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Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)

Author
Annekathryn Goodman, MD
Section Editor
Barbara Goff, MD
Deputy Editor
Sandy J Falk, MD, FACOG
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INTRODUCTION

The outer surface of the cervix and vagina are lined by cells called squamous cells (picture 1). The canal of the cervix is lined by cells called glandular cells. “High-grade squamous intraepithelial lesion” (HSIL) is the name given to squamous cells on a Pap test (also called a Pap smear or cervical cytology) that appear abnormal and signal an increased risk of squamous cervical cancer. “Atypical glandular cells” (AGC) is the name given to glandular cells on a Pap test that appear abnormal. Glandular cells on a Pap are usually cells from the cervical canal, but may also come from the uterus. A Pap result with AGC means there is a possibility that a precancer or cancer of the cervix or the uterus is present, and should be followed up as soon as possible with a clinician for further testing.

Cervical cancer screening is recommended starting at 21 years old. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)

This topic discusses the management of women whose screening results show HSIL or AGC. The management of women whose screening results indicate atypical squamous cells (ASC) or low-grade squamous intraepithelial lesions (LSIL) is discussed in a separate topic. (See "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)".)

HIGH-GRADE SQUAMOUS LESION (HSIL)

HSIL refers to moderate to severe changes in the cells of the cervix. The risk that these abnormalities reflect precancerous changes is as high as 71 percent, and the risk of cervical cancer is as high as 7 percent [1,2]. However, if the precancerous lesion is removed or destroyed, cervical cancer can usually be prevented.

For most women with HSIL on Pap test, follow-up is a colposcopy. Colposcopy is an examination of the cervix using a type of microscope, which is done in the clinician’s office. Colposcopy is discussed in a separate topic. (See "Patient education: Colposcopy (Beyond the Basics)".)

In some cases, the clinician will advise immediate treatment at the same visit with a loop electrosurgical excision procedure (also called a LEEP or LLETZ). This is a biopsy of the cervix that removes the area of the cervix (called the transformation zone) where precancers and cancers usually develop. This provides a larger amount of tissue to analyze for precancer or cancer and also treats cancer or precancer if either is present.

Immediate treatment is not an option for women ages 21 to 24 because even high-grade lesions often go away without treatment in young women, and there are concerns that treatment may increase the risk of complications in a future pregnancy. Also, immediate treatment is not an option for pregnant women, except if there is a high concern of cervical cancer.

Management after colposcopy is discussed separately. (See "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)".)

SQUAMOUS CELL CARCINOMA

Squamous cell carcinoma is the medical term for the most common type of cervical cancer. A finding of cells that are cancerous (rather than precancerous) on a Pap test is rare, occurring in only 4.5 per 100,000 Pap tests [1]. Women with this result require a biopsy of the cervix, which is usually performed during a colposcopy. (See "Patient education: Colposcopy (Beyond the Basics)".)

If the biopsy confirms that cancerous cells are present, treatment is strongly recommended. The diagnosis and treatment of early-stage cervical cancer is discussed in a separate article. (See "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)".)

ABNORMAL GLANDULAR CELLS (AGC)

Glandular cells develop from the inside of the cervix (called the endocervical canal). Glandular cells can also come from the endometrium (lining of the uterus), the fallopian tube, or the ovary (figure 1).

For most women with atypical glandular cells, colposcopy is performed. (See "Patient education: Colposcopy (Beyond the Basics)".)

If there is concern that there is also a risk of uterine cancer (eg, a family history or irregular or heavy periods), a biopsy of the lining of the uterus (endometrium) may also be performed. This is a procedure performed in the clinician’s office, during which an instrument is passed through the cervix into the uterus to collect tissue for analysis.

In some cases, the lab report shows a specific type of AGC. If the type of cells is most likely from the endometrium, only an endometrial biopsy is performed and a colposcopy is not needed as part of the initial evaluation.

If the type of cells is reported as most likely precancerous, or appears to be adenocarcinoma in situ or adenocarcinoma and there are no findings on colposcopy, a larger cervical biopsy called a cone biopsy may need to be done.

Management after colposcopy is discussed separately. (See "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)".)

SPECIAL CIRCUMSTANCES

Pregnant women — The evaluation of pregnant women with an abnormal Pap test is based upon ensuring the appropriate evaluation of the woman while avoiding pregnancy-related complications. In pregnant women, for example, a biopsy of the cervix is only done if there a high concern regarding a precancerous or cancerous lesion.

If a pregnant woman has a Pap test with high-grade intraepithelial lesion (HSIL) or atypical glandular cells (AGC), a colposcopy should be done.

Postmenopausal women — Postmenopausal women with HSIL or AGC are managed in the same manner as other women with these Pap test findings.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Cervical cancer (The Basics)
Patient education: Pap tests (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)
Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cervical adenocarcinoma in situ
Cervical cancer in pregnancy
Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing
Cervical cytology: Evaluation of atypical and malignant glandular cells
Cervical cytology: Evaluation of atypical squamous cells (ASC-US and ASC-H)
Cervical cytology: Evaluation of high-grade squamous intraepithelial lesions (HSIL)
Cervical cytology: Evaluation of low-grade squamous intraepithelial lesions (LSIL)
Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention
Cervical intraepithelial neoplasia: Management of low-grade and high-grade lesions
Epidemiology of human papillomavirus infections
Preinvasive and invasive cervical neoplasia in HIV-infected women
Screening for cervical cancer

The following organizations also provide reliable health information [3-5].

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

National Cancer Institute

     (www.nci.nih.gov)

American Society for Colposcopy and Cervical Pathology

     (www.asccp.org)

ACKNOWLEDGMENT

The authors and editors would like to recognize Dr. Christine Holschneider, who contributed to previous versions of this topic review.

Literature review current through: Nov 2016. | This topic last updated: Fri Mar 25 00:00:00 GMT+00:00 2016.
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