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Cervical Cancer Screening

Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer is the 3rd most common gynecologic cancer. More than 90% of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer cases are associated with high-risk human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) (hrHPV), which is transmitted by sexual contact. Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer can be prevented by early detection and treatment of precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesions caused by hrHPV. The methods of detection are cervical cytology and HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing. Screening Screening Preoperative Care is recommended by the age of 21 and is generally repeated every 3 years up to the age of 29 in an average-risk individual. By age 30, HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing with cytology is obtained. Since the screening Screening Preoperative Care program was initiated, there has been a 75% decline in the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of and mortality Mortality All deaths reported in a given population. Measures of Health Status from cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer.

Last updated: 31 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer

  • Cancer of the uterine cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Major histologic types:
    • Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC): approximately 80% of cervical cancers
    • Adenocarcinoma: 15%
    • Adenosquamous carcinoma: 3%–5%
  • Associated with human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV)): 
    • Detected in 99.7% of cervical cancers
    • Subtypes HPV 16 HPV 16 A type of alphapapillomavirus usually associated with genital warts; and laryngeal neoplasms. Papillomavirus (HPV) and 18 found in > 70% of cervical cancers

Epidemiology

  • Among gynecologic cancers, cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer is:
    • The 3rd most common cancer diagnosis
    • The 3rd most common cause of death 
  • More than 80% of new cases worldwide are from less developed countries.
  • In the United States: 
    • 14,000 new cases of invasive cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer are diagnosed annually.
    • Mean Mean Mean is the sum of all measurements in a data set divided by the number of measurements in that data set. Measures of Central Tendency and Dispersion age at diagnosis: 50 years

Risk factors

  • HPV-related:
    • Early onset of sexual activity
    • Multiple sexual partners
    • Multiparity and early age at 1st birth
    • History of vulvar or vaginal squamous intraepithelial neoplasia or cancer
    • Immunosuppression
    • Human immunodeficiency virus Human Immunodeficiency Virus Anti-HIV Drugs ( HIV HIV Anti-HIV Drugs) infection
    • Co-infection with Chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia trachomatis or herpes simplex virus Herpes Simplex Virus A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Encephalitis
  • Non-HPV related:
    • Low socioeconomic status
    • African American race
    • Use of oral contraceptives
    • Cigarette smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases (associated with squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC))
    • Family history Family History Adult Health Maintenance
    • Negative risk factor: circumcised male partners

Screening Rationale

  • Screening Screening Preoperative Care is recommended because:
    • Women 21‒65 years of age are at risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer due to potential exposure Exposure ABCDE Assessment to high-risk human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) (hrHPV) through sexual intercourse.
    • A 75% decline in the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency and mortality Mortality All deaths reported in a given population. Measures of Health Status of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer occurred in the past 50 years due to screening Screening Preoperative Care.
    • Most cases of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer are found in women who have not been adequately screened.
    • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer usually does not cause symptoms.
  • Screening Screening Preoperative Care is not recommended earlier than age 21 because:
    • Cancerous and precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesions are rare before the age of 21.
    • Prolonged progression from hrHPV infection, development of precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesions, to cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
    • Many precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesions and HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease will regress.
    • May lead to more harm from psychological distress and unnecessary procedures

Strategies for Screening

Screening Screening Preoperative Care strategies can be done independently or concurrently (co-testing).

  • Cervical cytology:
    • Ectocervical and endocervical cells are collected to evaluate the transformation zone Transformation zone Diagnostic Procedures in Gynecology (area at risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer).
    • The procedure is performed with an endocervical brush and ectocervical spatula.
    • Preparation methods:
      • Conventional Papanicolaou (Pap) smear: Ectocervical spatula is smeared and the brush rolled onto a slide, with fixative applied immediately
      • Liquid-based thin layer cytology: Collection device is placed and swirled in the liquid fixative solution, which is then processed by the laboratory.
  • HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing:

Cervical Cancer Screening for Average-Risk Individuals

The following recommendations are for average-risk individuals.

  • United States Preventive Services Task Force (USPSTF) recommendations:
    • Routine cytology screening Screening Preoperative Care every 3 years starting at the age of 21, regardless of sexual history 
    • For ages 21‒29: cytology alone every 3 years
    • For ages 30‒65, options are:
      • Cervical cytology alone every 3 years
      • hrHPV every 5 years
      • Cytology with hrHPV co-testing every 5 years 
    • Screening Screening Preoperative Care ends at the age of 65 if the patient has adequate negative screening Screening Preoperative Care.
  • Updated American Cancer Society recommendations (2020):
    • Initiate screening Screening Preoperative Care at the age of 25, regardless of sexual history, with primary HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing (approved testing that is adequate for screening Screening Preoperative Care by itself) every 5 years
    • If primary HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing cannot be done: 
      • Co-testing with HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) and Pap smear every 5 years
      • Pap smear alone every 3 years 
    • Screening Screening Preoperative Care ends at age 65 with adequate negative screening Screening Preoperative Care.
    • Rationale for the above:
      • Low incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer in those < 24 years of age
      • HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing is more specific.
      • About 70% of adolescents have received at least 1 dose of the HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination.
  • Adequate negative prior screening Screening Preoperative Care is defined as 1 of the following:
    • 3 consecutive negative cytology results, with the last result within the past 3 years
    • 2 consecutive negative co-test results within the past 10 years, with the most recent test within the past 5 years
    • 2 consecutive negative primary HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) test results within the past 10 years, with the most recent test within the past 5 years

Cervical Cancer Screening for Special Populations

High-risk individuals

Certain conditions have a high risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer, so screening Screening Preoperative Care must be individualized and more frequent:

  • HIV HIV Anti-HIV Drugs infection: Screening Screening Preoperative Care may start at the time of HIV HIV Anti-HIV Drugs diagnosis, but no sooner than 21 years of age, regardless of sexual history.
  • Immunocompromised immunocompromised A human or animal whose immunologic mechanism is deficient because of an immunodeficiency disorder or other disease or as the result of the administration of immunosuppressive drugs or radiation. Gastroenteritis: Screening Screening Preoperative Care may start at 21 years of age, regardless of sexual history.
  • In utero exposure Exposure ABCDE Assessment to diethylstilbestrol Diethylstilbestrol A synthetic nonsteroidal estrogen used in the treatment of menopausal and postmenopausal disorders. It was also used formerly as a growth promoter in animals. According to the fourth annual report on carcinogens, diethylstilbestrol has been listed as a known carcinogen. Noncontraceptive Estrogen and Progestins (last used in the 1970s, so most relevant in women born after 1980)
  • Previous treatment of a high-grade precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesion or cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer

Prior hysterectomy

  • Screening Screening Preoperative Care is still recommended in women:
    • With history of subtotal hysterectomy ( cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy intact)
    • With history of cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer), even after hysterectomy
  • No screening Screening Preoperative Care is recommended in women:
    • With history of hysterectomy with removal of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy for a benign Benign Fibroadenoma disease
    • Without history of a high-grade precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus lesion ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer grade 2 or 3) or cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer

Individuals > 65 years of age

Pap Test

Results (Bethesda system)

A standardized reporting of results, which includes the specimen adequacy, general categorization Categorization Types of Variables of findings, and results:

  • Negative for intraepithelial lesion or malignancy Malignancy Hemothorax
  • Epithelial cell abnormalities:
    • Squamous cell:
      • Atypical squamous cells (ASC) of undetermined significance (ASC-US) 
      • ASC cannot exclude high-grade squamous intraepithelial lesion (ASC-H).
      • Low-grade squamous intraepithelial lesion (LSIL) 
      • High-grade squamous intraepithelial lesion (HSIL)
      • Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC) 
    • Glandular cell (specify endocervical, endometrial, or not otherwise specified):
      • Atypical endocervical, endometrial, or glandular cells (AGC)
      • Atypical endocervical or glandular cells, favor neoplastic
      • Endocervical adenocarcinoma in situ ( AIS AIS Scoliosis)
      • Adenocarcinoma
  • Organism:
    • Trichomonas Trichomonas A genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum. Nitroimidazoles vaginalis
    • Fungal elements (consistent with Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis)
    • Cellular changes consistent with herpes simplex virus Herpes Simplex Virus A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Encephalitis or cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus
    • Bacterial vaginosis Bacterial vaginosis Polymicrobial, nonspecific vaginitis associated with positive cultures of gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli. Vulvovaginitis
    • Bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology consistent with Actinomyces Actinomyces Actinomyces is an anaerobic, gram-positive, branching, filamentous rod. Actinomyces israelii is the most common species involved in human disease. The organism is commonly found as part of the normal flora in the oral cavity, gastrointestinal tract, and reproductive tract. Actinomyces/Actinomycosis
  • Other non-neoplastic findings may be included:
    • Reactive cellular changes
    • Glandular cells status post-hysterectomy
    • Atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
    • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
Pap smear showing bacterial vaginosis with many clue cells hiv

Pap smear showing bacterial vaginosis Bacterial vaginosis Polymicrobial, nonspecific vaginitis associated with positive cultures of gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli. Vulvovaginitis with many clue cells
Clue cells are vaginal epithelial cells studded with adherent coccobacilli that are best appreciated at the edge of the cells. The bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology are stained blue-purple by the Pap stain (arrows).

Image: “Cervical cytological changes in HIV-infected patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship” by Mwakigonja AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation, Torres LM, Mwakyoma HA HA Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia, Kaaya EE. License: CC BY 2.0, edited by Lecturio

Interpretation of results

  • Negative for intraepithelial lesion or malignancy Malignancy Hemothorax: no cellular evidence of neoplasia
  • ASC: 
    • Some cells seen are not normal, but do not meet the requirements to be precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus
    • May be precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus or associated with infection, irritation, or intercourse
    • Categories:
      • ASC-US (abnormal cells, but no squamous intraepithelial lesions)
      • ASC-H (equivocal findings, but may be a sign of HSIL)
  • Squamous intraepithelial lesion (SIL): 
    • Premalignant findings for invasive squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC)
    • LSIL: 
      • Low-grade dysplasia Dysplasia Cellular Adaptation corresponding to cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 1)
      • Early, mild changes in the size or shape of cells
      • May regress on its own
    • HSIL: 
      • Moderate or high-grade dysplasia Dysplasia Cellular Adaptation ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 2, CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 3/ carcinoma in situ Carcinoma in situ A lesion with cytological characteristics associated with invasive carcinoma but the tumor cells are confined to the epithelium of origin, without invasion of the basement membrane. Leukoplakia)
      • Increased risk of progression to invasive carcinoma (compared with LSIL changes)
  • Glandular cell abnormalities:
    • AGC: endometrial or cervical cell changes are abnormal and must be evaluated more closely.
    • AGC, favor neoplastic: show features that suggest, but are not sufficient for, a diagnosis of adenocarcinoma
    • AIS AIS Scoliosis: premalignant lesion of invasive adenocarcinoma

Follow-up of abnormal results

Note: Colposcopy is a procedure in which a colposcope Colposcope Instruments inserted into the vagina for examination of the tissues of the vagina and cervix by means of a magnifying lens. Diagnostic Procedures in Gynecology ( magnifying device magnifying device Instruments inserted into the vagina for examination of the tissues of the vagina and cervix by means of a magnifying lens. Diagnostic Procedures in Gynecology) is used to enhance visualization of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy, identify macroscopic abnormal areas, and guide biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma.

  • Unsatisfactory for evaluation:
    • May be due to scant cellularity or obscured cells
    • If HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) positive: Repeat cytology in 2‒4 months or colposcopy.
    • If HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) negative: Repeat cytology in 2‒4 months.
  • Abnormal HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV), normal cytology (≥ 30 years of age):
    • If HPV 16 HPV 16 A type of alphapapillomavirus usually associated with genital warts; and laryngeal neoplasms. Papillomavirus (HPV) or 18: colposcopy
    • Repeat co-testing in 1 year; If still positive, perform colposcopy.
  • ASC-US:
    • Age 21–24 years: Repeat cytology in 12 months.
    • Age ≥ 25 years: Obtain HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing.
      • If negative, check co-testing in 3 years.
      • If positive, proceed with colposcopy.
  • ASC-H: colposcopy
  • LSIL:
    • Age 21–24 years: follow-up cytology at 12-month intervals 
    • Age ≥ 25 years: colposcopy 
    • Pregnant women: colposcopy (immediately, or deferred until 6 weeks postpartum)
  • HSIL: colposcopy
  • AGC and AIS AIS Scoliosis: colposcopy

References

  1. Feldman, S., Goodman, A. (2020). Screening for cervical cancer in resource-rich settings. UpToDate. Retrieved December 14, 2020, from https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings
  2. Frumovitz, M. (2020). Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis. UpToDate. Retrieved December 17, 2020, from https://www.uptodate.com/contents/invasive-cervical-cancer-epidemiology-risk-factors-clinical-manifestations-and-diagnosis
  3. Feldman, S., & Crum, C.P. (2020). Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing. UpToDate. Retrieved December 17, 2020, from https://www.uptodate.com/contents/cervical-cancer-screening-tests-techniques-for-cervical-cytology-and-human-papillomavirus-testing
  4. Crum, C.P, and Huh, W.K. (2020). Cervical and vaginal cytology: Interpretation or results (Pap test report). UpToDate. Retrieved December 20, 2020, from https://www.uptodate.com/contents/cervical-and-vaginal-cytology-interpretation-of-results-pap-test-report
  5. Iniesta M.D., Schmeler K.M., & Ramirez P.T. (2016). Tumors of the uterine cervix. In Kantarjian H.M., & Wolff R.A. (Eds.), The MD Anderson Manual of Medical Oncology, 3rd ed. McGraw-Hill.
  6. Karjane, N., & Ivey, S. (2018). Pap smear. Medscape. https://emedicine.medscape.com/article/1947979-overview#a9
  7. Papadakis M.A., McPhee S.J., & Bernstein J. (Eds.). (2020). Cervical cancer. Quick Medical Diagnosis & Treatment 2020. McGraw-Hill.
  8. U.S. Preventive Service Task Force (2018). Cervical cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening#fullrecommendationstart
  9. The American Cancer Society (2020). Guidelines for the prevention and early detection of cervical cancer. https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/cervical-cancer-screening-guidelines.html

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