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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

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.

* 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-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 (CIS)/CIN3 (16)

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:

--   Purpose and importance of the Pap smear,
   
--   Whether a Pap smear was obtained during the clinic visit,

--   Need for a Pap smear each year,

--   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 have had a Pap smear when they actually have not, and
therefore may report they have had a recent Pap smear.

     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 woman 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:

--   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;

--   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;

--   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:

--   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.

--   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.

--   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.

--   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.

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