Abnormal Pap Follow Up Plan


Knowing what to do next after an abnormal pap can be both confusing, anxiety producing and a matter of the prevailing gynecologic thought. Your own gyno may not be practicing according to the most recent guidelines. The guidelines are confusing, the possible alternatives may involve tests that are very expensive or are not available in your area, and your gyno may be taking factors in your case into consideration that do not adhere to the guidelines exactly. So if you thing your gyno has been changing her mind, you are lightly right, but you may also have choices. We are most concerned with women who have been diagnosed with the most severe pap smear changes that are not cervical cancers, but have to be carefully monitored.Moderate and severe dysplasia, also called CIN II and III is diagnosed in 500,000 American women each year. It is out of this group that cervical cancer will develop. So when advising as to follow up testing, we are trying to give you the best risk prediction regarding your personal chance of having cervical cancer. Aggressive diagnosis and treatment has lead to successful prevention of cancer and death. But too aggressive treatment in a young patient is not necessary to prevent the risk of cervical cancer. This is why we don't test those under 21 and if you are under 21 you may be suddenly have been told you do not need follow up tests for an abnormal pap. Most of the studies tell us exactly what your risk is if you have a abnormal pap today. It is important to know your HPV status, and now we also want to know the exact HPV you are infected with, that is done with an HPV DNA test. And if you have advanced dysplasia you need to be treated. Once you are treated, you have to have a follow up plan. But then what is next after this round of treatment for an abnormal pap? Here is where guidelines for care have gotten a bit confusing. Choice and careful follow up is usually the best. Have you had children? Are you planning pregnancy? Do you have immune system problems (HIV), and have you gotten the HPV vaccine? All possible factors in what you will be told to do. For many of us who treat young women it’s important to be able to discuss what may be recommended by the next gyno, as many women will move and have several gynos over time and several follow up strategies offered. Your abnormal pap condition may have been treated, but remember, the virus or the condition that led to the acquisition of the virus is often still present, and the future gyno plan is debated among experts, as explained in the November "Green Journal" Obstetrics and Gynecology, talks about women who have been completely treated, with clear margins on LEEP or conizations (operations to clear the CIN) can be followed by some combination of pelvic exams, HPV tests, type specific HPV plans, pap smears and colposcopies. And the guidelines do offer some flexibilities. No where do women have unlimited medical coverage for these follow up tests, so that cost effectiveness was the goal of the recent study undertaken by the newest group to look into this. The article clearly states that the precise order of tests, the timing of the tests, and the number of tests that an individual woman should have to maximize safety or to be reasonably safe has actually  not yet been determined. This article evaluated 12 (!)  different strategies on the most moderate risk individuals, as women with extensive residual disease, and multifocal (lots of spots, like in the vagina as well as on the cervix, or in the rectum) disease are the most high risk. They don't talk about women who have complicating STDs like HIV, Herpes or CT at the time of follow up, those are also separate cases. There have been no studies that link your contraception to any change in follow up, but we know estrogen and progesterone effect the cells of the cervix, and the inner cervix. Other strategies are possibly as effective or more effective, than those that are in the current guidelines, just so women can know that they need to understand some basics when evaluating what advice they are getting. For technical reading go to the ASCCP. So, to make this clear, you need to sit down with your gyno and come up with a personal plan, based on your own goals, and your own risks, and your own cost effectiveness thoughts.

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