screening for cervical cancer

1. - Dr Anakha P

2. Cervical cancer and CIN are caused by HPV.
Of the approximately 170 types of HPV, about 30 infect the anogenital tract.
16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82 - high-risk HPV types.
The majority of cervical cancers are caused by HPV 16 and 18.
Low-risk HPV types are not associated with cancer. However, low-risk types 6 and 11 are associated with
genital warts (condylomata acuminata) and with low- grade squamous intraepithelial lesions (LSILs).

3. HPV infects the cells of the
cervix.
The size and shape of the
cervix change depending
on age, hormonal status,
and number of children
(parity).
The upper part of the
cervix that opens into the
endometrial cavity is called
the internal os;
the lower part that opens
into the vagina is called the
external os.
The exterior portion of the
cervical canal is called the
ectocervix, and the interior
cervical canal is called the
endocervical canal.
The walls of the
endocervical canal contain
numerous folds and plicae.

4. The histology of the cervix is complex.
Overlying the fibrous stroma of the cervix is the cervical epithelium, a meshwork of
cells.
The epithelium is of two types: columnar (glandular) and stratified nonkeratinizing
squamous epithelia.
The columnar epithelium consists of a single layer of mucus-secreting cells that are
arranged into deep folds or crypts.
The area where the two types of epithelia meet is called the squamocolumnar junction
(SCJ). -it is the site where more than 90% of cervical neoplasias arise.

5. During childhood, the SCJ is located just inside the
external os.
Under the influence of hormones and the
acidification of the vaginal environment during
puberty, subcolumnar cells undergo metaplasia, a
process of transformation.
The metaplasia of these cells causes the SCJ to
“roll out,” or evert, from its prepubertal position
inside the external os to a position on the
enlarged cervical surface.
Columnar epithelium is also rolled onto the
cervical surface, where it is exposed to vaginal
secretions, irritants, and a changing hormonal
milieu.

6. • The area between the original SCJ (on
ectocervix) and the active SCJ (variable
throughout reproductive life) is called the
transformation zone (TZ).
• As metaplasia continues, the metaplastic
epithelium covers and eventually becomes
indistinguishable from the original squamous
epithelium.
• Glands within the columnar epithelium may
become trapped during this metaplastic activity
by squamous epithelium, causing Nabothian
cysts. These cysts are not considered pathologic
but are a normal consequence of the dynamic
histology of the cervix.

8. The metaplastic cells within
the TZ represent the newest
and least mature cells in the
cervix, and it is thought that
they are the most vulnerable
to oncogenic change.
The rate of metaplasia is
highest during adolescence
and early pregnancy.
During perimenopause, the
new SCJ recedes upward into
the endocervical canal, often
out of direct visual contact.

9. Most HPV infections are transient, indicating that the host’s
immune system is able to eradicate the virus before it can cause
neoplastic changes in cervical cells.
If the HPV DNA is not integrated into the host genome,
encapsulated virions are produced that are expressed
histologically as “koilocytes,” cells with shrunken or withered-
appearing nuclei surrounded by perinuclear clearing.
If HPV DNA is integrated into the host DNA, the expression of
the cell’s regulatory genes may be altered, leading to the
transformation of the cells into intraepithelial lesions or cancer.

11. Cervical cancer -3rd most
common gynecologic cancer
after breast, colon, and lung
cancer.
Worldwide, it is the fourth most
common cancer among women
and the most common cause of
mortality from gynecologic
malignancy, accounting for more
than 250,000 deaths per year.
Can be thought of as a
preventable cancer. - preceded
by an identifiable precursor
lesion (cervical intraepithelial
neoplasia [CIN]) that may (but
not always) progress to invasive
cancer.

12. Cervical intraepithelial neoplasia is
the premalignant condition
involving the uterine cervix in
which cellular abnormalities are
limited to the surface epithelium
and do not extend beyond the
basement membrane.
Earlier the terms mild, moderate,
severe dysplasia and carcinoma
insitu were used but subsequently
studies showed that all grades
could progress to invasive cancer
and hence the term CIN1 CIN2 and
CIN3 was introduced.

13. CIN 1 progresses to invasive cancer less frequently(1%) but CIN 2 and CIN 3
represent high grade lesions and progress to cancer more often (5% and 12%).
Therefore, the term
LSIL was used for CIN 1 and HSIL for CIN 2 and 3.
This is discussed in the bethesda system in later slides.

14. • Effective strategies for cervical cancer
screening and treatment have dramatically
reduced the incidence of and mortality from
this disease.

15. It is technically easy to screen for cervical
cancer because of the following reasons:
• The cervix can be easily visualised and tests
performed.
• Cervical cancer goes through premalignant changes
and if diagnosis is made at this stage, cancer can be
prevented.
• There is a lag time of 10 to 20 years before the
disease progresses from intraepithelial to invasive
disease.

16. • Characteristics of Screening Tests
• The principle behind routine screening is to detect the
presence of disease in asymptomatic individuals without
specific risk factors.
• Criteria for Screening Tests to detect the Disease
• Asymptomatic period long enough to allow
detection
• Prevalent enough to justify screening
• Treatable; treatment in an asymptomatic stage
• Sufficient effect on quality and/or length of life

17. • Criteria for the Test
• Sensitive
• Specific
• Safe
• Affordable
• Acceptable to patients

18. In August 2020 - WHO
launched the global strategy
to accelerate the elimination
of cervical cancer as a public
health problem.
The following targets must
be met by 2030 for
countries to be on the path
towards cervical cancer
elimination:
●Fully vaccinate 90 percent
of females by age 15 years.
●Screen 70 percent of
females with a high-
performance test by age 35
and again at age 45.
●Treat 90 percent of females
identified with cervical
disease (including
precancers and cancers).
If these targets are reached,
mathematical modelling
estimates that over 62
million cervical cancer
deaths will be averted by
2120.

19. BARRIERS
Competing
health
demands -focus
on urgent medical
needs and curative,
rather than
preventive, health
care.
•Other – Other barriers include
the lack of the following:
medical insurance programs,
medical equipment and supplies
and trained cytopathologists or
pathologists.

20. Recommendations for cervical cancer
screening :
• < 21 years: Should not be screened regardless of
age of sexual initiation/ behavior-related risk
factors.
• 21 to 29 years: Screening every 3 years with
cytology alone.
• 30 to 65 years: Co testing with cytology & HPV
testing every 5 years is preferred or Screening
every 3 years with cytology.
• > 65 years: screening by any method should be
discontinued with evidence of adequate
negative prior test results & no history of CIN 2
or higher.

21. • Adequate negative prior screening : 3
consecutive negative cytology reports within
10 years or 2 consecutive negative co testing
reports within the past 10 years, the most
recent within the past 5 years.
• Routine cytology & HPV testing should be
discontinued in women who have had a total
hysterectomy (removal of cervix) & no history of
CIN 2 or greater in the past 20 years. Women who
have undergone supracervical hysterectomy
should continue routine screening.

22. • Women with a history of CIN 2, CIN 3, or
adenocarcinoma in situ should continue
screening for a total of 20 years after
spontaneous regression or after appropriate
management of CIN 2, CIN 3, or
adenocarcinoma in situ, even if it extends the
screening past age 65 years.

23. Exceptions:
• Infected with HIV,
• Immunocompromised,
• Exposed to diethylstilbestrol in utero,
• Previously treated for CIN 2, CIN 3, or cancer

24. Immunocompromised
patients
With HIV ,
screening should
commence
within 1 year of
sexual activity,
no less than age
21 years.
Women aged 21
to 29 should
recieve Pap
smear testing at
the time of HIV
diagnosis.
If initial Pap test
is negative,
testing should be
repeated at 6 or
12 month later,
then continued
every 12 months.
After 3
consecutive
negative smears,
the interval of
testing can be
increased to 3
years.

26. VILI
VIAM

27. CERVICAL CYTOLOGY
The abnormal cells of cervical neoplasia exfoliate
and can be collected by scraping the cervix and
staining the smear.
• It is by 2 methods ,
• Conventional cytology – PAP
smear
• Liquid based cytology – LBC

28. Conventional cytology – PAP
smear
The conventional method of
screening was introduced by
Papanicolaou and is known
as Pap smear or Pap test.
The cervix is visualized using
a bivalved speculum and the
ectocervix is scraped using
an ayres spatula and the
endocervix using a
cytobrush.
The cells are smeared on a
glass slide and fixed in a 1:1
mixture of 95 % ethanol and
ether. Alternatively, the
smears may be fixed with a
fixative spray.
They are stained with
Papanicolaou stain and
examined.
It has a poor sensitivity (51%)
and high false negative rate
(49%) although specificity is
high (98%).

29. Clinical information aids accurate Pap
interpretation :
• Date of last menstrual period,
• Current pregnancy,
• Exogenous hormone use,
• Menopausal status,
• Complaints of abnormal bleeding,
• Prior abnormal Pap test results, CIN, or other
neoplasia.
• IUDs can cause reactive cellular changes

30. Performing a Pap smear:
Full visualization of the cervix. Identify SCJ.
Avoid douching the cervix prior to performing a Pap test (dysplastic epithelium may be
removed with minimal trauma.)
Discharge covering the cervix may be carefully absorbed by a large swab. Vigorous blotting or
rubbing may cause scant cellularity or a false-negative Pap test result.
Sampling of the transformation zone at the SCJ –increased sensitivity of the Pap test.
Women known or suspected of in utero DES exposure may also benefit from a separate Pap
test of the upper vagina, as these women carry an additional risk of vaginal cancer.

31. • Commonly used to sample the cervix:
• the spatula,
• broom
• endocervical brush (also known as a cytobrush)
• Straddle the squamocolumnar junction, sample the distal endocervical
canal- at least one full rotation with spatula.
• After that, the endocervical brush, is inserted into the endocervical
canal only until the outermost bristles remain visible just within the
external os, the brush is rotated only one-quarter to one- half turn.
• Broom - Five rotations in the same direction are recommended.
Reversing direction may cause loss of cellular material.

32. For a minimum of 24 to 48 hours before Pap tests:
• avoid menstruation
• abstain from vaginal intercourse, douching, vaginal tampon use
• avoid intravaginal medicinal or contraceptive creams
Treatment of cervicitis or vaginitis prior to Pap testing is
optimal.
However, Pap testing is not deferred due to
unexplained discharge or unscheduled bleeding, as
these may be signs of cervical or other genital tract
cancers.

33. • Cytology Collection
• Avoid air drying artifact (cause of poor slide quality).
• The spatula sample is quickly spread as evenly as
possible over one half to two thirds of a glass slide.
• The endocervical brush is firmly rolled over the
remaining area of the slide, after which fixation is
quickly carried out by spraying from a distance of 10
to 12 inches or immersing the slide in a fixative.

34. • Liquid based cytology
• The cells are scraped using a special broom collected in a
liquid medium and transported to the lab.
• It is processed , a smear of monolayer of cells is made and
fixed.
• Drying distortion is eliminated. Blood and other cells that
interfere with interpretation are removed.
• The residual sample can also be used for HPV testing.
• Broom devices are favored for liquid-based Pap testing.

35. Currently, two liquid-based
cytology (LBC) Pap tests are
FDA approved:
SurePath allows or the use
of all three device types but
uses modified tips that are
broken off and sent to the
laboratory in the liquid
medium.
ThinPrep requires
immediate and vigorous
agitation of the chosen
collection device(s) in the
liquid medium, after which
the device is discarded.

36. Cervical cytology reporting is
standardised by Bethesda
system of nomenclature.

38. Unsatisfactory Pap smear samples are unreliable
for the detection of cervical neoplasia.
These samples are repated in 2 to 4 months.
If atrophy or an infection is present, treatment
before repeat cytology may be helpful.
If sample is unsatisfactory again, colposcopy is
recommended.

39. Management of abnormal cytology

45. Primary
HPV
Testing
Role of HPV testing in cervical cancer is attractive because of its
greater immediate sensitivity for CIN 3 or cervical cancer and the
objectivity of its results.
HPV testing is usually performed from the residual LBC Pap
medium after the cytology slide is prepared.
Alternatively a cervical sample can be obtained separately.
HPV testing reduces cervical cancer mortality in resource-limited
settings and is superior to VIA or cervical cytology.

46. Tests to detect high risk HPV DNA are commonly used – usually 13 high
risk types.- hybrid capture or polymerase chain reactions are used.
Tests for RNA are also available.
HPV genotyping test are available for individual HPV types especially 16
and 18.
These tests have more sensitivity than cytology and high negative
predictive value.

47. • Sensitivity is 98 % and specificity is 85%. (low test
specificity may result in large numbers of patients being
treated unnecessarily.)
• The disadvantage of HPV testing was that more
patients underwent colposcopy and ultimately had
negative findings.
• It is recommended as a primary testing method for
women >25 years of age.

48. • It can be used for:
• Primary testing- maybe used alone for cancer
screening.
• Co-testing- used along with cytology to
improve sensitivity and screening interval
increased to 5 years. Not recommended for
women < 30 years- due to high prevalence of
HPV infection in this age group and resultant lack
of test specificity.
• Reflex testing- sample is collected along with
cytology but performed only if cytology is
equivocal. If high risk HPV is found ,colposcopy is
required.

49. Human papillomavirus (HPV) tests capable of
providing a rapid result include
Xpert HPV
(Cepheid)
careHPV
(Qiagen) .
Rapid-result HPV tests

50. Xpert HPV – Xpert HPV uses polymerase chain reaction
(PCR) technology to detect 14 high-risk types of HPV,
including HPV 16 and 18/45. It gives a result within one
hour and is uniquely positioned to provide screening and
treatment in one visit.
CareHPV – careHPV uses PCR technology to detect 14
high-risk types of HPV, similar to the 14 types detected
by the tests used in resource-rich countries. It is
affordable (each test costs less than USD $5), gives
results quickly (within 2.5 hours), and is portable; the
processing kit has its own reagents and water supply and
can be run using batteries.

53. • Visual inspection of the cervix after application of Lugol iodine, the first
method used for cervical cancer screening, was introduced in the 1930s
by Schiller.
• -poor specificity
• -almost entirely replaced with the advent of cervical
cytology.
• Visual inspection of the cervix has reemerged as a screening tool for
low-resource settings,
• economical and provides immediate results.
• Visual Inspection with Acetic Acid (VIA)
• Visual Inspection with Lugol Iodine (VILI).
VIA,
VILI
& VIAM

54. • Active cervicitis is treated before visual inspection because inflammation and infection
impede accurate assessment of epithelial abnormalities.
• Although vaginal infections do not interfere with evaluation, treatment before visual
inspection may allow the patient to be more comfortable during the examination.

55. Visual inspection with acetic acid
(VIA) [ 3 to 5% acetic acid] and
visual inspection with Lugol iodine
(VILI) [4 to 5% Lugol iodine ] have
similar efficacy for the detection of
cervical intraepithelial neoplasia or
cancer.
VILI is more sensitive than VIA but
equally specific. But VIA allows a
more detailed examination of the
cervix and is preferable to VILI.
VIA also allows for some
appreciation of the density of the
acetowhitening, the contour, as
well as vessel changes.
Note: Lugol iodine is a solution of 5
g of iodine and 10 g of potassium
iodide in 100 mL distilled water.
One disadvantage was that there
was there was a significant
decrease in VIA specificity in
patients with HIV infection.

56. ●Position the
patient in
lithotomy
position
●Insert a
speculum into
the vagina
and visualize
the cervix
●Inspect the
cervix and
note any
lesions
●Ensure that
the entire
cervix is
visible and
that the
squamocolum
nar junction is
visible in its
entirety
●Apply either
acetic acid or
Lugol iodine
using a cotton
swab, wait for
one minute
●Inspect the
cervix again
and note any
lesions or
color changes
●Document
the findings

57. When using acetic acid, a positive test is
characterized by
opaque, dense, well-defined acetowhite
areas that touch the squamocolumnar
junction or are close to the external os,
or by the presence of a cervical lesion
that turns acetowhite. The absence of
color change is a negative test.

58. • Acetic acid dehydrates cells so that squamous cells with relatively large or dense nuclei (eg, metaplastic
cells, dysplastic cells, cells infected with human papillomavirus [HPV]) reflect light and therefore appear
white.
• Blood vessels and columnar cells are not affected by acetic acid, but become easier to visualize against
the white background.
• It is important to note that not all acetowhite lesions are diagnostic of cervical precancer or cervical
cancer. The differential diagnosis of an acetowhite lesion includes
• changes associated with HPV infection,
• leukoplakia (caused by chronic irritation)
• squamous metaplasia.

59. So, low grade lesions – dull
white plaques and faint
borders.
High grade lesions – sharp
borders
It does not require expertise,
can be done with minimal
training.
Therefore good for low
resource settings.
•Sensitivity- 60 %
•Specificity- 79%
•PPV- 10 – 20 %
•NPV- 92-97 %

60. • VILI(Schillers test)
• When using Lugol iodine, a
positive test consists of pale
yellow areas against a darker
background; uniform uptake of
stain is a negative test.
• Glycogen-containing cells will
take up iodine and become dark
brown.
• Non-glycogenated cells, such
as normal columnar or
glandular cells, high-grade
lesions, and many low-grade
lesions, will not take up iodine
and remain light yellow.

61. VIAM- Magnification —
Visual inspection with
acetic acid (VIA) can be
combined with
examination of the cervix
with a 2 to 4x magnifying
lens. The addition of
magnification to VIA
(VIAM) does not improve
the detection of CIN or
cervical cancer over VIA.
Speculoscopy —
Speculoscopy is similar to
VIA, with the addition of a
blue-white
chemiluminescent light
source attached to the
upper speculum blade. The
examiner can assess the
cervix for acetowhite
lesions directly or with the
use of limited
magnification (4 to 6x).
Cervicography —
Cervicography refers to
standardized photography
of the cervix after the
application of acetic acid.
In its original design it used
a specially adapted camera
that could take a
photograph very rapidly.
The 35 mm magnified
images can then be
interpreted by qualified
evaluators anywhere in the
world, and the patient
triaged accordingly.
MODIFICATIONS OR ALTERNATIVE TECHNIQUES

62. If VIA is positive
REFER FOR COLPOSCOPY
FOLLOWED BY BIOPSY AND
TREATMENT
REFER FOR COLPOSCOPY
AND TREATMENT BASED ON
COLPOSCOPIC DIAGNOSIS
(SCREEN SEE AND TREAT)
REFER FOR VIAM
FOLLOWED BY BIOPSY AND
TREATMENT
IMMEDIATE TREATMENT
(SCREEN AND TREAT)

63. • Each specimen is individually labeled according to its location
on the cervix (as if taken from the face of a clock) and placed in
a separate, labeled container containing a permanent fixative,
such as 10% formalin.

64. • Optimal screening with VIA or
human papillomavirus (HPV) testing
would reduce the lifetime risk of
cervical cancer by 25 to 36 percent
and cost less than USD $500 per
year of life saved.

65. "Screen-and-treat" (also referred to as "see-and-
treat" or "one-visit") protocols include a screening
test followed in the same visit by treatment of
positive results. This approach is only possible in
settings where screening tests that produce
immediate results (ie, point of care, rapid-result
human papillomavirus [HPV] testing and/or visual
inspection with acetic acid [VIA]) are available.
SCREEN-AND-TREAT PROTOCOLS

66. Advantages and disadvantages
•Provide immediate results (eg, VIA) or results within several hours (eg, rapid-result HPV
testing) and eliminates intermediate steps (eg, colposcopy, histologic sampling).
•Eliminate communication difficulties involved in delivering and interpreting written
results for patients as well as the issue of noncompliance with follow-up.
•Can be performed by trained nurses or paramedical staff, particularly where there are
few or no clinicians, and be performed in a primary health care facility.
•Reduce the rate of high-grade cervical intraepithelial neoplasia (CIN) or cancer.
•Are feasible and accepted by patients.

67. Are more cost-effective than
protocols requiring two or
more visits.
Disadvantages –
careful explanation and
requires additional work on
already overloaded health
care workers and fragile
health systems
Furthermore, treatment
based on results of
screening tests with low
specificity, such as HPV
testing and VIA, will result in
some patients receiving
unnecessary treatment.

68. New innovations
The use of optical devices to either triage HPV testing or to use
as a primary screening test is a new approach under evaluation.
These devices use the technology included in smart phones
(smartphone VIA [S-VIA]) and are able to take pictures of the
cervix and to store data. Essentially, a mobile phone is used as
a colposcopist aid. Ultimately, these devices will rely on
artificial intelligence (AI) but clinical validation is awaited as
algorithms are tested and developed. The use of AI to interpret
cytology specimens has also been described.

69. • Two-visit protocols include a screening test (with
cervical cytology or human papillomavirus (HPV)
testing ) followed by a second (colposcopy ) visit
based on results from the screening test and
starting treatment.
• The three-visit protocol is the standard approach
to cervical cancer screening in resource-rich
settings; this approach typically includes HPV
testing and/or cytology, followed by colposcopy,
and then treatment based on the results of
colposcopic biopsies.
MULTIPLE-VISIT
PROTOCOLS

76. With colposcopy, areas with changes consistent with dysplasia are
identified, allowing directed biopsy (i.e., biopsy of the area where
dysplasia is most likely).
A colposcope is a binocular stereomicroscope with variable
magnification (usually 7× to 15×) and a light source with a green
filter to aid in the identification of abnormal-appearing blood
vessels that may be associated with intraepithelial neoplasia.
Colposcopy

79. Colposcopic criteria, such as white epithelium, abnormal vascular
patterns, and punctate lesions help identify such areas.
To facilitate the examination, the cervix is washed with a 3% to 4%
acetic acid solution, which dehydrates cells, causing those with large
nuclei (i.e., those undergoing metaplasia, dysplasia, or HPV infection)
to appear white.
Lesions usually appear with relatively discrete borders near the SCJ
within 10 to 90 seconds of acetic acid application.
Tissue samples for biopsy can be collected; the number of samples
obtained will vary depending on the number and severity of abnormal
areas found.

80. Visualization of the entire SCJ is required for a
colposcopy to be considered satisfactory.
If the SCJ is not visualized in its entirety, or if the
margins of abnormal areas are not seen in their
entirety, the colposcopic assessment is termed
unsatisfactory, and other evaluations such as
cervical conization and endocervical curettage
(ECC) are indicated.

81. Acetic acid in a 3- to 5-percent
solution is a mucolytic agent
thought to exert its effect by
reversibly clumping nuclear
chromatin. This causes neoplastic
lesions to assume a thicker density
and hue or white depending on the
degree of abnormal nuclear density.
Applying acetic acid to abnormal
epithelium results in the aceto-white
change characteristic of neoplastic
lesions. Several minutes may be
needed or this effect to become
fully developed.

82. Dilute Lugol iodine solution, stains mature squamous epithelial cells
a dark purple-brown color in estrogenized women as a result of
high cellular glycogen content.
Due to incomplete cellular differentiation, dysplastic cells have
lower glycogen content, fail to fully stain, and appear various
shades of yellow. This solution is particularly useful when
abnormal tissue cannot be found using acetic acid alone.
It is also used to define the limits of the active Zone, as immature
squamous metaplasia does not stain as strongly as mature ( fully
differentiated) squamous epithelium.
Lugol solution should not be used in patients allergic to iodine,
radiographic contrast, or shellfish.

84. General colposcopic assessment has three
components:
cervical visualization,
SCJ visibility, and
Z classification.

85. • The IFCPC (international federation of cervical pathology and
colposcopy)
• labels full cervix visualization as “adequate” and otherwise as
“inadequate.”
• Second, SCJ visibility is important, as nearly all cervical
neoplasia is located within the Z and at or adjacent to the SCJ.

86. If treatment is indicated, the size and location of the SCJ, Z, and visible lesions are important determinants of the
modality chosen.
Types 2 and 3 may have ectocervical Z components of varying extent.
The IFCPC classifies the Z location
A type 1 Z is entirely ectocervical and
visible;
a type 2 has an endocervical component
that is fully visible;
type 3 Z has an endocervical component
that cannot be completely visualized.
Therefore, the ability to see the entire SCJ and the upper limit of all lesions is essential to exclude invasive cancer and
to determine disease severity. – adequate visualization. Otherwise inadequate.

88. Colposcopically, normal squamous
epithelium of the cervix appears
as a featureless, smooth, pale-
pink surface. Blood vessels lie
below this layer and therefore are
not visible or are seen only as a
fine capillary network.
The mucin-secreting columnar
epithelium appears red due to its
thinness and the close proximity
of blood vessels to the surface. It
has a polypoid appearance due to
infoldings that form peaks and
clefts.
Lesion Grading

93. • Post colposcopy Surveillance without Treatment
• When colposcopy fails to reveal high-grade CIN or there is spontaneous regression o
high-grade CIN in young women, further surveillance is indicated given the significant false-
negative rate of colposcopy and an increased risk of developing CIN in the future. This
involves repeat cytology, HPV testing, or colposcopy alone or in combination depending on
the
• original abnormal cytology result and age of the patient. Early surveillance generally is
either cytology or co-test once or twice at 1-year intervals. Return to routine screening or
an additional co-test generally occurs 3 years later.

95. FOGSI guideline for management of abnormal screening
tests:
It is based on calculated risk of progression to CIN 3 in 5
years.
If risk is
>5 % - colposcopy
2-5 % - repeat testing in 6 – 12 months
0.1 – 2 % - repeat testing in 3 years
< 0.1 % - repeat testing in 5 years (routine screening)

96. Risk of progression to CIN 2 is highest in HPV positive women.
If normal cytology or negativce HPV testing or both – screening
according to guidelines.
If normal cytology and HPV positive – repeat cotesting again in 12
months
If ASCUS cytology risk is only 6.9 % - if its is HPV negative – risk becomes
1 % but if HPV positive – risk becomes 18%. Therefore HPV positive
with ASCUS cytology must undergo colposcopic evaluation.
ASC H has 35 % risk of CIN 2 – therefore need colposcopy irrespective of
HPV status.
Few points to
note :

97. Women with LSIL cytology
without HPV testing has a risk of
progression of 16 %, hence need
colposcopic evaluation. If
colposcopy is negative, repeat
cotesting after 1 year.
All HSIL need colposcopy.
All women with glandular cell
abnormality should be evaluated
by colposcopy and endocervical
curettage.
Endometrial sampling should be
added in women with
adenocarcinoma, endometrial
cells on cytology and AIS.
Women with ASCUS or LSIL who
are <30 yearscan be followed up
with repeat testing after 1 year.
Since HPV infection and
assosciated changes are
transient in younger women,
colposcopy is not indicated.