Clinical Expert Series Cervical Cytology Screening and Evaluation

For nearly 50 years, the gynecologist’s mantra has been “Yearly Pap and Pelvic.”1 Yet, it remains unclear how the practice of annual cytology became a de facto standard in the United States, because there never has been an organized, national screening program. I suspect that the test became an annual ritual for many women as a result of the widespread use of oral contraceptives in the 1960s and 1970s and the need for an annual examination to obtain prescription refills. However, now there is evidence that, for some women, annual cervical cytology screening is both not necessary and may even lead to unnecessary morbidity.2 Although the conventional Pap test is the best cancer-screening tool ever developed—it has reduced the incidence of invasive cancer of the cervix by approximately 70%—multiple publications have documented the fact that the test is insensitive and somewhat nonspecific. The reason that it is so effective in reducing cancer is a result of the natural history of the disease, rather than the ability of a single cytology sample to detect abnormalities. In addition, there are good data to support the fact that we have been far too aggressive in our management of women with minimal disease (ie, cervical intraepithelial neoplasia grade 1 [CIN 1]). Several national organizations, including the American College of Obstetricians and Gynecologists, the American Cancer Society, the American Society of Colposcopy and Cervical Pathology (ASCCP), and the U.S. Preventive Services Task Force, have reviewed the extensive literature that has been published about Pap tests and early lesions and have developed new guidelines for the use of Pap test screening, the evaluation of abnormal results, and management of low-grade cervical neoplasia.3–5 In this article, I will explain how I have incorporated some of the new guidelines into my practice, how the use of the human papillomavirus DNA (HPV-DNA) test can help us manage patients, and how I approach minimally abnormal cytology and biopsy (CIN1).