Abnormal Pap Smears -- Reading Your Results

The Bethesda System
The Betheseda is the third major reworking of the the Pap smear classification system, since the test's inception in 1941. It has been around for about 10 years and is the most common system used. How a woman's test is classified is important as it will determine what happens next. There are many levels of abnormal results. The majority are NOT cancer. Some are downright benign. Frequently, low end abnormalities will go away on their own. Still, all abnormalities could progress to cancer, so it is very important to do any follow-up tests or procedures to prevent this. While all the aspects of the results have guidelines attached to them, this is still a judgement call on the part of the reader. She looks at the slide and decides how the slide matches up against the classification criteria.

Pre-cancerous cells are called Cervical Intraepithelial Neoplasms (C.I.N.). They are classified I (1) through III (3). Doctors often call these "CIN 1" and so on. The more abnormal the cells and therefore closer to cancer they are, the higher the number. The CIN levels are determined by colposcopy and/or biopsy which are the follow-up tests for abnormal Paps.

Part I -- Statement of Adequacy
This has nothing to do with you, so don't worry. It is the lab's assessment of how good the sample was by the time it arrived on their end. If the clinician does not pick up enough cells in all the different areas, if the sample is not fixed quickly enough, or if it is damaged in transit, the results might be inferior. However, keep in mind that with the rise in lawsuits against labs for missing cervical cancers, they are very quick to label a sample as unsatisfactory. The possible results are :
1. "satisfactory" This is a sample with cells from each of the areas clearly defined -- the outer cervix, the inner cervix, and the vaginal wall.
2. Satisfactory, but limited by ______. The pathologists will state the reason for the limits. What is done will be up to the primary care doctor.
3. Unsatisfactory. Lubricants, excessive discharge, blood, inflammation, too few endocervical cells are possible reasons. The test should be repeated if there are too few endocervical cells. Although many labs state this result when their hurried slide readers simply don't see them right away. A cytobrush sampling can improve this too. A course of antibiotics should be used before repeating the slides marred by inflammation. If blood and inflammation cannot be cleared enough to get a readable sample, then doctor will skip ahead to more advanced testing.

Part II -- A General Categorization -- A Statement of Normal vs. Abnormal
This is the part that makes us nervous. It is a general statement as to the normalcy or lack thereof of the sample. There are three possible results:
1. Within normal limits This is the result every woman wants. There's no next step other than to have another pap at whatever yearly interval she and her provider have decided on.
2. Benign Cellular Changes. These are abnormalities that do not progress to cancer. Infections and/or inflammation is the most common cause. Antibiotics and repeat exam is the most likely outcome here.
3. Epithelial Cell Abnormality These are the results that make us worry. These are not always cancer and not all will lead to cancer, but they can.

Benign Cellular Changes -- Details

    Infection -- These are common sexually transmitted and non-sexually transmitted infrections. If they are suseptible to antibiotics, then the woman will be treated.
      Trichomonas vaginalis -- this is sexually transmitted and the woman's partner will have to be treated as well .
      Fungal organisms morphologically consistent with Candida ssp. This is yeast.
      Predominance of coccibacilli consistent with Actinomyces ssp.
      Cellular changes associated with herpes simplex virus-- this is sexually transmitted, but not curable.

    Reactive and reparative changes -- these may be due to gyny procedures or childbirth related.
      Inflamation (includes typical repair) -- the woman may be re-tested. Even if none of the definitive signs of infection above is present, her doctor may treat her with antibiotics, especially if the inflammatory result is persistent.
      Atrophy with inflamation ("atrophic vaginitis") This is usually seen in post-menopausal women. Hormone replacement, vaginal estrogen creasm, or lubricants may be suggested.
      Intrauterine contraceptive device (IUD)

Epithelial Changes -- Details

    Squamous Cell
      Atypical squamous cells of undetermined significance (ASCUS) -- the most common type of abnormal result. It is not cancer. It is often due to infection or irritation. Many times these resolve on their own. Most women will be re-tested in a few months. High risk women will have colposcopy right away.
      Squamous intraepithelial lesion (SIL)
      Low-grade squamous intraepithelial lesion (LSIL)-- A woman with these result will usually have a colposcopy within 4 weeks. It is not yet cancer. Encompassing: cellular changes associated with human papillomavirus
      Mild dysplasia (cervical intraepithelial neoplasia [CIN]-I)
      High-grade squamous intraepithelial lesion (HSIL) -- a woman will usually have a colposcopy right away. This is not yet cancer. Encompassing: Moderate dysplasia (CIN-II) --not cancer
      Severe dysplasia and carsinoma in situ (CIN-III) -- this is cancer, but limited to the cervix and still has an excellent chance of cure.
      Squamous cell carcinoma

    Glandular Cell
      Presence of unexpected endometrial cells -- these are from the uterine lining.
      Atypical glandular cells of undetermined significance(AGCUS) -- It could indicate cervical or endometrial problems (due to cells from the uterine lining being picked up on the Pap). This is handled the sometimes with endocervical curettage and endometrial biopsy.
      Endocervical adenocarcinoma
      Endometrial adenocarcinoma
      Other Adenocarcinoma

    Hormonal evaluation -- lastly there will be a hormonal evaluation. This means do the cells appear as they typically would for a reproductive age vs. menopausal age woman. These are done off the vaginal wall sample of the Pap.
      Hormonal pattern compatible with age and history
      Hormonal pattern incompatible with age and history
      specify -- depending on the specification, the doctor may do further testing for hormonal problems
      Hormonal evaluation not possible due to:
      specify -- if this results occurs, it is usually not necessary to re-do the test, as this is not the essential reason for the Pap.

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