Gynecology: Abnormal Pap Smears

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I. Abbreviations in common usage.

A. ASCUS: Atypical squamous cells of undetermined significance.

B. AGUS: Atypical glandular cells of undetermined significance.

C. LSIL: Low-grade squamous intraepithelial lesion (encompasses HPV and CIN I).

D. HSIL: High-grade squamous intraepithelial lesion (encompasses CIN II, CIN III, CIS)

II. Who needs a pap smear? Women who are sexually active (with men or women), women over age 18.

III. Who does not need a pap smear? Women who are status posthysterectomy if the hysterectomy was not for malignancy or cellular abnormality, women over age 65 who have had 2 negative pap smears.

IV. Rectal exam does not add information to the routine Pap smear and need not be done.

V. Approach Based on Pap Smear. Patients should be aware that Pap smears are not 100% accurate, yet they provide the best way to screen for cervical cancer and precancerous lesions.

A. If Pap smear is normal. Repeat every year from onset of coitus or age 18-20. If low risk (mutually monogamous, no prior abnormal Paps, no history of HPV or STDs, nonsmoker, no DES exposure), may change to every 2-3 years after 2 consecutive normals.

B. If pap reads "no endocervical cells present". Pap test is considered inadequate and should be repeated.

C. If pap reads "unsatisfactory for evaluation". Repeat the Pap.

D. If pap reads "ASCUS."

1. ASCUS, reactive/reparative changes noted. Look for causative agent on wet mount or cultures and treat only if a specific organism is identified. Follow-up Paps as detailed below.

2. ASCUS (unqualified). Repeat Pap test every 4-6 months for 2 years, until 3 consecutive negative Pap results are obtained, then return to yearly Paps. If another abnormal within 2 years, proceed to colposcopy. Immediate colposcopy is indicated if the patient is not able to comply with follow-up Pap smears.

3. ASCUS, neoplasm favored. Colposcopy indicated after the first abnormal Pap smear.

4. ASCUS in a postmenopausal patient. Atrophic cells may look like dysplastic cells. Use topical estrogen cream for 4-6 weeks and repeat the Pap smear. If still abnormal, proceed to colposcopy.

E. LSIL or HSIL: Proceed to colposcopy.

F. AGUS. Colposcopy with endocervical curettage.

G. Other indications for colposcopy. Visible lesion (even if Pap normal), squamous cell carcinoma, adenocarcinoma, human papillomavirus infection (cervical or external genitalia), persistent inflammation.

VI. Colposcopy. A discussion of colposcopy and the treatment of cervical dysplasia is beyond the scope of this manual.