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Old 04-26-2013
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ObGyn Pap Smear Question

I am looking at this Question on Uworld: 4758 - why did this pt receive a HPV testing? I thought the Guidelines state no HPV testing till 30 yoa or more.
http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

Second questions is why not have this patient come for a repeat pap smear at 6 and 12 months? (following the diagram off Question ID 4755)
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I think I was able to get it.

Just a general questions in terms of Abnormal Pap:

Women has 1 abnormal Pap you do Colpscopy next, is this correct? If Positive you do either repeat Pap at 6 and 12, or HPV test at 12. But what if Pap is positive and Colpscopy is negative, what do you do next?
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if pt. has abn. pap----> 2 scenarios ----->1)if pt. follow up is certain then do pap again 6 and 12 months and HPV test ---->if either posiitve in next pap or HPV +ve----> do colposcopy
2) if pt. follow up is uncertain --->then directly do colposcopy and biopsy


p.s -if pt. have 2 abnormal pap(ASCUS) then colposcopy done----,if pt. has abnormal pap with HSIL -then directly colposcopy
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Quote:
Originally Posted by venky2600 View Post
if pt. has abn. pap----> 2 scenarios ----->1)if pt. follow up is certain then do pap again 6 and 12 months and HPV test ---->if either posiitve in next pap or HPV +ve----> do colposcopy
2) if pt. follow up is uncertain --->then directly do colposcopy and biopsy


p.s -if pt. have 2 abnormal pap(ASCUS) then colposcopy done----,if pt. has abnormal pap with HSIL -then directly colposcopy
Thank you again Venky2600. My confusion is this: In UW 4755 in question stem the patient has ASC-US on 1st pap so they did a Colpscopy not another pap to confirm. This is where I am lost. Because I am thinking that in general that women with 1 abnormal pap go with Colpscopy and based of the colpscopy then you do the 6 and 12 month Pap or HPV testing. (Attached image).

Even in Question ID 2631 pt has LSIL on 1st pap and asked what the next step was and it is Colposcopy not another pap. And that diagram from above question ID also shows that LSIL and ASC-US are followed the same way.
Attached Files
File Type: docx Doc1.docx (359.9 KB)
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Quote:
Originally Posted by gear2d View Post
Thank you again Venky2600. My confusion is this: In UW 4755 in question stem the patient has ASC-US on 1st pap so they did a Colpscopy not another pap to confirm. This is where I am lost. Because I am thinking that in general that women with 1 abnormal pap go with Colpscopy and based of the colpscopy then you do the 6 and 12 month Pap or HPV testing. (Attached image).

Even in Question ID 2631 pt has LSIL on 1st pap and asked what the next step was and it is Colposcopy not another pap. And that diagram from above question ID also shows that LSIL and ASC-US are followed the same way.
thanks for your doubts.......

where did you get this doc file from..?

doubt #1 ) ya i told you that ASCUS ---> if pt. has regular follow up(mean pt is a regular pt. or home near by the hospital or she assure you will follow up)-------> do repeat pap at 6 and 12 months or HPV test
if follow up isnt there(mean pt. is not a regular or it's her 1st time come to you)---->then directly colposcopy..

there was a similar case like the doc file you attached in uworld, but unfortunately it's removed in online version now..(may be due to the controversy it had).....it's still in offline version now.....

doubt # 2) LSIL is different from ASCUS follow up----> if pt. is diagnosed with LSIL then ---->1)if premenopausal (i mean ovulating---> high chance of cervical cancer)----> so directly colposcopy and biopsy
2) postmenopausal-----> low chance than premenopausal ---> so 3 options given to pt. either repeat pap 6-12 months/HPV test /Colposcopy ---->based on the results you will treat her..

hope it helps..

p.s- the same doubt with word doc like question in uworld offline was raised by my friend when i was doing it online----surprisingly i didnt find it online------>so concluded it's controversy IMO--so better not to worry abt it
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if you still have doubt----> i attached a pdf in the following link download it....

it will be helpful....coz they are from original website and they created the original guidelines dude...
May 2013 Step 2 CK Exam Takers
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Quote:
Originally Posted by venky2600 View Post
if you still have doubt----> i attached a pdf in the following link download it....

it will be helpful....coz they are from original website and they created the original guidelines dude...
May 2013 Step 2 CK Exam Takers
Thank you again. Actual the diagram is right off Uworld. The ID 4755 it is still there. So is the process as stated in that question stem wrong then (the way it states that 1st pap was ASC-US then doing colposcopy )? It should be that if 1st pap ASC-US then skip to 6 and 12 month Pap then they should have did colposcopy? If my ASC-US turns into CIN 1 then follow the diagram?

In term of LSIL then you do colpscopy. What do you if positive or negative colpscopy?

Last edited by gear2d; 04-26-2013 at 03:42 PM.
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Quote:
Originally Posted by gear2d View Post
Thank you again. Actual the diagram is right off Uworld. The ID 4755 it is still there. So is the process as stated in that question stem wrong then (the way it states that 1st pap was ASC-US then doing colposcopy )? It should be that if 1st pap ASC-US then skip to 6 and 12 month Pap then they should have did colposcopy? If my ASC-US turns into CIN 1 then follow the diagram?

In term of LSIL then you do colpscopy. If colposcopy positive what do you do next? Do you do ECC?. If negative then Cone (since colposcopy not matching Pap findings)?
oh ! is it still in uworld..? i didnt remember of doing it (may be i totally forgot)

no dude, can you post the question also so that it clarifies me too...?

there is other ques. in uworld which states ASCUS follow up and non follow up pts screening modalities (as i told in my post above ).....but not seeing the question i cant say it as assuring..

LSIL ----> if non pregnant---->we do colposcopy and biopsy along with ECC----> if we find it then treatment ....(conization is when you cant find any lesions on colposcopy but pt. symptoms are assuring)

if pregnant-----> we do colposcopy and biopsy only (ECC C/I) ----------> then repeat every 3 months till delivery-----> repeat again 6wks postpartum








sorry didnt see your edited ques. if colposcopy +ve(mean CIN1)--->then repeat pap smear /HPV /colposcopy test every 6 months till 2 yrs follow up------>if no progression to CIN 2 /3----->then routine pap smear/colposcopy screening every 2years.......
if progress to CIN 2/3---->LEEP /cryosurgery etc


p.s ---> dude read cervical dysplasia topic in mtb 3---->it's okay i think your all doubts will be clarified from it

Last edited by venky2600; 04-26-2013 at 03:53 PM.
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28 yoa xx has ASC-US on routine pap smear. She has 3 consecutive negative pap smears prior to this. She has been monogamous with same person for 4 years. She is G0. Her LMP was 3 weeks ago. She is on no meds, no alcohol, tobacco, or illicit drugs. Exam is normal. Colposcopy guided biopsy shows CIN 1 (grade 1). Which is the next step in Mx:

-repeat Pap 6 and 12 months -> answer
-Cold knife
-Endoscervical curettage
-LEEP
-Hysterectomy
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Quote:
Originally Posted by gear2d View Post
28 yoa xx has ASC-US on routine pap smear. She has 3 consecutive negative pap smears prior to this. She has been monogamous with same person for 4 years. She is G0. Her LMP was 3 weeks ago. She is on no meds, no alcohol, tobacco, or illicit drugs. Exam is normal. Colposcopy guided biopsy shows CIN 1 (grade 1). Which is the next step in Mx:

-repeat Pap 6 and 12 months -> answer
-Cold knife
-Endoscervical curettage
-LEEP
-Hysterectomy
yeah dude...i thought ques. asked abt next step in diagnosis.......
the question only gave that ASCUS +ve undergone colposcopy (CIN1) ---so what's wrong in it...? (i mean pt. would have insisted to do colposcopy directly,so she did it..) --i mean it's just ques. dude...dont rely on it----> colposcopy done generally after 2 ASCUS +ve----edited

CIN1 is low grade malignancy dude----> we wont treat it unless it progresses
we generally follow up to resolve on it's own (so follow up is the answer)

if you have mtb3 ---open pg-431 ---it's clearly given in the 2nd table

Last edited by venky2600; 04-26-2013 at 04:10 PM.
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Originally Posted by venky2600 View Post
yeah dude...i thought ques. asked abt next step in diagnosis.......
the question only gave that ASCUS +ve undergone colposcopy (CIN1) ---so what's wrong in it...? (i mean pt. would have insisted to do colposcopy directly,so she did it..) --i mean it's just ques. dude...dont rely on it----> colposcopy done generally after 2 ASCUS +ve----edited

CIN1 is low grade malignancy dude----> we wont treat it unless it progresses
we generally follow up to resolve on it's own (so follow up is the answer)

if you have mtb3 ---open pg-431 ---it's clearly given in the 2nd table
Thank you so much again. I see what you are saying. So what happened here was that here ASC-US turned into CIN 1 so we do repeated Pap smear? Looking at Pg 431 it states to do Smear at 6 months for 2 years. Shouldn't it be 6 and 12 months then? But the concept is CIN 1 do Pap Smear again. If woman has ASC-US do Pap smear 2 times if +ve do Colcoscopy. Here in this question stem they just skipped to doing the scopy (which should have been done after 6 and 12 months Pap smear).
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suggestion---->dude, it's more confusing topic dude.....dont go overboard searching for it ,it will confuse you more
just be sure with the tested topics on exam --->i.e---ASCUS,LSIL,HSIL,pregnancy

exam takers know that we are about to join residency not residents in gynec-obs ---so i think they wont test that deep than this.....so revise mtb 3 and uworld topic given abt cervical screening (i think that's enough for exam)
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Thank you again for all the help. I think I am comprehending it better now. It was that diagram that got to me. But I will keep it simple as you did.

ASC-US -> 2 paps at 6 and 12 -> colposcopy if needed

LSIL -> colposcopy -> tx on findings

HSIL -> if no desire to be preg go with Cone or LEEP, if wants to preg try doing Pap 6 and 12 + Colposcopy

Preg -> HSIL on Pap -> Colposcopy+Bx -> Tx on finding as in MTB 3
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Quote:
Originally Posted by gear2d View Post
Thank you so much again. I see what you are saying. So what happened here was that here ASC-US turned into CIN 1 so we do repeated Pap smear? Looking at Pg 431 it states to do Smear at 6 months for 2 years. Shouldn't it be 6 and 12 months then? But the concept is CIN 1 do Pap Smear again. If woman has ASC-US do Pap smear 2 times if +ve do Colcoscopy. Here in this question stem they just skipped to doing the scopy (which should have been done after 6 and 12 months Pap smear).
if ASCUS +ve do follow up pap-6m and 12 m---->if negative continue as general screening every 3 years
here CIN1 --->so somewhat malignant than ASCUS --->so follow up for 2 yrs every 6 month(mean 6mon,12mon,18mon,24mon) then if it resolves----then routine screening every 3 yrs

hope it clears......dude that's just question ....actually it should have been like what you told above


p.s---keep that 1 diagram away ,i think you can master rest all ques. regarding this topic in uworld
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Thank you again for all the help and patience.
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Quote:
Originally Posted by gear2d View Post
Thank you again for all the help and patience.
hey that's okay dude......the more we discuss the more we learn.... i must say thankful to you.........PM me when any more doubts arise with this topic..
goodluck with your prep.....
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