Cervical Cancer Prevention and Early Detection

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Work-up of abnormal Pap test results

Other tests for women with abnormal test results

The Pap test is a screening test − not a diagnostic test − it cannot tell for certain that cancer is present. An abnormal Pap test result means that other tests will need to be done to find out if a cancer or a pre-cancer is actually present. The tests that are used include colposcopy (with biopsy) and endocervical scraping. If a biopsy shows a pre-cancer, doctors will take steps to keep an actual cancer from developing.

Sometimes these tests are also done to follow-up a positive HPV test result when the Pap test is normal.

Colposcopy

If you have certain symptoms that suggest cancer or if your Pap test shows abnormal cells, you will need to have a test called colposcopy. In this procedure you will lie on the exam table as you do for a pelvic exam. A speculum will be placed in the vagina to help the doctor see the cervix. The doctor will use a colposcope to examine the cervix. The colposcope is an instrument that has magnifying lenses (like binoculars). Although it stays outside the woman’s body, it lets the doctor see the surface of the cervix closely and clearly. The doctor will apply a weak solution of acetic acid (similar to vinegar) to your cervix to make any abnormal areas easier to see.

Colposcopy itself causes no more discomfort than any other speculum exam. It has no side effects, and can be done safely even if you’re pregnant. Like the Pap test, it’s rarely done during your menstrual period. If an abnormal area is seen on the cervix, a biopsy will be done. For a biopsy, a small piece of tissue is removed from the area that looks abnormal. The sample is sent to a pathologist to look at under a microscope. A biopsy is the only way to tell for certain if an abnormal area is a pre-cancer, a true cancer, or neither. Although the colposcopy procedure is not painful, cervical biopsy can cause discomfort, cramping, or even pain in some women.

Cervical biopsies

Several types of biopsies are used to diagnose cervical pre-cancers and cancers. If the biopsy can completely remove all of the abnormal tissue, it may be the only treatment needed. In some situations, additional treatment of pre-cancers or cancers is needed.

Colposcopic biopsy

For this type of biopsy, a doctor or other health care professional first examines the cervix with a colposcope to find the abnormal areas. Using a biopsy forceps, the doctor will remove a small (about 1/8-inch) section of the abnormal area on the surface of the cervix. The biopsy procedure may cause mild cramping or brief pain, and you may bleed lightly afterward. A local anesthetic is sometimes used to numb the cervix before the biopsy.

Endocervical curettage (endocervical scraping)

Sometimes the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope. In that situation, something else must be done to check that area for cancer. This means taking a scraping of the endocervix by inserting a narrow instrument (called a curette) into the endocervical canal (the passage between the outer part of the cervix and the inner part of the uterus). The curette is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the laboratory for examination. After this procedure, patients may feel a cramping pain, and they may also have some light bleeding. This procedure is usually done at the same time as the colposcopic biopsy.

Cone biopsy

In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the exocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The transformation zone (the border between the exocervix and endocervix) is contained within the cone. This is the area of the cervix where pre-cancers and cancers are most likely to develop. The cone biopsy can be used as a treatment to completely remove many pre-cancers and some very early cancers. Having a cone biopsy will not keep most women from getting pregnant, but if the biopsy removes large amount of tissue these women may have a higher risk of giving birth prematurely.

There are 2 methods commonly used for cone biopsies: the loop electrosurgical excision procedure (LEEP) (also called large loop excision of the transformation zone or LLETZ) and the cold knife cone biopsy.

  • electrosurgical procedure (LEEP or LLETZ): With this method, the tissue is removed with a thin wire loop that is heated by electrical current and acts as a scalpel. For this procedure, a local anesthetic is used, and it can be done in your doctor’s office. It can take as little as 10 minutes. You may have mild cramping during and after the procedure, and mild to moderate bleeding for several weeks.
  • knife cone biopsy: This method uses a surgical scalpel or a laser instead of a heated wire to remove tissue. It requires general anesthesia (you are asleep during the operation) and is done in a hospital, but no overnight stay is needed. After the procedure, cramping and some bleeding may persist for a few weeks.

How biopsy results are reported

The terms used for reporting biopsy results are slightly different from the Bethesda System for reporting Pap test results. Pre-cancerous changes on a biopsy are called cervical intraepithelial neoplasia (CIN), while on a Pap test they would be called squamous intraepithelial lesion (SIL). CIN is graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal when viewed under the microscope. In CIN1, not much of the tissue looks abnormal, and it’s considered the least serious cervical pre-cancer. In CIN2 more of the tissue looks abnormal, and in CIN3 most of the tissue looks abnormal. CIN3 is the most serious pre-cancer.

Sometimes the term dysplasia is used instead of CIN. CIN1 is the same as mild dysplasia, CIN2 is the same as moderate dysplasia, and CIN3 includes severe dysplasia as well as carcinoma in situ.

The terms for reporting cancers (squamous cell carcinoma and adenocarcinoma) are the same for Pap tests and biopsies.

When are these tests used?

What tests (or treatment) you will need depends on the results of the Pap test.

Atypical squamous cells (ASC-US and ASC-H)

If the Pap results show atypical squamous cells of uncertain significance (ASC-US), some doctors will repeat the Pap test in 12 months. Another option is to test for human papilloma virus (HPV). What is done next depends on how old you are. If you are 21 to 24 years old, and HPV DNA is found, the doctor will recommend a repeat Pap test in a year. If you are at least 25 years old and HPV is detected, the doctor will recommend a colposcopy. If HPV is not detected, then the doctor will recommend the Pap test be repeated in 3 years. If you are at least 25 years old, an HPV test will be done at the same time as the repeat Pap test.

If the results of a Pap test are labeled atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H), it means that a high grade SIL is suspected. The doctor will recommend colposcopy.

Squamous intraepithelial lesions (SILs)

These abnormalities are divided into low-grade SIL (LSIL) and high-grade SIL (HSIL).

For LSIL, further testing depends upon HPV testing:

  • the HPV test result was negative (meaning the virus wasn’t detected), then repeating the Pap test and HPV test in one year is recommended.
  • HPV was found, then colposcopy is recommended.
  • no HPV test was done and the woman is at least 25 years old, colposcopy is recommended.
  • the woman is under 25, she should have a repeat Pap test in a year.
  • women with LSIL should have colposcopy.

For HSIL, either colposcopy or a loop electrosurgical procedure is recommended for women 25 and older. For women under 25, colposcopy is recommended.

Atypical glandular cells and adenocarcinoma in situ (on a Pap test)

If the Pap results read atypical glandular cells or adenocarcinoma but the report says that the abnormal cells do not seem to be from the lining of the uterus (the endometrium), guidelines recommend colposcopy with the biopsy type called endocervical curettage (endocervical scraping). The doctor may also biopsy the endometrium (this can be done at the same time as the colposcopy). For information about endometrial biopsy, see our document Endometrial (Uterine) Cancer.

If the atypical glandular or adenocarcinoma cells look like they are from the endometrium (based on how they look under the microscope), experts recommend a biopsy of the endometrium along with an endocervical curettage, but a colposcopy isn’t needed unless the results from the endometrial biopsy are negative and do not explain the Pap test result. .


Last Medical Review: 09/17/2014
Last Revised: 10/16/2014