ALGORITHM 1: PAP & HIGH-RISK HPV SCREENING …

1 Women under 30 years Cytology negativeHigh-risk HPV not recommendedLiquid-basedcytology every 1-2 yearsWomen 30 years and olderCytology negativeHigh-risk HPV negativeNo previous history ofCIN 2 or 3, HIV,immunosuppression or DES exposure in uteroWomen 30 years and olderCytology negativeHigh-risk HPV positiveRepeat liquid-based cytology & HIGH-RISK HPV testingin 12 monthsCytologynegativeHigh-risk HPVnegativeCytology ASC-USHigh-risk HPV negativeALGORITHM 1: PAP & HIGH-RISK HPV SCREENING GUIDELINESL iquid-based cytology andhigh-risk HPV testing every 3 yearsRescreen withliquid-based cytology & high -riskHPV DNAin 12 monthsandLiquid-based cytology and HIGH-RISK HPVtesting every 3 yearsresultresultyesyesCytologynegative HIGH-RISK HPV positiveColposcopy*yesresultWomen 30 years and olderCytology negative x3 consecutive screensyesyesyes* Post-colposcopy follow-up per ASCCP guidelinesThere is no role for the useof routineHPV DNA testing in women in this age groupALGORITHM 2.

2 SCREENING GUIDELINES FOR WOMEN WITH HYSTERECTOMY AND OLDER WOMENW omen with supracervicalhysterectomy(cervix still intact)Screen according to the guidelines for women without hysterectomyDocument & confirmIfIfyesWomen older than 70 yearswith an intact uterus and cervixCytology negative x3 consecutive screens and no abnormal Pap tests in the last 10 years*History of cervical cancer, HIV,immunosuppression or DES exposure in uteroyesIfMay discussdiscontinuationof SCREENING withpatientIfContinue Pap tests as long as physically able* Risk factors for the development of cervical carcinoma should be assessed on an ongoing basis and taken into consideration when deciding how often and for how long to screen with completehysterectomy(cervix removed)History of benign disease such as fibroids or endometriosis and no prior abnormal Pap tests or cervical cancerHistory of DES exposure,pre-cancerous lesionsor any GYN cancerMay choose to discontinuescreeningContinue Pap testing of the vaginal cuff according to diversemanagement guidelinesWomen over 20 yearsCytology ASC-USHigh-risk HPV negativeRepeat liquid-based cytology & HIGH-RISK HPV DNAin 12 monthsCytologywith any resultHigh-risk HPVpositiveCytologynegativeHigh-risk HPVnegativeresultColposcopy*Repeat cytologyin 12 monthsyesyesWomen over 20 yearsCytology ASC-USHigh-risk HPV not done resultresultyesyesyesALGORITHM 3.

3 AGE SPECIFIC MANAGEMENT OF ASC-US PAP FINDINGSW omen over 20 yearsCytology ASC-USHigh-risk HPV positiveRepeat liquid-based cytology at 6 and 12 monthsyesWomen 20 years and underCytology ASC-USHigh-risk HPV not recommendedRepeat only liquid-based cytology in 12 monthsHigh-risk HPV not recommendedyesCytology HSIL or greaterCytologynegative, ASC-US, ASC-H or LSILC olposcopy*yesRepeat only liquid-based cytology in 12 monthsHigh-risk HPV not recommendedyesresultresult* Post-colposcopy follow-up per ASCCP guidelinesyesyesCytology at 6 and 12 months negativeCytologyASC-US or greaterColposcopy*Routine ScreeningColposcopy*CytologynegativeColp oscopy*CytologyASC-US orgreaterRoutine screeningCytology ASC-USor greaterHigh-risk HPV negativeWomen any ageCytology AGC or AIS*Close post-colposcopy follow-up per ASCCP guidelines is essential in the management of AGC Pap findingsColposcopy* (with endocervical sampling) ANDHigh-risk HPV DNA testingANDE ndometrial sampling**If >35 years OR at any age if at risk for endometrial neoplasiaWomen any ageCytology AGC or AIS with atypical endometrial cellsEndometrial samplingAND Endocervical samplingEndometrial abnormalitiesNo endometrial pathologyyesyesyesyesresultresultALGORIT HM 4: MANAGEMENT OF AGC PAP FINDINGSC olposcopy* AND HIGH-RISK HPV DNA testingFollow-up as appropriate forendometrial pathologyyesIf pregnantEndocervical cells/transformation zone not present with intact cervixRescreen postpartumMay repeat cytology in 12 months UNLESS one ormore of the following existSignificant clinicalhistory such as abnormal bleeding, discharge or spottingALGORITHM 5.

4 MANAGEMENT OF OTHER PAP FINDINGS - PART IInsufficient frequency of previous screeningImmuno-suppressionA positivehigh-risk HPVresult Within the past 12 monthsInabilityto clearlyvisualize orsample the endocervical canalPrevious cytologywith unexplainedglandular abnormalityPrevious abnormalcytology without3 subsequent negative resultsIfIfyesManage result per guidelinesRepeat liquid cytologyin 3-6 monthsPreviously obscured byinflammation, attempt to clearinflammatory process prior to repeatSpecimen unsatisfactory for evaluation (unsatisfactory indicates >75% of cells are not interpretable)Cytologyrepeatedlyunsatisf actoryRefer for furthergynecologic evaluation, possiblecolposcopyRepeat cytologyIn 6 monthsyesIf positiveIf negativeyesReview clinical history** Review clinical history-if significant positives on cancer SCREENING ( abnormal bleeding, spotting, discharge, post coital staining) further evaluation is needed, including possible colposcopy, endocervical curretage or endometrial biopsy** See Algorithim 4** Post-colposcopy follow-up per ASCCP guidelinesALGORITHM 6.

5 MANAGEMENT OF OTHER PAP FINDINGS - PART IIBlood or obscuring inflammationCytologyunsatisfactory for evaluationCytology otherwise negativeRepeat liquid-based cytology in 12 monthsif patient does not meet high risk criteria**yesyesIf unavailableresultresultNormal in postmenopausalwomen but result may show ASC-USIn settingof ASC-US,perform HIGH-RISK HPV testingColposcopy**May administer conjugated estrogen vaginally atbedtime for 4 weeks(if not contraindicated)Repeat cytology one week post treatmentIf HIGH-RISK HPV positiveAtrophyRepeat liquid-based cytologyin 3-6 monthsIf cytology after estrogen reveals ASC-US or greater, refer for colposcopy*resultresultIf cytology after estrogen is negative, repeat cytology In 4-6 monthsCytology negative, return to regular SCREENING intervalCytology ASC-US or greater, refer for colposcopy**yesIf evaluation not possibleTrichomonasInfectionEvaluate for symptoms, perform wet mount and/or culture if availableAntibiotictreatment Is reasonable iftrichomonasdetected on cytologyIfyesBenign appearing endometrial cells in a woman over 40 yearsIncreasedrisk of endometrial cancer, perform endometrial biopsyNote LMP.

6 In the absence of risk factors for endometrial cancer, continue routine careper guidelines.