Updated: 12/1/2021

Pap Smear

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  • Snapshot
    • A 27-year-old women presents to her gynecologist for a routine visit. She denies any acute complaints and is currently sexually active with two men. She reports consistent use of condoms and denies any abnormal vaginal smell or discharge as well as dysuria. A pap test is performed, which shows atypical squamous cells of undetermined significance (ASC-US). Her last pap test was normal. A reflex human papillomavirus (HPV) test is performed.
  • Introduction
    • Papanicolaou (pap) test (cytology) is a method used to screen for cervical cancer
      • cervical cancer
        • can be divided into two main types
          • squamous cell carcinoma
            • more prevalent
          • adenocarcinoma
      • cervical cancer mortality and incidence has decreased with its use
        • pap test enables detection of precancerous lesions and disease in its early stages
      • other screening tests involves testing for high-risk strains of human papillomavirus (HPV)
    • Method
      • the test involves obtaining cells by scraping or brushing them from the cervical os and endocervix
      • these cells are then sent to the laboratory for cytologic analysis
        • identifies abnormal cells in the
          • transformation zone (T-zone)
  • Screening Recommendations
    • Pap test
      • women who are 21-65 years of age
        • perform every 3 years
        • regardless of initiation of sexual activity
    • Pap test and human papillomavirus (HPV)
      • women who are 30-65 years of age
        • perform every 5 years
        • ideal for women who want to lengthen the screening interval
    • Discontinuing screening
      • women > 65 years of age with adequate prior screening
    • Special populations
      • hysterectomy with cervix removal and absent history of cervical intraepithelial neoplasia (CIN) grade 2 or 3 or cervical cancer
        • do not perform screening
  • Pap Test Results
    • Unsatisfactory cytology
    • Negative for intraepithelial lesion or malignancy (NILM)
    • Intraepithelial cell abnormalities
      • squamous cell abnormalities
        • atypical squamous cells of undetermined significance (ASC-US)
        • atypical squamous cells, can't exclude HSIL (ASC-H)
        • low-grade squamous intraepithelial lesion (LSIL)
        • high-grade squamous intraepithelial lesion (HSIL)
        • squamous cell carcinoma (SCC)
      • glandular cell abnormalities
        • atypical glandular cells (AGC)
  • Abnormal Pap Smear Management
    • Pap Smear Management
      Pap Smear Test Result21-24 Years Old25-29 Years Old≥30 Years Old & HPV Negative≥30 Years Old & HPV Positive
      Normal pap test result
      • Pap test ever 3 years
      • Pap test every 3 years
      • Co-testing (pap and HPV testing) every 5 years
        • preferred
      • Pap test every 3 years
        • acceptable
      • Co-testing in 1 year
        • acceptable
      • HPV testing
        • acceptable
      ASC-US
      • Pap test in 1 year
        • preferred
      • Reflex HPV test
        • acceptable
      • Pap test in 1 year
        • acceptable
      • Reflex HPV test
        • preferred
      • Repeat co-testing in 3 years
      • Colposcopy
      LSIL
      • Repeat pap test in 1 year
      • Colposcopy
      • Repeat pap test in 1 year
        • preferred
      • Colposcopy
        • acceptable
      • Colposcopy
      ASC-H
      • Colposcopy
      • Colposcopy
      • Colposcopy
      • Colposcopy
      HSIL
      • Colposcopy
      • Excisional treatment or colposcopy
      • Excisional treatment or colposcopy
      • Excisional treatment or colposcopy
    • Excisional treatments include
      • loop electrosurgical excision procedure (LEEP)
      • cold-knife conization
      • laser conization
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(M2.GN.15.30) A 27-year-old female presents to her OB/GYN for a check-up. During her visit, a pelvic exam and Pap smear are performed. The patient does not have any past medical issues and has had routine gynecologic care with normal pap smears every 3 years since age 21. The results of the Pap smear demonstrate atypical squamous cells of undetermined significance (ASCUS). Which of the following is the next best step in the management of this patient?

QID: 105667
1

Repeat Pap smear in 1 year

18%

(7/38)

2

Repeat Pap smear in 3 years

3%

(1/38)

3

Perform an HPV DNA test

58%

(22/38)

4

Perform colposcopy

16%

(6/38)

5

Perform a Loop Electrosurgical Excision Procedure (LEEP)

3%

(1/38)

M 6 E

Select Answer to see Preferred Response

(M2.GN.15.5667) A 31-year-old female presents to her gynecologist for a routine Pap smear. Her last Pap smear was three years ago and was normal. On the current Pap smear, she is found to have atypical squamous cells of unknown significance (ASCUS). Reflex HPV testing is positive. What is the best next step?

QID: 106992
1

Repeat Pap smear and HPV testing in 5 years

0%

(0/26)

2

Repeat Pap smear in 3 years

0%

(0/26)

3

Repeat Pap smear in 1 year

0%

(0/26)

4

Colposcopy

92%

(24/26)

5

Loop electrosurgical excision procedure (LEEP)

4%

(1/26)

M 7 E

Select Answer to see Preferred Response

(M2.GN.15.6) A 36-year-old female presents to her gynecologist for a check-up. She has had normal Pap smears as recommended every 3 years since she turned 30 years old. The physician conducts a pelvic examination that is without abnormality and obtains a cervical Pap smear. The results of the patient's Pap smear from the visit return as high grade squamous intraepithelial lesion (HGSIL). Which of the following is the best next step in the management of this patient?

QID: 102947
1

Repeat Pap smear in 12 months

0%

(0/23)

2

Repeat Pap smear in 3 years

0%

(0/23)

3

Obtain HPV DNA test

22%

(5/23)

4

Perform colposcopy

74%

(17/23)

5

Radical hysterectomy

0%

(0/23)

M 7 E

Select Answer to see Preferred Response

Evidence (7)
EXPERT COMMENTS (16)
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