Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
Discuss the purpose and importance of the Pap smear, determine whether a Pap smear
was truly obtained during the last clinic visit, explain the need for a Pap smear each
year (prevalence studies have found that precursor lesions for cervical cancer occur
approximately 5 times more often among women attending STD clinics than among women
attending primary care clinics). If a Pap smear is not ultimately obtained during this
examination, give her names of local providers or referral clinics that can obtain Pap
smears and adequately follow up results. Of note, health-care providers should be aware
that, after a pelvic examination, many women may believe they have had a Pap smear when
they actually have not, and therefore may report they have had a recent Pap smear. A woman
may benefit from receiving printed information about Pap smears as well as a report
indicating that a Pap smear was obtained during the visit and the result for her records
if possible.
Answer 2
A specific underlying infection should be treated and then repeat Pap smear is
obtained within 3 months. If the inflammation is nonspecific, the Pap smear should be
repeated after 2-3 months and repeated every 4-6 months for 2 years until the results of
three consecutive smears have been negative.
Answer 3
Low grade SIL encompasses cellular changes associated with HPV and mild
dysplasia/cervical intra epithelial neoplasia (CIN 1). High-grade SIL includes moderate
dysplasia/CIN 2, severe dysplasia/CIN 3, and carcinoma in situ (CIS)/CIN3. The following
recommendations are summarized from the Interim Guidelines for Management of Abnormal
Cervical Cytology published by the National Cancer Institute Consensus Panel: Notify the
patient and arrange for appropriate follow-up. Appropriate follow-up of Pap smears showing
a low-grade SIL or ASCUS may include a repeat Pap smear every 4-6 months for 2 years until
the results of three consecutive smears have been negative or referral to a health-care
provider who has the capacity to provide a colposcopic examination of the lower genital
tract and cervical biopsy if indicated. If persistent abnormalities are detected on
repeated smears, colposcopy and directed biopsy are indicated for low-grade SIL and should
be considered for ASCUS. High-grade SIL should be referred.
Answer 4
In the absence of coexistent dysplasia, treatment is not recommended for
subclinical genital HPV infection. Pap smear diagnosis of HPV does not always correlate
with detection of HPV DNA in cervical cells. Cell changes attributed to HPV in the cervix
are similar to those of mild dysplasia and often regress spontaneously without treatment.
In the presence of coexistent dysplasia, management should be based on the grade of
dysplasia. Tests that detect several types of HPV DNA or RNA in cells scrapped from the
cervix are available, but the clinical utility of these tests for managing patients is
unclear.
Answer 5
Genital warts are generally benign growths that cause minor or no symptoms aside
from their cosmetic appearance and are most commonly caused by HPV types 6 or 11. Other
HPV types (16, 18, 31, 33, 35) have been strongly associated with cervical dysplasia and
other genital neoplasia. These types of HPV infections are usually associated with
subclinical infection, but occasionally are found in exophytic warts.
The primary goal of treating visible genital warts is the removal of symptomatic warts. No evidence indicates that currently available treatments eradicate or affect the natural history of HPV infection. The removal of warts may of may not decrease infectivity. Treatment of external genital warts is not likely to influence the development of cervical cancer. A multitude of randomized clinical trials and other treatment studies have demonstrated that currently available therapeutic methods are 22-94% effective in clearing external exophytic genital warts, and that recurrence rates are high (usually at least 25% within 3 months). If left untreated, genital warts may resolve on their own, remain unchanged, or grow. In placebo-controlled studies genital warts have cleared spontaneously without treatment in 20-30% of patients within 3 months.
Recommended Treatments for External Genital Warts
Patient applied:
Podofilox 0.5% solution or gel applied with cotton swab or finger twice daily for 3 days followed by four days of no therapy. Repeat as necessary for a total of four cycles. (Safety in pregnancy not established)
Imiquimod 5% cream applied with a finger at bedtime three times a week for as long as 16 weeks.
Provider administered:
Cryotherapy with liquid nitrogen or cryoprobe. Repeat every one to two weeks.
Podophyllin resin 10%-25% in compound tincture of benzoin. Apply a small amount to each wart and allow to air dry. Repeat weekly as necessary. (Safety in pregnancy not established)
TCA or BCA 80%-90%. Apply a small amount only to warts and allow to dry. Cover white "frosting" with talc or sodium bicarbonate to remove unreacted acid. Repeat weekly as necessary.
Alternative treatments:
THE MMWR REFERENCE, 1998 GUIDELINES FOR TREATMENT OF SEXUALLY TRANSMITTED DISEASES SHOULD BE CONSULTED BEFORE ATTEMPTING ANY OF THE ABOVE TREATMENTS. THE GUIDELINES ALSO CONTAIN INSTRUCTIONS FOR TREATMENT OF WARTS INVOLVING THE CERVIX, VAGINA, URETHRAL MEATUS, ANUS AND ORAL CAVITY.