CERVICAL CANCER SCREENING OVERVIEW The Pap smear (Pap test) is a test used to screen women for cervical

precancer or cancer. Testing for human papillomavirus (HPV) is another type of test for cervical cancer sometimes used in women over age 30; HPV testing can be used alone or along with a Pap test. Pap tests find cervical cancer and precancer in the early stages when it can be treated, and thus may reduce the number of deaths from cervical cancer. This article reviews tests used to screen for cervical cancer and a description of both normal and abnormal Pap test results. The evaluation and treatment of abnormal Pap tests are discussed separately. (See "Patient information: Management of atypical squamous cells (ASC-US and ASCH) and low grade cervical squamous intraepithelial lesions (LSIL)" and "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)" and "Patient information: Treatment of precancerous cells of the cervix".) CERVICAL CANCER RISK FACTORS The most important risk factor for cervical cancer is infection with the human papillomavirus (HPV). There are over 100 different types of HPV, however most types of HPV do not cause cancer. At least 80 percent of women are exposed to the HPV virus during their lifetime. Most of the time, the body's immune system gets rid of the virus before it does harm. Researchers have labeled the HPV types as being high or low risk for causing cervical cancer.

Low risk types HPV types 6 and 11 can cause genital warts and are lowrisk types because they rarely cause cervical cancer. (See "Patient information: Genital warts in women".) High risk types HPV types 16 and 18 are considered high-risk types because they may cause cervical cancer in some women.

HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching an object, such as a toilet seat. In 2006, a vaccine became available in the United States to

help prevent infection with certain types of HPV. (See "Patient information: Human papillomavirus (HPV) vaccine".) Most people who are infected with HPV have no signs or symptoms. Most HPV infections are temporary and resolve within two years. When the virus persists (in 10 to 20 percent of cases), there is a chance of developing cervical precancer or cancer. However, it usually takes many years for HPV infection to cause cervical cancer. CERVICAL CANCER SCREENING TESTS There are several ways to screen for cervical cancer. The traditional screening test is called a Pap test. Pap smear The Pap test is a method of examining cells from the cervix (picture 1). The cervix is located at the lower end of the uterus (figure 1). To perform a Pap test, a doctor or nurse will perform a pelvic exam and use a small brush or spatula to collect cells from the cervix. The cells are smeared on a glass slide (called a traditional Pap smear) or added to a preservative fluid (called liquidbased, thin layer testing). HPV testing An HPV test can be done along with a Pap test or as a separate test. Like a Pap test, the HPV test is done during a pelvic exam, using a small brush to collect a sample from the cervix. If you are 30 years or older, your doctor or nurse may recommend HPV testing in addition to a Pap test. If your HPV test and Pap test are negative, repeat testing is not usually needed for 3 years. HPV testing may also be done if the results of your Pap test results are unclear. Women who are under age 30 are not usually tested for HPV because many women in this age group have temporary infections, which will go away without treatment. Even if you have had a vaccine for human papillomavirus, you will still need cervical cancer screening. (See "Patient information: Human papillomavirus (HPV) vaccine".) WHO SHOULD HAVE A PAP SMEAR?

Younger women In the United States, the first Pap test is recommended at age 21; some other countries suggest that screening begin at age 25. Cervical cancer is very rare in younger women. In the past, experts recommended that every woman have a Pap test every year. This has changed, and Pap testing is suggested every one to two years for most women age 21 to 29 years old, and every two to three years for most women age 30 or older. In women who are 30 or older, the time between Pap tests may vary depending on the results of human papillomavirus testing. A womans other risk factors for cervical cancer may also affect these recommendations. Older women Most experts feel that women who are 65 years or older can stop having Pap tests if:

You have had Pap tests on a regular basis in the past You have had at least three normal Pap tests in a row and no abnormal Pap tests in the past 10 years

After hysterectomy Women who have had a total hysterectomy (your uterus and cervix were removed) do not need a Pap test, unless:

The hysterectomy did not remove your cervix (eg, if the hysterectomy was "subtotal") Your hysterectomy was done because of cervical cancer or precancer You were exposed to diethylstilbestrol (DES) during your mother's pregnancy.

PREPARING FOR YOUR PAP SMEAR For two days before your Pap test, do not put anything in you vagina (eg, spermicide, creams). A Pap test can be done at any time during your menstrual cycle. PAP SMEAR RESULTS The results from your Pap test will be available a few weeks after your visit. Pap test results may be reported as: Negative Pap tests that have no abnormal, precancerous, or cancerous cells are labeled as "Negative for intraepithelial lesion or malignancy".

Abnormal results Cervical cells may appear abnormal for a variety of reasons. For example, you may have a cervical infection, or you may have a precancerous area or even cervical cancer. Follow up testing If your Pap test is abnormal, or if your Pap test is normal but your HPV test is abnormal (positive), you may need follow up testing; the best strategy depends on several individual factors. Follow up for abnormal Pap tests is discussed separately.

Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)
INTRODUCTION Squamous cells make up the outer layer of the cervix and vagina (picture 1). Atypical squamous cells (ASC) is the name given to squamous cells on a Pap smear or cervical cytology that do not have a normal appearance but are not clearly precancerous. Low grade squamous intraepithelial lesions (LSIL, also called low grade cervical intraepithelial neoplasia) refers to cells that appear slightly abnormal. Women who have ASC or LSIL require further testing because some women with these findings have a precancerous lesion of the cervix. This topic review discusses the management of women with ASC and LSIL. The management of women with high grade squamous intraepithelial lesions (HSIL) and atypical glandular cells (AGC) are discussed in a separate topic review. (See "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)".) ATYPICAL SQUAMOUS CELLS (ASC) ASC is subdivided into atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot rule out a high grade lesion (ASC-H). The risk of a high-grade precancerous lesion in women with ASC-US is 15 percent and for those with ASC-H, the risk is 38 percent [1].

Atypical squamous cells of undetermined significance (ASC-US) In women older than 20 years, there are three options for evaluation of a single ASC-US result. Women who are pregnant or younger than age 20 years are evaluated differently (see 'Adolescents' below and 'Pregnant women' below).

Perform HPV testing. This is the preferred follow up for ASC-US. HPV testing is often done at the same time as the Pap smear. This is convenient because a woman does not have to return for a second visit. HPV testing is described in detail in a separate topic review (see "Patient information: Cervical cancer screening"). Women who test positive for HPV types that are high risk for cervical cancer should have colposcopy because they are at greater risk of having an underlying precancerous lesion. Women who test negative for HPV are not likely to have cervical precancer. These women should have a repeat Pap smear in one year. In most cases, the ASC-US resolves during this time. Repeat the Pap smear in six months. If this test is normal, it is repeated once more after another six months until there have been two normal tests in a row; the woman can then return to routine screening. If the woman has a second ASC-US result or a more severe abnormality develops, colposcopy is recommended. (See 'Colposcopy' below.) Have colposcopy. (See 'Colposcopy' below.)

Atypical squamous cells, cannot rule out a high grade lesion (ASC-H) ASC-H is more likely than ASC-US to be caused by a precancerous change. This finding requires further evaluation with colposcopy (see 'Colposcopy' below). LOW-GRADE SQUAMOUS LESION (LSIL) LSIL is usually caused by mild cellular changes. Further testing with colposcopy and cervical biopsy is almost always recommended for women with LSIL because 12 to 16 percent of women with LSIL have a precancerous lesion [2,3]. However, adolescents and postmenopausal women are evaluated somewhat differently (see 'Adolescents' below and 'Postmenopausal women' below). Pregnant women are evaluated similarly to non-pregnant women but are also discussed separately below. The management of women with LSIL depends upon what is seen with colposcopy and biopsy (see 'Management after colposcopy' below); most clinicians will delay biopsy until after delivery in pregnant women (see 'Pregnant women' below). COLPOSCOPY Colposcopy is an office procedure that allows a clinician to closely examine the cervix. It is commonly performed after an abnormal Pap smear. Colposcopy is performed similar to a pelvic examination, while the woman lies on an exam table. A speculum is used to view the cervix, and the viewing device (called a colposcope) remains outside the woman's body (picture 1).

The colposcope magnifies the appearance of the cervix. This allows the clinician to better see the location and size of any abnormalities, and also to see any changes in the capillaries (small blood vessels) on the surface of the cervix. During colposcopy, a small piece of the abnormal area can be removed (biopsied). Anesthesia (numbing medicine) is not needed because the biopsy causes only mild discomfort or cramping. Some women also need to have a biopsy of the inner cervix during colposcopy; this is called endocervical curettage (ECC). Endocervix refers to the inner cervix and curettage means scraping. Pregnant women should not have ECC because it may disturb the pregnancy. Management after colposcopy Most women who have colposcopy have a biopsy of any abnormal-appearing areas. The biopsy samples are sent to a pathologist, who determines if there is any evidence of precancerous changes, termed cervical intraepithelial neoplasia (CIN). These changes are categorized as being mild (CIN 1) or moderate to severe (CIN 2 or 3).

CIN 1 biopsy in women with Pap smear results that were ASC-US, ASC-H or LSIL cytology Follow-up is recommended with either HPV testing at 12 months or a Pap smear at six and 12 months. The reason for this recommendation is that CIN I is a minor abnormality that usually goes away over time without treatment. Waiting and repeating testing allows time for the abnormality to resolve, and also enables the healthcare provider to identify the few situations in which the abnormality has become more severe. Repeat colposcopy is recommended if the results of the follow-up Pap smear are ASC or greater or if the HPV test is positive. Women with two consecutive negative repeat cytology results or a negative HPV test can resume routine screening. CIN biopsy in women with Pap smear results that were high-grade SIL (HSIL) or atypical glandular cells-not otherwise specified Follow-up can be one of three options: (1) Pap smear and colposcopy every six months for a year; (2) re-review of both Pap smear and biopsy results by a pathologist; or (3) a procedure to remove a larger piece of tissue from the cervix (cone biopsy or loop electrosurgical excision procedure [called LEEP, loop, or LLETZ]). CIN 2 or 3 CIN 2 or 3 is usually treated by removing or destroying the abnormal area (using a cone biopsy, LEEP, laser, or freezing procedure). The reason for this recommendation is that moderate to severe precancerous abnormalities (CIN 2 or 3) are unlikely to resolve over time without treatment, and may progress to cancer if left untreated over a period of years. (See "Patient information: Treatment of precancerous cells of the cervix".) However, adolescents and pregnant women are often able to delay treatment (see 'Adolescents' below and 'Pregnant women' below).

SPECIAL CIRCUMSTANCES Postmenopausal women In postmenopausal women, LSIL may be evaluated differently because thinning and drying of the tissues (referred to as atrophy) can cause the cells to appear abnormal. These changes often resolve with time and are often not related to changes caused by HPV. Options for postmenopausal women with LSIL include the following:

Colposcopy HPV testing Repeat Pap smear at six and 12 months

If the HPV testing or repeat Pap smear tests are negative, the woman may return to routine testing. If the HPV test or repeat Pap smear are abnormal (ASC or greater), colposcopy is recommended. The management of postmenopausal women after colposcopy is discussed above (see 'Management after colposcopy' above). Adolescents In adolescent women (age 20 years or younger), abnormal Pap smear is often approached differently because, in this age group, there is a good chance that the abnormal area will resolve over time, without treatment. There is a high rate of HPV infection in this group, but a very low rate of cervical cancer. ASC-US, LSIL, and/or CIN 1 Adolescents with ASC-US, LSIL, and/or CIN 1 are often advised to have repeat Pap smear in 12 months. HPV testing is not recommended because it is likely to be positive and would not affect the recommendation to repeat the test in 12 months.

If the 12 month cytology shows ASC-US, ASC-H, or LSIL, the test is usually repeated 12 months later (at 24 months). If the 12 month cytology shows HSIL or worse, the adolescent is usually advised to have colposcopy (see 'Colposcopy' above).

If the 24 month test is abnormal (ASC-US or greater), the adolescent is usually advised to have colposcopy. If the 24 month test is normal, Pap smear is recommended once yearly. High grade lesions (CIN 2 or 3) Adolescents with HSIL should undergo colposcopy. If cervical biopsy does NOT show HSIL, they can be followed with colposcopy and Pap smear every six months for two years. If cervical biopsy confirms HSIL, they can either be followed with Pap smear and colposcopy or HPV testing until they have had normal testing for one year. If these follow-up results are normal, they can resume routine screening. If follow-up testing shows abnormalities or the cervix cannot be fully evaluated, they will need further testing or removal of a part of the cervix (cone biopsy or LEEP). (See "Patient information: Treatment of precancerous cells of the cervix".) Pregnant women The evaluation and management of pregnant women is different from nonpregnant women because of the risk that trauma to the cervix could lead to preterm labor or delivery.

ASC-US Pregnant women with ASC-US and a positive HPV test may elect to have colposcopy during pregnancy or wait until at least six weeks after delivering their baby. The reason for this recommendation is that cervix appears somewhat different during pregnancy, which can make it difficult to determine if an area appears abnormal due to

pregnancy or due to precancerous changes. In addition, most mild abnormalities resolve over time without treatment. ASC-H Pregnant women with ASC-H should have a colposcopy. This is because ASC-H is more likely than ASC-US to be caused by a precancerous change. LSIL Colposcopy is recommended for pregnant women with LSIL, similar to nonpregnant women.

Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)

ABNORMAL PAP SMEAR OVERVIEW High grade cervical squamous intraepithelial lesion (HSIL, also called high grade cervical intraepithelial neoplasia) is the name given to moderately to severely abnormal-appearing cells on a Pap smear (also called a cervical cytology test). Any woman with HSIL requires further evaluation to determine if cancerous cells are present. While only about 2 percent of women with HSIL have invasive cancer, up to 20 percent of women with HSIL will eventually develop cancer if the abnormality is not treated. Atypical glandular cells (AGC) is the name given to abnormal appearing glandular cells on a cervical cytology test. Glandular cells line the opening in the cervix (picture 1). AGC is a relatively uncommon result, although it always requires further evaluation. AGC can be caused by benign conditions, such as cervical polyps, or more serious conditions, such as cancer of the cervix, uterine lining (endometrium), ovary, or fallopian tube. This topic review discusses the management of women with high grade squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC) of the cervix. Management of atypical squamous cells (ASC-US and ASC-H) and low grade squamous intraepithelial lesions (LSIL) is discussed separately. (See "Patient information: Management of atypical squamous cells (ASCUS and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)".) Cervical cancer screening tests are also discussed in a separate topic review. (See "Patient information: Cervical cancer screening".) HIGH-GRADE SQUAMOUS LESION (HSIL)

HSIL refers to moderate to severe precancerous changes of the cells of the cervix. Approximately 2 percent of women with HSIL on a Pap smear are found to have invasive cervical cancer when they undergo further evaluation and another 20 percent of women with HSIL will develop cervical cancer over a period of several years if they are not treated. However, if the precancerous lesion is removed or destroyed, cervical cancer can usually be prevented. Evaluation of HSIL All women with high-grade (HSIL) on Pap smear should have one of the following:

Colposcopy of the cervix, including biopsy of any abnormal areas and endocervical curettage (ECC). Management after colposcopy depends upon the results. (See 'Colposcopy' below.)

If the healthcare provider is unable to see the entire cervix during colposcopy, surgical removal of the abnormal area is recommended (eg, loop electrosurgical excision, conization). (See "Patient information: Treatment of precancerous cells of the cervix".)

Alternatively, the woman and her provider may decide to remove the abnormal area at the time of the initial colposcopy. This is called "see and treat". (See "Patient information: Treatment of precancerous cells of the cervix".) This option is not recommended for adolescents and pregnant women. (See 'Special populations' below.)

COLPOSCOPY Colposcopy is an office procedure that allows a clinician to closely examine the cervix. It is commonly performed after an abnormal Pap smear. Colposcopy is performed while the woman lies on an examination table, similar to a routine pelvic examination. A speculum is used to view the cervix, and the viewing device (called a colposcope) remains outside the woman's body (picture 1). The colposcope magnifies the appearance of the cervix. This allows the clinician to better see the location and size of any abnormalities, and also to see any changes in the capillaries (small blood vessels) on the surface of the cervix. Capillary changes are not detected by cervical cytology or human papillomavirus (HPV tests), but are important signs of the severity of cervical abnormalities. During colposcopy, a small piece of the abnormal area can be removed (biopsied). Anesthesia (numbing medicine) is not needed because the biopsy causes only mild discomfort or cramping. Women with HSIL or AGC usually require a biopsy of the inner cervix during colposcopy; this is called endocervical curettage (ECC). Endocervix refers to the inner cervix and curettage means scraping. Pregnant women should not have ECC because it may disturb the pregnancy. Management of HSIL after colposcopy Most women with HSIL results on a Pap smear will have a biopsy of any abnormal-appearing areas during colposcopy. The biopsy samples are sent to a pathologist, who determines if there is any evidence of precancerous changes, termed

cervical intraepithelial neoplasia (CIN). These changes are categorized as being mild (CIN 1) or moderate to severe (CIN 2 or 3). The following management strategies apply to non-pregnant women who are older than age 20 years. Management of adolescents and pregnant women is discussed separately (see 'Special populations' below). CIN 2 or greater If the healthcare provider is able to see the entire cervix during colposcopy and the biopsy shows CIN 2 or 3, treatment to remove (excise) or destroy (ablate) the abnormal area is recommended to prevent cancer, which would occur in one in five women. If the healthcare provider is not able to see the entire cervix during colposcopy or the endocervical curettage shows CIN, treatment to remove (excise, not ablate) the abnormal area is recommended. Delaying treatment (eg, watching and waiting) is not recommended for women age 21 or older with CIN 2 or 3, given the high risk of progression to cancer. (See "Patient information: Treatment of precancerous cells of the cervix".) CIN 1 or less preceded by HSIL Colposcopy can miss a significant number of seriously abnormal CIN lesions. If a woman has HSIL but the colposcopy/biopsy do not show a high grade lesion, the woman and her provider need to decide what else should be done to make sure a serious lesion has not been missed. The following options are available:

Close monitoring, including cervical cytology and colposcopy at six and 12 months. At these visits, the provider must be able to see the entire cervix during colposcopy and a test of the inner cervix (called endocervical curettage) must be negative. This may be the preferred approach for younger women who would like to preserve their ability to carry a pregnancy in the future. If these tests are negative, the woman may return to once yearly testing. If either test show persistent HSIL, a treatment to remove the abnormal area is recommended. (See "Patient information: Treatment of precancerous cells of the cervix".) Remove (excise, not ablate) the abnormal area. Excision is recommended because it can both treat any abnormal areas and determine with certainty what abnormality was present. (See "Patient information: Treatment of precancerous cells of the cervix".) In some cases, a healthcare provider will request an expert review of the woman's cytology and biopsy. This generally involves sending the cervical cytology and biopsy slides to an outside pathologist who is expert in evaluating abnormal Pap smears. If the expert feels that the woman has moderate to severe changes, a treatment to remove the abnormal area may be recommended. If the pathologist feels that there are mild to moderate changes, the woman and her provider may elect to monitor these changes with cervical cytology and colposcopy every six months.

SQUAMOUS CELL CARCINOMA

Squamous cell carcinoma is the medical term for cervical cancer. Women with this result require a biopsy, which is usually performed with colposcopy (see 'Colposcopy' above). If the biopsy confirms that cancerous cells are present, treatment is strongly recommended. The diagnosis and treatment of early stage cervical cancer is discussed in a separate article. (See "Patient information: Cervical cancer treatment; early stage cancer".) GLANDULAR CELL ABNORMALITIES (AGC) Glandular cells develop from the inside of the cervix (called the endocervical canal). Glandular cells can also come from the endometrium (lining of the uterus), the fallopian tube, or the ovary (figure 1). Evaluation All women with atypical glandular cells (AGC) require further testing, including HPV testing, colposcopy, cervical biopsy, endocervical curettage, and often endometrial biopsy. This is because 10 to 40 percent of women with atypical glandular cells have a precancerous or cancerous abnormality. These tests are usually performed in a single visit.

HPV testing is done by sweeping the surface of the cervix with a brush, which is then placed into a vial containing a liquid preservative. The vial is sent to a laboratory for evaluation. Colposcopy, cervical biopsy, and endocervical curettage are described above (see 'Colposcopy' above). Endometrial biopsy is performed by inserting a thin instrument through the vagina into the uterus to obtain a small sample of endometrial tissue. The tissue is then sent to a pathologist, who examines it with a microscope. The biopsy can be performed in a healthcare provider's office without anesthesia.

Management after colposcopy

If all of these tests are normal and the initial cervical cytology test showed AGC-NOS (not otherwise specified), follow-up recommendations depend on the HPV status. If the HPV test was positive (or unknown), a repeat cervical cytology smear and HPV test are recommended at 6 months. If the HPV test was negative, the cervical cytology smear and HPV test should be repeated at 12 months. If either is positive, repeat colposcopy with biopsies are recommended. If both tests are negative, the woman may return to routine screening. If all of these tests are normal and the initial cervical cytology test showed AGC-favor neoplasia or adenocarcinoma in situ, a treatment to remove (excise, not ablate) the abnormal area is recommended. (See "Patient information: Treatment of precancerous cells of the cervix".)

SPECIAL POPULATIONS

Adolescents and pregnant women may be evaluated and treated differently than non-pregnant women over age 20.

In adolescents, abnormal cervical cytology is often approached differently because, in this age group, there is a good chance that mild abnormalities will resolve over time, without treatment. There is a high rate of HPV infection in this group, but a very low rate of cervical cancer. The evaluation and management of pregnant women is different from non-pregnant women because of the risk that treatment to remove abnormal cervical tissue could lead to significant bleeding or preterm labor or delivery.

In both cases, women with HSIL are advised to have colposcopy. Any abnormal areas should be biopsied. The next step depends upon the result of the biopsy: Adolescents In this discussion, adolescents refers to age 20 or younger. CIN 1 or less Adolescents with HSIL on Pap smear and cervical biopsy results of CIN 1 or less severe (and with negative results of endocervical curettage) are followed with Pap smear and colposcopy at six-month intervals for up to two years. If HSIL on Pap smear or a colposcopic lesion that appears to be high-grade persists at one year, repeat biopsy and thorough examination of the vagina is recommended. If HSIL persists at 24 months as confirmed by either cytology or biopsy and if the examination of the vagina does not explain the abnormality, then treatment to remove the abnormal area is recommended. CIN2 Adolescents with HSIL on Pap smear who are found to have CIN 2 should discuss the risks and benefits of watchful waiting versus treatment with their healthcare provider.

Watchful waiting Watchful waiting would require the adolescent to have repeat cervical cytology and colposcopy at six and 12 months. If two consecutive tests show that the abnormality has resolved, the adolescent may return to once yearly testing. If the abnormality worsens or if the provider is unable to see the entire cervix during colposcopy, a treatment to remove the abnormal area is recommended. (See "Patient information: Treatment of precancerous cells of the cervix".) The advantage of watchful waiting is that it may allow the abnormality time to heal and potentially avoid the need for an excisional treatment. The disadvantage is that a greater number of follow up visits may be needed, depending upon whether the area improves or worsens over time. If the abnormality worsens or does not resolve, an excisional treatment may eventually be needed. Treatment Treatment would involve removal (excision, not ablation) of the abnormal area. Excision is recommended because it can both treat any abnormal areas and determine with certainty what abnormality was present. The advantage of this approach is that it could potentially mean fewer follow up visits. The disadvantage of this approach is that the abnormality could heal on its own, without

treatment, given adequate time. In addition, excisional treatments may increase the risk preterm labor during pregnancy. Excisional treatments are described in detail in a separate topic review. (See "Patient information: Treatment of precancerous cells of the cervix".) CIN 3 Treatment to remove or ablate the abnormal area is recommended for adolescents with HSIL and a biopsy that confirms CIN 3. Removal or destruction of the abnormality is recommended because 20 percent of these abnormalities will become cancerous over time if untreated. Delaying treatment (eg, watching and waiting) is not recommended. (See "Patient information: Treatment of precancerous cells of the cervix".) Pregnant women Cervical biopsy is performed only as necessary in pregnant women. CIN 1 After a cervical cytology report showing HSIL, if a pregnant woman's colposcopy and biopsy show CIN 1, a repeat cytology test and colposcopy are recommended no sooner than six weeks after the woman delivers her baby. The reason for this recommendation is that cervix appears somewhat different during pregnancy, which can make it difficult to determine if an area appears abnormal due to pregnancy or due to precancerous changes. Evaluating the area after delivery allows the provider to determine with more certainty if treatment is needed. CIN 2 or 3 If the biopsy confirms CIN 2 or 3, the woman and her provider can choose to repeat the cervical cytology and colposcopy later during the pregnancy (3 to 4 months later) or after the woman delivers her baby (six or more weeks after delivery). Treatment to remove the abnormal area is not recommended during pregnancy unless invasive cancer is suspected. The reason for this recommendation is that CIN 2 or 3 is caused by precancerous changes that have the potential to become cancerous when untreated. This is a slow process that takes many months to years. As long as the abnormality is monitored, it is not necessary to remove the area (and increase the risk of preterm delivery or miscarriage) until after delivery.

Colposcopy
COLPOSCOPY OVERVIEW Having a regular screening test for cervical cancer (Pap smear and/or human papillomavirus testing) is an important part of staying healthy and avoiding cervical cancer. If the results of your screening test are abnormal, further testing is needed to confirm the result and determine the severity of the abnormality. Colposcopy is the test that is usually recommended in this case. It allows your healthcare provider to look at your cervix using magnification. (See "Patient information: Cervical cancer screening".)

Not all women with an abnormal cervical screening test will need treatment. Colposcopy can help to determine if and when treatment of the abnormality is needed. More detailed information about colposcopy is available by subscription. (See "Colposcopy".) WHY DO I NEED COLPOSCOPY? Colposcopy is used to follow up abnormal cervical cancer screening tests (eg, Pap smear, human papilloma virus (HPV) testing) or abnormal areas seen on the cervix, vagina, or vulva. Your Pap smear may be abnormal if you have cervical pre-cancer or cancer, often caused by HPV infection of the cervix. HPV is explained in detailed separately. (See "Patient information: Cervical cancer screening".) The colposcope magnifies the appearance of the cervix (picture 1 and figure 1). This allows the clinician to better see where the abnormal cells are located and the size of any abnormal areas. The size and location of abnormal cells helps to determine how severe the abnormality is and also helps to determine what treatment, if any, is needed. When monitored and treated early, precancerous areas usually do not develop into cervical cancer. PREPARING FOR COLPOSCOPY Before your colposcopy appointment, you should not put anything in the vagina (eg, creams). Colposcopy can be done at any time during your menstrual cycle, but if you have heavy vaginal bleeding on the day of your appointment, call your healthcare provider to ask if you should reschedule. If you take any medication to prevent blood clots (aspirin, warfarin, heparin, clopidogrel), notify your healthcare provider in advance. These medications can increase bleeding if you have a biopsy during the colposcopy. If you know or think you could be pregnant, let your healthcare provider know. Colposcopy is safe during pregnancy, although healthcare providers usually do not perform biopsies of the cervix when you are pregnant. COLPOSCOPY PROCEDURE Colposcopy can be performed by a physician, nurse practitioner, or physician assistant who has had specialized training. Colposcopy takes approximately 5 to 10 minutes, can be performed during an office visit, and causes minimal discomfort. Colposcopy is performed similar to a routine pelvic examination, while you lie on an exam table. The healthcare provider will use an instrument called a speculum to open your vagina and look at your cervix (picture 1 and figure 1). The provider will usually repeat a Pap smear, then will look at your cervix using the colposcope. The colposcope is like a microscope on a stand, and it does not touch you.

The provider will apply a solution called acetic acid (vinegar) to your cervix. This solution helps to highlight any abnormal areas, making them easier to see with the colposcope. When this solution is used, you may feel a cold or slight burning sensation, but it does not hurt. During colposcopy, your healthcare provider may remove a small piece of abnormal tissue (a biopsy) from the cervix or vagina. Having a biopsy does not mean that you have precancerous cells. Anesthesia (numbing medicine) is not usually used before the biopsy because the biopsy causes only mild discomfort or cramping. The tissue sample will be sent to a laboratory and examined with a microscope. Some women also need to have a biopsy of the inner cervix during colposcopy; this is called endocervical curettage (ECC). Pregnant women should not have ECC because it may disturb the pregnancy. The ECC may cause crampy pain, although this resolves quickly in most women. If you have a biopsy, your provider may apply a yellow-brown solution to your cervix. This acts as a liquid bandage. AFTER COLPOSCOPY If you have a biopsy of your cervix, you may have some vaginal bleeding after the colposcopy. If your provider used the liquid bandage solution, you may have brown or black vaginal discharge that looks like coffee grounds. This should resolve within a few days. Most women are able to return to work or school immediately after having a colposcopy. Some women have mild pain or cramping, but this usually goes away within one to two hours. Do not put anything in the vagina (creams, douches, tampons) and do not have sex for one week after having a biopsy. If you have a biopsy, ask your healthcare provider when your results will be available (usually within 14 days). In most cases, further testing and treatment will depend on the results of the biopsy. (See "Patient information: Management of atypical squamous cells (ASC-US and ASCH) and low grade cervical squamous intraepithelial lesions (LSIL)" and "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)" and "Patient information: Treatment of precancerous cells of the cervix".) Do not assume that the biopsy results are normal if you do not hear from your healthcare provider call and inquire about the results. Most women will need a follow up test (repeat cervical cancer screening (Pap smear) and/or colposcopy) within 6 months. When to seek help after colposcopy Call your healthcare provider if you have any of the following after colposcopy:

Heavy vaginal bleeding (soaking through a large menstrual pad in an hour for two hours) Vaginal bleeding for more than 7 days

Foul smelling vaginal discharge; remember that the brown/black, coffee-ground discharge is normal for the first few days Pelvic pain or cramps that do not improve with ibuprofen (Advil, Motrin) Temperature greater than 100.4F or 38C

Treatment of precancerous cells of the cervix

INTRODUCTION Several treatments are available for women with cervical abnormalities, often referred to as dysplasia, CIN (cervical intraepithelial neoplasia) or CIS (carcinoma in situ). Treatments including cryosurgery (freezing), laser (high-energy light), and excision (surgical removal of the abnormal area). The tests performed to evaluate abnormal Pap smears are discussed separately. (See "Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)" and "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)".) CHOOSING THE BEST TREATMENT FOR ABNORMAL PAP SMEARS Abnormal pap smears are treated by identifying the area of abnormal cervical tissue and removing it to prevent worsening or spread to other areas of the cervix. There are two main types of treatment for cervical abnormalities:

Those that destroy the abnormal area (called ablative therapy) and Those that remove the abnormal areas (called excisional therapy).

Some abnormalities are best treated with one type of treatment while others can be treated with either type, depending upon the patient and physician's preference. There are some classes of abnormalities that can be followed without treatment, if the physician and patient are willing. Excisional therapy Excisional therapies include loop electrosurgical excision procedures (LEEP), also called large loop excision of the transformation zone (LLETZ), laser conization, and cervical conization procedures. Most clinicians prefer excisional therapy (see 'Excision' below).

Excisional therapy is recommended when the extent or type of cervical abnormality is not clear based upon colposcopy and biopsy. In this situation, excision is preferred because the abnormal tissue can be examined with a microscope. This allows the physician to determine if the entire abnormal area was removed and if a more serious condition (eg, cervical cancer) is present. Ablative therapy Ablative therapies include cryosurgery and laser ablation. Ablative therapy may be recommended when there is less concern about cancer or about the extent of the abnormal tissue. EXCISION Excision is a procedure that cuts out the abnormal area on the surface of the cervix; excision can also remove abnormalities that extend inside the cervical opening. Excision serves two purposes:

It provides a sample of tissue to confirm the degree of an abnormality and check for cancerous or precancerous cells deep within the cervix. Excision helps to ensure that the abnormality is removed completely. If the edges of the tissue that is removed show evidence of the abnormality or precancer, further treatment may be needed.

Loop electrosurgical excision procedure (LEEP) Excision can be done with a device that uses electrical current; this is called a LEEP procedure (loop electrosurgical excision procedure) or LLETZ (large loop excision of the transformation zone). A thin, wire loop is inserted through the vagina, where it uses an electric current to remove a cone-shaped portion of the cervix. This can also be performed with a laser knife, which uses high intensity energy from a light beam. Excision can be done in the office or operating room after the cervix is injected with local anesthesia to prevent pain. The woman may feel a dull ache or cramp during the procedure. A brown paste is applied after the treatment to prevent bleeding; this often causes a dark vaginal discharge (similar to coffee grounds). Most women are able to return to work or school after the procedure. Cervical cone biopsy (conization) Excision can also be done with a scalpel instead of a loop; this is called a cervical conization or cone biopsy (figure 1). Conization is usually done in an operating room after the patient has received general anesthesia (medicine given to induce sleep) or regional anesthesia (eg, epidural or spinal). Following LEEP or conization, most women have mild to moderate vaginal bleeding and discharge for one to two weeks. The bleeding should not be heavy (eg, should not soak a pad in less than one hour). Care after excision is described below (see 'Post-procedure care' below). Complications As with any surgical procedure, complications can occur during excision. These include:

Bleeding during the procedure Bleeding is rarely serious, and can usually be managed with suturing or by applying cauterizing material (a liquid or treatment that helps the blood to clot) to the cervix. Bleeding after the procedure Although light bleeding or spotting is normal, some women have heavy bleeding several days or weeks after the procedure. This can usually be treated in the office, but occasionally a procedure in an operating room is necessary. Infection Infections occur rarely after cone biopsy, either on the cervix itself or elsewhere in the reproductive tract. Most infections can be treated with oral antibiotic therapy. Perforation of the uterus This is an uncommon complication, and is more likely to occur in women who are postmenopausal or whose uterus is tipped forward. If the uterus is perforated, it usually heals without any need for treatment. Infrequently, laparoscopy or laparotomy is required to see and repair injuries to internal organs. Late complications (see 'Pregnancy after treatment for abnormal Pap smear' below).

ABLATIVE TREATMENTS Ablative treatment destroy, rather then cut away, abnormal cervical tissue. Cryosurgery Cryosurgery involves applying liquid nitrogen or carbon dioxide to the cervix. This causes the cervical tissue to freeze, which destroys the abnormal cells. Cryosurgery can be done in the office, similar to a pelvic examination, without any anesthesia. It may cause mild cramping or discomfort. Cryosurgery is not recommended in certain situations, such as when the extent and type of cervical abnormality are not clear based upon colposcopy and/or biopsy. Excisional therapy is preferred in these cases. Most women have watery vaginal discharge for one week after cryosurgery. Care after cryosurgery is described below (see 'Post-procedure care' below). Laser ablation Laser ablation uses high intensity energy from a light beam to destroy abnormal areas of the cervix. The laser is directed to the abnormal area of the cervix through the vagina. This is usually performed in an operating room after the woman has received general anesthesia (medicine given to induce sleep) or regional anesthesia (eg, epidural or spinal). Laser treatment requires special training and equipment. A disadvantage of laser ablation is that it destroys the abnormal tissue, similar to cryosurgery. Laser ablation is not recommended in certain situations, such as when the extent and type of cervical abnormality are not clear based upon colposcopy and/or biopsy. Most women have vaginal discharge for one to two weeks after laser treatment. Care after laser treatment is described below (see 'Post-procedure care' below). POST-PROCEDURE CARE

All women should ask about their ability to drive home from the procedure and when they can resume normal daily activities. Following treatment, most providers recommend avoiding sexual intercourse, not placing anything in the vagina (eg, douches, tampons), and not taking a bath or swim for a few weeks (showers are fine); other physicians may recommend a shorter period of "pelvic rest". This should be discussed in detail with the physician. In general, a woman should call her provider if she has bleeding that is heavier than a normal menstrual period (defined as soaking a pad in less than one hour, especially if there are clots), severe or worsening pain, fever over 101 F (38.4 C), or a foul-smelling vaginal discharge. Treatment efficacy The treatments described above cure most women with abnormal cervical cells. Women that are not cured after a first treatment may have persistence, recurrence, or progression of the abnormality, especially if a high risk type of HPV (types 16 and 18) is present. Additional treatment is sometimes needed in this case. For this reason, lifelong follow up with cervical cytology smears (Pap smear) is important. Follow up appointments Typically, a woman is seen for a follow up examination several weeks after treatment to make sure the cervix is healing. A Pap smear (with or without colposcopy) is recommended approximately every six months. Colposcopy is recommended if atypical squamous cells or other abnormalities are found and HPV testing is positive. The time interval between subsequent tests will depend upon the results of the initial testing after treatment and the woman's age. Follow up is best discussed with a woman's individual provider since it may vary significantly from one woman to another. Need for further treatment Some women will require additional treatments to ensure that all abnormal areas are removed. This is especially true if excision was done and microscopic analysis showed a larger abnormality than was expected. The decision to have additional treatment is individualized, based upon the type of abnormality seen, the woman's risk of cervical cancer, and whether or not childbearing is completed. (See "Patient information: Cervical cancer treatment; early stage cancer".) PREGNANCY AFTER TREATMENT FOR ABNORMAL PAP SMEAR Many women are concerned about the risks of infertility and preterm labor after being treated for an abnormal Pap smear. The risk of these complications depends upon a number of factors, including the type and number of treatment(s) performed (ablation versus excision) and the time between the treatment and the pregnancy. Other factors, such as underlying medical conditions and a woman's age can also increase a woman's risk of these conditions. Most women are advised to wait six to 12 months after conization before attempting to become pregnant to allow the tissue to heal fully. In general, the data suggest that excisional procedures slightly increase the risk of preterm delivery, but ablative procedures do not. The risk of infertility related to treatment is probably very small. More data are needed to better define these risks. (See "Patient information: Preterm labor", section on 'Cervical length'.)