Restraint Warranted in Pap Tests for Teenagers


BOSTON — Regarding Pap smears in adolescents: Don't do them in the first 3 years after their sexual debut, Dr. Michael S. Policar stressed.

Pap testing in this population is no longer recommended “because it can do more harm than good,” he said. “High-grade lesions are rare in teenagers, occurring in 3 cases per 1,000 15- to 19-year-olds, and they take years to develop. For example, it takes 3 years after sexual debut for high-grade squamous intraepithelial lesions to develop and 5 years for invasive cancers to emerge,” he said at a conference on contraceptive technology sponsored by Contemporary Forums.

Additionally, “approximately 91% of low-grade lesions in teens, such as cervical intraepithelial neoplasia 1 [CIN 1] often resolve spontaneously, while 6% remain stable and only 3% progress to high-grade dysplasia.” Biopsy-proven CIN 2 lesions in teenagers often regress spontaneously, as well, said Dr. Policar. Recognition of these early cytologic abnormalities on Pap testing could easily lead to unnecessary intervention and consequent risks, said Dr. Policar of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco.

For these reasons, the American College of Obstetricians and Gynecologists recommends that Pap testing should not be initiated in young women until age 21 or 3 years after first intercourse, Dr. Policar said. Even so, he noted, many clinicians are still screening virginal 18-year-olds as per the previous guidelines.

Restraint is also warranted in the management of teens whose Pap tests show atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL), Dr. Policar stated.

Although consensus guidelines for the general population call for reflex human papillomavirus (HPV) testing for women with ASC-US and colposcopic examination of the cervix for those with evidence of HPV infection, LSIL, and high-grade squamous intraepithelial lesion (HSIL), these guidelines do not apply to adolescents and young women, he said.

“Colposcopy and reflex HPV triage are no longer recommended as initial options,” he stated, referring to the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for the management of women with abnormal cervical screening tests that were released late last year (Am. J. Obstet. Gynecol. 2007;197:346–55).

Approximately 80% of female adolescents become HPV-DNA positive soon after their first sexual encounters and the majority of these infections clear spontaneously within 2 years.

The identification of abnormal cervical cytology on HPV-DNA testing in adolescents could lead to the unnecessary referral of many teens for colposcopy despite their low cervical cancer risk, Dr. Policar warned.

Rather than immediate colposcopy, adolescents with ASC-US or LSIL on Pap testing should undergo a repeat Pap smear in 12 months. “If the repeat Pap shows high-grade squamous intraepithelial lesions, the adolescent should be referred for colposcopy,” said Dr. Policar. Those patients with less than HSIL, however, should undergo a repeat Pap in another 12 months, at which point, evidence of ASC-US or greater warrants a colposcopy referral, he said.

While the same 24-month conservative pathway should be followed for adolescent patients with biopsy-proven CIN 1 or CIN 2 to allow for regression, the management options for adolescents and young women with a histologic diagnosis of CIN 2,3 include treatment using either excision or ablation of the T-zone depending on the adequacy of the colposcopic exam, or colposcopic and cytologic observation at 6-month intervals for 24 months, “as long as colposcopy results are normal and cytology is negative,” said Dr. Policar.

“If colposcopy worsens or high-grade cytology or colposcopy persists, the biopsy should be repeated,” he said. “If, on repeat biopsy, CIN 3 or CIN 2,3 persists for 24 months [the initial diagnosis], treatment should be undertaken to reduce the potential risk of cervical cancer.”

Dr. Michael Policar disclosed that he is a speaker for Graceway Pharmaceuticals LLC, Merck & Co., and TyRx Pharma Inc.

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