AIDS INFORMATION NEWSLETTER Michael Howe, MSLS, Editor AIDS Information Center VA Medical Center, San Francisco (415) 221-4810 ext 3305 September 23, 1994 Women and HIV Infection (Part IX) Cervical Cancer Screening for Women Who Attend STD Clinics or Who Have a History of STDs Women who have a history of STDs are at increased risk for cervical cancer, and women attending STD clinics may have additional characteristics that place them at even higher risk. Prevalence studies have found that precursor lesions for cervical cancer occur approximately five times more often among women attending STD clinics than among women attending family planning clinics. The Pap smear (cervical smear) is an effective and relatively low-cost screening test for invasive cervical cancer and squamous intraepithelial lesions (SIL)*, the precursors of cervical cancer. The screening guidelines of both the American college of Obstetricians and Gynecologists and the American Cancer Society recommend annual Pap smears for sexually active women. Although these guidelines take the position that Pap smears can be obtained less frequently in some situations, women who attend STD clinics or who have a history of STDs should be screened annually because of their increased risk for cervical cancer. Moreover, reports from STD clinics indicate that many women do not understand the purpose or importance of Pap smears, and many women who have had a pelvic examination believe they have had a Pap smear when they actually have not. Recommendations Whenever a woman has a pelvic examination for STD screening, the health-care provider should inquire about the result of her last Pap smear and should discuss the following information with the patient: o Purpose and importance of the Pap smear, o Whether a Pap smear was obtained during the clinic visit, o Need for a Pap smear each year, o Names of local providers or referral clinics that can obtain Pap smears and adequately follow up results (if a Pap smear was not obtained during this examination). If a woman has not had a Pap smear during the previous 12 months, a Pap smear should be obtained as part of the routine pelvic examination in most situations. Health-care providers should be aware that, after a pelvic examination, many women may believe they had a Pap smear when they actually have not, and therefore may report they have had a recent Pap sear. In STD clinics, a Pap smear should be obtained during the routine clinical evaluation of women who have not had a documented normal smear within the past 12 months. A woman may benefit from receiving printed information about Pap smears and a report containing a statement that a Pap smear was obtained during her clinic visit. Whenever possible, a copy of the Pap smear result should be sent to the patient for her records. FOLLOW-UP If a Pap smear shows severe inflammation with reactive cellular changes, the women should be advised to have another Pap smear within 3 months. If possible, underlying infection should be treated before the repeat Pap smear is obtained. If a Pap smear shows either SIL (or equivalent) or atypical squamous cells of undetermined significance (ASCUS), the woman should be notified promptly and appropriate follow-up initiated. Appropriate follow-up of Pap smears showing a high-grade SIL (or equivalent) on Pap smears should always include referral to a health-care provider who has the capacity to provide a colposcopic examination of the lower genital tract and, if indicated, colposcopically directed biopsies. Because clinical follow-up of abnormal Pap smears with colposcopy and biopsy is beyond the scope of many public clinics, including most STD clinics, in most situations women with Pap smears demonstrating these abnormalities will need to be referred to other local providers or clinics. Women with either a low-grade SIL or ASCUS also need similar follow-up, although some experts believe that, in some situations, a repeat Pap smear may be a satisfactory alternative to referral for colposcopy and biopsy. OTHER MANAGEMENT CONSIDERATIONS Other considerations in performing Pap smears are the following: o The Pap smear is not an effective screening test for STDs; o If a woman in menstruating, a Pap smear should be postponed and the woman should be advised to have a Pap smear at the earliest opportunity; o If a woman has an obvious severe cervicitis, the Pap smear may be deferred until after antibiotic therapy has been completed to obtain an optimum smear; o A woman with external genital warts does not require Pap smears more frequently than a woman without warts, unless otherwise indicated. SPECIAL CONSIDERATIONS PREGNANCY Women who are pregnant should have a Pap smear as part of routine prenatal care. A cytobrush may be used for obtaining Pap smears from pregnant women, although care should be taken not to disrupt the mucous plug. HIV INFECTION Recent studies have documented an increased prevalence of SIL among women infected with HIV. Also, HIV may hasten the progression of precursor lesions to invasive cervical cancer; however, evidence supporting such a progression is limited. The following provisional recommendations for pap smear screening among HIV-infected women are based partially on consultation with experts in the care and management of cervical cancer and HIV infection among women. These provisional recommendations may be altered in the future as more information regarding cervical disease among HIV-infected women becomes available: o Women who are HIV-infected should be advised to have a comprehensive gynecologic examination, including a Pap smear, as part of their initial medical evaluation. o If initial Pap smear results are within normal limits, at least one additional Pap smear should be obtained in approximately 6 months to rule out the possibility of false- negative results on the initial Pap smear. If the repeat Pap smear is normal, HIV-infected women should be advised to have a Pap smear obtained annually. o If the initial or follow-up Pap smear shows severe inflammation with reactive squamous cellular changes, another Pap smear should be collected within 3 months. o If the initial or follow-up Pap smear shows SIL (or equivalent) or ASCUS, the woman should be referred for a colposcopic examination of the lower genital tract and, if indicated, colposcopically directed biopsies. HIV infection is not an indication for colposcopy among women with normal Pap smears. *The 1988 Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses introduced the new terms low-grade squamous intraepithelial lesion (SIL) and high-grade SIL. Low-grad SIL encompasses cellular changes associated with HPV and mild dysplasia/cervical intraepithelial neoplasia 1 (CIN 1). High- grade SIL includes moderate dysplasia/CIN 2, severe dysplasia/CIN 3, and carcinoma in situ (CIS)/CIN 3 (16). (Centers for Disease Control and Prevention. 1993 Sexually Transmitted Diseases Treatment Guidelines. 1993 Sept;42(No. RR- 14):[pages inclusive].) MEDICAL MATTERS: Treatment of an Abnormal Pap Smear (From PWAC/NY Newsline: People with AIDS Coalition of New York - January, 1994.) If a Pap smear shows any degree of abnormality, the woman can be scheduled for a colposcopic examination. However, it is very important for the clinician to treat any condition that can be treated before making the referral for colposcopy. It is important to treat Vaginal Thrush (also called candida, monilia, or fungal vaginitis), Trichomonal, Bacterial Vaginosis (also called BV or gardnerella), Atrophic Vaginitis (due to low estrogen levels, and treated with estrogen creams), Herpes Simplex Infection, and any other condition. If a condition is diagnosed and treated, it is quite reasonable to reschedule the Pap test in 6-8 weeks. This is because any of these conditions can give an inaccurate Pap result, either falsely positive or falsely negative. If the Pap returns with Aytpia or CIN 1, some clinicians will repeat it in two to three months before making a referral. There is nothing wrong with rhis practice in healthy women. The same is true for women with HIV who are healthy. There is also nothing wrong with referring for colposcopy right away. This is an individual decision that should be based on the relationship between the woman and her provider. However for women with low CD4 counts, or who have signs of immune compromise, it is probably best to go right to colposcopy. This is because not enough is really known about the process of cervical disease in women with low CD4 cells. Also, any Pap that shows moderate or severe dysplasia (CIN 2, CIN 3, or CIS) should be evaluated by colposcopy within six weeks. The appointment should not be scheduled when the woman is menstruating. The Colposcope is a magnifying instrument (which looks something like a microscope with a lens that can be focused on the vulva, vagina, and cervix. It rests on a stand, and the examiner looks through it. The colposcope does not go inside the vagina. It magnifies the surface of the cervix, so that the examiner can see the transformation zone (T-Zone), where most abnormalities start. The T-Zone occurs at the border between two different types of cells; Squamous Cells and Columnar Cells. It is a very active area which undergoes frequent replication of new cells, and also reacts in response to the hormonal signals of puberty, menstruation, pregnancy and menopause. It is this intense activity that makes it such a vulnerable area. In general, the examiner is looking for abnormalities in the squamous cells that line the outside of the cervix (the ecocervix) and which might extend into the vagina or even the vulva. There can also be abnormalities of the inner lining of the cervical canal, the columnar cells. This is a much more rare phenomenon, however, and the examiner must be sure of the type of abnormality and in what type of cells it is occurring. The exam must also make clear the extent of the abnormality. Like with the Pap smear, the degree of abnormality is graded, and in general, the same terms are used. The difference is that, in colposcopy, the abnormalities are evaluated in a tiny sample of cervical tissue called a biopsy. The purpose of using the colposcope is to find the most abnormal looking areas, and to take samples of them with biopsies. Two types of biopsies may be taken of the cervix: and Endocervical Biopsy and a Cervical Biopsy. The endocervical biopsy samples columnar cells and the cervix biopsy samples squamous cells. Remember that the examiner needs to know which type of cells are abnormal tissue. Biopsies hurt a little, like a sharp pinch; but only for a few seconds. After having a biopsy, a woman may have some spotting or bleeding for a day or two, and must not put anything into the vagina during the first two or three days it takes for the biopsy to heal. Before the colposcope was used widely, any abnormal Pap test was followed with a Surgical or Cone Biopsy. In a cone biopsy a wedge of tissue (about the size of the end of your thumb) is removed under general anesthesia. I will discuss this diagnostic test more later. However, in general, the use of colposcopy reduces the need to place women under general anesthesia and remove a large sample of tissue for diagnosis. But with colposcopy, an accurate diagnosis depends on the clinician finding the most abnormal looking area to take the biopsy sample. This takes training. The colposcopic exam and biopsies are for diagnosis, and do not treat the problem. Therefore, the woman must be scheduled to return to the clinic in two to three weeks for treatment and consultation, depending on how long it takes to get the biopsy report back. When the woman returns the diagnosis is shares with her. If the biopsies agree with the Pap smear, and do not indicate invasive cancer, a local treatment of the cervix can be planned. The following treatments are all considered adequate for treating dysplasia of the cervix: Cryotherapy This is most commonly used because it is an easy technique to learn, it can be done in an office without anesthesia, and the equipment is inexpensive. The "cryo unit" holds a gas tank attached to a probe that can touch the cervix. The gas gets very cold under pressure in the tank, and the cold probe is held against the abnormal areas until the tissue is frozen. The frozen tissue dies, sloughs off, and if all goes well, new healthy tissue replaces the "bad" tissue. The healing process takes two to three weeks, and the woman usually has heavy, watery discharge during this time. Shd should not put anything into the vagina during healing. Cone Biopsy This procedure is done if the dysplasia is severe, if it may extend up into the cervical canal, if the Pap report and the biopsies do not agree on the degree of abnormality, or it may also be used for minor dyxplasia. In a surgical cone, the woman must be under anesthesia for the surgery, but can go home the same day. Electronic Therapy (also called LEEP) In this therapy a thin wire loop and electrical current are used to remove and destroy abnormal tissue. In some cases this is performed as surgery, and done under anesthesia; often this is done when a cone biopsy is being done by LEEP to treat high grade dysplasia. The technique may also be used in the clinic setting without anesthesia, to obtain biopsy specimens. In these cases, the diagnostic procedure may remove the entire area of abnormal tissue, eliminating the need for further treatments. However the woman should be scheduled to return for follow-up care and to learn the results of her biopsy. Laser Treatment Laser therapy uses intense light energy which can destroy abnormal tissue by creating sufficient heat to "vaporize" cells. Laser treatment of dysplasia must be performed by an expert in the technique. When done properly, cure rates are good, and complications are rare. Laser of the cervix can be performed with local or no anesthesia. When used to perform a cone biopsy, or to treat the vulva, general anesthesia is used. Healing from laser therapy usually occurs more rapidly than with cryotherapy. Naturopathic Remedies Naturopaths are doctors who use "natural," herbal and traditional remedies, instead of conventional medicines and treatments. There is literature which describes naturopathic remedies for dysplasia. In all cases, the literature advises proper diagnosis by colposcopy, close follow-up, and referral for more conventional therapy if the problem does not improve or gets worse. The scientific study of these treatments is extremely limited (that is we don't know whether they work or not). The treatments include local therapy called Escharotic Treatment, in which herbal packs that cause tissue sloughing are applied to the cervix in the doctor's office. This is done twice weekly for several weeks. In addition, the woman is instructed as to certain nutritional supplements, dietary changes, and use of suppositories and herbs. Treating Cervical Cancer In some cases, the biopsy report will confirm invasive cancer. In these cases, another process, called Staging, must be performed. Staging is a series of tests and evaluations that will determine where the invasion has spread, and whether or not the organs are involved. When the Centers for Disease Control and Prevention added cervical cancer to the list of AIDS-defining illnesses, they specified that the cancer must be invasive, and it must extend beyond the cervix itself. Some AIDS activists and women's advocates feel that this requirement is quite stringent; we hope to treat any dysplasia or microinvasive cancer before it spreads beyond the cervix. A cancer that does not extend beyond the cervix is generally treated by total hysterectomy, or hysterectomy with removal of lymph nodes (radical hysterectomy). Once the disease has spread beyond the cervix, radiation therapy is generally used. Occasionally, microinvasive cancers are treated by cone biopsy alone, with very close follow-up. The treatment decision must take into account whether or not the woman desires to carry a pregnancy in her future. Chemotherapy plays very little in the treatment of cervical cancer. In women with immune compromise, surgery and radiation pose greater risks than the risks to women with good immune function. But, even in HIV infection, cervix cancer can be prevented by early detection of dysplasia. This is a powerful reason to recommend frequent gynecological check-ups and Pap tests every six months for an HIV-positive woman. Who can perform colposcopy? Almost all Obstetrician/Gynecologists (OB/GYNs) are trained in their residency to do the procedure. Some OB/GYNs even specialize in cervical diseases. Other primary care doctors (such as family practitioners or internists) can learn the technique on their own, or by attending special training programs. Primary care doctors may feel they see enough women with abnormal Pap tests to justify getting the extra training. Also, some nurse-practitioners, who specialize in women's health care, complete training programs in colposcopy. However, most primary care providers consider colposcopy a specialized procedure; so most women who need the exam have to be referred to someone else, usually someone they have never met. Of course, gynecologic surgeries are only performed by gynecologists, and laser therapy should only be performed by a gynecologist who has a special training in its use. Nurse practitioners and physician's assistants who perform colposcopy usually learn to do so in order to follow their own patients, and most work in close cooperation with a gynecologist. In my own practice, I really appreciate being able to offer colposcopy to women that I already know, instead of having to refer them to a stranger. I am also fortunate to work with a compassionate and skilled gynecologist. I mention this because, at the present time, there are not enough clinicians trained in colposcopy to provide the service in a timely way to all the women who need it. Further, referrals often lack a personal touch, frightening women unnecessarily, and then blaming these women for "poor compliance." It seems clear that our present medical system is not meeting basic gynecological needs for women, and that women with HIV may be at the greatest risk of inadequate, insensitive and unsatisfying gynecological care. It is important that those of us involved in women's health look at these problems, and come up with solutions that make the care more accessible, more comfortable and more user friendly. [Copyright (c) 1994 - PWAC/NY Newsline. Non commercial reproduction permitted provided no fees or dues are charged for the material and proper credit to PWAC/NY Newsline in excerpts or quotes.]