Perform a colposcopy and endocervical curettage in women under the age of 40. (In contrast to ASCUS management, an ECC is almost mandatory for glandular cell abnormalities since adenocarcinoma, both intraepithelial and invasive, do not produce the visible lesions seen with squamous lesions.) Take endometrial samplings from the following: patients 40 and older, women with endometrial cell abnormalities, and postmenopausal women with normal endometrial cells not receiving any form of hormone replacement therapy.6
If the colposcopy and evaluation of the endocervix or endometrium, as indicated previously, is negative, repeat the smear in 3 months. If a second AGUS smear is reported, repeat colposcopy, loop electrical excision procedure (LEEP), or conization should be performed. However, if colposcopy and evaluation of the endocervix or endometrium is abnormal, proceed directly to LEEP or cone biopsy. Appropriate treatment of endometrial abnormalities should be individualized.
Future screening techniques
Cytology has become much more sophisticated in the past few years. However, it remains a screening test and is still not diagnostic. Never treat a patient based solely on an abnormal smear. Limit “see and treat” protocols to patients with high-grade cytology confirmed by colposcopy.
Currently, HPV testing is being evaluated in many clinical situations. There are more than 100 types of this virus, allowing affected patients to be separated into low- and high-risk groups. However, the value of HPV typing appears to be limited to patients with ASCUS and AGUS Pap smears and the follow-up of patients with histologically proven low-grade dysplasias. In these instances, if a patient has a high-risk HPV type, including 16, 18, 31, or 33, she should be referred for colposcopy. Clinical studies are underway to determine the benefit of HPV typing in all patients.7
New technologies aimed at decreasing the 30% false-negative rate, including computerized screening, speculoscopy, and cervicography, may soon serve to augment conventional Pap test results. However, more studies are needed to fully evaluate their efficacy in cervical cancer screening.
The author reports no financial relationship with any companies whose products are mentioned in this article.