Screening for cervical cancer in women who go to STD clinics or have a history of an STD

Women with a history of STDs are at increased risk of developing cervical cancer, and women who go to STD clinics may have characteristics that can be classified as an even higher risk group. Studies of the prevalence of this pathology revealed that in women who go to STD clinics, precancerous lesions occur about five times or more more often than women who visit family planning clinics.

Pap smear test for Pap smear is an effective and relatively inexpensive screening test for invasive cervical cancer, squamous intraepithelial lesions (PID) * and precancerous lesions of the cervix. The screening guidelines for the American College of Obstetricians and Gynecologists and the American Cancer Society recommend an annual Pap smear study in sexually active women. Although these guidelines indicate that, in some situations, Pap smear can be examined less often, women who go to STD clinics or have a history of an STD should be screened annually because they belong to the group at increased risk of developing cervical cancer. Moreover, the reports of STD clinics show that many women do not understand the purpose and importance of Pap smear research, and many women who undergo an intra-vaginal examination believe that swabs are taken from them, although in reality this was not done.

* In 1998, in the manual "Bethesda System for the registration of cytological diagnoses of cervical and vaginal pathologies", the terms squamous intraepithelial lesions (PIP) were introduced, none-differentiated and highly differentiated. The term "non-epitentiated PIP" refers to cellular changes associated with HPV and with minor dysplasia / cervical intraepithelial neoplasia 1 (CIN I). The term "highly differentiated PIP" refers to moderate dysplasia / CIN II, severe dysplasia / CIN-III, carcinoma in situ / CIN III.

Recommendations

During a vaginal examination for STD screening, the doctor should ask the patient about the results of the latest Pap smear test and discuss the following information with her:

• The purpose of Pap smears research and their significance, 
• Did she have a Pap smear examination while visiting the clinic, 
• The need for a Pap smear study every year, and 
• Coordinates of the doctor or clinic where the Pap smear can be performed, and the possibility of follow-up (if the Pap smear was not taken at this examination). 

If a Pap smear has not been studied in the past 12 months, getting a Pap smear should be part of a routine intra-vaginal examination. The medical worker should keep in mind that after conducting an intravaginal examination, many women believe that a Pap smear was obtained from them, although in reality this was not done, and therefore can report on the newly taken Pap maeca. Therefore, in STD clinics, a PAP smear test should always be carried out in the routine clinical examination of women who do not have a record in the medical history of receiving a normal result of this analysis in the last 12 months (intra-clinical recording or obtained from a centralized system).

It is advisable that a woman receive a memo with information about the significance of Pap smear research and data that the Pap smear was taken during a visit to the clinic. If possible, a copy of the form with Pap smear results should be sent to the patient.

Follow-up

Clinicians and health care providers who are screening for Pap smear are allowed to use cytopathological laboratories that record results according to the Bethesda System classification. If the results of the Pap smear test indicate a pathology, the assistance of such patients should be provided in accordance with the recommendations of the Guidelines for the Management of Patients with Pathological Results of Cervical Cancer Cytology published by the Specialists Group of the National Cancer Institute, a summary of which is given below. When identifying signs of highly differentiated PID in Pap smears, colposcopic examination of the lower part of the reproductive tract should be performed, and if there are indications, a targeted biopsy. If Pap smears show a low-grade PIP or abnormal, flat cells of undetermined significance (APSCH), follow-up can be performed without colposcopy if there is no possibility to monitor the patient in this institution or when colposcopic examination can aggravate the process. In general, repeated Pap smears are recommended every 4-6 months for 2 years until three consecutive negative results are obtained. If, as a result of repeated Pap smear tests, persistent pathology is detected, colposcopy and targeted biopsy is indicated for both low-grade PID and APNCH. In women diagnosed as APSCH associated with a severe inflammatory process, repeated Pap smear tests are performed 2-3 months later, and then every 4-6 months, for 2 years until they are received three consecutive negative results. If a specific infection is identified, repeated examinations should be performed after appropriate treatment. In all subsequent follow-up cases, when performing Pap smear tests, the results should not only be negative, but also should be interpreted by the laboratory as "satisfactory".

Since the clinical observation of patients with pathological Pal-smears with the use of colposcopy and biopsy goes beyond the capabilities of many public clinics, including most STD clinics, in most cases, women who have a highly differentiated PID, or constantly identify low-grade PIP, or APS, will need to be referred to other clinics for colposcopy and biopsy. Clinics and health care providers who screen Pap smears but do not provide appropriate colposcopic follow-up for pathological Pap smears should organize the referral of patients to other facilities that can: 1) ensure correct evaluation and treatment of patients and 2) report the results of this by sending it to a clinician or other health worker. Clinics and health workers who conduct follow-up care for patients with repeated Pap smears should develop protocols for identifying women who have lost their original directions for reappearance and use them routinely. The results of the Pap smear, the type and location of the institution where the patient is being sent should be clearly recorded in the medical history. It is recommended to master on-site methods of colposcopy and biopsy, especially where it is not possible to examine patients in other institutions and there is no guarantee of follow-up control.

Other observations on patient management

Other comments on Pap smears include:

• Pap smear is not an effective screening test for STDs;
• If a woman has menstruation, taking a Pap smear should be delayed, and it is recommended for a woman to come for a Pap smear at the first opportunity;
• The presence of mucopurulent discharge can distort the result of Pap smear. However, if there is no guarantee that the woman will return for follow-up control, Pap smear should be taken after removing the secretions with a cotton swab dipped in saline.
• Women with external genital warts do not need a more frequent Pap smear examination than women who do not have warts (except for specially stipulated cases).
• In clinics of STDs or in other institutions where material is taken for sowing or other methods of testing for STDs, Pap smear should be taken last.
• Women with a previous hysterectomy do not need an annual Pap smear, even if the operation was performed for cervical cancer or precancerous lesions. In this case, women should be advised to seek follow-up care for the doctor who leads them in a given period of time.
• Health workers who received basic retraining to collect Pap smears and clinics using simple measures that guarantee the quality of this study receive less unsatisfactory Pap smears.
• While type-specific testing for HPV, aimed at identifying patients with a high and low risk of cervical cancer, may become clinically significant in the future, currently the value of this study for clinical practice is uncertain, and this study is not recommended.

Special Remarks

Pregnancy

In pregnant women, the Pap smear test should be part of a routine prenatal examination. To obtain Pap smears, pregnant women can use a brush, although care must be taken not to destroy the mucous plug.

HIV infection

Recent studies have shown an increase in the prevalence of PID in women infected with HIV, and many experts believe that HIV can contribute to the transformation of precancerous lesions into invasive cervical cancer. The following recommendations for Pap smear screening in HIV-infected women, in particular, are based on expert advice on the management and monitoring of women with cervical cancer and HIV infection and are consistent with the recommendations in other USPHS guidelines.

After collecting a complete history of previous cervical disease, women with HIV should undergo a full gynecological examination, including pelvic examination and Pap smear as part of a general medical examination. Pap smear should be taken 2 times in the first year after the diagnosis of HIV infection and, with normal results, 1 time per year in subsequent years. If abnormalities are found in the Pap smear results, these patients should be administered according to the Guidelines for the Management of Patients with Pathological Results of Cervical Cancer Cervical Cytology: Women with a cytologic diagnosis of highly differentiated PID or squamous cell carcinoma should undergo colposcopic research and targeted biopsy: HIV infection is not an indication for colposcopy in women with normal Pap smears.

[1], [2], [3], [4], [5]