontaneous clearance
of disease. Recommend q 6 months colposcopy x2
with HPV typing at 12 months. Patients with
persistent CIN should be treated. Patients with
normal colposcopy but positive HPV should be
followed closely until resolution is documented.
()
(-)
Annual screening (stress need for
indefinite Routine screening)
Colposcopy
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Colposcopy in PregnancyIndex Next Slide
Repeat colposcopy every three months in
pregnancy, and again 8 weeks after delivery.
Treatment of lesion should be based on post
partum colposcopy and histology. If colposcopic
impression or pathology during pregnancy suggests
CIS, patient needs to be referred to an OB/GYN
for possible excisional procedure while pregnant.
Cervical biopsies are considered safe in
pregnancy, although there is an increased risk of
bleeding. ECC IS CONTRAINDICATED.
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Immunosuppressed Patients (HIV,
immunosuppressive therapy including chronic
steroid use) Index
Treatment of low grade lesions in
immunosuppressed women results in poor clearance
rates and no observable decrease in the rate of
progression to high grade disease. The
literature therefore supports observational
management of immunosuppressed women with low
grade disease. Treatment of CIN 2, 3 results in
high rates of recurrence for CIN , but does
appear to be effective in preventing progression
to invasive cancer. The addition of 5-FU after
treatment of CIN 2,3 halved the reoccurrence rate
in one study. In HIV positive women, the
administration of highly active antiretroviral
therapy (HAART) at the time of treatment may help
to clear disease. Consider OB/GYN and ID
consultation prior to treating this group of
women.