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Abnormal Cervical Smear Results

The 2003 European age-standardised annual incidence rate of cervical cancer in the UK is 8.2 per 100,000 females. Cervical cancer is the second most common cancer after breast cancer in the under 35s, with 625 new cases diagnosed in the UK in 2003.1

Cervical screening has prevented an epidemic that would have killed about one in 65 of all British women born since 1950 and culminated in about 6000 deaths per year in this country.
Cervical cancer mortality in England and Wales (in women younger than 35 years) rose three-fold from 1967 to 1987. By 1988, incidence in this age-range was among the highest in the world, despite substantial opportunistic screening. Since national screening was started in 1988, this rising trend has been reversed.2

From 2003 screening has been performed using liquid based cytology (LBC). Meta-analyses have shown LBC to have higher sensitivity, equal specificity and lower rates of inadequate samples.3

Standard recall schedule

Standard UK Smear Recall Schedule4
Age group (years) Frequency of screening
Age 25 First invitation
Age 25 - 49 3 yearly
Age 50 - 64 5 yearly
Age 65+ Only screen those who have not been screened since age 50 or have had recent abnormal tests
Dysplasia (dyskaryosis) on cervical smear4

Management of Dysplasia (Dyskaryosis) on Cervical Smear

Result

Action
Negative
  • Investigate and manage incidental findings (e.g. infections).
  • Ensure that the patient is informed of the result.
  • Recall as appropriate for a negative result.
Inadequate
  • Repeat sample immediately after treating any infection or atrophy, preferably within 3 months
  • Repeat sample as soon as convenient if technically inadequate
  • If persistent (3 inadequate samples), advise assessment by colposcopy5
Borderline
  • Borderline nuclear change in endocervical cells - refer for colposcopy.

  • Borderline nuclear change in squamous cells

    • Treat any associated condition and repeat the screen at no more than 6 months (particularly important where there
      is an association with HPV).
      The majority of smears will return to normal by this stage.
    • Refer for colposcopy if there are 3 smears in a series reported as borderline nuclear change in squamous cells) without the woman being returned to routine recall, or 3 borderline or more severe results in a 10 year period.
    • Three consecutive negative results, 6 months apart, are required before returning to routine recall.
    • Repeat sample in 3-6 months when the differential diagnosis is between benign/reactive changes and higher
      degrees of dyskaryosis or possible glandular neoplasia.
    • The laboratory may recommend a repeat screening in a shorter interval, or that gynaecological referral should be considered.
Mild Dyskaryosis
  • Ideally, women should be referred for colposcopy after one mild dyskaryotic smear, but it remains acceptable to recommend a repeat test within 6 months - many will have returned to normal by this stage.
  • Always refer for colposcopy after two tests reported as mild dyskaryosis
    without a return to routine recall.
  • If a single mild dyskaryotic result is obtained after treatment for CIN2 or worse, refer for colposcopy.
  • Three consecutive negative results, 6 months apart, are required before returning to routine recall.
  • If in a 10 year period there are 3 borderline or more severe results, refer to colposcopy.
Moderate Dyskaryosis Refer for colposcopy.
Severe Dyskaryosis Refer for colposcopy.
Other results
  • Inflammatory changes usually indicate infection4:
    • Mild inflammation
    • Moderate inflammation
    • Severe inflammation.
  • High risk Human papilloma virus (HPV) types (16, 18, 31, 33) have been found to be present in close to 100% of all cervical cancers. Research has indicated that women with a mild or borderline smear result, who have no evidence of high risk HPV infection are very unlikely to develop cervical cancer.5 A Health Technology Assessment review concluded that HPV testing could not currently be recommended for primary screening without further research.6 Current evidence does, however, support limited introduction of the test in certain limited situations, such as the management of borderline smears or in older women when regular screening is problematic. Also known as 'wart virus'.
  • Actinomyces; a smear may show actinomycete-like organisms (ALO), especially if an IUCD is in situ, but unless there is clinical evidence of pelvic inflammatory disease, they are of no significance.
  • Candida; many treatments are available, including topical or oral imidazoles.
  • Gardnerella; treatment is metronidazole e.g. 400-500mg twice daily for seven days.
  • Herpes; antiviral therapy is effective in both initial attacks and recurrences. The licensed drugs are aciclovir, valaciclovir and famciclovir. Oral therapy is required. Topical treatment is inadequate. There is no benefit in combining topical and oral therapy.
  • Koilocytosis; this is the presence of koilocytes (cells infected by HPV). They typically have shrivelled nuclei with a halo.7 They have a low prognostic value for CIN.8
  • Trichomonas; metronidazole is treatment of choice
  • Viral inflammation unspecified.

Document references
  1. UK Cervical Cancer mortality statistics, Cancer Research UK, 2006
  2. Peto J, Gilham C, Fletcher O, et al; The cervical cancer epidemic that screening has prevented in the UK. Lancet. 2004 Jul 17-23;364(9430):249-56. [abstract]
  3. Cervical cancer - cervical screening, NICE Technology Appraisal (Oct 2003); Liquid-based cytology for cervical screening (review)
  4. NHS Cervical Screening Website
  5. Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme, NHS Cancer Screening Programme (2004)
  6. Cuzick J et al. Health Technology Assessment 1999; Vol. 3: No. 14 A systematic review of the role of human papillomavirus testing within a cervical screening programme; 1999
  7. PathGuy. Koilocytes.; Photo.
  8. Kruse AJ, Baak JP, Helliesen T, et al; Prognostic value and reproducibility of koilocytosis in cervical intraepithelial neoplasia. Int J Gynecol Pathol. 2003 Jul;22(3):236-9. [abstract]
Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 4053
Document Version: 21
DocRef: bgp25985
Last Updated: 20 Feb 2007
Review Date: 19 Feb 2009




















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PS - Health and Poverty

Perhaps the biggest cause of ill health in the world is poverty. Help to Make Poverty History. For example, why not lend some of your money to disadvantaged communities to enable them to trade their way out of poverty through schemes such as Shared Interest.

See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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