Abnormal Pap Smear

The reporting system used by all Australian laboratories is the Australian Modified Bethesda System (2004). It recognises recently acquired knowledge about the natural history of HPV infection and its role in cervical carcinogenesis.

The key points for management of patients are:

• Repeat smear for most women with a low grade squamous abnormality
• No treatment necessary for women with biopsy proven CIN-1
• Colposcopic assessment for all women with atypical glandular abnormalities
• HPV DNA testing as test of cure following treatment of CIN-2/3

Should you treat?

Low Grade Squamous Abnormalities

Many of these abnormalities are considered to be an expression of productive HPV infection and do not progress to significant disease. On the basis of epidemiological data from the Pap Smear Registries, and studies of the natural history of HPV infection, it is recommended that most women with these abnormalities have a repeat smear in twelve months. Women over 30 years of age with no history of negative cytology in the preceding 2 – 3 years should be offered immediate colposcopy or a repeat smear in six months.

Atypical Glandular Abnormalities

Women with any glandular abnormality should be referred for colposcopic assessment rather than for repeat smears in the first instance. Productive HPV infection does not exist in glandular cells and these lesions are more likely to progress than squamous abnormalities.

Biopsy Proven CIN-1

The new guidelines recommend that biopsy proven CIN-1/HPV (now described as 'low-grade squamous intraepithelial lesion') should not be treated. Treatment is reserved for women with high grade lesions.

How do I manage these clinical circumstances?

Unsatisfactory smear – repeat in three months.

Abnormal Pap test during pregnancy – women with low and high grade lesions should be managed in the same way as non-pregnant women.

Previous hysterectomy:

• Benign conditions – routine screening is not justified.
• CIN-2/3 – follow up as for high grade lesions.
• Genital malignancy – ongoing surveillance by a gynaecologist.
• Subtotal hysterectomy – routine surveillance.

Immunosuppressed women – refer all screen-detected abnormalities for colposcopy. Follow-up should be annual and continued indefinitely.

Women exposed to diethylstiboestrol (DES) in utero – annual smear and colposcopy of both cervix and vagina.

• Unsatisfactory or normal – annual screening until 2 normal repeat smears obtained. Revert to normal screening.
• Low grade squamous intraepithelial abnormality – repeat at 12 and 24 months.

- If both are normal, revert to routine screening.

- If either smear is low grade, repeat 12 months until at least two smears are normal then revert to normal screening.

• High grade squamous intraepithelial abnormality – treat.