Balanced Women’s Health: The Abnormal Pap Smear
What does it mean if my Pap smear is abnormal?
Realize that if your Pap smear is abnormal it does not mean that you have cancer and that you are not alone.
About 55 million Pap tests are performed each year in the United States. Of these, approximately 3.5 million (6 percent) are abnormal and require medical follow-up. The Pap smear procedure samples cells which are on the surface of the cervix and these cells are looked at underneath the microscope. The procedure is named after the doctor who first discovered that cervical cells changed before cancer of the cervix develops, Dr. George Papanicolaou. Cells on the surface of the cervix sometimes appear abnormal but are very rarely cancerous. The Pap smear was designed to pick up abnormal cells before they have a chance to become cancerous and having regular Pap smear tests and appropriate treatment and follow-up of abnormal results, significantly reduces the chance that cervical cancer will ever develop. Prior to the introduction of the Pap test, cervical cancer was a leading cause of cancer death in women, and still is in some parts of the world. Since the introduction of the Pap test, deaths caused by carcinoma of the cervix have been reduced by up to 99% in some populations where women are screened regularly. A healthcare provider may simply describe Pap test results to a patient as “abnormal.” It is important to remember that abnormal conditions do not always become cancerous, and some conditions are more likely to lead to cancer than others.
The cells of the cervix may be abnormal due to infection, lack of estrogen in older women, or precancerous changes. Although the Pap smear is not designed to reliably pick up abnormal cells from sources other than the cervix, some abnormal Pap smears may be due to vaginal, endometrial, fallopian tube, ovarian, or rectal abnormalities. Breast cancer cells have even been found in Pap smears, although quite rarely. The vast majority of precancerous changes in the cervix are due changes in the cells that cover the outer surface of the cervix, the squamous cells. Some precancerous changes will be due to the cells lining the inner portion of the cervix, called glandular cells. If any unusual cells are detected, further tests are done to determine if treatment is needed. This is the best way to find out if cancerous or precancerous cells are present.
Precancerous changes in the squamous cells of the cervix are referred to as cervical dysplasia or cervical intraepithelial neoplasia (CIN). If these type of changes are detected on your Pap test, they will be graded as mild (CIN 1), moderate (CIN 2), or severe (CIN 3). CIN 1 is also referred to as a low-grade squamous intraepithelial lesion (LGSIL) and CIN 2 and CIN 3 are referred to as a high-grade squamous intraepithelial lesions (HGSIL). Any of these changes require further discussion and evaluation with your health care professional.
We now understand that virtually all precancerous and cancerous changes in the cervix are due to the human papilloma virus (HPV), a very common, sexually transmitted virus. HPV infection is the primary risk factor for cervical cancer, however only a very small percentage of women with untreated HPV infections develop cervical cancer. Approximately 80% of women will become infected with the HPV virus in their lifetime and many times there are no associated signs or symptoms other than an abnormal Pap smear. About 6 million new genital HPV infections occur each year in the United States. HPV may also cause vulvar, vaginal and rectal cancers. In most cases of HPV infection, the immune system quickly attacks the virus, and it is cleared from a woman’s system. For other women, the immune system does not rid the body of the virus, and a small number of these women will develop CIN. The development of CIN is more likely to occur in older women who have had HPV for a long time. Women who smoke and have HPV face twice the risk of developing CIN than women who do not smoke. The good news is that if you have regular Pap smear tests and appropriate, regular follow-up, it’s unlikely that cervical cancer will develop.
The most common system for describing Pap smear test results is the Bethesda System. The Bethesda System uses a number of terms to relate the results. Squamous intraepithelial lesion (SIL) describes precancerous changes in cervical cells. Using this system, your Pap smear test results may be:
Normal
Atypical squamous cells of undetermined significance (ASCUS) This is the most common abnormal Pap smear test result indicating the presence of cervical cell changes. This term simply means that the squamous cells of the cervix appear unusual and cannot be further categorized. These changes may be due to infections, thinning of the cervix and vagina in women who have low estrogen levels, or precancerous or cancerous changes.
Squamous intraepithelial lesion (SIL) This term describes abnormal cervical cell changes that may be a sign of precancer. SIL is either low grade (LGSIL) or high grade (HGSIL). LGSIL or HGSIL refers to the grade of dysplasia and CIN. LGSIL is indicative of either the presence of HPV or mild precancerous changes; this is a common type of abnormal Pap smear result. HGSIL, on the other hand, indicates more serious cervical cell changes.
Atypical squamous cells, cannot exclude HGSIL (ASCH)This Pap smear test result means there is uncertainty about whether HSIL is present.
Atypical glandular cells (AGC) This term implies precancerous changes to the upper cervix or uterus.
Cancer Hopefully, you will never get this result from your Pap smear. Having regular Pap smear tests can help that you will never get a result of cancer
Endocervical and endometrial abnormalities can also be detected, as well as a number of infectious processes, including yeast, herpes simplex virus, and trichomonas.
What next?
Make sure that you review results with your health care professional. Many times, this will mean a trip to the office to review the meaning of an abnormal Pap smear and review recommendations for treatment.
Not all abnormal Pap smear test results require other tests and sometimes observation and closer surveillance will be recommended. The important thing is that you follow recommendations after having any type of abnormal Pap smear test result. In some instances, further investigation of the cervix with colposcopy will be recommended.
If the Pap test shows an ambiguous or minor abnormality, the healthcare provider may repeat the test to determine whether further follow-up is needed. Many times, cell changes in the cervix go away without treatment. In some cases, healthcare providers may prescribe estrogen cream for women who have ASC–US and are near or past menopause as these cell changes are often caused by low hormone levels. Applying an estrogen cream to the cervix for a few weeks can usually help to clarify the cause of the cell changes.
If the Pap test shows a finding of ASCUS, ASC–H, LGSIL, or HGSIL, the healthcare provider may perform a colpsocopy. A colposcope is a microscope that provides a closer view of the cervix. The colposcopic exam is similar to a regular pelvic exam and should only take a few minutes to perform. Anesthesia is not required.
During colposcopy, dilute acetic acid (vinegar solution) is placed in the vagina to help determine of there are any abnormal areas, they turn white and may be referred to as aceto-white lesions. The colposcopy itself is painless, however if abnormal areas are seen, then very small (2-3mm) pieces of tissue may be removed in the form of a colposcopically directed biopsy. This may lead to a small about of pain, cramping and bleeding which usually rapidly resolves. This cervical tissue is then sent for laboratory evaluation. These biopsies cause no long-term damage to your cervix. Endocervical sampling may also be performed, which is a scraping from the inside of the cervix. This may also lead to cramping and spotting.
If the testing shows abnormal cells that have a high chance of becoming cancer, further treatment is needed. Treatment options include the following: LEEP (loop electrosurgical excision procedure) is surgery that uses an electrical current which is passed through a thin wire loop to act as a knife and is a larger cervical biopsy, CO2 laser which uses a narrow beam of intense light to destroy or remove abnormal cells, or conization which removes a cone-shaped piece of tissue using a knife, a laser, or the LEEP technique.
Summary
The vast majority of abnormal Pap smears do not indicate the presence of cancer.
Follow your healthcare providers recommendations for treatment and follow-up.
Treatment of abnormal Pap smear test results depend on the type of cervical changes seen, the age of the women, and other individual circumstances.
With appropriate treatment, cervical cancer can be prevented in the vast majority of the time.
Resources:
http://www.cancer.gov/cancertopics/factsheet/Detection/Pap-tes
http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
http://www.cancer.gov/cancertopics/understandingcervicalchanges
ACOG Guidelines to Evaluation of an Abnormal Pap Smear
