A 27-year-old woman, gravida 3 para 3, comes to the office for an annual examination. She has no intermenstrual or postcoital bleeding or abnormal vaginal discharge. Her last menstrual period was 2 weeks ago. The patient has no chronic medical conditions and takes a multivitamin daily. She has had 3 uncomplicated vaginal deliveries and no surgeries. The patient has had 2 sexual partners in the past 3 years and uses oral contraceptive pills. Her last Pap test 3 years ago demonstrated atypical squamous cells of undetermined significance (ASCUS), and reflex human papillomavirus (HPV) testing at that time was negative. The patient has no history of sexually transmitted infections. Vital signs are normal. BMI is 22 kg/m². The cervix appears parous and without visible lesions. The uterus is small, anteverted, and mobile, with notable descent of the cervix to the introitus during the Valsalva maneuver; the adnexa are not enlarged. Pap testing indicates a high-grade squamous intraepithelial lesion (HSIL). Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_bee4_5cf4_8f63_e3af78ec6863_MD0005_00 A Pap test screens for precancerous lesions of the uterine cervix. A high-grade squamous intraepithelial lesion (HSIL) on Pap testing is concerning for underlying severe cervical intraepithelial neoplasia (eg, CIN2, CIN3) or invasive cervical cancer. All patients with such results require evaluation with immediate colposcopy. Repeat Pap testing is not indicated (Choice D). Patients with an HSIL result on Pap testing undergo colposcopy, a diagnostic procedure in which the cervix is magnified so that abnormal areas are more easily identified and biopsied. Some patients can proceed directly to a loop electrosurgical excision procedure (LEEP), an excision of the cervical transformation zone and surrounding endocervix; these are women who are age >25, are not pregnant, and have completed childbearing. Colposcopic biopsies or a LEEP specimen are required for a histologic diagnosis to make further management decisions. colposcopy loop electrosurgical excision procedure (LEEP) (Choice B) Endometrial biopsy is used in the evaluation of endometrial cancer, which typically presents as anovulatory or postmenopausal bleeding. Pap test results may demonstrate abnormal glandular cells (from the endocervix or endometrium) but not abnormal squamous cells. (Choice C) Women with HSIL demonstrated by Pap test are at high risk of CIN2 or CIN3 and require colposcopy regardless of human papillomavirus (HPV) results. HPV co-testing is used to triage Pap tests demonstrating atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL); in these patients, further evaluation with colposcopy is indicated if high-risk HPV is present. (Choice E) A vaginal hysterectomy is not indicated as treatment for abnormal Pap test results; the next step in evaluation is colposcopy or a LEEP to rule out cancer. If cancer is detected, early stage disease is treated with radical hysterectomy, whereas more advanced disease is treated with chemoradiation. Educational objective: If Pap testing reveals a high-grade squamous intraepithelial lesion, the next step in management is with either colposcopy or a diagnostic excisional procedure, due to the risk of premalignant or malignant cervical disease. References: Evaluating cytology for the detection of invasive cervical cancer. (http://www.ncbi.nlm.nih.gov/pubmed/26126636)

A 27-Year-Old Woman, Gravida 3 Para 3, Comes to the Office