Pap smear and hpv vaccine

o&g update course 2012 hospital segamat

1. PAP SMEAR AND HPV VACCINE DR. ARIVENDRAN M.D (UKM ) MRCOG (UK)

2. PAP SMEAR Papanicolaou test – exfoliative cytology test cells collected are from normally shedding epithelium . collected using spatulas or brushes. Specimen is fixed, stained and studied for morphology under microscope.

3. HISTORY Initially using vaginal pool smears to study hormonal status . Found cancer cells on a slide containing a specimen from a woman's uterus. Dr. George Papanicolaou reported the usefulness of the technique for detecting neoplastic cervical cells in 1941. late 1940s to early 1950s, Pap smear became widely used as a screening technique. Dr. George Nicholas Papanicolaou

4. HOW TO PERFORM PAP SMEAR

5. OBTAINING A GOOD PAP SMEAR Visual inspection of the lower genital tract and cervix. Locate the TZ. An optimal cervical specimen includes sampling of the squamous and columnar epithelium encompassing in particular the transformation zone

6. The aim of sampling is to obtain as much as possible a well-preserved cellular smear from the endocervix , ectocervix and transformation zone. Correct timing Correct technique Correct instruments Correct sampling technique Correct spreading technique Correct fixation

7. SAMPLING INSTRUMENTS AYRE’S SPATULA

8. SAMPLING INSTRUMENTS CERVICAL BROOM/BRUSH

9. SAMPLING INSTRUMENTS CYTOBRUSH

10. WHEN TO DO A PAP SMEAR ? After menses preferably midcycle . When there is no signs of inflammation or infections No prior vaginal douching or contraceptive cream / jelly . No sexual intercourse < 12 hours prior to pap smear. Pregnancy is NOT a contraindication for pap smear.

11. COLLECTING THE PAP SMEAR Label the frosted end of the glass slide with the patient's name prior to collection. Insert the speculum. Visually inspect the cervix for abnormalities. Identify the transformation zone and direct sampling efforts to encompass this area. The endocervical limit of the transformation zone is dynamic, defined by the leading edge of the migrating squamo -columnar junction. In post menopausal women, it is often high in the endocervical canal and not visible.

12. An optimal cervical specimen includes sampling of the squamous epithelium (Ectocervix) and columnar epithelium (Endocervix) and in particular the TRANSFORMATION ZONE , where the majority of cervical neoplasias arise.

13. OLD SCJ NEW SCJ TRANSFORMATION ZONE

14. COLLECTING PAP SMEAR : SPATULA Choose the contoured end of the spatula which best conforms to the cervix and the transformation zone. Rotate the spatula 360o about the circumference of the cervix, while maintaining firm contact with the epithelial surface. With a clockwise rotation beginning and ending at 9 o'clock (or counter-clockwise rotation from 3 o'clock to 3 o'clock), the collected material is retained on the upper horizontal surface as the instrument is removed.

15. COLLECTING PAP SMEAR : CERVICAL BRUSH These brushes have circumferential bristles that come into contact with the entire os surface on insertion. The brush need only be turned 1/4 turn. Roll the brush across the slide by twirling the handle. Not recommended for pregnancy.

16. PLACEMENT ON SLIDE Spread : quick and even , cellular material in a monolayer on the slide. Thin out large clumps of material as much as possible, avoide excessive manipulation which can damage cells. Fix the specimen by either immersing the slide in 95% ethanol or coating the slide with a surface fixative.

17. Spreading Spread the material collected on the spatula / cervix brush evenly over the slide with a painting action and single smooth stroke motion using both sides

18. SPREADING OPTIONS Spatula / Cervix brush Endocervical brush Spatula / Cervix brush Endocervical brush Endocervical brush Spatula / Cervix brush

19. Alcohol fixation : Immediately immerse into 95% Alcohol for 20-30 minutes. Drying the slide – 5 minutes Alcohol fixation Slide jacket

20. USAGE OF LUBRICANTS? May be moistened with water or saline if necessary. Traditionally, no other lubricants are recommended. study in 182 patients randomly assigned to have either only warm water or a water soluble lubricant to assist speculum insertion, only 2 unsatisfactory smears were found among 93 patients with the lubricant and two were found among 89 using only warm water. They concluded that use of a water soluble lubricant on the vaginal introitus and external speculum facilitates examination with no adverse effect on Pap smear interpretation. Harer WB. Valenzuela G Jr. Lebo D. Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears. Obstet Gynecol 2002; 100:887-8. Do not use any lubricants other than water or saline on Thin-prep slides since they plug the filter and may produce an unsatisfactory smear.

21. PAP SMEAR REPORTING SYSTEM BETHESDA 2001 REPORTING SYSTEM

22. The Bethesda System Report Includes: Whether the pap is an adequate sample Incidental findings such as evidence of infection Evidence of lesions: low-grade SIL, high-grade SIL, or cancer

23. BETHESDA 2001 1. Specimen adequacy 2. Negative for intraepithelial lesion or malignancy 3. Epithelial Cell Abnormalities A. Squamous Atypical (ASCUS/ASC-H) LSIL ( Mild Dyskaryosis / HPV/CIN 1) HSIL (Mod or Severe Dyskaryosis / CIN 2,3) Invasive Squamous Carcinoma B. Glandular / Columnar Atypical (undetermined or favour neoplastic ) Adenocarcinoma in situ (AIS) Invasive adenocarcinoma C. Endometrial cells in women age > 40

24. New Bethesda System Classification Terms: Low-grade squamous lntraepithelial lesion (low-grade SIL) Cellular changes associated with HPV Mild (slight) dysplasia/CIN 1 High-grade squamous intraepithelial lesion (high-grade SIL)" Moderate dysplasia/CIN II Severe dysplasia/CIN III carcinoma in situ/CIN III Atypical Squamous Cells (ASC) Unspecified (ASC-US) - includes uspecified and favor benign/inflammation Cannot exclude HSIL (ASC-H) Atypical Glandular Cells of Uncertian Significance (AGC) AGC is broken down into favoring endocervical , endometrial, or not otherwise specified origin or endocervical adenocarcinoma in situ (AIS) Unspecified (AGC-US) Atypical glandular cells, favor neoplastic (AGC-H)

25. AN ABNORMAL PAP SMEAR Abnormal due to dysplastic changes Abnormal due to inadequacy Abnormal due to inflammation Abnormal due to infection

26. Dysplastic Changes Squamous Atypical (ASCUS/ASC-H) LSIL ( Mild Dyskaryosis / HPV/CIN 1) HSIL (Mod or Severe Dyskaryosis / CIN 2,3) Invasive Squamous Carcinoma Glandular Atypical (undetermined or favour neoplastic) Adenocarcinoma in situ (AIS) Invasive adenocarcinoma

27. INADEQUATE SMEARS Sampling Scanty cells Blood, mucous, pus Mainly endocervical cells * Preparation Too thick due to poor spreading Air drying artifact

28. How to deal with Inadequate smears Correct timing of smear Do not use cream or gel Cleaning of excessive mucus Choice of sampling devices Correct spreading Rapid fixation (< 10 second)

29. INFLAMMATORY SMEARS Infection Chronic cervicitis Atrophic cervicitis

30. Management of Abnormal Pap Smear

31. Management of Abnormal Pap Smear : Options Observed and repeat pap smear Treat (inflammation & infection) and repeat pap smear Refer for Colposcopy

32. OBSERVE AND REPEAT PAP SMEAR Unsatisfactory/Inadequate smear Reactive cellular changes due to radiation, repair or IUCD ASCUS with Low Risk HPV type or no facility for HPV typing Selected LSIL – repeat in 6 months, if persistent, do colposcopy HPV effect

33. TREAT AND REPEAT INFECTIONS Trichomonas vaginalis ( Metronidazole 400mg tds and Doxycyline 100mg bd for 1 week) Fungal infection : Antifungal Bacterial vaginosis (Metronidazole, Clindamycin) Actinomyces species : Penicillin Herpes simplex : Acyclovir Repeat smear in 6-8 weeks, if persistent in 3 occasion, refer for colposcopy. ATROPHIC SMEAR Local oestrogen cream/tab (1 gm nighty for 2 weeks then twice weekly) 6-8 weeks and repeat pap smear in 3-4 months.

34. COLPOSCOPY   Suspicious looking cervix.   Unexplained post-coital bleeding.   Persistent unsatisfactory smear on 3 occasions, 3 monthly.   Persistent inflammatory smear on 3 occasions, 3 monthly (despite treatment).   Persistent Atypical Squamous Cells of Undetermined Significance (ASC-US) on 2 occasions.   Atypical Squamous Cells of Undetermined Significance (ASC-US) positive for high risk HPV.   Atypical Squamous Cells –cannot exclude high grade lesion (ASC-H)  

35. COLPOSCOPY Persistent Low Grade Squamous Intraepithelial Lesion (LSIL) on 2 occasions, 6 monthly.   Persistent Low Grade Squamous Intraepithelial Lesion (LSIL) with high risk factors.   High Grage Squamous Intraepithelial Lesion (HSIL).   Squamous Cell Carcinoma (SCC).   Atypical Glandular Cells (AGUS).   Adenocarcinoma .   High risk HPV DNA positive.

36. ABNORMAL PAP SMEAR IN PREGNANCY Complicates up to 5% of pregnancies Most women will have low-grade disease A significant degree of expertise and experience is required in the colposcopic triage of the abnormal pap smear in pregnancy Cervical biopsy is safe in pregnancy. Cone biopsy is best avoided and delayed until 6-8 weeks after delivery (Risk of spontaneous miscarriage 25%, excessive bleeding in 5-15% and risk of persistent disease 50%) The most important aspect in management of abnormal pap smear in pregnancy is to exclude invasive cancer .

37. Satisfactory and negative PAP SMEAR UNSATISFACTORY FOR EVALUATION Repeat smear in 3 months 2 nd smear unsatisfactory Negative for malignant cells Repeat smear in 3 months 3 rd smear unsatisfactory Refer for colposcopy Refer to Flowchart for Management of ‘Negative For Malignant Cells’ Smear. * NOTE Treat any infection. Give a course of estrogen if there are atrophic changes.

38. changes resolve changes resolve PAP SMEAR NEGATIVE FOR MALIGNANT CELLS Atrophic changes (without inflammation) No endocervical cells seen Specific micro- organisms identified Inflammatory changes Endometrial cells seen Correlate with clinical findings, client’s age, hormonal and menstrual status Refer Gynaecologist if necessary Treat appropriately as clinically indicated Treat any infection or atrophy. Repeat smear in 3–6 months. 2 nd smear with similar changes 3 rd smear with similar changes Treat any infection or atrophy. Repeat smear in 3–6 months. Refer Gynaecologist Repeat smear in 1 year Routine screening schedule Routine screening schedule

39. Cannot exclude high grade lesion (ASC-H) Undetermined significance (ASC-US) PAP SMEAR ATYPICAL SQUAMOUS CELLS Refer for colposcopy Repeat smear in 6 months Negative for malignant cells Repeat smear in 6 months Resume routine screening if negative for malignant cells Atypical squamous cells Low-grade squamous intraepithelial lesion High-grade squamous intraepithelial lesion Refer for colposcopy NOTE HPV DNA testing should be considered if available If positive for high risk HPV, to refer for colposcopy

40. No Yes Presence of at least one criteria: Age > 30 years Poor compliance Immunocompromised Symptomatic History of pre invasive lesion High risk HPVpositive. Repeat smear in 6 months PAP SMEAR LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL) Negative for malignant cells Resume routine screening schedule Mild dysplasia or CIN I Refer for colposcopy Immediate colposcopy Assessment of client

41. HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL)/ SUSPICIOUS FOR INVASION SQUAMOUS CELL CARCINOMA PAP SMEAR Refer to Gynaecological Oncologist Refer for colposcopy

42. ALL ATYPICAL GLANDULAR CELLS (except Atypical Endometrial Cells) ADENOCARCINOMAIN SITU (AIS) & ADENOCARCINOMA PAP SMEAR Refer to Gynaecological Oncologist Refer to Gynaecologist for: colposcopy ( with endocervical sampling) endometrial sampling ( if > 35 years or abnormal bleeding ) ATYPICAL ENDOMETRIAL CELLS Refer to Gynaecologist

43. HPV VACCINE

44. STIGMA !!!!

45. HUMAN PAPILOMA VIRUS Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most sexually active people will get HPV at some time in their lives, though most will never even know it. HPV infection is most common in people in their late teens and early 20s

46. HUMAN PAPILOMA VIRUS Two HPV types ( HPV-16 and HPV-18 ) that cause 70% of cervical cancers, 80% of anal cancers, 60% of vaginal cancers, and 40% of vulvar cancers. These HPV types also cause most HPV induced oral cancers, and some other rare genital cancers.

47. GENERAL INFO Bivalent vaccine ( CERVARIX) Quadrivalent vaccine (GARDASIL). Gardasil , also prevents HPV types that cause most genital warts Both vaccines are given in 3 shots over 6 months.

48. HPV VACCINE HPV vaccination is recommended with either vaccine for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years

49. PREGNANCY AND HPV VACCINE The vaccines are not recommended for pregnant women. Studies show that HPV vaccines do not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of either HPV vaccine until her pregnancy is completed.  Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy.

50. EFFICACY OF HPV VACCINE The vaccines target the HPV types that most commonly cause cervical cancer. Both vaccines are highly effective in preventing the targeted HPV types The vaccines are less effective in preventing HPV-related disease in young women who have already been exposed to one or more HPV types. That is because the vaccines prevent HPV before a person is exposed to it.  HPV vaccines do not treat existing HPV infections or HPV-associated diseases

51. Research suggests that vaccine protection is long-lasting. Current studies have followed vaccinated individuals for six years, and show that there is no evidence of weakened protection over time

52. BE WARY…….. The vaccines do not protect against all HPV types— so they will not prevent all cases of cervical cancer. About 30% of cervical cancers will not be prevented by the vaccines, so it will be important for women to continue getting screened for cervical cancer (regular Pap tests). Also, the vaccines do not prevent other sexually transmitted infections (STIs)

53. SAFETY OF VACCINE Both vaccines have been licensed by the Food and Drug Administration (FDA). The CDC has approved these vaccines as safe and effective. Side effects reported in these studies were mild, including pain where the shot was given, fever, dizziness, and nausea

54. QUESTIONS ?????

55. Thank you !!!!!