Ambulatory Talks‎ > ‎

Pap Smears

Facilitator: Felise Milan

Read:

Read the abstracts: 

Review the guidelines:


Cases for Discussion:

 

Case 1

 You receive a Pap smear report from an annual exam that you did on a 21-year-old woman.  She has been sexually active for almost 2 years and had 1 Pap smear in the past that was entirely normal.  This Pap result reads, “atypical cells of undetermined significance” (ASC-US).  At her visit she was completely asymptomatic and her exam was normal.

a)    Would an HPV test be helpful in this patient?

b)    What should you do next?

c)    What would you tell her?  What does she need to know?

The patient comes back a year later and has a pap smear done.  The result now is LSIL.  Now what should you recommend?

  

Case 2

You are seeing a 36-year-old woman in the clinic for a walk-in visit.  You address her urgent problem and discover that she hasn’t had a check-up or pap smear in over 12 years.  She says she had a Pap, maybe 2, in college that were OK.  She resists scheduling one with you and tells you that she has one female sexual partner and doesn’t really need a Pap anyway.

a)     What would you advise her to do?

b)    How often should she come back for cervical cancer screening?  Which tests would you use?

After convincing this patient to have a Pap smear, it comes back “satisfactory for evaluation, note absence of endocervical cells.”  What do you do next?


Case 3

You are seeing a 48 yr-old woman for an annual exam.  She is still menstruating but irregularly and reports occasional hot flashes that wake her from sleep.  She has gotten Pap smears yearly for many years and they have always been normal.  She is divorced and hasn’t been sexually active for 2-3 years.  This year’s Pap smear comes back “atypical squamous cells cannot exclude HSIL” (ASC-H).

a)     What would you do next?

b) Would an HPV test be helpful?

You realize that you were reading the wrong Pap results.  This patient’s Pap is actually, “atypical glandular cells” (AGC).  What do you do now?


Case 4

A 40 yr-old woman who is HIV positive comes in to follow-up her abnormal pap result.  She previously had normal yearly Pap smears for at least 5 years.  She is not currently sexually active but used IV drugs in the past and had many different sexual partners over her lifetime.  On HAART her CD4 count is 725 and viral load is undetectable.  Her pap result was ASC-US and her HPV test was negative.

a)     What would you do next?

b)    If her CD4 count was 150 and her viral load was 75,000, what would you do then?

 

Case 5
You are seeing a 65 yr-old woman who is new to you but not new to the clinic.  She is widowed and not sexually active.  She doesn’t come every year for a physical but you can find at least 4 normal Paps from the past and all are normal.  You do a Pap and the results are “negative for intraepithelial lesions or malignancy.  Specimen satisfactory.  Note absence of endocervical/transformation zone component.”

What do you do next?

 

Case 6

A 28-year-old woman has cervical screening using liquid cytology.  She is sexually active with 1 partner currently.  This is a new boyfriend of about 4 months.  She has no complaints and her exam is normal.  Her pap comes back “Negative for intraepithelial lesion or malignancy. Specimen satisfactory.  Trichomonas vaginalis seen.”

a)     What do you do tell her?

b)    What do you recommend to her next?

 

 Case 7

A 56 yr-old woman comes in because she was sent by her workplace after being found to have high blood pressure during a screening.  She hasn’t been to the doctor in many years and has no past medical problems other than a 30-pack-year smoking history.  She is not currently sexually active.  You convince her to have a full physical exam with a Pap smear.  On exam, you notice a small area of discoloration and irregular contour adjacent to the cervical os.  Her Pap smear comes back, “satisfactory for evaluation negative for intraepithelial lesion or malignancy."

What do you do next?

 

Case 8

A 37 year-old woman comes to see you as a new patient needing a full physical.  You don’t have the records from her old clinic but she tells you that she gets her Pap smears done regularly and they are always normal.  You do a Pap that comes back “negative for intraepithelial lesion.”  The lab also did an HPV test that is positive.

a)    What do you recommend to her to do now?

b)    Would HPV genotyping help in deciding on management?