Guidelines 2016 – PAP Smear & Colposcopy

Guidelines for Nurse Practitioners in Gynecologic Setting, 2016
PAP Smear & Colposcopy

I. DEFINITION

the Pap smear is collected from exfoliated cells in the endocervix and on the portia to detect preinvasive lesions (e.g., dysplasia, carcinoma in situ), as well as invasive lesions.

History
1. Des exposure in utero
2. smoking; exposure to passive smoke
3. Previous abnormal Pap smear; cervical treatment
4. HPv, other sexually transmitted diseases
5. sexual practices, partners (number, partner[s] had previous partner[s] with abnormal Paps, partner’s sexual history)
6. Personal history of cancer
7. age of beginning sexual activity
8. immunosuppressive therapy; immunosuppression
9. Hiv/aiDs or risk
10. Hormone use
11. Per american College of obstetricians and Gynecologists (aCoG), american Cancer society, or guidelines for practice setting

II. TECHNIQUE

Preparation for Pap
1. ideally, cervical screening should be done when the woman is not menstruating.
2. Women should have been instructed to avoid intercourse, douch- ing, use of tampons, and medicinal or contraceptive creams for 24 to 48 hours prior to cervical
3. if cervicitis is found on exam, it should be treated before cervical screening is
4. if the woman is experiencing non-menses-related bleeding or persistent cervicitis, these symptoms may be related to cervical dysplasia or neoplasm and should be
Cytologic specimens should be obtained prior to the bimanual pelvic exam; a nonlubricated specimen must be used.
May do a palpation of the vagina and cervix to locate the cervix and identify the position of the os
the cervix and vagina must be fully visible when the smear is obtained to see entire squamocolumnar junction.
vaginal discharge, when present in large amounts, should be care- fully removed with a large swab prior to obtaining the smear. a small amount of blood should not preclude cytologic sampling.
both liquid-based and conventional methods of cervical cytology screening are acceptable. exfoliated cells are collected from the trans- formation zone of the cervix and may be transferred to a vial of liq- uid preservative that is processed in the laboratory to produce a slide for interpretation (the liquid-based technique) or may be transferred directly to the slide and fixed using the conventional
1. With the liquid-based technology, thin Prep Pap test, the sample is collected on a broom-type cervical-sampling rotate this device five times in the same direction while applying soft pres- sure on the cervix. Detach the broom head and deposit into the liq- uid solution. alternatively, a plastic spatula is applied to the entire cervix to include the entire squamocolumnar junction. a cyto brush is inserted into the endocervix and rotated a half turn and removed, and both are rinsed in a vial of preserving solution and discarded. the vial is capped, labeled, and sent to the laboratory.
2. liquid-based technology, surePath, is performed the same as in Technique, 1, except the devices are left in the solution, snap- ping off the handles. the vial is capped, labeled, and sent to the laboratory.
3. Conventional method technology is performed the same as in Technique, 1, except the spatula and cyto brush are used, and the material is rolled onto the slide, without clumping both sides of the spatula; rolling the brush on the slide with immediate fixation (within 10 seconds) to prevent drying is required (spray 9–12 inches away). in some settings, the handle of the spatula is used to sample the vaginal pool prior to sampling the cervix.
For Des-exposed women, additional slides are prepared using a smear taken from the upper two thirds of the vagina at its circumfer- ence. Gentle wiping of the vaginal wall mucosa initially to remove discharge increases the diagnostic accuracy.

III. BETHESDA (2001, UPDATED 2011) TERMINOLOGY FOR PAP SMEARS

specimen adequacy
1. satisfactory for evaluation
2. Unsatisfactory for evaluation (specify reason), repeat cytology in 2 to 4 months
3. specimen rejected/not processed (specify reason)
4. specimen processed and examined, but unsatisfactory for evalua- tion of epithelial abnormality because of (specify reason)
General categorization
1. negative for intraepithelial lesion or malignancy
2. epithelial cell abnormality
3. other malignancies
interpretation/result
1. negative for intraepithelial lesion or malignancy
2. organisms
  1. Trichomonas vaginalis
  2. Fungal organisms morphologically consistent with Candida species
  3. shift in flora, suggestive of bacterial vaginosis
  4. bacteria morphologically consistent with Actinomyces genus
  5. Cellular changes consistent with herpes simplex virus
other nonneoplastic findings
1. evidence of injury and/or response to injury previously termed benign cellular changes
2. endometrial cells in women age 40 or older
3. atrophy
epithelial cell abnormalities
1. squamous cell
2. atypical squamous cells (asC) of undetermined significance (asC-Us) cannot exclude high-grade squamous intraepithelial lesion (asC-H)
low-grade squamous intraepithelial lesion (lsil)
1. encompassing: HPv/mild dysplasia/cervical intraepithelial neoplasia (Cin)
High-grade squamous intraepithelial lesion (Hsil)
1. With features suspicious for malignancy
squamous cell carcinoma
Glandular cell
1. atypical glandular cells not otherwise specified (aGC-nos)
2. aGCs, favor neoplastic (specify endocervical or nos)
3. endocervical adenocarcinoma in situ (ais)
4. adenocarcinoma
  1. endometrial (uterus)
  2. endocervical (cervix)
  3. extrauterine origin from outside the uterus and cervix
  4. site of malignancy cannot be determined based on Pap smear
other malignancies
1. other than those listed previously may be seen and reported on a Pap smear

IV. 2012 CONSENSUS ASCCP GUIDELINES

atypical squamous cells of undetermined significance
1. repeat cervical cytology testing (Pap) at 12 months; if test is nega- tive, repeat cytology every 3 years; if asC on result, refer for col- poscopy or
2. Do HPv Dna testing (preferred) if liquid-based cytology or cocol- lection is
3. if positive for HPv Dna, refer for colposcopy; if Cin positive on biopsy, manage per american society for Colposcopy and Cervical Pathology (asCCP) if HPv Dna negative asC-Us, repeat cotesting at 3 years is recommended. if asC or HPv posi- tive, repeat colposcopy; if negative, cotesting at 12 months is recommended.
asC-Us special population
1. For women aged 21 to 24 years with asC-Us, cytology alone at 12-month intervals is preferred, but reflex HPv testing is accept- if reflex HPv testing is performed with asC-Us and is posi- tive, repeat cytology in 12 months is recommended. immediate colposcopy or repeat HPv testing is not recommended. if reflex HPv testing is performed and is negative, repeat cytology alone in 3 years is recommended.
2. immunosuppressed women with asC-Us should be managed the same as women in the greater
3. Pregnant women older than 20 years with asC-Us are managed identically to nonpregnant women with the exception that it is acceptable to defer colposcopy until at least 6 weeks postpartum. endocervical curettage is unacceptable in pregnant
4. Postmenopausal women with asC-Us should be managed the same as women in the general population, except when consider- ing exit from screening for women aged 65 years and For those women, HPv-negative asC-Us results should be considered abnormal. repeat screening in 1 year; cotesting is recommended.
asC cannot exclude asC-H.
1. For women with asC-H cytology, colposcopy is recommended regardless of HPv reflex HPv testing is not recommended. if negative, return to routine screening. if positive Cin 2,3, manage per asCCP guidelines.
low-grade squamous intraepithelial lesion
1. For women with lsil cytology and no HPv test or a positive test, colposcopy is recommended. if cotesting shows HPv-negative lsil, repeat cotesting at 1 year is preferred, but colposcopy is if repeat cotesting at 1 year is elected, and if the cytology is asC-Us or worse or the HPv test is positive, colposcopy is recommended. if the cotesting at 1 year is HPv and cytology negative, repeat cotest- ing in 3 years is recommended. if all tests are negative at that time, return to routine screening.
2. lsil special population
  1. For women with lsil who are aged 21 to 24 years, follow-up cytology at 12-month intervals is recommended. Colposcopy is not at the 12-month follow-up, only women with Hsil or greater should be referred for colposcopy. at the 24-month follow-up, those with asC-Us or greater are referred for colposcopy. HPv Dna testing is unacceptable for ado- lescents with lsil. if HPv Dna testing is inadvertently per- formed, results should not influence management. For women with two consecutive negative results, return to routine screen- ing is recommended.
  2. Pregnant women with lsil: Colposcopy is preferred for preg- nant women. if no Cin 2,3 identified, postpartum follow-up rec- ommended. endocervical curettage is unacceptable in pregnant women. For pregnant women aged 21 to 24 years, follow-up according to the guidelines for management of lsil in women aged 21 to 24 is recommended. Deferring initial colposcopy until at least 6 weeks postpartum is acceptable. additional colposcopic and cytologic examinations during pregnancy are unacceptable for these women
Hsil
1. immediate loop electrosurgical excision (lee) or
2. Colposcopy with endocervical assessment
3. no Cin 2,3 with negative endocervical sampling and satisfactory colposcopy
  1. observation with cotesting at 12 months and 24 months is recommended.
  2. if positive Cin 2 or 3, manage per asCCP guidelines
4. if Hsil at either visit, refer for diagnostic excisional procedure
5. other results—manage per guidelines
6. Diagnostic excisional procedure if unsatisfactory colposcopy at either visit
7. if negative cytology at both visits, return to routine screening
Hsil special population
1. Women aged 21 to 24 years with Hsil
  1. Colposcopic examination (immediate lee is unacceptable)
    1. if no Cin 2,3, observation with colposcopy and cytology at 6-month intervals up to 2 years is preferred, provided that the colposcopic exam is satisfactory and endocervical sampling is
    2. if other results, manage per asCCP guidelines
    3. if Hsil persists for 24 months with no Cin 2,3 identified, refer for excisional procedure
    4. if high-grade colposcopic lesion or Hsil persists for 1 year, perform biopsy
    5. if Cin 2,3, manage per asCCP guideline for adolescents with Cin 2,3
    6. if two consecutive negative Pap smears and no Hsil col- poscopic abnormality, return to routine screening
    7. if unsatisfactory colposcopy or Cin of any grade on endocer- vical assessment, perform diagnostic excisional procedure
Pregnant women with Hsil
1. Colposcopy is recommended for Hsil. biopsy of lesions suspi- cious for Cin 2,3 or cancer is preferred; biopsy of other lesions is acceptable. endocervical curettage is unacceptable in pregnant
2. reevaluation with cytology and colposcopy is recommended no sooner than 6 weeks postpartum for pregnant women with Hsil with negative Cin 2,3
atypical glandular cells
1. initial workup
  1. all subcategories of aGCs or ais, except atypical endo- metrial cells—colposcopy with endocervical sampling is recommended regardless of HPv result, and endometrial sam- pling is recommended in conjunction with colposcopy and endocervical sampling in women 35 years of age and older with all subcategories of aGCs and ais.
  2. atypical endometrial cell—initial evaluation limited to endo- metrial and endocervical sampling is preferred (if no endome- trial pathology, refer for colposcopy).
2. subsequent management for women with aGCs
  1. initial Pap screening of aGC-nos
    1. if no Cin 2+ and no glandular neoplasia are identified, cotesting at 12 and 24 months is
    2. if both cotests are negative, return for cotesting in 3 years is
    3. if any test is abnormal, colposcopy is
    4. if Cin 2+ but no glandular neoplasia, manage per 2012 con- sensus asCCP guidelines
    5. if glandular neoplasia irrespective of Cin, manage per 2012 consensus asCCP guidelines
  2. initial Pap of aGC favors neoplasia or ais
    1. no invasive disease—diagnostic excisional procedure
other forms of glandular abnormalities
1. benign-appearing endometrial cells
  1. asymptomatic premenopausal women with benign endome- trial cells, endometrial stromal cells, or histiocytes—no further treatment
  2. Postmenopausal women with benign endometrial cells—endo- metrial assessment is recommended regardless of symptoms
  3. Posthysterectomy women with a cytologic report of benign glandular cells—no further evaluation
aGs special population
1. Pregnant women—initial evaluation of aGCs, refer to nonpregnant women guideline, except endocervical curettage and endometrial biopsy are unacceptable
recommended management, different combinations of results
1. General recommendations
  1. HPv Dna testing to target only high-risk (oncogenic) HPv types
  2. Women with an unsatisfactory cytology result and no unknown, or negative, HPv test result—repeat cytology in 2 to 4 months is recommended
    1. treatment to resolve atrophy or obscuring inflammation when a specific infection is present is
  3. Women aged 30 years and older who are cotested who have unsatisfactory cytology and a positive HPv test—repeat cytol- ogy in 2 to 4 months is acceptable
  4. Colposcopy is recommended for women with two consecutive unsatisfactory cytology tests.

V. CLINICAL MANAGEMENT GUIDELINES FOR CERVICAL CANCER SCREENING (ACOG RELEASE NOVEMBER 2009)

initial Pap screening at age 21 years
screen every 3 years between 21 and 29 years of age; cotesting is not recommended
screen every 5 years for women aged 30 to 65, with cytology and HPv testing every 5 years preferred or every 3 years with cytology alone. screening with HPv testing alone is not recommended
Cease screening at age 65 if a woman has an adequate history and is at low risk for cervical cancer. Women with a history of Cin 2 or 3 or adenocarcinoma must continue screening after age 65
no screening for a woman without a cervix or without a history of high-grade lesion (Cin 2 or 3) or history of cervical cancer in 20 years; for women with high-grade lesions before hysterectomy, screening with cytology every 3 years for the next 20 years
HPv-vaccinated women have the same schedule as non-vaccinated women.
these routine guidelines do not apply to women who are immuno- compromised, are Hiv positive, were exposed to Des in utero, or have a history of cervical cancer

VI. INDICATIONS FOR COLPOSCOPY

as indicated by Pap test; algorithm with 2012 asCCP consensus guidelines
History of physical examination that revealed possible Des exposure
any obvious lesions of the cervix
lesions in vagina or vulva that are a diagnostic problem
if deemed necessary by physician or nurse practitioner

VII. COLPOSCOPY REFERRAL PROCEDURE

refer woman to a clinician of her choice
instruct woman that there will be a charge for the procedure, which is generally covered by insurance
a signed release form and referral sheet should be sent so that a copy of the referral visit can be returned to the original facility.