Stephen R. Wells MD

If you receive a phone call from our office regarding an abnormal PAP smear result, or if your family practice physician or internist has referred you to us because of an abnormal PAP smear, keep in mind that it is highly likely that the result is unlikely to impact your long-term health. Most abnormalities we see require either a repeat PAP in the next 3-6 months or further clarification of the abnormal PAP by Colposcopy. So if you are nervous, let us put your mind at rest. Because women generally have their PAP smears annually, we don’t actually diagnose cervical cancer very frequently at all. We tend to find abnormal changes long before they would have a chance to develop into cancer and treat them promptly. It is highly likely that you are coming to us to make sure you don’t develop cancer, not to be treated because you have cancer. Until your appointment comes around, read the following to put your mind more at ease.

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WHAT EXACTLY IS THE PAP SMEAR?

When the PAP is done, we place a speculum into the vagina to visualize the cervix, located at the uppermost part of the vagina. We then gently scrape off cells from the surface of the cervix, as well as cells located higher in the cervical canal (endocervix). We place the cells in a solution that is centrifuged and separated from blood, mucus and other debris. The cells are then placed on a slide and evaluated by a cytotechnologist or pathologist.

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HOW ARE THE PAP RESULTS CLASSIFIED?

The PAP smear is now classified under a fairly standardized (and slightly confusing) system. To simplify, results can be considered in this way:

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• Normal

• Atypical cells of undetermined significance  (ASCUS)

• Low Grade Dysplasia(mild pre-cancerous change)

• High Grade Dysplasia(moderate to severe pre-cancerous change)

• Suspicious for Cancer

 

WHAT IS DYSPLASIA?

From the Latin, it’s “Dys (abnormal) – plasia (growth). Abnormal growth of the cells of the surface (skin) of the cervix. This refers to benign cells that may, left unchecked, progress to malignant cells. Often times, when patients present with Low-grade dysplasia, the cellular changes that have occurred may spontaneous change back to normal with no therapy. High-grade dysplasia, however, is more likely to progress to cancer, and therefore is usually treated more aggressively.

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I KEEP GETTING “ASCUS” ON MY PAP, WHAT DOES THAT MEAN?

This is the term used when the PAP isn’t entirely normal, but doesn’t have the characteristics that fall into the dysplasia category either. When the pathologist reads a PAP that falls into this category, they will test the fluid specimen to see if there is evidence of the Human Papilloma Virus (HPV). If the virus is NOT present, then it is assumed that inflammation from a common yeast or bacterial infection or even trauma from recent intercourse may be the cause of the cells appearing slightly irregular or “atypical”. In that case, we may recommend a repeat PAP in 6 months to one year. On the other hand, if the test DOES detect the presence of the HPV virus, we may re-evaluate with a repeat PAP sooner or may proceed with further evaluation using an instrument called the Colposcope.

So,

• ASCUS PAP without HPV detection = Repeat in 6 months to one year.

• ASCUS PAP with HPV detection =  further evaluation with Colposcopy.

 

Keep in mind that the PAP is a screening test. If abnormal changes are seen on PAP, they must be confirmed with Colposcopy and Biopsy. During this procedure, the cervix is examined more closely, and if any suspicious areas are seen, a small (1-2mm) tissue biopsy is performed to confirm the presence or absence of precancerous change in the cells of the cervix.

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MY PAP SHOWED LOW GRAGE DYSPLASIA, WHAT DOES THAT MEAN?

This finding is usually associated with an HPV infection. Please see my discussion on this common infection in the section on HPV Vaccine. The virus attacks the cells and induces changes in the cells nucleus that makes them pre-cancerous. “Low-Grade” means that the changes occur in only few cells in the “skin” of the cervix. In a PAP showing Low Grade Dysplasia (LGSIL), colposcopic evaluation and biopsy is indicated to confirm the presence of precancerous cells. If LGSIL is confirmed, then options for therapy include freezing the cervix (Cryotherapy) to kill normal and pre-cancerous cells alike so that healthy cells grow back in their place. Alternatively, since a significant number of LGSIL cells revert back to normal spontaneously, follow-up serial PAP smears can be performed to track the resolution of dysplasia.

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MY PAP SHOWED HiGH GRADE DYSPLASIA, WHAT DOES THAT MEAN?

In this scenario, a greater concentration of cervical or endocervical cells contain abnormal nuclei showing precancerous change. If colposcopy reveals these changes, we are typically more aggressive with evaluation and treatment. The reason for this is that with High Grade Dysplasia, the condition is more likely to continue to progress, either rapidly or slowly, to cancer. Still, the timing of conversion from a precancerous condition to a malignancy may take anywhere from a few months to many years. Not knowing how a particular strain of HPV may act, we tend to move more rapidly.

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Colposcopy is performed and any a biopsy is taken from the most suspicious looking area. After receiving results of the biopsy (may take 3-4 working days so please call us for results at that time), we will tailor treatment depending on the severity, location, and extent of the abnormality. We typically prefer the LEEP procedure, as it assists in diagnosis and provides treatment in an office setting. In the LEEP procedure, a thin wire loop electrode is used to “scoop” out the entire dysplastic lesion. The amount of tissue removed is typically minimal. The procedure takes about 15 minutes of total time and patients typically leave the office and return to their usual daily routine. Please see my section on LEEP PROCEDURE.

If the lesion is too big or the changes very suspicious for cancer, then a “cold knife cone biopsy” is performed in an outpatient surgery center. This entails a deeper cut into tissue, and therefore since risk is greater, it is done in a surgical suite. It is rare that I find that cone biopsy is preferred to LEEP, because I like to preserve as much cervical tissue as possible.

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WHAT IS THE FOLLOW-UP AFTER I’VE HAD
TREATMENT FOR LOW OR HIGH GRADE DYSPLASIA?

After Cryotherapy, I usually recommend a repeat PAP smear in three months. If the follow-up PAP is normal, then return to yearly PAP smears would be appropriate. After the LEEP procedure or Cone Biopsy, PAP smears should be done every three months for a year. If they are consistently normal, then yearly PAP smears should be resumed.

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