Abnormal PAP Smears, HPV, Cervical Dysplasia and Cancer

Edited excerpts from 
A Gynecologist's Second Opinion

WHAT DO THE PAP SMEAR RESULTS MEAN?
The terminology used to describe pap smear results has changed over the past few years, leading to confusion about what the results of your pap smear actually mean. Originally, pap smears were divided into 5 "classes" based on what the cells looked like to the pathologist. Class I was normal, while class II cells appeared a little irregular to the pathologist, usually representing bacterial infection. Class III and IV pap smears suggested that dysplastic cells were present, and further testing needed to be done. Class V usually meant cancer.

Unfortunately, this class system led to confusion regarding what "number" pap smear a woman had and what that really meant. Recently, a new system for pap smear classification called the Bethesda System has been introduced. The term "low grade" lesion is now used for cells that appear to be infected with HPV or are only mildly abnormal. "High grade" is the new terminology for more abnormal appearing cells, the type that would have been called class III or IV with the old "class" system. A pap smear that looks like cancer is now labeled "cancer" rather than called class V. The Bethesda System allows the pathologist to actually describe what is seen, rather than just assign a number to the pap smear result. In that way it is an improvement over the old "class system". 

WHAT IS CERVICAL DYSPLASIA AND CARCINOMA-IN-SITU?
During sexual intercourse, viruses or other, as yet unidentified, cancer-causing agents may get into the cells of the cervix and cause them to grow abnormally. When these cervical cells grow abnormally, they are considered to have dysplasia. This is a word derived from Greek which means "abnormal tisssue growth". Early on, dysplastic cells stay within the cervical skin. The skin has no blood or lymph vessels that the abnormal cells can invade and, therefore, they have no way to leave the cervix and spread to other areas of the body. Because dysplasia is confined to the skin, it is easy to treat. 

Carcinoma-in-situ (CIS) is not cancer. In fact, it is just a severe form of dysplasia, and the abnormal cells still remain confined within the skin and CIS can not spread to other areas of the body. Recently, in order to eliminate confusion, the term carcinoma-in-situ was replaced with the term high-grade dysplasia. However, if high-grade dysplasia is left untreated over a number of years, the cells may eventually break through the skin layer into the layer beneath, where blood and lymph vessels do exist. These cells can now spread to other areas of the body and cervical cancer is said to be present. 

Because I was not able to see this area of Susan's cervix, I recommended that we remove a portion of the canal of the cervix with the LEEP instrument. Removal would serve two purposes. First, the pathologist could examine the tissue under the microscope and make a final diagnosis of how abnormal the cells appeared. Second, the cells would be removed and, therefore, no further treatment would likely be needed. Susan agreed. With an extremely small needle, I injected a small amount of anesthetic, mixed with a chemical to help prevent bleeding, into her cervix. The injection did not bother her at all. Next, the wire loop of the LEEP instrument was used to remove a portion of the canal area from her cervix. Because of the anesthetic, she did not feel this at all. I then scraped the cells high up in the remaining cervical canal for the pathologist to check and make sure that no abnormal cells had been left behind. The entire procedure had taken about three minutes. 

The pathology report came back about a week later. It showed that the cells were indeed precancerous and had been growing up inside the cervical canal. Fortunately, all the abnormal cells appeared to have been removed, and the scrapping of cells from the remaining part of the cervical canal were entirely healthy. The follow-up for Susan included pap smears every three months for a year, then every six months after that. They have all been fine and no further evaluation or treatment has been neccesary. 

WHAT IS COLPOSCOPY?
The colposcope is essentially a set of binoculars attached to the top of a stand. This instrument allows the doctor to see a magnified view of the blood vessels on the skin covering the cervix. As abnormal cells grow, they push the normal blood vessels of the cervix out of their way. These red blood vessels can be seen as they form unusual patterns on the pale pink background of the skin. The patterns typically change as the cells become more abnormal. Your doctor will look for these patterns to determine whether abnormal cells are present, how abnormal they appear to be, and how large or small an area they involve. Colposcopy is an accurate way to check on the results of the pap smear. If abnormal patterns are seen when viewed by the colposcope, then a cervical biopsy will be needed.

WHAT IS LEEP?
LEEP stands for loop electrosurgical excision procedure. This procedure was developed in Europe years ago and has been frequently performed in the United States since the 1980's. A small wire loop is placed against the cervix, and an electric current is passed through the loop making it extremely hot. The loop is then able to cut through the cervix in much the same way that a hot knife can cut through butter. The procedure requires special instruments, but can be performed in the doctor's office and only takes a few minutes to do. Local anesthesia is injected into the cervix, and virtually no discomfort occurs during LEEP. The small portion of the cervix that is removed is then sent to the pathologist for examination. Healing of the cervix occurs over a 6 week period of time. LEEP is both diagnostic and therapeutic, in that the abnormal cells are removed as treatment, and they are also sent to the lab for diagnosis. LEEP removes somewhat more tissue than the regular cervical biopsy and is also more expensive. Therefore, we use it only when we think that removing more tissue will be neccesary. 

The following questions and answers can be found in our book

• ABOUT FIBROIDS
• What Causes Fibroids? 
• Do Birth Control Pills Cause Fibroids? 
• What Are the Different Types of Fibroids? 
• Can Fibroids Cause Bleeding Problems? 
• Can Fibroids Cause Pain or Pressure? 
• Can Fibroids Cause Sudden Pain? 
• Can Fibroids Cause Urinary Problems? 
• Can Fibroids Cause Infertility? 
• Can Fibroids Cause Miscarriage? 
• Can Fibroids Cause Problems During Pregnancy? 
• Do Fibroids Mean A Cesarean Section? 
• Do Growing Fibroids Mean Cancer? 
• What If You Have Large Fibroids? 
• Can My Fibroids Just Be Watched? 

• TREATMENT OPTIONS FOR FIBROIDS
• What Are the Treatment Options for Fibroids? 
• Can You Take Medication for Fibroids? 
• Are There Any New Medicines for Fibroids? 
• What Are the Side Effects of Lupron and Synarel? 
• When Should Lupron or Synarel Be Used? 
• What About Danacrine? 
• Can Progesterone Be Used To Treat Fibroids? 
• Are Holistic Remedies Effective for Treating Fibroids? 
• Do You Need Surgery for Fibroids? 
• What If You Have Uncontrollable Bleeding? 
• What If You Are at Risk for Kidney Damage? 
• What If There Is Concern That The Fibroids Might Be Cancer? 

• TYPES OF SURGERY FOR FIBROIDS 
• What Is a Myomectomy? 
• What is an Abdominal Myomectomy? 
• What is a Laparoscopic Myomectomy? 
• Can Lasers Be used for Myomectomy? 
• Can Myomectomy Lead to Scar Tissue ? 
• What is a Vaginal Myomectomy? 
• What is Myoma Coagulation (Myolysis)? 
• What is Resectoscope Myomectomy? 
• What is Endometrial Ablation? 
• Do I Need a Hysterectomy for Fibroids? 

• ADENOMYOSIS
• What is Adenomyosis? 
• What Are the Symptoms of Adenomyosis? 
• How Is the Diagnosis of Adenomyosis Made? 
• What Is the Treatment for Adenomyosis?