Abnormal Pap Smears: Faculty Management and Seshu P. Sarma, M.D. Counseling Emory Regional Training Center Satellite Conference and Live Webcast Atlanta, Georgia Wednesday, February 14, 2007 2:00 - 4:00 p.m. (Central Time)

Produced by the Alabama Department of Public Health Video Communications and Distance Learning Division

Program Objectives Program Objectives • Discuss the epidemiology and • Describe Bethesda 2001 Pap etiology of cervical precancerous terminology. and cancerous disease. • Describe the natural course of HPV • Discuss management guidelines for infection and its role in the development of . various abnormal Pap smear findings. • Discuss new Pap smear recommendations and the rationale behind the new changes.

Cervical Cancer Etiology of Cervical Cancer • Incidence of Cervical Cancer: • Infection with high risk HPV – 9.2 per 100,000 (age-adjusted for the US population) in 2000 – 16,18,31,33,35,39,45,51,52,56,58,59 and 68 • Cervical cancer incidence has decreased by 77.7% from 1950 to – Mostly 16,18,45 and 31 2001 • Mortality reduced by as much as 70% – Due to pap smear screening

1 HPV Infection HPV and Cervical Cancer • The prevalence of genital HPV • HPV infections resolve infection spontaneously within 1-2 years. • Persistent infection with High Risk – Highest among sexually active HPV infection is a prerequisite for teens and women in their 20s the development of cervical cancer. • Although HPV infection is necessary – Decreases after age 30 for the development of cervical cancer, majority of women who are infected with HPV do not develop cervical cancer.

Risk Factors for Methods of Testing Cervical Cancer • Conventional Method: • Infection with high-risk HPV – Glass slide, wooden spatula and • Smoking cytobrush • Immunosuppression • Liquid Based Method: • Multiple sex partners • Young age at first – Cervex brush or broom • Low socioeconomic status – Plastic spatula and cytobrush • Long term oral contraceptive use

Pap Screening Liquid Based Pap Smears • Conventional Pap smear is • Shorge et al reported that ThinPrep associated with a high rate of false- yielded a higher pickup of negative results. – Atypical glandular cells of undetermined significance (AGUS) • The use of liquid based Pap testing has decreased the incidence of false- – negative Pap results. – 0.17% of LBP vs 0.09 of conventional

2 Liquid Based Paps Smears HPV Vaccination • In addition, the sensitivity of AGUS • In June 2006, the first HPV , and adenocarcinoma was found to was introduced be significantly greater with the liquid-based test – Effective against types 6 and 11 which cause genital – 72.0% with LBP vs 41.5% with – 16 and 18 that are associated with conventional cervical cancer

Gardasil Gardasil • The quadrivalent vaccine • Recently, the American College of Obstetrics and Gynecology – Approved by the US FDA for administration to females between published its recommendations: 9 and 26 years of age – prior to vaccination – Can be given even if infected with HPV – Continue Pap after vaccination – Given as 0.5 ml dose initially, at 2 months and 6 months

Barriers to Vaccination HPV Vaccine • Cost • Protection against HPV 16 and 18 only. • Potential for side effects • It is unknown how long the immunity lasts. • Parents’ acceptance of the concept • Other oncogenic subtypes account of vaccinating their preadolescent for 30% of cervical cancers. and adolescent daughters against a • All these are important reasons to STD continue screening for cervical cancer.

3 Computer-Assisted Screening Focal Point Slide Profiler • CAS with an automated microscope • FPSP works with image analysis was developed to prescreen slides and identify those that contain cells software that makes algorithmic of interest. judgments about whether a slide • Two systems have been approved by the FDA for use with liquid based specimen is normal or abnormal. Pap smears: – Thin Prep Imaging System (TPIS). – Focal Point Slide Profiler (FPSP).

Thin Prep Image System New Pap Guidelines

• TPIS scans slides and identifies cells • American Cancer Society proposed of interest. new Pap smear screening • TPIS imager scans each slide and recommendations in 2002 which identifies 22 fields that contain cells were later endorsed by United States of interest. Preventive Services Task Force and The cytotechnologist then reviews • American College of Obstetrics and those 22 fields using an automated microscope and reports the results. Gynecology.

New Pap Guidelines New Pap Guidelines • Begin screening approximately 3 • Consider discontinuing Pap after age years after the 1st vaginal 65 to 70 in well-screened women intercourse or at age 21 whichever comes first – With no history of significant • Test every 1 to 2 years until age 30 dysplasia • Every 2 years with liquid-based Pap (ACS) – Age 65 according to USPSTF and • Test every 2 to 3 years after age 30 – In well screened women with 70 according to ACS negative Pap

4 New Pap Guidelines New Pap Recommendations

• Discontinue Pap testing in women • Continue annual Pap screening in women with no : whose uterus and cervix have been – History of cervical removed for benign conditions with cancer/precancer no history of high-grade cervical – In utero exposure to dysplasia or cancer. diethylstilbestrol – Immunocompromised women • HIV positive individuals

New Pap Guidelines New Pap Guidelines ACS USPSTF ACOG Screening Conventional or Conventional Conventional or ACS USPSTF ACOG Method liquid liquid Termination Age 70 if Age 65 if Same as of uterus recent ACS Initial 3 years after the Same as ACS Same as ACS screening onset of vaginal screening intact, three screening Recommen- intercourse or consecutive was dations no later than 21 negative adequate years Paps and with Screening Annual with At least Annual no normal Pap interval conventional every 3 years screening before abnormal smears pap or every 2 age 30 and then tests in the years with every 2-3 years if last 10 liquid based 3 consecutive years pap until age 30 tests are negative

The Main Questions The Main Questions • Why wait three years after first • What is the role of HPV DNA testing? intercourse for the first pap test? • How should we deal with abnormal results? • Why is the age 21 the “default” age • How should we counsel the for first pap test? patients? • What is the harm in continuing Pap • What are the risks and costs of tests in all women? screening every two to three years in • Will women return for annual exams well-screened women over age 30? as we advise, if we change their Pap Over age 65? routine?

5 Rationale Yearly Pap Smears

• Why wait three years after first • The yearly Pap test was advocated intercourse for the 1st pap test? long before data suggested one

• Why is the default age 21 for the 1st interval might be better than another. pap test?

Why Wait Three Years After Rationale Intercourse? • Cervical cancer develops only after • The goal of Pap smear screening is persistent HPV infection, many years to diagnose and treat precancerous lesions and prevent cancerous from the initial infection. progression. • HPV infections in young women are • A three year delay is highly unlikely to compromise timely diagnosis of usually transient. high grade lesions. • Up to 90% of young women who test • It does allow discovery and eradication of dysplastic changes positive for HPV DNA will revert to long before they become malignant. negative within 2 years.

Problems of Screening Early STD Screening and • Squamous cancer of the cervix is Contraception exceedingly rare under age 21. • Delaying Pap by three years in sexually active young women does • HPV infections are exceedingly common in women under age 21. not mean that these women do not need routine gynecologic care. • Diagnosis of self limited HPV infections and transient low grade • They still need dysplastic lesions would lead to – STD screening and counseling. unnecessary repeat Pap smears and/or colposcopies. – Contraceptive counseling.

6 Why Is Age 21 the “Default” Aggressive Screening Until for First Pap? Age 30 • Incidence of High Grade SIL • Screening increases with age. – Every year with conventional Pap • Cervical Cancer is rare in teenagers smears and young women. – Every two years with liquid based • Cytology screening starting at age 21 Pap smears would capture most women at risk. • According to ACS guidelines • A 21 year old who has never had • According to ACOG yearly vaginal intercourse does not need to screening regardless of the be screened for cervical cancer. method is recommended

Rationale Pap Screening: Ages 30-65

• Frequent screening until age 30 • Research indicates that it is allows us to identify and treat young reasonable to reduce the screening women with histologic cervical interval from every year to every two intraepithelial neoplasia (CIN II and to three years in previously well- CIN III or worse) which may progress screened women over age 30. to cancer.

Rationale Pap Screening: Ages 30-65 • These women have the protection • Both ACOG and ACS recommend offered by frequent pap tests during annual screening regardless of age if following risk factors are present the 20s. – History of cervical cancer/precancer • By the time most women reach their – Immunocompromise (HIV) 30s, the area of active squamous – DES exposure metaplasia which serves as the – Those not screened well under age 30 should have at least three substrate for cervical neoplasia is negative Pap smears reduced.

7 Screening Interval Studies How Many Cancers Will • Frequent screening would detect We Miss? very few additional cancers at an • In a theoretical cohort of 100,000 exceedingly high cost. women who had at least three consecutive negative pap tests, • We can confidently counsel patients screening at one year rather than that a previously well-screened three year intervals would uncover woman over age 30 who has no three additional cancers in women history of dysplasia has an aged 30-44, a single additional exceedingly small risk of cervical cancer in women aged 45-59 and no cancer, whether her next Pap test is additional cancers in women 60-64 1, 2 or 3 years after her last. years of age.

Sawaya Study Pap Smears in Older Women

• To find all three additional cancers in • If an older woman’s sexual practices the 30-44 age group, it would require change, consider restarting 69,665 Pap tests and 3,861 colposcopies. screening.

• To find the only additional cancer in the 45-59 age group, it would require 209,324 Pap tests and 11,502 colposcopies.

Postmenopausal Screening Postmenopausal Women

• Women over 65 do get cervical • However, incident cases of cancer. squamous cancer among older

• 25% of new cases of cervical cancer women are seen in those who have are in women above age 65. not been well screened previously.

• 41% cervical cancer mortality is in women above age 65.

8 Postmenopausal Screening Postmenopausal Screening • An older woman in a long-term • American Cancer Society recommends discontinuing monogamous relationship who has a screening at age 70 in low-risk history of frequent negative Pap previously well screened women. smears is at such low risk for • While acknowledging the acquiring cervical cancer that the US recommendations of these other Preventive Services Task Force professional organizations, ACOG recommends discontinuing notes that there is no good evidence to establish an age to discontinue screening at age 65. screening.

Postmenopausal Screening Postmenopausal Screening • Heart and estrogen/progestin • Among low risk population, routine replacement study: Pap screening may lead to: – 2,561 women – Pap every 1-2 years – Additional tests – 110 recalled for follow-ups – Unnecessary cost – 231 interventions (repeat Paps, colposcopies, cervical and – Anxiety endometrial and D&C) – Only one woman with histologic • Limited value of screening moderate dysplasia

Screening Women With Pap Smear in Women Hysterectomy Without Cervix • Since 1996, US Preventive Services • For any screening procedure to be Task Force has recommended cost effective, there must be a against Pap screening in women who had uterus and cervix removed for threshold prevalence of the disease benign reasons. in the population to be screened. • A recent study showed as many as 45.6% of such women were still having Pap smears.

9 Pap Smear in Women Pap Smear in Women Without Cervix Without Cervix • While women with prior cervical • In essence, screening in these women becomes a search for cancer or high-grade dysplasia primary . remain at increased risk for • Primary vaginal cancer is very rare- recurrences at the vaginal cuff, only 0.3% of cancers in women. women with no history of such • Continued screening in the absence disease are at extremely low risk of of cervix results in screening an cancer. unacceptably large number of women to diagnose a rare cancer.

Pap Smear in Women HPV Testing Without Cervix • Hybrid capture DNA 2 assay to • Cytology screening in this group is detect 13 high-risk HPV subtypes: far more likely to diagnose low grade – Triage of ASCUS Pap smears vaginal intraepithelial neoplasia (VAIN 1) which reflects self-limited – Combined PAP-HPV DNA epithelial changes that are extremely unlikely to progress to cancer.

PAP-HPV DNA PAP-DNA • A combination Cytology+HPV DNA • PAP-DNA screening in women under test 30 is not useful:

• US FDA approved PAP-DNA in 2003 – High prevalence of high-risk HPV for use in women over age 30 in this age group.

• Both ACS and ACOG approved the – Results in unacceptably high combination test numbers of women testing positive whose risk of invasive cervical • Should be used every three years if both tests are negative cancer is low.

10 Women Under 30 PAP-DNA • Women under 30 should be screened • Prevalence of HPV declines after age with Pap smear alone. 30

• Routine HPV testing is not indicated • PAP-DNA test is valuable in this age in this group. group

• High negative predictive value of the combination test

PAP-DNA Test PAP-DNA Test

• Sherman et al determined that the • Women can be assured that if they test negative on the combination negative predictive value of the test, their risk of CIN3 or squamous combination of cytology plus HPV cancer is negligible at least for three DNA testing is 99.88% at 33 months. years.

• If both cytology and HPV are • At 45 months, it was still 98.84%. negative, repeat the test in three years.

PAP-DNA Test Negative Cytology and • ASCUS on Pap and HPV positive: Positive HPV DNA • Repeat Pap / HPV DNA in 6-12 months – • If both are negative, resume three year screening • ASC-H, AGC, LGSIL and HGSIL on • ASCUS and HPV negative, repeat Pap Pap and HPV in one year • ASC-H, LGSIL, AGC, HGSIL: – Colposcopy even if HPV is – Colposcopy negative • HPV positive with negative cytology: – Colposcopy

11 Putting New Guidelines Into Counseling HPV Patients Practice • Sexually transmitted • Easier said that done High prevalence: >75% population of • Patients need a clear message • reproductive age • Tell patients: – Don’t stop annual exams • Low risk of cancer for the partner

– Breast exams and other health • Low risk of cervical cancer related check ups are necessary • Importance of timely Pap screening

References Management of Abnormal • Cervical cancer screening: Revised Pap Smears Guidelines. Mravcak S; The Female patient;Vole 29: December 2004;36- Seshu P. Sarma, M.D. 44

• Pap test every Year? Not for every woman; Waxman AG; OBG Management: December 2004. 36-55

Cervical Cancer Pap Smear Reporting Pap smear screening resulted in • • Pap system of reporting dramatic reduction in cervical cancer. • Bethesda 1988 system

• Bethesda 1991 system • The value of accurate screening results can be reduced by loss to • Bethesda 2001 system follow-up or under-treatment of significant lesions. • Bethesda 2006 system

12 Adequate Specimen Adequacy of Specimen • Conventional smear: • Satisfactory specimen contains: – 8,000-12,000 well visualized cells should be seen – 10 well preserved endocervical • Liquid-based Pap: cells – 5,000 well visualized cells should be seen – 10 squamous metaplastic cells – Epithelial cells may be obscured by inflammation – If > 75% of cells are obscured, it is considered unsatisfactory

Transformation Zone Not No T Zone Components Present • Repeat testing is recommended for • If Pap is otherwise normal, no higher women at higher risk of neoplasia such as: risk of subsequent detection of high grade SIL – Immunocompromised – HPV + Most women without an endocervical • – Previous abnormal Pap smears or transformation zone component – Inability to visualize the cervix can be rescreened in 12 months – Insufficient previous screening

Unsatisfactory Pap Smears Abnormal Pap Smears • Pap smears that are unsatisfactory • 50-60 million Pap tests per year in need to be repeated in 2-4 months. the US • 3.5 million are classified as abnormal • If three consecutive specimens are and require some form of medical unsatisfactory, colposcopy is follow-up recommended. • 10,000 new cases of cervical cancer • Histologic abnormalities were found seen each year in the US in 16% of this population. • 4,000 deaths from cervical cancer

13 Abnormal Pap and Inconclusive Pap Smears Cervical Cancer • Almost two million Pap smears each • Determining which women with year are classified as “inconclusive” abnormal Pap tests are at risk of – ASC-US, ASC-H and LSIL significant cervical disease and • Most of them have no detectable treating them presents a major problem public health challenge and a • Less than one fifth of these women multibillion dollar cost to our have a significant precancerous healthcare system. lesion

Inconclusive Pap Smears Abnormal Pap Smears • Although these changes are mild, • Effective cervical cancer prevention they may result in: requires recognition and treatment of the precursors of invasive cancer. – Anxiety

– Unnecessary medical procedures • The 2001 Bethesda System of nomenclature describes the – Extra costs to healthcare system categories of epithelial cell abnormalities seen on Pap smears.

The 2001 Bethesda System The 2001 Bethesda System Squamous Cell Squamous Cell • Atypical Sqaumous Cells • High-grade squamous intraepithelial – ASC-US (undetermined lesions significance) – ASC-H (can not exclude HSIL) – Moderate and severe dysplasia and carcinoma-in-situ • Low-grade squamous intraepithelial lesions (CIN II and CIN III) – Mild dysplasia • – HPV changes

14 The 2001 Bethesda System The 2001 Bethesda System Glandular Cell Glandular Cell • Atypical glandular cells (AGC) • Endocervical adnocarcinoma in situ – Endocervical (AIS) – Endometrial – Not otherwise specified (NOS) • Adenocarcinoma • Atypical glandular cells – Favor neoplasia • Specify endocervical • Not otherwise specified (NOS)

Precancerous Precursors HPV and Abnormal Paps • CIN 2, CIN 3, adenocarcinoma in situ • The presence of HPV is a marker for (AIS) are collectively referred to as the risk of diagnosis of CIN2/3+ CIN2/3+ • CIN2/3+ need to be identified and • Only 1 in 10 to 1 in 30 HPV infections treated in a timely manner to prevent are associated with abnormal invasive cancer cervical cytology • Cancer precursors include: – CIN 3, AIS and to a lesser extent • Even a smaller proportion are CIN 2 associated with CIN2/3/+

HPV CIN Regression • Among women with negative cytology and a positive HPV test • Regression for CIN result, only 15% will have abnormal cytology results within five years. – 60% for CIN 1 and 40% for CIN 2

• HPV can express as CIN within months after infection.

• However, the time course from CIN 3 to invasive cancer averages between 8.1 and 12.6 years.

15 CIN 1 Cervical Cancer Screening • CIN 1 is the histologic appearance of • Measures the risk that CIN2/3+ is cells producing HPV present • The goals of cervical cancer • The risk that CIN2/3+ will screening: subsequently be diagnosed – Not to prevent CIN • These risks define the – But to prevent and treat – Intensity of initial evaluation • Early invasive cervical cancer • Reduce mortality – Interval and intensity of follow up

Colposcopy Colposcopy • Colposcopy with directed is • Evaluation of the the technique of choice for – Cervix and vagina evaluation of abnormal Pap smears. – Vulva • In 1-10% of cases, lesions more severe than anticipated by biopsy • With 10-25 times magnification were found on excision. • Acetic acid 3-6 % solution used • 16 missed invasive cancers were • Cervix and vagina are evaluated found among 1,975 patients before and after acetic acid is undergoing excision. applied

Colposcopy Directed Biopsies Colposcopy • Single colposcopic examination • The risk of undiagnosed cancer is – Very low sensitivity • Studies indicate that biopsies of all the major reason for the visible lesions are warranted recommendation of excision for regardless of the colposcopic impression women with unexplained high-grade • Multiple colposcopic evaluations are abnormal cytology results. necessary for persistent low-grade abnormalities or persistently positive HPV

16 Management of Abnormal Pap Atypical Squamous Cells • Atypical Squamous Cells: • Options include:

– These are cellular changes that are – Immediate colposcopy more marked than those attributable to reactive changes but • Provides rapid diagnosis but fall short of a definitive diagnosis of expensive Squamous Intraepithelial Lesion – HPV DNA testing triage • The risk of cancer and CIN 2/3+ is low – 0.1-0.2% for cancer – Repeat cytology at 6 and 12 months – 6.4-11.9% for CIN2/3+

HPV Testing for ASCUS HPV Testing • Reflex testing for high risk HPV using • Hybrid Capture DNA 2 assay for 13 the liquid cytology specimen oncogenic HPBV sub types –HPV positive: • 15-27% chance of having a CIN2/3+ • Performed on the liquid based Pap • Need colposcopic evaluation specimen –HPV negative • Less than 2% chance of having a • Usually done within three weeks of CIN2/3+ obtaining the specimen • Annual Pap screening is adequate

ASCUS (HPV+) In Adolescents Adolescents • Recommendations are similar for The risk of invasive cancer • ASC and LSIL in adolescent girls. approaches zero in adolescents. • HPV infections are common and self • LSIL represents HPV infection and limiting in adolescents. most adolescents clear HPV and • Colposcopic evaluation is not LSIL. necessary. • Can be monitored with pap smears at • Follow up Pap at 6 and 12 months is 6 and 12 months. adequate.

17 Repeat Pap for ASC Repeat Pap for ASC Management Management • Follow-up with Pap smears may • The ALTS trail reported that a larger allow some women to avoid colposcopy number of women who completed – Waiting 6-12 months can create both follow-up cytology anxiety examinations were referred to – May delay the diagnosis colposcopy than those undergoing – Loss to follow-up can be triage with HPV testing (67% vs 56%) substantial

LSIL LSIL • More frequent in younger • The risk of CIN 2/3+ at initial populations with larger number of colposcopy following an LSIL is recent partners. between 15% and 30%. • Colposcopy is recommended for • Represents the appearance of cells these women. that are actively engaged in HPV replication. • For adolescents with LSIL, follow up with Pap at 6 and 12 months is • HPV testing is of limited value. reasonable.

ASC-H Follow Up After Colposcopy • Atypical squamous cells-cannot • ASCUS Pap and Negative exclude HSIL (ASC-H) Colposcopy – Includes 5-10% of ASC Pap smears – Repeat Pap in 1 year – CIN2/3+ seen in 24-94% of such • ASC-H and Negative Colposcopy cases – Repeat Pap smears at 6 and 12 – Immediate colposcopic months intervention is necessary – HPV DNA at 12 months – HPV testing is not cost effective – Excision is not recommended

18 Follow Up After Colposcopy HSIL Cytology Results • LSIL and Negative Colposcopy • CIN 2 and CIN 3 have been reported in 70% or more cases – Repeat Pap smears at 6 and 12 • Invasive cancer is seen in 1-2% of months cases • Colposcopy with endocervical – HPV DNA at 12 months evaluation should be done • Entire vagina should be examined • See and treat approach can be followed if lesion seen

HSIL on Pap Atypical Glandular Cells • CIN 1 or less on biopsy: • Histological correlation: – Review of cytology and histology – Squamous lesions in 33.7% – With unsatisfactory colposcopy, – 2.5% Adnocarcinoma in Situ excision is recommended – 1% cervical adenocarcinoma – Adolescents are exceptions since risk of invasive disease is low • Risk of CIN2/3+ is • Colposcopy and cytology at 4-6 – 9-41% in AGC smears month intervals is recommended as – 27-96% in AGC favor neoplasia long as colposcopy and endocervical curettage are negative • 2001 Consensus Guidelines

Atypical Glandular Cells Atypical Glandular Cells • Evaluation includes: • Source of the lesion – Colposcopy – Cervix – Endocervical curettage – Endocervix – Endometrial sampling – Endometrium • With abnormal endometrial cells • Women >35 years of age • Younger women with abnormal bleeding, morbid obesity and oligomenorrhea

19 Atypical Glandular Cells: How Should CIN 1 Be Negative Evaluation Managed? • AGC NOS: repeat Pap and • Depends on the preferences of the endocervical curettage every 6 physician and the patient months X 4 • For most young women, observation • AGC: repeat Pap and endocervical seems appropriate sampling at 12 months (provided colpo, ECC and HPV were negative) • Follow up with Pap smear every 6 months X 2 • AGC favor neoplasia: excision is warranted • Colposcopy for an ASC or higher or – Cold knife cone is a good choice a positive HPV at 12 months

CIN 2 and 3 CIN 2 In Adolescents • CIN 2 and 3 are recognized potential • Care of the adolescent with CIN 2 cancer precursors. may be individualized – CIN 2 is associated with significant spontaneous regression. • Treatment may be deferred – 40% of CIN 2 cases regress over two years. • Close follow up with Pap and • Immediate treatment of CIN 2 and colposcopy may be adequate CIN 3 with excision or ablation is recommended in non-pregnant patients.

Excision v. Ablation Management Of AIS • A large body of evidence indicates • Cold-knife conization is that rates for the clearance of recommended to preserve specimen squamous dysplasia of all grades are orientation and permit optimal the same for laser therapy, LEEP, interpretation of histology and and cryotherapy. margin status.

• Endocervical sampling before • LEEP is not recommended. ablation is recommended to avoid unrecognized invasive cancer.

20 Hysterectomy for CIN 2/3+ Abnormal Pap In Pregnancy • Hysterectomy is not the initial • ASC or LSIL: Colposcopy during pregnancy or at 6-12 weeks treatment of choice for CIN 2 or 3. postpartum

– May be considered for persistent • ASC-H: Immediate colposcopy or recurrent CIN 2 or 3. • HSIL: Immediate colposcopy • AGC: Immediate colposcopy • No endocervical sampling is done during pregnancy

Pregnancy Pregnancy • CIN is not treated in pregnancy • Biopsies should be done only as • Excision should be considered if needed in pregnancy to avoid lesion is suspicious for invasive unnecessary bleeding. cancer • Repeat colposcopic evaluation is • The purpose of biopsy in these done during pregnancy as needed women is only to exclude invasive cancer. • Reassessment by colposcopy 6-12 weeks postpartum

Treatment Modalities For CIN See and Treat Approach

• Cryotherapy • During colposcopic evaluation, when • Laser ablation significant abnormality is found,

• LEEP LEEP is performed to both evaluate and treat the precancerous • Cold knife cone biopsy condition. • Cryotherapy or laser ablation are done only when endocervical is ruled out

21 Reference Upcoming Programs Perspectives on Suicide Prevention: What • ACOG Practice Bulletin: Clinical School Counselors Need to Know Management Guidelines for Tuesday, February 20, 2007 1:00 - 3:00 p.m. (Central Time) Obstetrician-Gynecoogists Number Suicide Prevention and Risk Reduction: What 66, September 2005 Mental Health Practitioners Need to Know Thursday, February 22, 2007 1:00 - 3:00 p.m. (Central Time)

For complete list of upcoming programs visit our website at www.adph.org/alphtn

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