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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
CERVICAL CANCER SCREENING FOR WOMEN WHO ATTEND STD CLINICS OR HAVE A HISTORY OF STDs
Women who have a history of STD are at increased risk for cervical cancer, and women attending STD clinics may have other risk factors that place them at even greater risk. Prevalence studies have determined that precursor lesions for cervical cancer occur about five times more frequently among women attending STD clinics than among women attending family planning clinics.
The Pap smear (i.e., cervical smear) is an effective and relatively low-cost screening test for invasive cervical cancer and SIL, * the precursors of cervical cancer. Both ACOG and the American Cancer Society (ACS) recommend annual Pap smears for all sexually active women. Although these guidelines take the position that Pap smears can be obtained less frequently in some situations, women with a history of STDs may need more frequent screening because of their increased risk for cervical cancer. Moreover, surveys of women attending STD clinics indicate that many women do not understand the purpose or importance of Pap smears, and almost half of the women who have had a pelvic examination erroneously believe they have had a Pap smear when they actually have not.
Recommendations
At the time of a pelvic examination for STD screening, the health-care provider should inquire about the result of the patient's last Pap smear and discuss the following information with the patient:
The purpose and importance of a Pap smear;
Whether a Pap smear was obtained during the clinic visit;
The need for an annual Pap smear; and
The names of local providers or referral clinics that can obtain Pap smears and adequately follow up results (i.e., 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. Health-care providers should be aware that, after a pelvic examination, many women believe they have had a Pap smear when they actually have not, and thus may report having had a recent Pap smear. Therefore, in STD clinics, a Pap smear should be strongly considered during the routine clinical evaluation of women who have not had a normal Pap smear within the preceding 12 months that is documented within the clinic record or linked-system record.
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. If possible, a copy of the Pap smear result should be provided to the patient for her records.
Follow-Up
Clinics and health-care providers who provide Pap smear screening services are encouraged to use cytopathology laboratories that report results using the Bethesda System of classification. If the results of the Pap smear are abnormal, care should be provided according to the Interim Guidelines for Management of Abnormal Cervical Cytology published by the National Cancer Institute Consensus Panel and briefly summarized below (27). Appropriate follow-up of Pap smears showing a high-grade SIL always includes referral to a clinician who has the capacity to provide a colposcopic examination of the lower genital tract and, if indicated, colposcopically directed biopsies. For a Pap smear showing low-grade SIL or atypical squamous cells of undetermined significance (ASCUS), follow-up without colposcopy may be acceptable in circumstances when the diagnosis is not qualified further or the cytopathologist favors a reactive process. In general, this would involve repeated Pap smears every 4-6 months for 2 years until the results of three consecutive smears have been negative. If repeated smears show persistent abnormalities, colposcopy and directed biopsy are indicated for low-grade SIL and should be considered for ASCUS. Women with a diagnosis of unqualified ASCUS associated with severe inflammation should at least be reevaluated with a repeat Pap smear after 2-3 months, then repeated Pap smears every 4-6 months for 2 years until the results of three consecutive smears have been negative. If specific infections are identified, the patient should be reevaluated after appropriate treatment for those infections. In all follow-up strategies using repeated Pap smears, the tests not only must be negative but also must be interpreted by the laboratory as "satisfactory for evaluation."
Because many public health clinics, including most STD clinics, cannot provide clinical follow-up of abnormal Pap smears with colposcopy and biopsy, women with Pap smears demonstrating high grade SIL or persistent low-grade SIL or ASCUS usually will need a referral to other local health-care providers or clinics for colposcopy and biopsy. Clinics and health-care providers who offer Pap smear screening services but cannot provide appropriate colposcopic follow-up of abnormal Pap smears should arrange referral services that a) can promptly evaluate and treat patients and b) will report the results of the evaluation to the referring clinician or health-care provider. Clinics and health-care providers should develop protocols that identify women who miss initial appointments (i.e., so that these women can be scheduled for repeat Pap smears), and they should reevaluate such protocols routinely. Pap smear results, type and location of follow-up appointments, and results of follow-up should be clearly documented in the clinic record. The development of colposcopy and biopsy services in local health departments, especially in circumstances where referrals are difficult and follow-up is unlikely, should be considered.
Other Management Considerations
Other considerations in performing Pap smears are as follows:
The Pap smear is not an effective screening test for STDs.
If a woman is menstruating, a Pap smear should be postponed, and the woman should be advised to have a Pap smear at the earliest opportunity.
The presence of a mucopurulent discharge might compromise interpretation of the Pap smear. However, if the woman is unlikely to return for follow-up, a Pap smear can be obtained after careful removal of the discharge with a saline-soaked cotton swab.
A woman who has external genital warts does not need to have Pap smears more frequently than a woman who does not have warts, unless otherwise indicated.
In an STD clinic setting or when other cultures or specimens are collected for STD diagnoses, the Pap smear may be obtained last.
Women who have had a hysterectomy do not require an annual Pap smear unless the hysterectomy was related to cervical cancer or its precursor lesions. In this situation, women should be advised to continue follow-up with the physician(s) who provided health care at the time of the hysterectomy.
Both health-care providers who receive basic retraining on Pap smear collection and clinics that use simple quality assurance measures obtain fewer unsatisfactory smears.
Although type-specific HPV testing to identify women at high and low risk for cervical cancer may become clinically relevant in the future, its utility in clinical practice is unclear, and such testing is not recommended.
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 in pregnant women, although care should be taken not to disrupt the mucous plug.
HIV Infection
Several studies have documented an increased prevalence of SIL in HIV-infected women, and HIV is believed by many experts to hasten the progression of precursor lesions to invasive cervical cancer. The following recommendations for Pap smear screening among HIV-infected women are consistent with other guidelines published by the U.S. Department of Health and Human Services (10,11,27,28) and are based partially on the opinions of experts in the care and management of cervical cancer and HIV infection in women.
After obtaining a complete history of previous cervical disease, HIV-infected women should have a comprehensive gynecologic examination, including a pelvic examination and Pap smear as part of their initial evaluation. A Pap smear should be obtained twice in the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter. If the results of the Pap smear are abnormal, care should be provided according to the Interim Guidelines for Management of Abnormal Cervical Cytology (28). Women who have a cytological diagnosis of high-grade SIL or squamous cell carcinoma should undergo colposcopy and directed biopsy. HIV infection is not an indication for colposcopy in women who have normal Pap smears.
*The 1988 Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses introduced the terms "low-grade SIL" and "high-grade SIL" (27). Low-grade 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/CIN 3.
