Cervical

Cervical Cancer

  • Cervical cancer is MC caused by human papilloma virus (skin to skin)

    • Risks of cervical cancer are pretty much the risk factors for STI

  • HPV infection ➔ Cervical Intraepithelial Neoplasia (CIN) (premalignant epithelial dysplasia that precedes cervical cancer)

    • Screen for current risk of CIN with cytology (PAP SMEAR)

    • Screen for current and future risk of CIN with HPV testing

      • HPV subtypes 16, 18, 45 have ↑ risk of cervical cancer in 5-10 years

        • HPV-16 ➔ squamous cell carcinoma (usually)

        • HPV-18 ➔ adenocarcinoma (usually)

      • Vaccination recommended to all persons aged 9–26yo (before first sexual contact)

  • SSX

    • Usually asx until late in course of disease

    • Early disease can have spotting, postcoital bleeding, dyspareunia, discharge

    • Later disease ➔ ulcerated/indurated cervix that can adhere

      • Mets ➔ back/pelvix/abd pain and bowel/urinary sx, hydronephrosis

  • DX

    • Colposcopy

      • CIN 1: cervical intraepithelial neoplasia 1 (mild dysplasia)

      • CIN 2: cervical intraepithelial neoplasia 2 (moderate dysplasia)

      • CIN 3 cervical intraepithelial neoplasia 3 (severe dysplasia)

  • TX

    • Surgery, chemo/radiation

Cervical cancer screening

USPSTF/ACOG

  • < 21yo

    • No screening

  • 21-29yo

    • Only Pap test every 3 years

    • 25 to 29yo can have HPV testing alone but Pap preferred

  • 30-65yo

    • Only Pap test every 3 years

    • HPV testing every five years OR

    • Co-test (PAP and HPV test) every five years

  • Start to screen at 21 but only with cytology (Pap) every 3yrs

    • Why? Because this age group can typically clear HPV without having dysplasia

      • PAP > HPV test because high false-positives rates

  • ACS: Start to screen at 25yo but only with HPV testing every 5yrs

    • Why? 21-25yo tend to clear HPV so let's just do HPV every 5 years until 65yo

      • HPV test > PAP because more specific than PAP alone

Cytology (Pap smear) results and follow-up

  • Negative for intraepithelial lesion or malignancy (NILM)

  • Atypical squamous cells of undetermined significance (ASC-US)

  • Atypical squamous cells cannot exclude HSIL (ASC-H)

    • Always get colposcopy (even if pregnant)

  • Low-grade squamous intraepithelial lesion (LSIL)

  • High-grade squamous intraepithelial lesion (HSIL)

  • Atypical glandular cells (AGC)

  • Squamous cell carcinoma (SCC)


  • < 25yo with ASCUS or LSIL and HPV negative: Continue routine screening (PAP q3yrs)

  • < 25yo with ASCUS or LSIL and HPV positive: Repeat cytology in one year

    • If next cytology is unchanged then repeat cytology (again) in one year

    • If 2nd cytology is negative ➔ routine screening

    • If any change in (eg ASC-US ➔ ASC-H) ➔ colposcopy

  • > 25yo:

    • Use hx of previous positive HPV tests and previous PAP results to calculate risk of CIN3+

      • Risk of CIN3+ > 4% ➔ colposcopy

  • TX

    • In office Loop Electrosurgical Excision Procedure (LEEP) OR laser conization

    • General anesthesia cold knife conization