A 31-year-old woman comes to the office for follow up of an abnormal Pap test. Two weeks ago, the patient underwent her annual well-woman examination, and Pap testing revealed a high-grade squamous epithelial lesion. She has no chronic medical conditions and has had no prior surgery. The patient smokes a half pack of cigarettes daily. She has been in a monogamous relationship with a female partner for the past 2 years. The patient has regular monthly menses, and her last menstrual period was a week ago. Vital signs are normal. BMI is 33 kg/m². Colposcopy reveals a nulliparous cervix with no raised or ulcerated lesions. The entire squamocolumnar junction cannot be visualized. Which of the following is the best next step in management of this patient?

Question

A 31-year-old woman comes to the office for follow up of an abnormal Pap test.  Two weeks ago, the patient underwent her annual well-woman examination, and Pap testing revealed a high-grade squamous epithelial lesion.  She has no chronic medical conditions and has had no prior surgery.  The patient smokes a half pack of cigarettes daily.  She has been in a monogamous relationship with a female partner for the past 2 years.  The patient has regular monthly menses, and her last menstrual period was a week ago.  Vital signs are normal.  BMI is 33 kg/m².  Colposcopy reveals a nulliparous cervix with no raised or ulcerated lesions.  The entire squamocolumnar junction cannot be visualized.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d261_46db_bc81_3721eed4ee31_MD0003_00 The Pap test is a screening examination for precancerous and cancerous cervical lesions. High-grade squamous intraepithelial lesion (HSIL) on Pap testing is concerning for underlying high-grade cervical intraepithelial neoplasia (CIN) or invasive cancer; therefore, patients with HSIL require colposcopy. Colposcopy evaluates the cervix under magnification to identify abnormalities (eg, acetowhite changes, abnormal vessels) that require biopsy to aid diagnosis and treatment planning. Cervical neoplasia typically occurs at the squamocolumnar junction, or transformation zone, because the epithelium at this location undergoes constant cell division and metaplasia (ie, simple columnar endocervix transitioning to stratified squamous ectocervix). magnification This patient's colposcopy reveals no raised or ulcerated lesions. However, the entire squamocolumnar junction is not visualized. Because the most at-risk area cannot be seen in its entirety, the evaluation is unsatisfactory, and occult CIN or cancer could be missed. Therefore, the best next step in management is endocervical curettage, which can sample tissue from the transformation zone to assess for lesions. (Choice B) Endometrial biopsy is indicated in patients with abnormal uterine bleeding (eg, postmenopausal bleeding), a common sign of endometrial cancer. Although unopposed estrogen (eg, obesity as in this patient) is a risk factor, this patient has regular menses and, therefore, does not require endometrial biopsy. Endometrial biopsy (Choices C and D) Women age ≥30 with normal cervical cancer screening results can undergo human papillomavirus testing in 5 years for routine screening. This patient has HSIL and requires additional management (eg, endocervical curettage, cervical biopsy) besides repeat Pap testing. (Choice E) Transvaginal pelvic ultrasound is used to assess patients with uterine or adnexal conditions (eg, abnormal uterine bleeding, pelvic pain, adnexal mass). It is not used to evaluate cervical dysplasia. Educational objective: Patients with high-grade squamous intraepithelial lesions on Pap testing are at high risk for cervical intraepithelial neoplasia and cervical cancer. Because these lesions typically arise from the transformation zone, patients with an unsatisfactory colposcopy (ie, entire squamocolumnar junction cannot be visualized) require endocervical sampling (eg, endocervical curettage). References: 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. (http://www.ncbi.nlm.nih.gov/pubmed/23519301) ACS/ASCCP/ASCP guidelines for the early detection of cervical cancer. (http://www.ncbi.nlm.nih.gov/pubmed/23062041) Management of histologic abnormalities of the cervix. (http://www.ncbi.nlm.nih.gov/pubmed/16417073)

A 31-Year-Old Woman Comes to the Office for Follow Up