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Cervical Cancer Screening
Module III
Techniques of Screening
Screening Guidelines
Special Screening Situations
Cervical Cancer Screening
Techniques of Screening
Physical Exam
Visual Inspection with Acetic Acid
Pap Smear
HPV Testing

...
Techniques of Screening
Physical Exam
1. Visually examine the vulva and perianal region

2. Insert the speculum into the v...
Techniques of Screening
Visual Inspection with Acetic Acid
With the speculum in the vagina and the
cervix visualized, appl...
Visual Inspection
Author, year of
publication, country of
study

No. of participants

Sensitivity, % (95%
CI)

Specificity...
Techniques of Screening
Pap Smear
With a spatula, rotate the spatula 360
degrees around the exocervix

With a cytobrush, p...
SCREENING
 conventional cytologic sampling
 Thin layer (or liquid-based) cytology





ThinPrep (1996)
AutocytPrep (...
Sources of potential error in the Pap smear
The clinician may not sample the area of cervical
abnormality.
The abnormal ce...
Techniques of Screening
HPV Testing
HPV testing should be confined to testing
for high risk (oncogenic) subtypes
HPV testi...
HPV TESTING
p16 cytology
P16 cytology can be used as a triage test in HPV-positive
women.
P16 is a marker of HPV oncogene ...
Techniques of Screening
Colposcopy &Cervical Biopsies

Module III
Cervical Cancer Screening
Screening Guidelines
Screening Guidelines can be separated
into two sections
General guidelines ...
Cervical Cancer Screening
Screening Guidelines
Guidelines are only for women at average risk for cervical cancer.
These gu...
Screening Guidelines
When to perform pap smear
Do not screen before age 21 years

Screening should start at age 21
Screeni...
PREVALENCE OF CIN 3 OR GREATER BY AGE
MOORE 2008

CIN3 OR
GREATER

LESS THAN CIN 3

TOTAL

<50 YEARS

189 (71%)

77 (29%)
...
Vaccination Against HPV
Recommend routine HPV vaccination for females aged
11 to 12 years
Recommend routine vaccination fo...
Screening Guidelines
When to perform pap smear
Ages 21- 29 years: PAP SMEAR screening every three
years
No screening HPV t...
Screening Guidelines
When to perform pap smear
Ages 30 – 65 years:
screening with both PAP SMEAR and HPV testing
every fiv...
Screening Guidelines
When to perform PAP SMEAR
Ages greater than 65: No Further Pap Smear Testing
who have had > 3 consecu...
Cervical Cancer Screening
Screening Guidelines
In 2012 the American Society for
Colposcopy and Cervical Pathology
(ASCCP) ...
ASCCP Guidelines
Guidelines for management of abnormal pap smears
are different by the following age categories:
Ages 21- ...
ASCCP Guidelines
Unsatisfactory Cytology
Repeat pap smear after 2 to 4 months

Refer to colposcopy for persistently unsati...
ASCCP Guidelines
Absent Endocervical Cells
For ages 21-29: perform routine screening

For ages > 30 : HPV testing
http://w...
ASCCP Guidelines
Age > 30: Cytology Negative & HPV positive
For HPV 16 and 18: colposcopy

Repeat co-testing in one year i...
Risk of HSIL with + HPV HR
2% (52 of 2562 over 10 years) Khan 2005

3% (88 of 2941 over 10 years) Castle 2002

1.2% (30 or...
ASCCP Guidelines
ASC - US
Repeat pap smear in one year, if ASC-US again: refer
to colposcopy
OR
Upfront HPV testing, if HP...
ASCCP Guidelines
Ages 21-24 – ASC-US or LSIL
HPV testing:
If HPV negative: return to routine testing
If HPV positive: repe...
ASCCP Guidelines
ASC-US ages 21-24
Initial Management
Cytology alone in 12 months is preferred

Reflex HPV testing accepta...
ASCCP Guidelines
LSIL

If LSIl and HPV negative, repeat pap smear in one year

If LSIL and HPV positive: refer to colposco...
ASCCP Guidelines
ASC-H
Refer all ASC-H to colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 1...
ASCCP Guidelines
Ages 21-24 -ASC-H
If colposcopy is negative, repeat pap smear and
colposcopy every six months for two yea...
ASCCP Guidelines
HSIL
Immediate LEEP or colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 13)
ASCCP Guidelines
AGC

All women with AGC need colposcopy

Women > AGC also need an endometrial biopsy
http://www.asccp.org...
ASCCP
Subsequent management of AGC after
colposcopy
For CIN 2 but no glandular lesion, manage per
ASCCP guideline

For neg...
Histologic Outcome after Atypical Glandular Cells
Obstet Gynecol 2010; 115:243-248

Age < 50 years

Age < 50 years

Age > ...
ASCCP Guidelines
Biopsy: CIN I
No treatment

Repeat pap smear and HPV testing in one year
http://www.asccp.org/Portals/9/d...
ASCCP Guidelines
Biopsy: CIN I after Pap ASC-H or HSIL
Treatment not recommended

Repeat pap smear and HPV testing yearly ...
ASCCP Guidelines
Ages 21-24 – Biopsy CIN I
Treatment not recommended

After ASC-US or LSIL pap: Repeat pap smear
After ASC...
ASCCP Guidelines
Biopsy: CIN 2-3
Recommend excisional procedure
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p...
ASCCP Guidelines
Young women, Biopsy: CIN 2-3
Excisional procedure
OR
Pap smear and colposcopy every six months for one
ye...
ASCCP Guidelines
Biopsy: AIS
Excisional procedure
Hysterectomy is preferred treatment
http://www.asccp.org/Portals/9/docs/...
Cervical Cancer Screening
Special Screening Situations
Immunosuppression

Pregnancy
After Hysterectomy
After Treatment for...
Special Screening Situations
Immunosuppression
Human Immunodeficiency Virus
Organ Transplant
Chronic Steroid Use

Module I...
Immunosuppression
Human Immunodeficiency Virus
Women with HIV infection are at high risk
for preinvasive lower genital tra...
Immunosuppression
Organ Transplant
Women who are on high dose
immunosuppressants are at high risk for
lower genital tract ...
Immunosuppression
Chronic Steroid Use
Chronic steroid use can lead to a
reduction in the clearance of HPV
infection

They ...
Special Screening Situations
Pregnancy
Pap smear is performed at first prenatal
visit and at the six week post partum visi...
Special Screening Situations
Pregnancy: ASC-US pap
Identical to non-pregnant women

It is acceptable to defer colposcopy u...
ASCCP Guidelines
Pregnant with LSIL
Colposcopy in pregnancy
Treatment of all preinvasive lesions delayed until after
deliv...
Special Screening Situations
After Hysterectomy
Cervical cancer screening is not indicated if
removal of cervix or entire ...
Special Screening Situations
After Treatment for Cervical Cancer
No age cut off for stopping screening

Women should under...
Special Screening Situations
After Pelvic Radiation
There is a higher risk of radiation induced
malignancies after pelvic ...
Special Screening Situations
Challenging Anatomy
Vaginismus

Vaginal Atrophy
Pelvic Floor Prolapse

Vaginal Agglutination
...
Challenging Anatomy
Vaginismus
Vaginismus is the painful and
involuntary contraction of vaginal
muscles
Causes: sexual ass...
Challenging Anatomy
Vaginal Atrophy
Consideration should be given to a short
course of estrogen vaginal cream prior to
per...
Challenging Anatomy
Pelvic Floor Prolapse
Uterine prolapse can place the cervix at
the introitus leading to trauma and
cor...
Challenging Anatomy
Vaginal Agglutination
Vaginal agglutination can occur after
radiation, trauma, surgery, and infection
...
Challenging Anatomy
Cervical Stenosis
Cervical stenosis is defined as the inability
to place a cutip or cytobrush within t...
Challenging Anatomy
Obesity
Obesity can in some women lead to
difficulty examining the cervix due to
discomfort, vaginal w...
Special Screening Situations
History of Sexual Assault
Women who have survived the trauma of sexual
assault should be scre...
Special Screening Situations
In Utero DES (diethylstilbestrol) exposure
The cohort of women exposed to
Utero DES were born...
CERVICAL CANCER
SCREENING
MODULE III
CONCLUSIONS

-This module summarizes the screening recommendations
for the average ri...
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Cervical Cancer Screening Module 3 - from Massachusetts Medical Society. Copyright © 2013. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

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Transcript of "Cervical cancer screening module 3"

  1. 1. Cervical Cancer Screening Module III Techniques of Screening Screening Guidelines Special Screening Situations
  2. 2. Cervical Cancer Screening Techniques of Screening Physical Exam Visual Inspection with Acetic Acid Pap Smear HPV Testing Cervical Biopsies Module III
  3. 3. Techniques of Screening Physical Exam 1. Visually examine the vulva and perianal region 2. Insert the speculum into the vagina 3. Visually examine the cervix and the walls of the vagina 4. Palpate the cervix and the walls of the vagina. 5. Palpate the parametria and uterosacral ligaments by rectovaginal exam Module III
  4. 4. Techniques of Screening Visual Inspection with Acetic Acid With the speculum in the vagina and the cervix visualized, apply 3% acetic acid using a sponge (ALERT: confirm that the acetic acid has been diluted. 100% acetic acid will cause third degree burns) Wait 60 seconds and then visually examine . Dysplastic lesions are nuclear dense. The dehydration of the mucous membrane will temporarily cause dysplastic lesions to look white Module III
  5. 5. Visual Inspection Author, year of publication, country of study No. of participants Sensitivity, % (95% CI) Specificity, % (95% CI) University of Zimbabwe/JHPIEGO [5], 1999, Zimbabwe 2148 77 (70–82) 64 (61–66) Denny et al. 2000, South Africa 2885 67 (56–77) 84 (82–85) Belinson et al. [24], 2001, China 1997 71 (60–80) 74 (71–76) Denny et al. [8], 2002, a,c South Africa 2754 70 (59–79) 79 (77–81) Cronjé et al. [9], 2003, South Africa 1093 79 (69–87) 49 (45–52) 54,981 79 (77–81) 86 (85–86) Sankaranarayanan et al. [25], 2004 India and b,c Africa Sensitivity – 67-79% Specificity – 49-86% Technique :Place Speculum Apply 3-5% Acetic Acid Wait at least 1 Minute; record Observations Module III
  6. 6. Techniques of Screening Pap Smear With a spatula, rotate the spatula 360 degrees around the exocervix With a cytobrush, place the brush within the endocervix and rotate 360 degrees Apply both the spatula and cytobrush to a slide and then apply fixative Or place spatula and cytobrush into liquid based solution and break off the tips Module III
  7. 7. SCREENING  conventional cytologic sampling  Thin layer (or liquid-based) cytology     ThinPrep (1996) AutocytPrep (1999) SurePath (2000) MonoPrep (2006)  liquid-based : other diagnostic assessments (only Thin Prep is FDA approved )    testing for gonorrhea chlamydia HPV Module III
  8. 8. Sources of potential error in the Pap smear The clinician may not sample the area of cervical abnormality. The abnormal cells may not be plated on the slide or transferred to the liquid medium. The cells may not be adequately preserved with fixative. The cytologist may inaccurately report the findings The cytopathologist may not identify the abnormal cells. Module III
  9. 9. Techniques of Screening HPV Testing HPV testing should be confined to testing for high risk (oncogenic) subtypes HPV testing for low risk (nonocogenic) subtypes has NO role in the evaluation of abnormal pap smears Module III
  10. 10. HPV TESTING p16 cytology P16 cytology can be used as a triage test in HPV-positive women. P16 is a marker of HPV oncogene activity that is independent of carcinogenic HPV tyoe Carozzi . Lancet Oncol 2012 Of 1170 HPV positive women,493 (42%) overexpressed p16 at baseline At baseline, 55 of these 493 women had CIN3 (9.7%) Compared to p16 negative over expression, positive p16 had a longitudinal sensitivity of 82.4% Module III
  11. 11. Techniques of Screening Colposcopy &Cervical Biopsies Module III
  12. 12. Cervical Cancer Screening Screening Guidelines Screening Guidelines can be separated into two sections General guidelines for when to pap smears and on whom What follow up and intervention is recommended based on pap sear results Module III
  13. 13. Cervical Cancer Screening Screening Guidelines Guidelines are only for women at average risk for cervical cancer. These guideline do not apply to women with: history of cervical cancer In Utero exposure to DES who are immuno-compromised organ transplantation, chronic steroid use, chemotherapy HIV positive Module III
  14. 14. Screening Guidelines When to perform pap smear Do not screen before age 21 years Screening should start at age 21 Screening guidelines are age dependent Annual pap smears in women without a history of premalignant or malignant lower genital disease are no longer recommended Recommended Screening practices should not change on the basis of HPV vaccination status Module III
  15. 15. PREVALENCE OF CIN 3 OR GREATER BY AGE MOORE 2008 CIN3 OR GREATER LESS THAN CIN 3 TOTAL <50 YEARS 189 (71%) 77 (29%) 266 >50 YEARS 51 (59%) 35 (41%) 86 TOTAL 240 112 352 Patients older than 50 had Signif higher Prevalence CIN3 Module III
  16. 16. Vaccination Against HPV Recommend routine HPV vaccination for females aged 11 to 12 years Recommend routine vaccination for females aged 13 to 18 years to “catch-up” those who missed earlier screening Insufficient data to recommend for or against universal vaccination of females aged 19 to 26 years Module III
  17. 17. Screening Guidelines When to perform pap smear Ages 21- 29 years: PAP SMEAR screening every three years No screening HPV testing HPV testing only for evaluation of atypical squamous cells of uncertain significance Module III
  18. 18. Screening Guidelines When to perform pap smear Ages 30 – 65 years: screening with both PAP SMEAR and HPV testing every five years (preferred) Or PAP SMEAR testing every three years (accepted) Module III
  19. 19. Screening Guidelines When to perform PAP SMEAR Ages greater than 65: No Further Pap Smear Testing who have had > 3 consecutive normal pap tests or > 2 consecutive negative HPV tests and pap tests in last 10 years with the most recent pap occurring within the last 5 years or women who have had hysterectomies for benign disease Module III
  20. 20. Cervical Cancer Screening Screening Guidelines In 2012 the American Society for Colposcopy and Cervical Pathology (ASCCP) published new guidelines for management of pap smear results Guidelines should never replace clinical judgment Module III
  21. 21. ASCCP Guidelines Guidelines for management of abnormal pap smears are different by the following age categories: Ages 21- 24 Ages over 30 Guidelines for management of abnormal pap smears are different for the pregnant woman (see screening: special situations) Module III
  22. 22. ASCCP Guidelines Unsatisfactory Cytology Repeat pap smear after 2 to 4 months Refer to colposcopy for persistently unsatisfactory pap smears http://www.asccp.org/Portals/9/docs/Algorithms%207.30.1 3.pdf (Page 4)
  23. 23. ASCCP Guidelines Absent Endocervical Cells For ages 21-29: perform routine screening For ages > 30 : HPV testing http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 5)
  24. 24. ASCCP Guidelines Age > 30: Cytology Negative & HPV positive For HPV 16 and 18: colposcopy Repeat co-testing in one year is acceptable http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 6)
  25. 25. Risk of HSIL with + HPV HR 2% (52 of 2562 over 10 years) Khan 2005 3% (88 of 2941 over 10 years) Castle 2002 1.2% (30 or 2562 over 10 years) Miller 2002 Module III
  26. 26. ASCCP Guidelines ASC - US Repeat pap smear in one year, if ASC-US again: refer to colposcopy OR Upfront HPV testing, if HPV positive: refer to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 7)
  27. 27. ASCCP Guidelines Ages 21-24 – ASC-US or LSIL HPV testing: If HPV negative: return to routine testing If HPV positive: repeat pap smear in one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30. 13.pdf (Page 8)
  28. 28. ASCCP Guidelines ASC-US ages 21-24 Initial Management Cytology alone in 12 months is preferred Reflex HPV testing acceptable If HPV positive, repeat cytology one year If HPV negative, return to routine screening with cytology alone in three years Module III
  29. 29. ASCCP Guidelines LSIL If LSIl and HPV negative, repeat pap smear in one year If LSIL and HPV positive: refer to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 9)
  30. 30. ASCCP Guidelines ASC-H Refer all ASC-H to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 11)
  31. 31. ASCCP Guidelines Ages 21-24 -ASC-H If colposcopy is negative, repeat pap smear and colposcopy every six months for two years If HSIL is found, acceptable to monitor for one year. If lesion is persistent for one year, treat with excision http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 12)
  32. 32. ASCCP Guidelines HSIL Immediate LEEP or colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 13)
  33. 33. ASCCP Guidelines AGC All women with AGC need colposcopy Women > AGC also need an endometrial biopsy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 14)
  34. 34. ASCCP Subsequent management of AGC after colposcopy For CIN 2 but no glandular lesion, manage per ASCCP guideline For negative biopsies, repeat pap and HPV testing yearly for two years For preinvasive glandular lesion, treat by excisional biopsy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 15)
  35. 35. Histologic Outcome after Atypical Glandular Cells Obstet Gynecol 2010; 115:243-248 Age < 50 years Age < 50 years Age > 50 years Age > 50 years HPV neg (n=656) HPV pos (n=269) HPV neg (n=420) HPV pos (n=497) CIN 2 10 34 4 9 CIN 3 3 42 1 5 Cervical 4 adenoca in situ 29 1 4 Cervical SCC 2 10 1 6 Cervical adenoca 0 7 1 2 Endometrial atypical 10 0 10 0 Endo CA 10 3 44 0 Other cancers 0 0 6 0
  36. 36. ASCCP Guidelines Biopsy: CIN I No treatment Repeat pap smear and HPV testing in one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 16)
  37. 37. ASCCP Guidelines Biopsy: CIN I after Pap ASC-H or HSIL Treatment not recommended Repeat pap smear and HPV testing yearly for two years http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 17)
  38. 38. ASCCP Guidelines Ages 21-24 – Biopsy CIN I Treatment not recommended After ASC-US or LSIL pap: Repeat pap smear After ASC-H or HSIL pap: repeat pap smear and colposcopy every six months for one year If colposcopy is inadequate: excisional procedure http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 18)
  39. 39. ASCCP Guidelines Biopsy: CIN 2-3 Recommend excisional procedure http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 19)
  40. 40. ASCCP Guidelines Young women, Biopsy: CIN 2-3 Excisional procedure OR Pap smear and colposcopy every six months for one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 20)
  41. 41. ASCCP Guidelines Biopsy: AIS Excisional procedure Hysterectomy is preferred treatment http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 21)
  42. 42. Cervical Cancer Screening Special Screening Situations Immunosuppression Pregnancy After Hysterectomy After Treatment for Cervical Cancer After Pelvic Radiation Challenging Anatomy History of Sexual Assault In Utero DES (diethylstilbestrol) exposure Module III
  43. 43. Special Screening Situations Immunosuppression Human Immunodeficiency Virus Organ Transplant Chronic Steroid Use Module III
  44. 44. Immunosuppression Human Immunodeficiency Virus Women with HIV infection are at high risk for preinvasive lower genital tract disease and cervical cancer They are high risk for persistent HPV infections They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  45. 45. Immunosuppression Organ Transplant Women who are on high dose immunosuppressants are at high risk for lower genital tract neoplasia They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  46. 46. Immunosuppression Chronic Steroid Use Chronic steroid use can lead to a reduction in the clearance of HPV infection They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  47. 47. Special Screening Situations Pregnancy Pap smear is performed at first prenatal visit and at the six week post partum visit Abnormal Pap smears are evaluated in a similar manner to non-pregnant women Module III
  48. 48. Special Screening Situations Pregnancy: ASC-US pap Identical to non-pregnant women It is acceptable to defer colposcopy until 6 weeks postpartum Endocervical curettage is unacceptable For pregnant women with no cytologic, colposcopic , or histologic findings of CIN, postpartum follow-up is recommended Module III
  49. 49. ASCCP Guidelines Pregnant with LSIL Colposcopy in pregnancy Treatment of all preinvasive lesions delayed until after delivery http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 10)
  50. 50. Special Screening Situations After Hysterectomy Cervical cancer screening is not indicated if removal of cervix or entire uterus in women with no history of cervical cancer or preinvasive disease. Women who have undergone a subtotal hysterectomy with preservation of the cervix should follow screening recommendations of average risk women Module III
  51. 51. Special Screening Situations After Treatment for Cervical Cancer No age cut off for stopping screening Women should undergo pap smears every 3 to 4 months for the first two years after treatment for cervical cancer. Pap smear screening is performed every 6 months from years 2 to 5 after treatment Annual pap smear screening five years after treatment Module III
  52. 52. Special Screening Situations After Pelvic Radiation There is a higher risk of radiation induced malignancies after pelvic radiation. Annual pap smear screening should be performed in women who receive pelvic radiation for all cancer types (lymphoma, cervical cancer, endometrial cancer, rectal and anal cancer) Module III
  53. 53. Special Screening Situations Challenging Anatomy Vaginismus Vaginal Atrophy Pelvic Floor Prolapse Vaginal Agglutination Cervical Stenosis Obesity Module III
  54. 54. Challenging Anatomy Vaginismus Vaginismus is the painful and involuntary contraction of vaginal muscles Causes: sexual assault, vulvar vestibulitis, inflammatory conditions of the pelvic floor such as diverticulitis Adequate pelvic examination and pap smear may require an examination under anesthesia Module III
  55. 55. Challenging Anatomy Vaginal Atrophy Consideration should be given to a short course of estrogen vaginal cream prior to performing a pap smear Module III
  56. 56. Challenging Anatomy Pelvic Floor Prolapse Uterine prolapse can place the cervix at the introitus leading to trauma and cornification of the cervix Module III
  57. 57. Challenging Anatomy Vaginal Agglutination Vaginal agglutination can occur after radiation, trauma, surgery, and infection Evaluation by examination under anesthesia should be considered Use of vaginal dilators and estrogen vaginal cream should be considered Module III
  58. 58. Challenging Anatomy Cervical Stenosis Cervical stenosis is defined as the inability to place a cutip or cytobrush within the endocervix There is increased risk of a false negative pap smear Recommendation: Dilation of cervix In a postmenopausal woman, consideration of a transvaginal ultrasound to evaluate the endometrial cavity for fluid Module III
  59. 59. Challenging Anatomy Obesity Obesity can in some women lead to difficulty examining the cervix due to discomfort, vaginal wall redundancy, or increased vaginal length. Sensitive use of larger speculums and retraction of the labia by an assistant can be helpful in optimally postioning the speculum to visualize the cervix Module III
  60. 60. Special Screening Situations History of Sexual Assault Women who have survived the trauma of sexual assault should be screened for sexually transmitted disease including HIV testing. For women who are older than age 30, high risk HPV testing should be offered. Consideration should be given for a pap smear regardless of the timing of their previous pap smear test within six months of sexual assault for women older than age 21 years. Module III
  61. 61. Special Screening Situations In Utero DES (diethylstilbestrol) exposure The cohort of women exposed to Utero DES were born before 1980. In- They have a twofold increased risk of cervical dysplasia Based on clinician judgment, they should be screened at least every three years if they have had three consecutive normal pap smears Module III
  62. 62. CERVICAL CANCER SCREENING MODULE III CONCLUSIONS -This module summarizes the screening recommendations for the average risk patient. -The full algorithms can be reviewed on the asccp website: http://www.asccp.org/Guidelines -Providers must be cognizant of special screening situations and tailor evaluation to each patient, their particular anatomy, and their particular risk factors.
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