A 17-year-old girl comes to the office for an annual physical examination. The patient learned about the association between sexual activity and cervical cancer and wonders when she should undergo Pap testing. She became sexually active 2 years ago and has had 4 sexual partners. The patient received the human papillomavirus vaccination series at age 11. She uses condoms and depot medroxyprogesterone acetate for contraception and has gained 5 kg (11 lb) during the 2 years she has taken the medication. The patient has been amenorrheic for over a year. She had a negative screen for sexually transmitted infections a year ago. The patient has seasonal allergies but no other chronic medical conditions. She does not use tobacco, alcohol, or illicit drugs. Vital signs and general physical examination are within normal limits. A urine gonorrhea and chlamydia nucleic acid amplification test is collected. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

Question

A 17-year-old girl comes to the office for an annual physical examination.  The patient learned about the association between sexual activity and cervical cancer and wonders when she should undergo Pap testing.  She became sexually active 2 years ago and has had 4 sexual partners.  The patient received the human papillomavirus vaccination series at age 11.  She uses condoms and depot medroxyprogesterone acetate for contraception and has gained 5 kg (11 lb) during the 2 years she has taken the medication.  The patient has been amenorrheic for over a year.  She had a negative screen for sexually transmitted infections a year ago.  The patient has seasonal allergies but no other chronic medical conditions.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs and general physical examination are within normal limits.  A urine gonorrhea and chlamydia nucleic acid amplification test is collected.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bee6_58c5_8f63_ad199cf01da9_MD0005_00 Screening for cervical cancer by cytology (ie, Pap test) is an effective way of detecting early preinvasive dysplasia caused by human papillomavirus (HPV). Regardless of age at onset of sexual activity, cervical cancer screening by Pap test is not recommended for asymptomatic, immunocompetent patients prior to age 21. Nearly half of sexually active women are infected with HPV within 3 years of onset of sexual activity. However, in women age <30, most HPV infections (and therefore abnormal Pap test results) are transient and resolve without intervention. (Choice A) Primary HPV testing has low specificity and low positive predictive value in women age <30, and is not recommended. (Choice B) Age at onset of sexual activity is not a factor in the initiation of Pap test screening due to the high likelihood of HPV clearance in women age <30. An exception to this is for immunocompromised women (eg, HIV, systemic lupus erythematosus) in whom screening begins with the onset of sexual activity. These women are more likely to have persistent HPV infection and corresponding abnormal Pap tests that are less likely to resolve spontaneously over time. (Choice C) HPV screening guidelines are the same regardless of vaccination status. Not all strains of high-risk oncogenic HPV are included in the vaccine, and some women who receive the vaccine may already have been infected with the included strains. (Choice E) Pap test with HPV cotesting every 5 years, primary HPV testing every 5 years, or Pap testing alone every 3 years is recommended for women age 30-65. Educational objective: Cervical cancer screening begins at age 21 in most women (except for those who are immunocompromised) regardless of age at onset of sexual activity. Routine testing for human papillomavirus is not indicated for women age <21. References: Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/22711081)

A 17-Year-Old Girl Comes to the Office for an Annual