Screening for Sexually Transmitted Infections and Cervical Cancer in Young Women

Screening for sexually transmitted infections and cervical cancer in young women

By Paul M. Krueger, DO nual chlamydia/gonorrhea screening if they cian is considering testing for chlamydia are at high risk of infection. Among women and gonorrhea because of a female patient’s Women between the ages of 19 and 25 are at high risk of chlamydia/gonorrhea infec- sexual behavior, the clinician should also at risk for a great number of sexually trans- tions, as listed by the CDC, are those who discuss HIV testing with that patient. mitted infections (STIs), including chlamy- are substance abusers; those with histories Women between the ages of 19 and 25 dia, gonorrhea, human immunodeficien- of STIs; those with more than one sexual will sometimes request testing for STIs be- cy virus (HIV), and genital herpes simplex partner in a single year; those living in cor- cause of concerns stemming from their virus (HSV). Human papillomavirus rectional facilities; and those living in com- own sexual activity or that of a sexual part- (HPV) is the most common STI among munities with high rates of STIs.3 The ner. Reasonable testing in this population women in this age group. The federal Cen- CDC also recommends that high-risk group includes screening for chlamydia ters for Disease Control and Prevention women receive annual serological testing (using NAAT), gonorrhea (using culture), (CDC) estimates that 80% of women in for syphilis. Furthermore, because individ- syphilis (using serological testing), and the United States become infected by HPV uals who have positive results on tests for HIV.2,3 Screening for hepatitis B should be by the time they are 50 years of age.1 This STIs are often difficult to locate for subse- performed in these women as well. How- infection rate is high because many young quent treatment, presumptive antibiotic ever, screening for hepatitis C is not indi- adult women continue to engage in the therapy for high-risk women is recom- cated unless the woman is immunocom- risk-taking sexual behaviors of adolescence. mended.3 promised.3 Counseling such women about safe sexual The CDC notes that heterosexual HIV Some clinicians test the cervical secre- practices is discussed on page 10 in this transmission is now “responsible for the tions of young female patients for HSV issue of AOA’sWomen and Wellness. most rapidly increasing subset of US AIDS using pcr technology—even if the patient The United States Preventive Services cases.”3 This statement is true for all groups has never been diagnosed with a genital Task Force (USPSTF) recommends that of women and is particularly striking in re- herpes infection. Such testing is done to all sexually active females aged 25 or younger gard to African American women.3 Thus, identify women who are asymptomatically be screened annually for chlamydia and gon- screening for HIV should be offered to all shedding HSV. The subsequent initiation orrhea. According to USPSTF guidelines, at-risk women. In other words, if a clini- of antiviral therapy in these women de- screening for chlamydia should be performed by using nucleic acid amplification technology (NAAT), a commonly available test based on the analysis of deoxyribonucle- ic acid (DNA). Because of the increasing antibiotic resistance of Neisseria gonorrhoeae, the causative agent of gonorrhea, the USP- STF recommends the use of a culture to screen for this microorganism.2 Many clinicians prefer the convenience of using polymerase chain reaction (PCR) technology in screening for both chlamydia and gonorrhea, as well as in reflex testing for oncogenic strains of HPV. If the clinician chooses to use PCR for these purposes, he or she should also test for gonorrhea by culturing—in order to differen- tiate antibiotic resistance from reinfection.

High-risk populations The CDC recommends that women who are 25 years of age or older be offered an-

7 creases the risk of spreading the infection to The report on cervical cytology testing of Ⅲ Atypical squamous cells of their sexual partner(s). a patient consists of two main parts: a state- undetermined significance (ASCUS) ment of test adequacy and the test results.7,8 Screening for HPV and cervical Inadequate Pap smears need to be repeated. Ⅲ Atypical squamous cells, cannot exclude cancer The older terminology used in Pap smear re- high-grade squamous intraepithelial Papanicolaou (Pap) smears are performed ports—”satisfactory, but limited by...”—is lesions (ASC-H). to save the lives of women from cervical no longer utilized.7,8 The cytologist will cancer. In the 1920s and 1930s, cervical sometimes note the presence of vaginal can- Ⅲ Low-grade squamous intraepithelial cancer was a common cause of death in didiasis (ie, yeast infection) or bacterial vagi- lesions (LSIL) women, and it was the leading cause of nosis in a report. However, the sensitivity of women’s cancer-related deaths.4 After Pap testing for these infections is low, and Ⅲ High-grade squamous intraepithelial George N. Papanicolaou, MD, PhD, pub- treatment should be based on clinical find- lesions (HSIL) lished his landmark research on cervical cy- ings only. Some physicians are comfortable tology in the early 1940s, deaths from cer- treating a patient for trichomoniasis on the Ⅲ Squamous cell carcinoma vical cancer plummeted. The American basis of Pap smear results, but others prefer Cancer Society estimates that 11,150 new to confirm the diagnosis with a wet-mount Most patients with LSIL will have cervical cases of invasive cervical cancer were diag- examination before initiating treatment. intraepithelial neoplasia (CIN) grade 1 nosed in the United States in 2007.5 How- ever, only 3,670 deaths were attributed to cervical cancer during that same year.5 The Pap smear has been called the “ideal” screening test.6 However, it is actu-

All women between the ages of 19 and 25 require an annual [Pap smear. ally ideal only for cervical cancer screening. It should not be used as the primary screening tool for STIs or endometrial or ovarian carcinoma. Nor should it be used as the primary method for etiologic analysis of vaginal infection or work-up testing for dys- functional uterine bleeding. Cervical cytology screening of a patient should begin within three years after she Managing abnormal cervical (previously called mild dysplasia) revealed commences sexual activity, but no later cytology results on biopsy. Patients with HSIL most com- than age 21 years. Screening should contin- The American Society for Colposcopy and monly will have CIN grades 2 or 3 on ue annually until the patient reaches age Cervical Pathology (ASCCP) is a tremen- biopsy. Squamous cell carcinoma is rarely 30 years, after which it can be performed dously useful resource for physicians reported in Pap smear results. Of course, every two or three years in low-risk women. who are treating patients with abnormal if a clinician sees a visible tumor on the Therefore, all women between the ages of cervical cytology test results. The ASCCP’s cervix, a biopsy should be performed.9 19 and 25 require an annual Pap smear.4 Web site (http://www.asccp.org) provides Women with a diagnosis of ASC-H, It is not clear whether the use of liquid- algorithms for the management of cyto- LSIL, HSIL, or squamous cell carcinoma based cytology(LBC) improves the sensitiv- logic abnormalities and cervical neo- without a visible tumor should undergo a ity and specificity of Pap smear cervical can- plasia.9 colposcopic examination. Treatment of cer screening. However, LBC does decrease The Bethesda System 2001,7,8 for these women should be based on multiple the number of inadequate Pap smear results, reporting cervical/endocervical/vaginal biopsies taken during the colposcopic ex- and it allows for reflex testing for oncogenic cytology results, delineates the following amination.9 The management of a patient’s HPV DNA without the need of a second of- five epithelial (ie, squamous) cell abnormal- glandular cell abnormalities is more com- fice visit by the patient. ities: plex than the previous conditions and is

8 usually referred to a gynecologist.9 dure or ablation of the cervical transforma- 6. Eddy DM. Screening for cervical cancer [review]. There are three appropriate ways to man- tion zone.9 Ann Intern Med. 1990;113:214-226. age a patient’s ASCUS result from a Pap Hysterectomy is reserved for patients smear: repeat cervical cytology screening with cervical adenocarcinoma in situ who 7. Solomon D, Davey D, Kurman R, Moriarty A, O’Con- every six months for two years; a colposcop- do not desire future pregnancy, and for nor D, Prey M, et al; Forum Group Members; Bethesda ic examination; or testing for HPV DNA.10 patients who have recurrent disease or an 2001 Workshop. The 2001 Bethesda System: terminol- The latter option is clearly preferred if the uncertain diagnosis in which uterine carci- ogy for reporting results of cervical cytology [review]. Pap smear was performed with a liquid- noma cannot be ruled out. JAMA. 2002;287:2114-2119. based medium, because no repeat office visit will be required of the patient. Final notes 8. NCI Bethesda System 2001: 2001 terminology. Women who are between the ages of 19 Bethesda 2001 Workshop Web site. Available at: Use of liquid-based cytology and 25 require annual cervical cytology http://bethesda2001.cancer.gov/terminology.html. Many clinicians prefer the ease of reflex screening and effective management of the Accessed July 3, 2008. testing for oncogenic strains of HPV in pa- results, based on ASCCP algorithms. Rou- tients who have ASCUS Pap smear results. tine testing for chlamydia and gonorrhea 9. Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, These clinicians have, therefore, adopted should be performed annually in women Wilkinson EJ, Solomon D; 2006 American Society for the routine use of a liquid-based medium aged 25 years and younger. Women who Colposcopy and Cervical Pathology-sponsored Consen- for cervical cytology screening. With the are older than age 25 should be screened sus Conference. 2006 consensus guidelines for the use of LBC, the lab can simply perform for STIs based on their risk factors. If a management of women with abnormal cervical cancer testing on all patients with ASCUS Pap woman is at high risk, she requires not only screening tests [review]. Am J Obstet Gynecol. smear results and discard the specimens testing for chlamydia and gonorrhea, but 2007;197:340-345. Available at: http://www.asccp.org/ of all patients with other Pap smear results. also testing for HIV, syphilis, and hepati- consensus/cytological.shtml. Accessed July 3, 2008. A patient with an ASCUS Pap smear tis B. Many clinicians also perform testing result who also has positive results for for HSV in high-risk women.9 ❙ ww 10. Solomon D, Schiffman M, Tarone R; ALTS Study oncogenic HPV DNA should undergo an group. Comparison of three management strategies immediate colposcopic examination. A pa- References for patients with atypical squamous cells of undeter- tient with an ASCUS Pap smear result 1. Centers for Disease Control and Prevention. Genital mined significance: baseline results from a random- who has negative results for oncogenic HPV Infection—CDCFact Sheet. Rockville, MD: CDC ized trial. J Natl Cancer Inst.. 2001;93:293-299. Avail- HPV DNA should undergo a repeat Pap National Prevention Information Network; 2008. Avail- able at: http://jnci.oxfordjournals.org/cgi/content/ smear in no sooner than one year.9 More able at: http://www.cdc.gov/STD/HPV/STDFact- full/93/4/293. Accessed July 2, 2008. frequent screening is unnecessary. HPV.htm. Accessed July 2, 2008. It should be noted that the use of HPV 11. American College of Obstetricians and Gynecolo- DNA testing with Pap smears is not appro- 2. United States Preventive Services Task Force. Guide gists. ACOG Practice Bulletin. Clinical management priate for primary screening in women aged to Clinical Preventive Services. 2nd ed. Baltimore, Md: guidelines for obstetrician-gynecologists. Number 61, 19 through 25. HPV DNA testing is most Williams & Wilkins; 1996. April 2005. Human papillomavirus. Obstet Gynecol. commonly used in women who are older 2005;105:905-918. . Available at: http://www.green than 30 years of age to help identify those 3. HIV prevention through early detection and treat- journal.org/cgi/reprint/105/4/905. Accessed July 2, patients who need cytologic screening at ment of other sexually transmitted diseases—United 2008. less frequent intervals.11 States. Recommendations of the Advisory Committee for HIV and STD Prevention. MMWR Recomm Rep. Paul M. Krueger, DO, is associate dean for Treating patients diagnosed 1998;47(RR-12):1-24. Available at: http://www.cdc Academic Affairs and professor of Obstetrics with CIN .gov/mmwr/preview/mmwrhtml/00054174.htm. Ac- and Gynecology at the University of Medicine Patients who are diagnosed with CIN cessed July 2, 2008. and Dentistry of New Jersey––School of Osteo- grade 1 can be treated by conducting care- pathic Medicine in Stratford. In addition, Dr Krueger is a member of the Editorial Advisory ful follow-up testing or by immediate use 4. American College of Obstetricians and Gynecolo- Board of JAOA—The Journal of the American of a diagnostic excision procedure (eg, loop gists. ACOG Practice Bulletin. Cervical cytology Osteopathic Association. He can be reached at electrode excision procedure or cold-knife screening. Number 45, August 2003. Int J Gynaecol (856) 566-6031 or via email at krueger@ umdnj.edu. cervical conization). The choice of treat- Obstet. 2003;83:237-247. ment option depends on the patient’s age, cytologic abnormality, and likely 5. American Cancer Society. Cancer Facts & Figures adherence to a treatment plan. Patients 2007. Atlanta, Ga: American Cancer Society; 2007:4. with CIN grades 2 and 3 are typically treat- Available at: http://www.cancer.org/downloads/ ed with either a diagnostic excision proce- STT/caff2007PWSecured.pdf. Accessed July 2, 2008.