Specific Populations

NATIONAL CERVICAL SCREENING PROGRAM GUIDELINES

THE RENEWED NATIONAL CERVICAL SCREENING PROGRAM: AND QuickINVESTIGATION Reference Guide SPECIFIC POPULATIONS OF ABNORMAL VAGINAL BLEEDING INVESTIGATION OF ABNORMAL VAGINAL BLEEDING

VAGINAL SCREENING AFTER TOTAL HYSTERECTOMY

Women at any age who have signs or symptoms suggestive of cervical cancer should have a co-test, and referral for appropriate investigation to exclude genital tract malignancy should be considered. The vast majority of symptomatic women, especially younger women, will NOT have cervical cancer.

Women with a normal cervical screening history, who have undergone hysterectomy for benign disease (e.g. menorrhagia, uterine fibroids or utero-vaginal prolapse), and have no cervical pathology at the time of hysterectomy, do not require further screening or follow up.

Women with abnormal vaginal bleeding Consider sexual health history & perform appropriate tests

Unexplained intermenstrual bleeding

Postcoital bleeding (PCB)

Co-test (HPV & LBC) HPV not detected & negative LBC

Single episode PCB (Pre-menopausal women)

Recurrent or persistent PCB (any age)#

Clinically normal cervix No colposcopy required (advise to see healthcare professional if symptoms persist)

Refer for gynaecological assessment*

Total hysterectomy † Postmenopausal bleeding

Co-test (HPV & LBC) HPV detected (any type) &/or abnormal LBC result

Refer for gynaecological assessment (regardless of test result)*

Refer for gynaecological assessment (regardless of test result)*

Note: Co-testing is not indicated in the vast majority of women presenting with vaginal discharge and/or dyspareunia. If due for cervical screening then a routine CST is appropriate.

* May include colposcopy # If significant delay (3–6 months from the previous test) following original HPV/LBC test, a repeat LBC could be considered

Prior screening history

Indication for hysterectomy

Cervical pathology in histoloy specimen

Previous treatment for Abnormal HSIL (CIN2/3) screening with (prior to Test of histologically confirmed HSIL Cure) on routine surveillance with (CIN2/3) normal tests

Treated HSIL (CIN2/3) with completed Test of cure

Normal

HSIL (CIN2/3) + associated benign gynaecological disease

Benign gynaecological disease

Positive for No No Cervical cervical cervical pathology pathlogy pathology LSIL or HSIL

No Recommended Follow follow-up up

Test of cure

*

No Follow up

Positive for cervical pathlogy LSIL or HSIL

*

Test of cure

Benign gynaecological disease

Positive for No No cervical cervical cervical pathlogy pathology pathology LSIL or HSIL

Regardless of findings

Test of cure

* an annual co-test on a speciman from the vaginal vault

No known screening history

*

Test of cure

*

Test of cure

HPV test at 12/24 months

Positive for cervical pathlogy LSIL or HSIL Test of cure

*

† not including total hysterectomy performed for AIS

until two consecutive negative co-tests

SCREENING IN WOMEN WHO HAVE EXPERIENCED EARLY SEXUAL ACTIVITY OR HAVE BEEN VICTIMS OF SEXUAL ABUSE • Routine cervical screening is not recommended in women under the age of 25 years • For women who experienced either first sexual activity or sexual abuse prior to 14 years of age and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis.

www.vcspathology.org.au

For more information, visit: http://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening

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NATIONAL CERVICAL SCREENING PROGRAM GUIDELINES

SPECIFIC POPULATIONS AND INVESTIGATION OF ABNORMAL VAGINAL BLEEDING SCREENING IN WOMEN EXPOSED TO DIETHYLSTILBOESTROL (DES) IN UTERO

SCREENING IN PREGNANCY • Cervical screening during pregnancy should be undertaken if the woman is due or overdue for screening.

• A woman whose screening result requires assessment or colposcopy should NOT defer this visit as colposcopy is performed to exclude the presence of invasive cervical cancer.

• It will also confirm the presence of pre-invasive disease and reassure the pregnant woman that it is safe to continue with her pregnancy.

• Conservative management of high-grade squamous intraepithelial lesions (HSIL) is recommended during pregnancy.

• Postpartum regression of CIN lesions is common.

Women with abnormal vaginal bleeding

• Women exposed to DES in utero should be offered an annual co-test and colposcopic examination of both the cervix and vagina indefinitely.

• Those who have a screen-detected abnormality should be managed by an experienced colposcopist.

• Daughters of women exposed to DES should have 5-yearly HPV testing. If these women have concerns, testing similar to that recommended for their DES-exposed mothers could be considered on an individual basis. Self-collection for HPV testing is not recommended.

SCREENING IN IMMUNE-DEFICIENT WOMEN

Immune deficient women who should be screened every three years include: • Women with HIV • Solid organ transplant recipients Other women who may be considered immune deficient include: • Women with congenital (primary) immune deficiency • Women treated with intensive immunosuppressant therapy for autoimmune disease • Allogenic bone marrow recipients treated for graft versus host disease • Other groups who may be immune deficient due to disease, immunosuppressive drugs or both.

Postcoital LBC prediction of HSIL in pregnancy

Immune-deficient

bleeding (PCB)

Screening HPV test 3 yearly Colposcopy

HPV detected (any type)

Normal TZ

Colposcopy review postpartum >6–12 weeks

Colposcopy review postpartum >6–12 weeks

Colposcopic impression Invasive

If no change, colposcopy review postpartum >6–12 weeks

Refer to gynaecological oncologist *Biopsy not usually necessary in pregnancy

www.vcspathology.org.au

Assess entire lower anogenital tract

Repeat LBC & colposcopy 20–24 weeks

Abnormal TZ*

Colposcopic impression CIN 2/3*

Cytopathology review

Colposcopy Reflex LBC result

Type 3 TZ

Type 1 or 2 TZ

Histologically confirmed abnormalities managed according to these guidelines

No confirmed histological abnormality

HSIL (CIN 2/3)

AIS

Excisional treatment recommended

Type 3 excisional TZ

Test of Cure** completed

Annual co-test (HPV/LBC)#

Return to routine HPV testing every 3 years

Follow up based on HPV/LBC/ colposcopy in accordance with these guidelines

** Co-test (HPV and LBC) test 12 months after treatment & annually thereafter until the woman has had negative cotest on 2 consecutive occasions, after which she returns to routine 3-yearly screening # Until sufficient data become available to support return to 3-yearly screening

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