Bethesda System & Follow-up of Abnormal Pap Smears

Please review the current Bethesda Guidelines. What effect does virus typing have on your plans?

Bethesda System, Revised
First published JAMA 4/24/02. Refer to Bibliography for new articles r/t the guidelines. American Society for Colposcopy and Cervical Pathology website. www.asccp.org contains all of the information and excellent flow charts.

Consensus guidelines by the American Society for Colposcopy and Cervical Pathology (ASCCP) and the National Cancer Institute

Specimen Adequacy Criteria: well visualized squamous cells 8000 - 12000 conventional smear (slide) 5000 liquid based (ThinPrep) *preferred with "reflex" available, eg DNA test the sample if ASC-US for the high risk types	If you do not have an adequate specimen, your results are worthless. You must have endocervical cells, readable cells, no drying effect, not obscured by blood, etc) Satisfactory for evaluation Unsatisfactory for evaluation (reason given)
General category	Within normal limits Metaplasia. This is a normal process. Epithelial cell abnormality: see descriptive diagnosis
Negative for intraepithelial lesion or malignancy. Benign cellular changes Infection Trichomonas vaginalis Fungal organism (Canada) Bacteria consistent with Actinomyces) Cellular changes consistent with herpes Other Reactive changes Inflammation repair) Atrophy with inflammation(atrophic vaginitis Radiation IUD Postpartum)	Benign reactive cellular changes may occur in response to factors such as infection, inflammation, irritation, radiation or chemotherapy These changes have no premalignant potential, so they are reported only when it appears that they may be clinically significant or when they affect the adequacy or interpretability of the smear. When ASCUS is associated with and might be due to inflammation/reaction, these changes are noted so that the condition can be treated before the smear is repeated.
Epithelial cell abnormalities. Squamous cell
	Atypical squamous cell of undetermined significance ASC-US These cellular changes exceed those which can be a benign process, but fall short of an intraepithelial lesion or cancer. 1 in 1000 will progress to cervical cancer. Many of these will revert to normal
	Abnormal squamous cells , cannot exclude high-grade squamous intraepithelial lesion (SIL) ASC-H 1/10 risk of progressing to cervical cancer Also includes LSIL, HSIL, (Moderate and severe dysplasia CIN 2, 3 and CIS)
	Squamous cell carcinoma Probable invasive cancer, requires histology
Epithelial cell abnormalities. Glandular Cell	Atypical glandular cells (AGC) Higher risk of underlying high-grade disease associated with AGC.



	Endocervical Endometrial Not otherwise specifies (AGC NOS) Favor neoplasia Endocervical adenocarcinoma in situ

Atypical squamous cell of undetermined significance (ASC-US)	1. Re-Pap 2 times in a period of 8 - 12 months. a. two negatives, return to annual pap b. ASC-US or greater, refer for colposcopy 2. Colposcopy as a follow-up choice AND for high-risk HPV DNA a. negative colposcopy, HPVDNA test 6 and 12 months or Pap in 6 and 12 months. If any of these are positive, do another colposcopy. Treat any CIN 3. DNA testing for high-risk HPV types. If not high-risk type, may do annual pap.


Abnormal Glandular Cell (AGC)	1. Colposcope all AGUS

	Cryotherapy Laser therapy Leep therapy