Se|ected 1op|cs: Vag|n|t|s, Cra| Contracept|ves and Cerv|ca| Cancer Screen|ng
Ian|ce kyden, MD, Leah Wo|fe, MD
Learn|ng Cb[ect|ves
AL Lhe compleLlon of Lhls module Lhe learner wlll be able Lo: 1. ldenLlfy and LreaL Lhe mosL common causes of vaglnlLls. 2, lmplemenL raLlonal cervlcal cancer screenlng and approprlaLe Lrlage of resulLs. a. ldenLlfy approprlaLe candldaLes and lnLervals for screenlng based on 2012 Culdellnes. b. roperly collecL, lnLerpreL and Lrlage a cervlcal cyLology smear based on Lhe 2006 Consensus Culdellnes. 3. ApproprlaLely prescrlbe oral conLracepLlves, lncludlng: a. undersLand and communlcaLe Lhe rlsks and healLh beneflLs of oral conLracepLlves, b. recognlze and manage Lhe mosL common slde effecLs of oral conLracepLlves, and c. compeLenLly prescrlbe emergency conLracepLlon.
Case 1: D|agnos|s and management of vag|n|t|s A 22-year-old woman presenLs complalnlng of a flshy-smelllng vaglnal dlscharge for Lhe pasL 2 days. She reporLs LhaL has had unproLecLed lnLercourse wlLh a new parLner for approxlmaLely 2 monLhs. elvlc examlnaLlon reveals a whlLlsh homogeneous (l.e. havlng Lhe conslsLency of mllk) dlscharge wlLh a poslLlve "whlff LesL". 1here ls no cervlcal moLlon Lenderness or uLerlne or adnexal Lenderness presenL. Whlch of Lhe followlng ls Lhe mosL llkely eLlology of Lhls paLlenL's sympLoms? A. Candlda vaglnlLls 8. 8acLerlal vaglnosls C. !"#$%&'&()* +),#()-#* u. LlLher bacLerlal vaglnosls or !"#$%&'&()* +),#()-#* L. .%-)'/0#) lnfecLlon op-up answers: A. lncorrecL. 1he dlscharge assoclaLed wlLh Candlda vaglnlLls ls usually odorless. 1yplcally Lhe dlscharge appears Lhlck and whlLe (or yellowlsh) and adheres Lo Lhe walls of Lhe vaglna. CfLen Lhe vaglna and vulva appear lnflamed and/or edemaLous. 8. lncorrecL. AlLhough Lhe paLlenL's sympLoms and physlcal exam flndlngs are conslsLenL wlLh bacLerlal vaglnosls, Lhey may also resulL from !"#$%&'&()* +),#()-#*, mlcroscopy ls needed Lo dlsLlngulsh beLween Lhe Lwo. C. lncorrecL. AlLhough Lhe dlscharge assoclaLed wlLh !"#$%&'&()* ls "classlcally" green or yellow, lL ls ofLen whlLlsh and malodorous and may resemble Lhe dlscharge assoclaLed wlLh bacLerlal vaglnosls. Mlcroscopy ls necessary Lo make Lhe dlagnosls. u. CorrecL! 1hls could be elLher bacLerlal vaglnosls or !"#$%&'&()* +),#()-#*, offlce mlcroscopy ls essenLlal Lo dlagnoslng Lhe cause of vaglnlLls. L. lncorrecL. .%-)'/0#) lnfecLlon causes cervlclLls, noL vaglnlLls. AlLhough lL ls posslble LhaL Lhls paLlenL may be harborlng an asympLomaLlc .%-)'/0#) lnfecLlon of her cervlx, Lhe physlcal exam flndlngs lndlcaLe LhaL Lhe paLlenL's sympLoms resulL from a vaglnal dlscharge, noL a dlscharge emanaLlng from Lhe cervlcal os. Summary answer: 1he correcL answer ls D. L|ther bacter|a| vag|nos|s or !"#$%&'&()* +),#()-#*
vaglnlLls ls a general descrlpLlve Lerm for lnflammaLlon of Lhe vaglnal mucosa. lL ls Lhe mosL common gynecologlc problem encounLered ln prlmary care and ls one of Lhe mosL common reasons for ouLpaLlenL vlslLs by women. 1he Lhree ma[or causes of lnfecLlous vaglnlLls are bacLerlal vaglnosls (40-30), candldlasls (20-30), and Lrlchomonlasls (10-30). revalence varles accordlng Lo Lhe populaLlon sLudled. nonlnfecLlous vaglnlLls [prlmarlly aLrophlc and chemlcal vaglnlLls] wlll be dlscussed ln a laLer secLlon. noLe LhaL cervlclLls and pelvlc lnflammaLory dlsease should also be consldered ln Lhe dlfferenLlal dlagnosls ln women who presenL wlLh vaglnal dlscharge, space consLralnLs do noL permlL dlscusslon of Lhese Loplcs. 8rlef menLlon wlll be made, however, of Lhe new need Lo LreaL gonorrhea cervlclLls wlLh Lwo anLlbloLlcs, as dolng so may hlnder Lhe developmenL of anLlmlcroblal-reslsLanL 23 ,&(&""%&4)4, an emerglng global LhreaL (2).
C||n|ca| aspects 1he vaglnal dlscharge ln vaglnlLls may have varled and overlapplng presenLaLlons, co-lnfecLlon ls also falrly common. 1herefore, Lhe dlagnosls of vaglnlLls cannoL be based solely on Lhe presence or absence of parLlcular slgns or sympLoms. Powever, Lhere are cerLaln characLerlsLlcs, whlch make one dlagnosls or anoLher more llkely. (1)
lor lnsLance, candldlasls ls Lyplcally assoclaLed wlLh prurlLls, so Lhe lack of prurlLls ln Lhe hlsLory makes Lhls less llkely. 1he lack of percelved odor ln Lhe hlsLory makes bacLerlal vaglnosls less llkely. Cn exam, Lhe presence of slgns of lnflammaLlon ls conslsLenL wlLh candldlasls or Lrlchomonlasls, lack of odor ls suggesLlve of candldlasls.
noLwlLhsLandlng Lhese generallzaLlons, offlce mlcroscopy uslng boLh sallne weL mounL and kCP preparaLlons ls essenLlal ln dlagnoslng vaglnlLls. Speclmens should be obLalned from Lhe laLeral wall of Lhe vaglna. 1he speclflclLy of mlcroscopy ls vlrLually 100 when Lrlchomonads, clue cells, or hyphae are deLecLed. Powever, candldlasls and Lrlchomonlasls cannoL be deflnlLlvely ruled ouL by Lhe absence of Lhese flndlngs. An lncreased number of whlLe blood cells on weL mounL lndlcaLes an lnflammaLory condlLlon such as Lrlchomonlasls or candldlasls, buL lL should be noLed LhaL aLrophlc or chemlcal vaglnlLls, cervlclLls and pelvlc lnflammaLory dlsease (lu) can produce Lhls flndlng as well. lf nlLrazlne pP paper ls avallable, assesslng Lhe acldlLy of Lhe vaglnal secreLlons may be useful: lf Lhe pP ls normal, candldlasls may be Lhe cause of vaglnlLls, lf Lhe pP ls elevaLed (>4.3), bacLerlal vaglnosls (8v), Lrlchomonlasls or aLrophlc vaglnlLls may be Lhe cause (see 1able 1 below).
AlLhough cervlclLls, lu and S1u screenlng are beyond Lhe scope of Lhls dlscusslon, lL should be noLed LhaL lmmedlaLely followlng sampllng of Lhe dlscharge from Lhe laLeral vaglnal wall deep ln Lhe vaglna, a second swab ls used Lo permlL LesLlng for 23 ,&(&""%4) and .%-)'/0#). 1hls second swab can be dlscarded lf ulLlmaLely deemed unnecessary, buL ls uLlllzed ln many cllnlcal presenLaLlons, for lnsLance lf excess leukocyLes buL no culprlL organlsms are found on weL mounL-- suggesLlng posslble cervlclLls, and cerLalnly lf Lhe weL mounL examlnaLlon uncovers !"#$%&'&()* (an S1u).
1he CuC recenLly publlshed new guldellnes regardlng Chlamydla and gonorrhea LesLlng. 1he new preferred speclmen source for women ls Lhe vaglnal swab, elLher paLlenL-collecLed or cllnlclan-collecLed. lf Lhe paLlenL ls undergolng a pelvlc exam, Lhen an endocervlcal sample ls a second, accepLable" speclmen. 1esLlng uslng urlne speclmens ls also accepLable" buL has 10 reduced senslLlvlLy compared Lo Lhe Lwo former speclmen Lypes. (3)
8acter|a| Vag|nos|s 8acLerlal vaglnosls (8v) ls Lhe mosL common cause of vaglnal lnfecLlon. SympLoms and slgns are varlable and some paLlenLs are asympLomaLlc. 1he maln flndlng ls a vaglnal dlscharge wlLh a flshy odor, caused by Lhe release of amlnes from anaeroblc bacLerlal overgrowLh. 1hls smell may be enhanced by Lhe addlLlon of kCP Lo secreLlons (poslLlve "whlff LesL"). 1he dlscharge has a homogeneous (Lhln or "mllky") conslsLency and adheres Lo Lhe vaglnal walls. ulagnosls ls based on Lhe presence of greaLer Lhan 20 "clue cells" (eplLhellal cells whose membranes are sLudded wlLh bacLerla, wlLh a "beaded" appearance), and a flshy odor. Slnce Lhe condlLlon ls noL lnflammaLory, leukocyLes are noL lncreased.
.-54 $4--* are eplLhellal cells whose borders are sLudded wlLh bacLerla raLher Lhan appearlng smooLh. 6%&7&'#$"&,")8% $&5"74*/ &9 .:.;<3 =4#(3
1reaLmenL of 8v can be elLher Loplcal or oral. 1he Lwo meLronldazole LreaLmenL reglmens are equally efflcaclous (greaLer Lhan 90 cure raLe), cllndamycln cream ls oll-based and can weaken laLex condoms and dlaphragms. 8ecall LhaL an AnLabuse-llke reacLlon can occur lf alcohol ls consumed wlLh oral meLronldazole durlng Lherapy and for 24 hours LhereafLer. ! MeLronldazole 300 mg C 8lu x 7 days ! MeLronldazole gel (0.73) one appllcaLor per vaglna qPS x 3 days ! Cllndamycln cream (2) one appllcaLor per vaglna qPS x 7 days
AlLernaLlve CuC reglmens lnclude Cllndamycln ovules 100 mg lnLravaglnally CPS x 3 days, bloadheslve cllndamycln (Cllndesse) applled once, or cllndamycln 300 mg C 8lu x 7 days (noL luA-approved for Lhls lndlcaLlon).
Slnce 8v ls noL sexually LransmlLLed beLween heLerosexual parLners, male parLners do noL requlre LreaLmenL. Powever, sLudles of monogamous lesblan couples demonsLraLe a concordance raLe of lnfecLlon LhaL ls hlgher Lhan expecLed, suggesLlng posslble female-Lo-female Lransmlsslon of 8v. 1reaLmenL of lesblan parLners ls noL currenLly recommended, buL cleanslng of shared sex Loys beLween uses mlghL be helpful (2). 8ecurrences are common and are someLlmes LreaLed wlLh a medlcaLlon dlfferenL from Lhe orlglnal reglmen (2).
Case 2: Vag|n|t|s part 2 ?our 23-year-old paLlenL phones you complalnlng of a yeasL lnfecLlon and asks for a prescrlpLlon. Cn quesLlonlng she reporLs recenL anLlbloLlc use for SLrep pharynglLls. She has noL been sexually acLlve for 6 monLhs. She denles abdomlnal paln, dysurla and fever or chllls. ?ou advlse Lhe paLlenL LhaL: A. She needs an urgenL appolnLmenL Loday for pelvlc exam and evaluaLlon. 8. She should come for evaluaLlon aL your nexL avallable appolnLmenL ln 1 week. C. She should Lry swlLchlng soaps for 2 weeks Lhen call you back wlLh her progress. u. She should purchase an C1C anLl-yeasL vaglnal preparaLlon, wlLh Lhe caveaL LhaL she should arrange an appolnLmenL lf noL beLLer ln 1 week, or call lmmedlaLely lf she develops abdomlnal paln or fever or chllls. op-up Answers: A. lncorrecL. ln Lhls case urgenL evaluaLlon would represenL an overuLlllzaLlon of resources glven LhaL Lhe dlagnosls ls falrly cerLaln, as long as provlslons have been made for urgenL evaluaLlon lf Lhe dlagnosls comes lnLo quesLlon. 8. lncorrecL. osLponlng evaluaLlon and/or LreaLmenL of vaglnlLls for 1 week ls lnapproprlaLe. C. lncorrecL. AlLhough Lhe sympLoms and slgns of chemlcal vaglnlLls resemble LhaL of yeasL vaglnlLls, Lhere ls llLLle ln Lhe hlsLory Lo supporL Lhls dlagnosls. u. CorrecL! When Lhe paLlenL and physlclan are falrly confldenL LhaL Lhe paLlenL has a yeasL lnfecLlon, emplrlc LreaLmenL can be approprlaLe, as long as Lhe paLlenL ls aware Lo seek lmmedlaLe evaluaLlon for sympLoms poLenLlally relaLed Lo more concernlng processes (such as lu), and less urgenL evaluaLlon lf her sympLoms perslsL afLer LreaLmenL. Summary answer 1he correcL answer ls D: She shou|d purchase an C1C ant|-yeast vag|na| preparat|on, w|th the caveat that she shou|d arrange an appo|ntment |f not better |n 1 week, or ca|| |mmed|ate|y |f she deve|ops abdom|na| pa|n, fever, or ch|||s. A|though th|s modu|e emphas|zes the ob[ect|ve off|ce eva|uat|on of vag|na| d|scharge, a re||ab|e report of ||ke|y yeast vag|n|t|s represents an except|on.
./-+&+),#()- $)(1#1#)*#* vulvovaglnal candldlasls (vvC) ls mosL commonly caused by .)(0#0) )->#$)(* (60 Lo 80 of vaglnal fungal lnfecLlons). vvC ls seen more commonly ln paLlenLs who are pregnanL, obese, have dlabeLes melllLus, or Plv lnfecLlon. 1he use of corLlcosLerolds or anLlbloLlcs may also predlspose women Lo vvC, however, Lhe ma[orlLy of healLhy women have no ldenLlflable preclplLaLlng facLor. (2) noLe also LhaL approxlmaLely 30 of asympLomaLlc women are colonlzed wlLh Candlda as parL of Lhelr normal vaglnal flora, Lhese women do noL requlre LreaLmenL.
east vag|n|t|s. Large hyphae are vlslble ln Lhe cenLral porLlon of Lhe sllde, and small round spores are scaLLered LhroughouL. 1he mlcrograph deplcLed ls a sallne weL mounL, Lhe kCP sllde ls superlor for deLecLlng hyphae and spores as surroundlng cellular maLerlal ls lysed. 6%&7&'#$"&,")8% $&5"74*/ &9 .:.;:"3 ?75)"7 @"&A(3
1he sympLoms of yeasL vaglnlLls lnclude lLchlng or burnlng ln boLh vaglnal and vulvar areas, someLlmes accompanled by a Lhlck dlscharge. uyspareunla and dysurla may also be presenL. 1he classlc flndlng ls Lhe presence of a Lhlck, whlLe or yellowlsh, cheesy dlscharge, alLhough 23 of Lhe Llme a Lhln dlscharge ls noLed. 1he dlscharge ls noL malodorous. 1yplcally boLh Lhe exLernal genlLalla and vaglnal walls appear lnflamed and dlffusely eryLhemaLous. Mlcroscoplc examlnaLlon of vaglnal dlscharge dlluLed wlLh sallne or 10 kCP may reveal hyphal forms or buddlng yeasL, ln 30-70 of women wlLh yeasL lnfecLlons, Lhere are also an lncreased number of leukocyLes. Lven afLer close scruLlny of 10 Lo 20 hlgh-power flelds, Lhe senslLlvlLy of mlcroscoplc evaluaLlon ls only 30-60 for yeasL vaglnlLls, and Lhe dlagnosls musL ofLen be made on oLher cllnlcal grounds. ln such seLLlngs close follow-up ls someLlmes warranLed, as conLacL vulvovaglnlLls has slmllar feaLures.
1here are a wlde varleLy of anLlfungal agenLs avallable for Lhe LreaLmenL of vvC. MosL .3 )->#$)(* ls suscepLlble Lo Loplcal buLoconazole, cloLrlmazole, mlconazole, or Lloconazole. lf sympLoms fall Lo resolve wlLh Lhese over-Lhe-counLer anLlfungal agenLs, non-alblcans specles may be lnvolved and alLernaLlve LreaLmenLs may be necessary (e.g., Lerconazole 0.8 cream 1 appllcaLor per vaglna qhs x 3 days). noLe LhaL Lhese Loplcal medlcaLlons are oll-based and may weaken condoms and dlaphragms. Cral anLlfungal agenLs (e.g. fluconazole 130 mg C x 1 dose) may also be used, alLhough Lhese drugs have several cllnlcally lmporLanL drug lnLeracLlons and are lneffecLlve agalnsL non-alblcans specles. Cccaslonally, male parLners have balanlLls (eryLhema of Lhe glans penls wlLh assoclaLed prurlLus or lrrlLaLlon), whlch can be LreaLed wlLh Loplcal agenLs.
Case 3: Vag|n|t|s part 3 ?ou have dlagnosed your 23-year-old paLlenL wlLh Lrlchomonlasls. She reporLs LhaL she has been ln a monogamous relaLlonshlp wlLh a slngle male parLner for Lhe pasL 3 monLhs. ?ou provlde Lhe paLlenL wlLh Lhe followlng: A. A prescrlpLlon for oral fluconazole. 8. A prescrlpLlon for a 2-gram one-Llme dose of oral meLronldazole for Lhe paLlenL as well as for her parLner--along wlLh accompanylng lnsLrucLlons and recommendaLlon for LesLlng for oLher S1us. C. A prescrlpLlon for oral meLronldazole 300 mg Lhree Llmes dally for one week along wlLh a warnlng Lo avold alcohol durlng Lhls perlod of Llme. u. A prescrlpLlon for a slngle 2-gram dose of oral meLronldazole along wlLh reassurance LhaL Lrlchomonlasls ls noL an S1u. op-Up Answers: A. lncorrecL. lluconazole ls lneffecLlve agalnsL Lrlchomonas. 8. CorrecL! 1rlchomonlasls ls an S1u, and parLners of paLlenLs lnfecLed wlLh Lrlchomonas should be LreaLed and LesLed for oLher S1us. C. lncorrecL. 1rlchomonlasls can be LreaLed wlLh a slngle dose of meLronldazole. u. lncorrecL. 1rlchomonlasls ls an S1u, and parLners of paLlenLs lnfecLed wlLh Lrlchomonas should be LreaLed and LesLed for oLher S1us. Summary answer 1he correcL answer ls 8: 1rlchomonlasls ls an S1u, and parLners of paLlenLs lnfecLed wlLh Lrlchomonas should be LreaLed and LesLed for oLher S1us. aLlenL dellvered parLner Lherapy (u1) ls one opLlon, and should be accompanled by clarlflcaLlon of posslble drug allergles and lnformaLlon regardlng slde effecLs, and wrlLLen recommendaLlon LhaL Lhe paLlenL be evaluaLed for oLher S1us.
!"#$%&'&(#)*#* 1rlchomonlasls, caused by Lhe proLozoan paraslLe !"#$%&'&()* +),#()-#*, ls a commonly occurrlng sexually LransmlLLed dlsease (S1u) LhaL can also be LransmlLLed by fomlLes (LolleL seaLs, shared Lowels, hoL Lubs). ln men, Lhe ureLhra ls Lhe slLe of lnfesLaLlon, some men experlence sympLoms of ureLhrlLls whlle oLhers remaln asympLomaLlc. 1he prlmary sympLom ln women ls an abnormal vaglnal dlscharge, whlch ls ofLen malodorous, and someLlmes accompanled by vulvovaglnal soreness and dyspareunla. urlnary sympLoms are occaslonally reporLed. 1rlchomonlasls may be suspecLed on physlcal examlnaLlon by Lhe appearance of Lhe yellow-green or grey-green dlscharge havlng a pP of greaLer Lhan 4.3. AlLhough noL always presenL, Lhe classlc flndlng of bubbles ln Lhe dlscharge ls hlghly speclflc for !"#$%&'&()* lnfecLlon and ls LhoughL Lo resulL from Lhe whlpplng flagellae. uemonsLraLlon of moLlle Lrlchomonads on Lhe weL mounL ls deflnlLlve, an lnflux of leukocyLes ls also Lyplcally seen. !"#$%&'&()* lnfecLlon leads Lo overgrowLh of anaeroblc bacLerla ln Lhe vaglna, so Lhls lnfecLlon shares some feaLures wlLh bacLerlal vaglnosls: a poslLlve "whlff LesL" may accompany Lhe lnfecLlon and clue cells can be presenL on weL mounL examlnaLlon.
1wo offlce-based Lechnologles can deLecL !3 +),#()-#* on vaglnal secreLlons wlLh sllghLly beLLer senslLlvlLy Lhan Lhe weL mounL (only 60-70 senslLlve), buL are noL ln common use. Powever, laboraLory nAA1 LesLlng for 1rlchomonas ls very senslLlve and may be helpful when Lhe cllnlcal susplclon ls hlgh buL Lhe mlcroscopy negaLlve. Cne can add Lhe 1rlchomonas LesL Lo swab speclmens senL for Chlamydla/gonorrhea LesLlng, or even Lo llquld cyLology speclmens.
1r|chomonas vag|na||s. 1hls weL mounL deplcLs several Lrlchomonads surroundlng Lwo clue cells. !"#$%&'&()* ls a pear-shaped proLozoan usually sllghLly larger ln slze Lhan Lhe surroundlng leukocyLes. 1he organlsm's wrlggllng moLlon and lLs flagellae's roLaLory acLlon ald ln lLs deLecLlon. 6%&7&'#$"&,")8% $&5"74*/ &9 .:.3
1wo drugs are avallable Lo LreaL Lrlchomonlasls: meLronldazole and Llnldazole, boLh glven orally ln a slngle 2-g dose. (2) 1oplcal Lherapy ls lnadequaLe because of Lhe common lnvolvemenL of Lhe ureLhra and paraureLhral glands. 8ecause Lhls dlsease ls almosL always spread sexually, boLh parLners should be LreaLed concurrenLly and be LesLed for oLher S1u's. 1hey should also be educaLed and counseled approprlaLely, lncludlng a recommendaLlon for absLlnence or condom use unLll boLh parLners are LreaLed and wlLhouL sympLoms. aLlenLs should also be advlsed LhaL slde effecLs lnclude a LranslenL meLalllc LasLe and rlsk of dlsulflram-llke reacLlon. 1lnldazole ls more expenslve Lhan meLronldazole and requlres a longer perlod of absLlnence from alcohol (72 hours beyond Lherapy ln conLrasL Lo 24 hours), buL may have superlor efflcacy. (2) 8oLh drugs are ln Lhe nlLrolmldazole class, drug allergy would requlre desenslLlzaLlon.
1ab|e 1: Summary of I|nd|ngs |n Infect|ous Vag|n|t|s
Non|nfect|ous Vag|n|t|s 1he mosL common forms of non-lnfecLlous vaglnlLls are aLrophlc vaglnlLls and chemlcal (or "lrrlLanL" or "conLacL") vaglnlLls:
23"&4%#$ +),#(#3#* ALrophlc changes ln Lhe vulvovaglnal Llssues are Lhe resulL of esLrogen deflclency, Lhus, Lhls condlLlon ls mosL commonly seen ln perl- or posL-menopausal women and occaslonally ln women who are breasLfeedlng or recelvlng uepo-rovera conLracepLlon. Cne should suspecL aLrophlc vaglnlLls ln Lhese hosLs lf Lhey complaln of leukorrhea, prurlLls, burnlng, Lenderness or dyspareunla. Cn mlcroscopy, Lhe usual large, flaL eplLhellal cells are replaced by smaller, more rounded cells wlLh less cyLoplasm. An lncreased number of leukocyLes may also be presenL.
1he LreaLmenL of aLrophlc vaglnlLls ls esLrogen vaglnal cream (6"4')"#( or B*7")$4), one appllcaLor lnLravaglnally nlghLly for Lwo weeks, Lhen 1 Lo 3 Llmes per week as malnLenance dose. AlLernaLlvely, an lnLravaglnal esLrogen LableL (C),#94') or low-dose Lrl-monLhly rlng (B*7"#(,) can be prescrlbed. CerLaln lubrlcaLlng vaglnal gels (=48-4(*, D$#E4-) used Lhree Llmes a week can lmprove boLh slgns and sympLoms of aLrophlc vaglnlLls and may be sufflclenL LreaLmenL ln mllder cases.
5%6'#$)- +),#(#3#* aLlenLs wlLh chemlcal vaglnlLls complaln of burnlng, lLchlng and occaslonally dlscharge. 1hese paLlenLs should be quesLloned abouL any use of new soaps, perfumes, laundry deLergenLs, douches, spermlclde, condoms, Loplcal medlcaLlons, or any oLher poLenLlal local lrrlLanLs. Cn exam, Lyplcally Lhe vulva ls lnvolved as well as Lhe vaglna, and Lhe lnflammaLory changes can resemble LhaL seen wlLh vvC. 1reaLmenL ls removal of Lhe offendlng agenL, lncludlng Lemporary cessaLlon of sexual acLlvlLy lf lL ls parL of Lhe eLlology. Cool baLhs and compresses can provlde sympLomaLlc rellef, as can vegeLable olls lf skln ls cracked and flssured. ln severe cases, 1 hydrocorLlsone olnLmenL (noL cream) and anLlhlsLamlnes aL bedLlme may be helpful.
CASL 4: ract|ce case 1 ?our nexL paLlenL ls a 49-year-old woman wlLh a 1-monLh hlsLory of vaglnal burnlng and dyspareunla. She recenLly swlLched Lo a perfumed soap. elvlc examlnaLlon reveals a normal-appearlng vulva buL lnflamed vaglnal mucosa wlLh loss of Lhe normal folds and scanL whlLe homogeneous dlscharge. Mlcroscopy reveals no yeasL, Lrlchomonas or "clue cells", however, Lhe eplLhellal cells appear ovold and small, lacklng ln cyLoplasm. 1reaLmenLs LhaL you should offer her lnclude: A. Cool compresses and swlLchlng back Lo her usual soap. 8. SysLemlc posLmenopausal hormone Lherapy. C. Acldlfylng vaglnal gel or lnLravaglnal esLrogen LreaLmenL. u. lnLermlLLenL douchlng. op-up Answers: A. lncorrecL. 1he normal appearance of Lhe vulva does noL supporL Lhe dlagnosls of chemlcal vaglnlLls from soap. 8. lncorrecL. Whlle Lhe small eplLhellal cells supporL Lhe dlagnosls of aLrophlc vaglnlLls, opLlmal LreaLmenL conslsLs of lnLravaglnal Lheraples. SysLemlc posLmenopausal hormone Lherapy ls less effecLlve Lhan lnLravaglnal esLrogen Lherapy.ln LreaLlng aLrophlc vaglnlLls. Moreover, sysLemlc hormone Lherapy ls prescrlbed only afLer a Lhorough assessmenL of Lhe poLenLlal rlsks and beneflLs for an lndlvldual. C. CorrecL! lnLravaglnal Lheraples are Lhe opLlmal LreaLmenL for aLrophlc vaglnlLls. Acldlfylng gels are someLlmes sufflclenL LreaLmenL, and are assoclaLed wlLh reLurn of normal vaglnal flora on ob[ecLlve evaluaLlon. vaglnal esLrogen ls hlghly effecLlve and noL assoclaLed wlLh any harmful slde effecLs. u. lncorrecL. uouchlng can be harmful and ls generally dlscouraged.
Summary answer 1he correcL answer ls C: Acldlfylng vaglnal gel or lnLravaglnal esLrogen LreaLmenL ls lndlcaLed. 1hls paLlenL has flndlngs suggesLlve of aLrophlc vaglnlLls, wlLh loss of vaglnal folds. 1he mlcroscoplc evaluaLlon ls also conslsLenL wlLh aLrophlc vaglnlLls. 1reaLmenL may lnclude ad[usLlng lnLravaglnal pP wlLh acldlfylng gels (Lo resLore vaglnal flora) or vaglnal esLrogen. lease proceed Lo nexL case.
CASL S: Cerv|ca| cancer screen|ng. ?ou perform a rouLlne llquld-based cervlcal cyLology (ap smear) for a 28-year-old woman. 1wo weeks laLer Lhe paLhology reporL shows "aLyplcal squamous cells of undeLermlned slgnlflcance" (ASCuS). Whlch CnL of Lhe followlng managemenL opLlons ls 8LS1 per Lhe 2012 Culdellnes? A. 8epeaL Lhe ap smear ln 2 monLhs. 8. 8efer for cone blopsy C. 8equesL hlgh rlsk Puman apllloma vlrus (Pv) LesLlng on Lhe sample, lf poslLlve, repeaL ap smear ln 6 monLhs. u. 8equesL hlgh rlsk Pv LesLlng on Lhe sample, lf poslLlve, refer for colposcopy. L. 8equesL hlgh rlsk Pv LesLlng on Lhe sample, lf negaLlve, repeaL Lhe ap smear ln 12 monLhs. op-up answers: A. lncorrecL. 1wo monLhs ls Loo shorL an lnLerval Lo allow for regresslon of abnormal cyLologlc flndlngs, Lwelve monLhs are Lyplcally recommended beLween follow-up LesLs. Powever, per Lhe 2012 Culdellnes, Lhe approprlaLe nexL sLep would be reflexlve Pv LesLlng. 8. lncorrecL. er Lhe 2012 Culdellnes, Lrlage of Lhe ASCuS resulL should be performed by reflexlve Pv LesLlng. Colposcopy ls recommended lf Pv LesLlng ls poslLlve, buL one should noL presume LhaL cone blopsy wlll be necessary. C. lncorrecL. Whlle lL ls correcL Lo requesL Pv LesLlng (only ordered "reflexlvely" followlng ASCuS for women under age 30), a poslLlve LesL resulL should prompL referral for colposcopy. u. CorrecL. Colposcoplc evaluaLlon ls an approprlaLe managemenL for paLlenLs wlLh ASCuS and poslLlve Pv LesLlng. L. lncorrecL. Whlle lL ls approprlaLe Lo requesL hlgh rlsk Pv unA LesLlng, a negaLlve Pv LesL resulL warranLs LhaL Lhe ASCuS be managed wlLh re-screenlng ln 3 years. Summary Answer 1he correcL answer ls D: kequest h|gh r|sk numan ap|||oma V|rus (nV) test|ng on the samp|e, |f pos|t|ve, refer for co|poscopy.
Lp|dem|o|ogy of Cerv|ca| Cancer and Imp||cat|ons for Screen|ng Cervlcal cancer screenlng ls probably Lhe greaLesL success sLory of any cancer-screenlng program (see also module on Cancer Screenlng). uesplLe Lhls progress, each year approxlmaLely 12,000 women ln Lhe u.S. wlll be dlagnosed wlLh cervlcal cancer, of whom 4,000 wlll dle of Lhe dlsease (4) Cervlcal cancer ls unusual ln LhaL, unllke mosL oLher cancers, lL ls noL a dlsease of agelng. Cases have been documenLed ln women as young as Lhe early 20s and cervlcal cancer lncldence peaks beLween ages 33-44. neverLheless, cervlcal cancer ls also seen ln mlddle-aged and elderly paLlenLs, especlally when Lhere has been a gap ln screenlng. knowledge of Lhe naLural hlsLory of Pv lnfecLlon and Lyplcal course of cervlcal dysplasla ls helpful ln undersLandlng screenlng sLraLegles.
Cerv|ca| Cancer and numan ap|||omav|rus (nV) Cervlcal cancer ls almosL always caused by hlgh-rlsk subLypes of human paplllomavlrus (Pv). Pv ls Lhe mosL common S1u ln Lhe u.S., where an esLlmaLed 73 of people are lnfecLed aL some polnL ln Lhelr llfe, mosL commonly durlng adolescence or Lhelr early 20s. ln mosL cases, Lhe Pv lnfecLlon ls LranslenL and ls cleared by an approprlaLe lmmune response, usually wlLhln 2 years. (3)
lf an lndlvldual's lmmune sysLem falls Lo clear Lhe lnfecLlon, Lwo ouLcomes are posslble: subcllnlcal lnfecLlon, ln whlch molecular LesLlng ldenLlfles Lhe presence of Pv unA, yeL Lhere ls no cyLologlc or hlsLologlc evldence of Lhe lnfecLlon, or cllnlcally apparenL lnfecLlon, where cyLopaLhology or hlsLopaLhology ls evldenL. AL leasL Lwo decades of perslsLenL hlgh-rlsk Pv lnfecLlon are necessary for progresslon Lo mallgnancy (6, 7, 8). Cne cannoL predlcL ln whom Pv lnfecLlon wlll perslsL, buL ln general, lmmunocompromlsed paLlenLs (parLlcularly Lhose wlLh AluS or on lmmunosuppresslve Lherapy for LransplanL) and clgareLLe smokers are aL lncreased rlsk.
1wo cllnlcal recommendaLlons regardlng Lhe use of Pv LesLlng sLem from Lhe above: llrsL, due Lo Lhe hlgh prevalence yeL hlgh llkellhood of sponLaneous resoluLlon of Pv lnfecLlon ln Lhe younger age group, guldellnes expllclLly sLaLe LhaL for women younger Lhan age 30, Pv LesLlng should be llmlLed Lo reflex LesLlng followlng ASCuS, and per Lhe updaLes Lo Lhe 2012 Culdellnes (hereafLer referred Lo as Lhe updaLed 2012 Culdellnes"), and preferably avolded alLogeLher unLll age 23 (9). Second, when followlng up on abnormal resulLs, Pv LesLlng should noL be repeaLed ln Lhe same paLlenL any sooner Lhan 12 monLhs, Lo allow adequaLe Llme for sponLaneous clearance.
Screen|ng kecommendat|ons: When to start, frequency, and when to stop Cervlcal cancer screenlng beglns aL age 21, regardless of Lhe age of onseL of sexual experlence (9), Lhe raLlonale belng LhaL cervlcal cancer ls exceedlngly rare ln women age 21 and younger. Moreover, [usL as Pv lnfecLlon usually sponLaneously resolves, Lhe AL1S sLudy (10) demonsLraLed LhaL mosL cyLologlc abnormallLles sponLaneously regress, and walLlng unLll age 21 avolds unnecessary lnLervenLlons (e.g. cone blopsy) LhaL could poLenLlally affecL ferLlllLy or cause obsLeLrlc compllcaLlons. ln addlLlon, overly aggresslve screenlng may cause undue expense and psychologlcal sLress.
new guldellnes from Lhe ACS/ASCC/ASC (8) released ln May 2012 and endorsed by Lhe uSS1l (11), (hereafLer referred Lo as 2012 Culdellnes"), lengLhened Lhe screenlng lnLervals from prlor recommendaLlons. 1he 2012 Culdellnes recommend LhaL women age 21-29 be screened wlLh cyLology every 3 years (raLher Lhan every 2). lor women age 30-63, Lhe preferred screenlng meLhod ls Lo coLesL" (dual LesL") wlLh boLh cyLology and hlgh-rlsk Pv LesLlng aL an lnLerval of every 3 years. 1he alLernaLe screenlng meLhod for Lhls older group (age > 30) ls Lo screen uslng cyLology alone (buL wlLh reflex Pv LesLlng for ASCuS), aL a more frequenL lnLerval of every 3 years (See 1able 2).
1hese proLracLed lnLervals recognlze Lhe hlgh frequency of sponLaneous regresslon of dysplasla, Lhe ease of deLecLlng and LreaLlng premallgnanL sLages, and Lhe slow progresslon Lo cervlcal cancer. ln addlLlon, Lhe lmpllcaLlons of Pv LesLlng flgured promlnenLly ln Lhe 2012 guldellnes. 1he Pv assay ls a hlghly senslLlve LesL for Lhe presence of lnfecLlon, pre-cancerous leslons and cervlcal cancer (>90) LhaL carrles slgnlflcanL long Lerm prognosLlc value, such LhaL a negaLlve Pv resulL predlcLs wlLh confldence an absence of cervlcal cancer (or slgnlflcanL precancer) for Lhe subsequenL 10-13 years (8), Lhereby [usLlfylng Lhe 3-year lnLerval when uslng coLesLlng.
1here conLlnue Lo be excepLlons Lo Lhe recommended screenlng lnLervals, lncludlng women wlLh Plv or oLher forms of lmmunosuppresslon (e.g., followlng solld organ LransplanL), or prlor LreaLmenL for Cln 2 or 3 or cervlcal cancer. Women wlLh Plv should undergo cervlcal cyLology Lwlce ln Lhe year followlng dlagnosls, Lhen annually LhereafLer (2). Women wlLh oLher forms of lmmunosuppresslon are generally screened annually. 1here are no formal guldellnes for paLlenLs wlLh mllder forms of lmmunosuppresslon (such as Lhose on lmmumodulaLors for rheumaLologlc dlsease, eLc.), buL one could conslder screenlng Lhem more frequenLly Lhan sLandard guldellnes recommend. Women LreaLed ln Lhe pasL for Cln 2 or 3 or cervlcal cancer remaln aL elevaLed rlsk for perslsLenL or recurrenL dlsease for Lhe nexL 20 years, and followlng a perlod of lnLense survelllance for approxlmaLely Lwo years, should subsequenLly conLlnue Lo undergo sLandard screenlng unLll 20 years afLer dlagnosls, even lf Lhey have undergone hysLerecLomy, and even lf Lhls 20-year Llme perlod exLends beyond age 63-- Lhe usual age Lo exlL screenlng (8).
ln addlLlon, noLe LhaL ln general, paLlenLs whose recenL ap smears are abnormal or who have undergone colposcopy are consldered "under survelllance" for some Llme. Such women undergo repeaL screenlng annually for Lwo years. lf boLh follow-up screenlngs are negaLlve Lhey are nexL screened ln 3 years. SubsequenL follow-up ls relaxed Lo rouLlne screenlng" for some buL noL all orlglnal abnormallLles (9) (see also algorlLhms and LexL aL asccp.org). ManagemenL of abnormal resulLs ls revlewed laLer ln Lhls module.
1he ASCC convened ln SepLember 2012 and made several changes Lo Lhe orlglnal 2012 Culdellnes, produclng Lhe updaLed 2012 Culdellnes" as menLloned above. 8evlslons ln Lhe updaLed 2012 Culdellnes lnclude subdlvldlng women under age 30 lnLo Lwo groups for dlsLlncL screenlng and managemenL. lor Lhe 23 Lo 29 year old women, screenlng remalns Lhe same: cyLology alone, wlLh reflex Pv LesLlng for ASCuS. Powever, for women age 21 Lo 23 Lhe new preferred meLhod of screenlng ls Lo use cyLology alone, avoldlng use of Pv alLogeLher. 1he prevlous approach of uslng reflex Pv LesLlng for ASCuS ln Lhls youngesL age group ls remalns an accepLable" alLernaLlve, buL Lhe preferred managemenL of ASCuS (and even LSlL) ln Lhe 21-24 year old ls Lo repeaL Lhe cyLology ln 12 monLhs. 8ouLlne gynecologlc screenlng guldellnes by age are shown ln 1able 2.
Annually for sexually acLlve women, usually performed on urlne speclmen***
?es, annually
Age 21-24
Lvery 3 years
no (referred),
(AlLernaLlve): Pv LesLlng as reflex LesLlng followlng ASC-uS accepLable
Annually for sexually acLlve women < age 26, and for older women aL rlsk
?es, annually
Age 23-29
Lvery 3 years
?es, buL only as reflex LesLlng followlng ASCuS
Annually for sexually acLlve women < age 26, and for older women aL rlsk
?es, annually
Age 30-64
Lvery 3 years uslng co-LesLlng (preferred) C8 Lvery 3 years uslng cyLology alone wlLh reflex Pv LesLlng (alLernaLlve) unLll age 63 1
?es, as parL of coLesLlng (dual LesLlng) (referred)
C8
as reflex LesLlng only (AccepLable)
Annually for women consldered aL rlsk only
Assess needs perlodlcally * 1he proLracLed screenlng lnLervals do noL apply Lo women wlLh abnormal cyLology or Pv resulLs wlLhln Lhe pasL 2 years or wlLh recenL dlagnosls of Cln 2/3 or cervlcal cancer, or wlLh Plv or oLher form of lmmunosuppresslon.
**SlmulLaneous screenlng for n. gonorrhea ls also recommended for Lhose consldered aL rlsk.
***When a pelvlc exam ls noL needed, Chlamydla/gonorrhea LesLlng can be performed wlLhouL a speculum exam, uslng elLher a vaglnal swab or urlne speclmen.
1 lor excepLlons, see followlng paragraphs.
SomeLlmes a 21 year-old woman glves a rellable hlsLory of never havlng had sexual lnLercourse. Powever, Lhe cllnlclan should be aware of Lhe posslblllLy of a hlsLory of unacknowledged non-consensual sexual conLacL, a relucLance by some paLlenLs Lo reveal Lhelr Lrue sexual experlence, and also of Lhe evldence LhaL nonpeneLraLlve skln-Lo-skln sexual conLacL can LransmlL Pv. (12) Also, slnce Pv lnfecLlon can be spread from one woman Lo anoLher durlng sexual conLacL, and cervlcal dysplasla and cancer have been reporLed ln women who reporLed excluslvely homosexual acLlvlLy durlng Lhelr llfeLlme (13, 14), lesblans should undergo cervlcal cancer screenlng and be offered Pv vacclnaLlon per sLandard guldellnes. LasLly, prlor vacclnaLlon wlLh Pv vacclne also does noL alLer screenlng recommendaLlons, slnce noL all oncogenlc Pv genoLypes are lncluded ln Lhe vacclne, and due Lo lack of long-Lerm daLa (9).
lL should be acknowledged LhaL whlle sexually acLlve women younger Lhan age 21 do noL requlre cervlcal cancer screenlng, oLher prevenLlve care ls lndlcaLed. Annual Chlamydla screenlng ls cosL-effecLlve and recommended by Lhe CuC for all sexually acLlve women unLll age 26 (2), and LhereafLer for Lhose aL rlsk. Counsellng and screenlng for oLher S1us ls also usually warranLed, as ls paLlenL educaLlon and provlslon and monlLorlng of conLracepLlon. Clven Lhe avallablllLy of Chlamydla and gonorrhea LesLlng uslng self- collecLed vaglnal swab (preferred) or urlne speclmens, Lhe ACCC Culdellnes remark LhaL ln Lhe asympLomaLlc paLlenL such screenlng can be provlded wlLhouL Lhe use of a speculum (10).
1he opLlmal age for dlsconLlnuaLlon of ap smears ls unknown, buL organlzaLlons have recommended LhaL older women, even Lhose wlLh conslsLenLly negaLlve ap smear resulLs and Lhose who have been sexually lnacLlve for decades, conLlnue regular screenlng unLll age 63. 1hls ls parLly due Lo Lhe poor senslLlvlLy of Lhe ap smear (approxlmaLely 30) for deLecLlng dlsease, whlch ls compensaLed for Lhrough serlal LesLlng. Also, half of Lhe deaLhs from cervlcal cancer ln Lhe u.S. occur ln women over age 63, Lhls ls almosL enLlrely conflned Lo women who were never (or were mlnlmally) screened. 1he 2012 Culdellnes sLaLe LhaL screenlng may be dlsconLlnued aL age 63, as long as Lhree negaLlve cyLology resulLs or Lwo negaLlve coLesLs have been documenLed ln Lhe pasL decade - wlLh Lhe mosL recenL resulL belng wlLhln Lhe pasL 3 years, and no hlsLory of cervlcal precancer wlLhln Lhe pasL 20 years. (9) 1he updaLed 2012 Culdellnes clarlfy LhaL ASCuS/negaLlve Pv represenLs an abnormal resulL, and as wlLh oLher abnormal resulLs should prompL conLlnued screenlng unLll a decade of negaLlve resulLs are obLalned, even when Lhls enLalls survelllance pasL age 63 (9)
AlLhough prlor guldellnes recommended resumpLlon of screenlng lf a woman older Lhan 63 acqulred a new sexual parLner, Lhe 2012 Culdellnes dlffer. 1hey polnL ouL LhaL even lf new Pv lnfecLlon were acqulred by an older, prevlously well-screened woman, Lhere would be lnsufflclenL Llme for progresslon Lo lnvaslve cancer over Lhe paLlenL's remalnlng llfeLlme, and such screenlng would prevenL very few cancers and even fewer deaLhs (7). 1hus, once cervlcal cancer screenlng ls exlLed, lL should noL be resumed.
lL should be noLed LhaL ln Lhe u.S. Lhere are a slgnlflcanL number of underscreened women, lncludlng populaLlons of lmmlgranLs from counLrles where screenlng ls noL performed and women who may noL have had healLh lnsurance unLll age 63. Ior such unscreened and underscreened women the "upper age ||m|t" of screen|ng does not app|y. A recenL modellng sLudy deLermlned LhaL for such women, screenlng every 2-3 years from approxlmaLely age 63 Lo 70 would be Lhe mosL efflclenL sLraLegy (4), buL no formal guldellnes exlsL.
Lven greaLer numbers of unscreened/underscreened women can be ldenLlfled Lhrough Lhelr lower socloeconomlc and mlnorlLy raclal sLaLus. 8ecenL Lechnologlc advances ln screenlng wlll have llLLle lmpacL on cervlcal cancer morLallLy lf Lhey do noL reach Lhese populaLlons. 8eLLer efforL by prlmary care physlclans ls needed Lo ldenLlfy and screen Lhese underscreened paLlenLs.
Women who have undergone hysLerecLomy for benlgn lndlcaLlons and lack a cervlcal remnanL do noL requlre furLher ap smears (even lf Lhey do noL recall havlng undergone screenlng), unless Lhere ls a hlsLory of prlor hlgh-grade Cln or cervlcal cancer wlLhln Lhe pasL 20 years (8, 9).
lL should be noLed LhaL a careful hlsLory and physlcal examlnaLlon also conLrlbuLe Lo cervlcal cancer screenlng. 8eporL of posLcolLal or oLher unexplalned vaglnal bleedlng, abnormal dlscharge, pelvlc paln or a concernlng vlslble leslon on Lhe cervlx (ulcer, mass, polyp or leukoplakla) should prompL lndlvlduallzed evaluaLlon (9).
CASL 6: ract|ce case 2 ?ou have 4 female paLlenLs on your mornlng cllnlc schedule. Whlch one ls due for cervlcal cancer screenlng? (Choose Lhe 8LS1 answer): A. A 33 y.o. Plv poslLlve woman who has always had normal ap smears, lncludlng her mosL recenL one 1 year ago. 8. A 21 y.o. woman who presenLs for her annual vlslL. C. A 29 y.o. woman whose lasL ap smear was 3 years ago, aL whlch Llme she compleLed Lhe Pv vacclnaLlon serles. u. A 40 y.o. lesblan who has never had a ap smear because she felL lL was unnecessary slnce she has never engaged ln heLerosexual lnLercourse. L. All of Lhe above paLlenLs are due for screenlng. op-Up Answers: A. lncorrecL. ?es, Lhls Plv poslLlve paLlenL ls due for screenlng, as annual screenlng ls recommended for her as well as paLlenLs wlLh oLher forms of lmmunocompromlse. Powever, oLher responses Lo Lhls quesLlon are also correcL. 8. lncorrecL. ?es, Lhls paLlenL ls due for her flrsL cervlcal cyLology slnce she ls now 21 years old. Powever, oLher responses Lo Lhls quesLlon are also correcL. C. lncorrecL. ?es, Lhls woman ls due for screenlng, slnce Pv vacclnaLlon sLaLus does noL alLer screenlng recommendaLlons. Powever, oLher responses Lo Lhls quesLlon are also correcL. u. lncorrrecL. ?es, lesblans are aL rlsk for cervlcal cancer and should undergo screenlng and Pv vacclnaLlon per sLandard guldellnes. Powever oLher responses Lo Lhls quesLlon are also correcL. L. CorrecL! All of Lhe above paLlenLs are due for screenlng. Summary answer: 1he correcL answer ls L. All of Lhe above paLlenLs are due for screenlng. lease proceed Lo nexL case.
CASL 7: ract|ce case 3 Whlch of your paLlenLs below can S1C cervlcal cancer screenlng? A. An 80 y.o. woman who recenLly emlgraLed from a developlng counLry. 8. A 67 y.o. woman whose ap smear lasL year was normal, buL whose coLesLlng 3 years ago showed ASCuS/negaLlve Pv. C. A 78 y.o. woman who reporLs hysLerecLomy for cervlcal precancer" 18 years ago. u. A 33 y.o. woman wlLh meLasLaLlc non-small cell lung cancer whose lasL ap smear was 6 years ago. L. A 66 y.o. woman who has healLh lnsurance (Medlcare) for Lhe flrsL Llme, and no recollecLlon of havlng had ap smears. op-up Answers: A. lncorrecL. Aslde from Lhe unlLed SLaLes, Canada and many counLrles ln Lurope, Lhere are few esLabllshed cancer screenlng programs, maklng lmmlgranLs a LargeL group for lnLenslve efforLs Loward ldenLlflcaLlon and screenlng. 8. lncorrecL. Screenlng ls sLopped aL age 63 only lf Lhere have been 2 or more documenLed normal resulLs and no abnormal ap smear resulLs ln Lhe pasL decade. AlLhough a resulL of ASCuS/negaLlve Pv was prevlously managed as a normal resulL, Lhls ls no longer Lhe case. C. lncorrecL. Cervlcal cancer screenlng should conLlnue for 20 years beyond a dlagnosls of cervlcal cancer or pre-cancer", even lf hysLerecLomy ls performed for Lhls reason or for benlgn cause. u. CorrecL! 1he shorLened pro[ecLed llfe span for Lhls woman wlLh meLasLaLlc cancer does noL supporL screenlng for cervlcal cancer. L. lncorrecL. ln Lhe u.S. Lhere are many women older Lhan age 63 who have never been screened or have been underscreened. Such women represenL a LargeL group for ldenLlflcaLlon and screenlng by prlmary care physlclans. Summary answer: u. 1he shorLened pro[ecLed llfe span of Lhe woman wlLh meLasLaLlc cancer does noL supporL screenlng for cervlcal cancer. lease proceed Lo Lhe nexL case.
CASL 8: Management of ap smear resu|ts A 33-year-old woman presenLs for rouLlne check-up. ?ou perform a gynecologlc exam and a ap smear (llquld cyLology). 1wo weeks laLer, her cyLology reporL sLaLes "ALyplcal squamous cells of undeLermlned slgnlflcance (ASCuS). Plgh rlsk Pv LesLlng resulLs pendlng". Cnce Lhe Pv coLesL resulL ls avallable, you would manage Lhe paLlenL as follows: (Choose Lhe 8LS1 answer). A. lf Lhe ASCuS ls assoclaLed wlLh a negaLlve Pv coLesL resulL you would screen Lhe paLlenL nexL ln 3 years. 8. lf Lhe ASCuS ls assoclaLed wlLh a negaLlve Pv coLesL resulL you would re-screen ln 3 years. C. lf Lhe ASCuS ls assoclaLed wlLh a poslLlve Pv coLesL resulL you would refer Lhe paLlenL Lo colposcopy. u. 8oLh A and C are Lrue. op up Answers A. lncorrecL. ?es, one should manage ASCuS assoclaLed wlLh negaLlve Pv LesLlng by re-screenlng ln 3 years however C ls also correcL. 8. lncorrecL. er Lhe updaLed 2012 Culdellnes ASCuS assoclaLed wlLh a negaLlve Pv resulL ls now managed wlLh re-screenlng ln 3 years. C. lncorrecL. ?es, when ASCuS ls assoclaLed wlLh a poslLlve Pv resulL ln a paLlenL age > 23 years she should be referred Lo colposcopy, however A ls also correcL. u. CorrecL! ASCuS ln Lhe presence of a negaLlve Pv LesL ls managed wlLh re-screenlng ln 3 years, buL when assoclaLed wlLh a poslLlve Pv LesL should prompL referral for colposcopy.
Summary answer 1he correcL answer ls u: er Lhe updaLed 2012 Culdellnes, one should manage ASCuS assoclaLed wlLh negaLlve Pv LesLlng wlLh re-screenlng ln 3 years (Lrue for all ages) (9), buL manage ASCuS assoclaLed wlLh a poslLlve Pv resulL by referrlng Lhe paLlenL Lo colposcopy (excepL for very young women age 21-24).
Screen|ng Moda||t|es: Appropr|ate Use of Cerv|ca| Cyto|ogy and nV 1est|ng Cervlcal cyLology (Lhe "ap smear") has been Lhe malnsLay of cervlcal cancer screenlng ln Lhe developed world, and Lhere ls an abundance of evldence Lo supporL lLs effecLlveness, desplLe Lhe poor senslLlvlLy of a slngle ap smear (approxlmaLely 30). 1hls poor senslLlvlLy ls compensaLed for Lhrough serlal LesLlng, as well as sponLaneous resoluLlon of leslons. Cver Lhe pasL decade, glass slldes have been lncreaslngly replaced by llquld cyLology, whose senslLlvlLy raLher surprlslngly has noL been shown Lo be slgnlflcanLly superlor (13). A ma[or advanLage of llquld cyLology, however, ls LhaL Lhe speclmen allows for "reflex" Pv LesLlng when Lhe cyLology resulL ls ASCuS, obvlaLlng Lhe need for a paLlenL reLurn vlslL. Slnce Lhe 2012 Culdellnes rely more on Pv LesLlng Lhan prevlous recommendaLlons, glass sllde cyLology has essenLlally been rendered very lnconvenlenL lf noL obsoleLe.
1he hlgh-rlsk Pv unA assay (hereafLer referred Lo as Pv LesLlng") LesLs for 13 or 14 of Lhe known oncogenlc Pv Lypes and can be conducLed uslng a llquld cyLology speclmen (or a swab collecLlon placed ln Lhe proprleLary LransporL medlum--alLhough Lhls ls currenLly noL ln common use). lL should be noLed LhaL noncarclnogenlc low rlsk" Pv LesLlng has no role ln cancer screenlng.
8ecause of Lhe hlgh Pv prevalence yeL poor prognosLlc value of Pv poslLlvlLy ln younger women, coLesLlng" wlLh boLh cyLology and Pv ls noL performed on women younger Lhan 30. 8aLher, Pv LesLlng ls only used ln reflex LesLlng" followlng a dlagnosls of ASCuS (16). 1he orlglnal 2012 Culdellnes promoLed use of reflex Pv LesLlng for ASCuS ln all women under age 30, however recall LhaL Lhe updaLed 2012 Culdellnes recommend lL only for women age 23-29, and endorse cyLology alone as Lhe preferred meLhod of screenlng for women age 21-24 (9).
8ecall LhaL Lhe sLandard hlgh-rlsk Pv assay deLecLs any of Lhe 13-14 oncogenlc subLypes. 1here are also avallable more reflned Pv assays LhaL can LesL speclflcally for Pv genoLype 16 or Lypes 16/18 LogeLher. 1hese are someLlmes used ln Lhe Lrlage of poslLlve Pv resulLs when cyLology ls negaLlve. Pv 16 ls Lhe mosL oncogenlc genoLype, felL Lo be responslble for 33-60 of all cases of cervlcal cancer, whlle Pv 18 ls Lhe second mosL oncogenlc genoLype, responslble for 10-13 of cases (8). ueLecLlon of Lhese speclflc genoLypes lncreases concern for Lhe presence of precancerous leslons, and prompLs referral for colposcopy, even ln Lhe seLLlng of negaLlve cyLology (See 1able 4).
SLudles lndlcaLe LhaL overall Pv LesLlng ls a much more senslLlve screenlng LesL for cervlcal dysplasla and cancer Lhan cyLology, such LhaL 90 of precancerous cervlcal leslons LesL poslLlve for Lhe Pv assay. 8ecenL large Lrlals ln Canada (17) and lndla (18) comparlng Pv LesLlng alone Lo cyLology alone demonsLraLed Lhe superlor senslLlvlLy yeL mlnlmally reduced speclflclLy of Pv LesLlng. 1he laLLer Lrlal demonsLraLed LhaL screenlng wlLh Pv LesLlng resulLed ln decreased advanced cervlcal cancer lncldence and relaLed morLallLy compared Lo screenlng wlLh cyLology. ln Aprll 2014, due Lo Lhe demonsLraLed superlorlLy of Lhe Pv LesL, an luA advlsory panel voLed unanlmously Lo recommend for luA approval Pv LesLlng as Lhe lnlLlal, sole screenlng LesL for cervlcal cancer for women age 23 and older. luA approval ls anLlclpaLed endorslng lL as one screenlng opLlon.
keport|ng of Cyto|og|c D|agnos|s and Management of Abnorma| Cyto|ogy 1he classlflcaLlon of ap smear flndlngs has been sLandardlzed ln whaL ls known as Lhe 8eLhesda SysLem. 1hls sysLem classlfles eplLhellal cell abnormallLles as:
1he mosL common lnLerpreLaLlon of an abnormal ap smear ls ASCuS. ASCuS represenLs a morphologlc uncerLalnLy, wlLh poor lnLer- and lnLraobserver reproduclblllLy, and Lherefore, aL leasL for women age 23 and older, ls lnLerpreLed ln llghL of Pv resulLs, elLher ln Lhe form of coLesLlng or reflex LesLlng. ASCuS wlLh a poslLlve Pv LesL ls referred Lo colposcopy (see 1able 3). ASCuS wlLh a negaLlve Pv resulL ls now managed wlLh re-screenlng ln 3 years (whlch, for women under age 30, admlLLedly amounLs Lo rouLlne follow-up"). Women age 23 or older wlLh )(7 Lype of cyLologlc abnormallLy or perslsLenL Pv poslLlvlLy on Lhe 3-year follow-up co-LesLlng are referred Lo colposcopy.
1he flndlng of ASCuS ln women age 21-24 ls now managed dlfferenLly, as cyLologlc abnormallLles ln Lhese hosLs frequenLly resolve glven adequaLe Llme. lor Lhese young women an ASCuS resulL should no longer Lrlgger reflex Pv LesLlng buL raLher be managed wlLh repeaL cyLology aL 12 and 24 monLhs. 1hese paLlenLs are only referred Lo colposcopy lf Lhe 12-monLh follow-up cyLology ls ASC-P, ACC or PSlL, or lf Lhe 24- monLh cyLology ls ASCuS or worse (l.e., any abnormallLy) (9). LSlL ln Lhls very young age group ls managed slmllarly (see nexL secLlon).
1ab|e 3. Management of ASCUS by Age and Screen|ng Method Age Group Screen|ng Moda||ty Management of ASCUS
Age 21-24
Screen wlLh cyLology alone (preferred)
C8
CyLology wlLh reflex Pv LesLlng for ASCuS (accepLable)
ASCuS: 8epeaL cyLology ln 12 and 24 monLhs. 8efer Lo colposcopy for ASC-P, ACC or PSlL aL 12 monLhs, or any cyLologlc abnormallLy aL 24 monLhs.
(AlLernaLlve): lf reflex LesLed for Pv and poslLlve, follow above sequence. lf Pv negaLlve resume rouLlne screenlng
Age 23-29
Screen wlLh cyLology alone (wlLh reflex Pv LesLlng) every 3 years
ASCuS wlLh reflex Pv poslLlve: 8efer Lo colposcopy
When coLesLlng ls uLlllzed for women age 30 and older, occaslonally Lhe cyLology ls negaLlve buL Lhe Pv ls poslLlve. Such paLlenLs are managed wlLh repeaL coLesLlng ln 12 monLhs. lf elLher LesL ls poslLlve aL Lhe 12- monLh follow-up, Lhe paLlenL ls referred Lo colposcopy (See 1able 4). AlLernaLlvely, one can opL for lmmedlaLe LesLlng for Pv genoLype 16 (or 16/18), as menLloned ln Lhe prevlous secLlon. lf poslLlve, Lhe paLlenL should be referred for colposcopy, and lf negaLlve, Lhe paLlenL should undergo repeaL coLesLlng ln 12 monLhs. negaLlve cyLology wlLh lnsufflclenL endocervlcal componenL wlLh a poslLlve Pv can be managed ln Lhe same way. 1he updaLed 2012 Culdellnes for managemenL of ASCuS and for Pv poslLlve/cyLology negaLlve coLesL resulLs are lncluded ln 1able 4 below.
1ab|e 4. Management of D|scordant nV os|t|ve ] Cyto|ogy Negat|ve kesu|ts Age Group Screen|ng Moda||ty Management of D|scordant nV os|t|ve ] Cyto|ogy Negat|ve kesu|ts Age 30-63 uual 1esLlng Pv poslLlve buL cyLology negaLlve: 1wo opLlons:
1) lollow-up ln 12 monLhs wlLh coLesLlng:
a) lf Pv poslLlve/(or any + cyLology) on repeaL Lhen refer Lo colposcopy. b) lf Pv negaLlve/cyLology negaLlve on repeaL, Lhen repeaL coLesLlng ln 3 years. C8
2) lmmedlaLe LesLlng for Pv 16 or Pv 16/18 genoLypes:
a) lf 16 or 16/18 poslLlve, refer Lo colposcopy b) lf 16 or 16/18 negaLlve, follow-up ln 12 monLhs wlLh coLesLlng.
Cne should Lake speclal care noL Lo confuse or equaLe ACC wlLh ASCuS. ALyplcal glandular cells (ACC) noL uncommonly lndlcaLe elLher an endomeLrlal or endocervlcal process as serlous as cancer. Women wlLh ACC are managed aggresslvely and musL be referred for colposcopy and endocervlcal cureLLage, and ln cerLaln clrcumsLances endomeLrlal blopsy as well. Lven lf no abnormallLles are found on lnspecLlon or upon blopsy, Lhe paLlenL needs very close follow-up for Lhe nexL Lwo years. noLe LhaL ASC-P ls assoclaLed wlLh an lncldence of Cln 3+ approachlng LhaL of PSlL, and Lhus ls managed as PSlL.
lor mosL women, cervlcal paLhology LhaL ls LSlL or hlgher grade (l.e. PSlL, ASC-P, ACC) ls lmmedlaLely referred Lo colposcopy (See 1able 3 below). Powever, posLmenopausal women wlLh LSlL have for years been LreaLed less aggresslvely, as long as Lhe Pv LesL ls negaLlve (or noL performed). 1hls ls due Lo a lower lncldence of boLh Pv lnfecLlon and abnormal flndlngs on colposcopy ln Lhls age group. 1hese women can be managed wlLh elLher reflex Pv LesLlng, repeaL cyLology aL 6 and 12 monLhs, or colposcopy. lf Lhe flrsL or lasL opLlon ls chosen and resulLs are negaLlve, subsequenL repeaL co-LesLlng should be performed aL 12 monLhs and Lhen agaln ln 3 years.
Less aggresslve managemenL of LSlL ls also now recommended for women age 21 Lo 24, per Lhe updaLed 2012 Culdellnes. lor Lhese women, repeaL cyLology aL 12 and 24 monLhs ls recommended. arallellng Lhe managemenL of ASCuS for Lhls age group, Lhese young paLlenLs are referred Lo colposcopy only lf Lhe 12- monLh follow-up cyLology ls ASC-P or PSlL, or lf Lhe 24-monLh cyLology ls ASCuS or worse (l.e., any abnormallLy) (9).
noLe LhaL slnce 2006, abnormal ap smear resulLs ln Plv-poslLlve (and oLher lmmunosuppressed women) have been managed ln Lhe same manner as Lhe general populaLlon, meanlng LhaL one uses LhaL same Lhreshold for referral Lo colposcopy. (8ecall, however, LhaL such lmmunosuppressed women are *$"44(40 more aggresslvely, Lyplcally annually). AbnormallLles ln pregnanL women are overall managed less aggresslvely, as Lhe lncldence of cancer ln Lhls group ls qulLe low (8). 1ab|e S: Consensus Gu|de||nes for Management of n|gher Grade Abnorma| Cyto|ogy |n Nonpregnant Women ap resu|t Management Cpt|ons Notes
ASCuS
lease see 1able 3
ACC Colposcopy and endocervlcal cureLLage lf age >33, abnormal bleedlng, or rlsk facLors for endomeLrlal neoplasla, endomeLrlal blopsy should also be performed. lf all resulLs are negaLlve, conLlnue close follow-up (l.e., ap smear q6 monLhs) unLll Lhere are 4 consecuLlve negaLlve resulLs. LSlL* or PSlL or ASC-P Colposcopy LSlL: 13-30 rlsk of hlgh-grade Cln PSlL: 70-73 rlsk of hlgh-grade Cln noLe LhaL ASC-P ls managed as PSlL *LSlL ln posLmenopausal women and young women age 21 Lo 24 ls now managed less aggresslvely, ofLen wlLhouL colposcopy (see paragraphs above). AdapLed from recommendaLlons ln WrlghL 1C eL al. 2006 Consensus Culdellnes, 2007 and Massad LS eL al. 2012 updaLed Consensus Culdellnes, 2013.
ract|ce case 8b. Management of abnorma| ap smear resu|ts ?ou recelve a reporL of LSlL on your paLlenL. Accordlng Lo Lhe 2012 updaLed Culdellnes you would manage Lhe paLlenL as follows: A. lf she ls age > 23 years old and ferLlle you would llkely refer her Lo colposcopy. 8. lf she ls posLmenopausal you could choose Lo manage her less aggresslvely uslng repeaL cyLology ln 6 and 12 monLhs, and only refer her Lo colposcopy lf Lhese follow-up LesLs are abnormal (l.e. ASCuS or worse). C. lf she ls 21 Lo 24 years old you would repeaL Lhe cyLology ln 12 monLhs and agaln ln 24 monLhs. lf a serlous abnormallLy (ASC-P or PSlL) ls presenL on Lhe 12 monLh cyLology, or any abnormallLy (l.e. ASCuS or worse) ls presenL on Lhe 24-monLh follow-up cyLology, she would be referred Lo colposcopy. u. All of Lhe above managemenL sLraLegles are approprlaLe. op up Answers A. lncorrecL. ?es, mosL women wlLh LSlL are sLlll referred Lo colposcopy, however oLher responses are also correcL. 8. lncorrecL. ?es, Lhls less aggresslve managemenL for posLmenopausal paLlenLs ls correcL, however oLher responses are also correcL. C. lncorrecL. ?es, careful survelllance wlLh follow-up cyLology aL 12 and 24 monLhs ls approprlaLe for Lhe young (21 Lo 24 year old) paLlenL, however oLher responses Lo Lhls quesLlon are correcL. u. CorrecL! Summary Answer 1he correcL answer ls u: All of Lhe above managemenL sLraLegles are approprlaLe accordlng Lo Lhe updaLed 2012 Culdellnes. LSlL ln posLmenopausal women ls less ofLen assoclaLed wlLh elLher Pv lnfecLlon or abnormallLles aL colposcopy, and Lhus managemenL wlLh follow-up cyLology ls approprlaLe. ConservaLlve managemenL of LSlL ln very young women ls supporLed by daLa from sLudles such as Lhe AL1S Lrlal, whlch documenL Lhe frequenL resoluLlon of LSlL ln Lhese hosLs.
Adequacy of Cyto|ogy, Add|t|ona| Informat|on on ap Smear keports 1he 8eLhesda sysLem lncludes reporLlng on Lhe adequacy of Lhe speclmen and a descrlpLlve dlagnosls. A relaLlvely common cyLology reporL ls negaLlve cyLology buL endocervlcal cells are absenL". er Lhe updaLed 2012 Culdellnes, Lhls can be now managed slmply as a negaLlve cyLology resulL, as sLudles have demonsLraLed LhaL women wlLh absenL or lnsufflclenL endocervlcal cells, whlch lmplles lnadequaLe sampllng of Lhe LransformaLlon zone", do noL have a greaLer rlsk for cervlcal cancer Lhan Lhose wlLh saLlsfacLory endocervlcal componenL.
ln conLrasL, an "unsaLlsfacLory" ap smear ralses concern, as lL mosL commonly lmplles lnsufflclenL squamous cells. Lven an accompanylng negaLlve Pv LesL ls noL reassurlng, as lL may be falsely negaLlve due Lo lnadequaLe sampllng. An unsaLlsfacLory ap smear ls managed by a repeaL cyLology ln 2-4 monLhs, followlng LreaLmenL of aLrophy or lnfecLlon lf such a problem ls ldenLlfled (21). SomeLlmes addlLlonal sampllng Lools such as spaLulas and brushes can be used (ln addlLlon Lo Lhe usual broom) aL subsequenL LesLlng Lo reLrleve more cells.
1he descrlpLlve dlagnosls can also lnclude commenLs such as "reacLlve cellular changes" (l.e., lnflammaLlon). Whlle mosL lnflammaLlon and aLrophlc changes requlre no speclflc LreaLmenL, "severe lnflammaLlon" has been assoclaLed wlLh progresslon Lo more abnormal paLhology and closer follow-up may be lndlcaLed (20). lor speclflc lnfecLlons reporLed on a saLlsfacLory ap smear, Lhe broader cllnlcal plcLure wlll deLermlne Lhe need for LreaLmenL. Squamous meLaplasla ls a normal flndlng LhaL lndlcaLes successful sampllng of Lhe LransformaLlon zone. 1he presence of "benlgn endomeLrlal cells" on Lhe ap smear of an asympLomaLlc premenopausal woman ls consldered normal, however, such a flndlng for a posLmenopausal woman lndlcaLes need for endomeLrlal assessmenL, regardless of sympLoms (20).
Commun|cat|ng resu|ts When communlcaLlng abnormal ap smear resulLs Lo paLlenLs, dlrecL oral communlcaLlon ls Lhe preferred mode. 1hls allows for approprlaLe educaLlon and reassurance, as well as speclflc counsellng regardlng follow-up. Smokers should be educaLed LhaL qulLLlng may posslbly lncrease Lhe llkellhood of resoluLlon of abnormal cyLology and Pv lnfecLlon.
roper 1echn|que for Cbta|n|ng the ap Smear 1hls secLlon revlews proper Lechnlque for obLalnlng cervlcal cyLology.
Cbta|n|ng the spec|men lor vldeo demonsLraLlon of ap smear speclmen collecLlon uslng boLh llquld-based and LradlLlonal Lechnlques, you can use Lhls llnk for Lhe new Lngland !ournal of Medlclne's elvlc Lxam procedural vldeo.
roper sampllng ls essenLlal Lo avold false negaLlve resulLs. lmporLanL sLeps ln obLalnlng an adequaLe sample lnclude Lhe followlng: ! ldeally, Lhe enLlre cervlx should be vlslble when Lhe smear ls obLalned. ! Cross abnormallLles of Lhe cervlcal eplLhellum (such as ulcers, leukoplakla or polyps) should prompL referral for colposcopy regard|ess of ap smear resu|ts. ! naboLhlan cysLs and cervlcal ecLopy ("ecLroplon") are Lwo normal flndlngs LhaL should noL be confused wlLh paLhologlc leslons. ! Large amounLs of vaglnal dlscharge coaLlng Lhe cervlx should be genLly removed (so as noL Lo dlsLurb Lhe eplLhellum) uslng a procLo swab before obLalnlng Lhe smear. Small amounLs of blood wlll noL lnLerfere wlLh cyLologlc evaluaLlon, buL large amounLs, as occurrlng durlng menses, preclude cyLologlc sampllng. 1hls ls conslderably less of a problem when llquld based cyLology ls used. ! lf Lhe paLlenL complalns of vaglnal dlscharge LhaL ls suspecLed Lo be lnfecLlous ln naLure and has no sympLoms or vlsual slgns of a cervlcal abnormallLy, conslderaLlon may be glven Lo evaluaLlng and LreaLlng Lhe vaglnlLls flrsL and posLponlng Lhe ap smear.
WaLer-based lubrlcanL does noL lnLerfere wlLh cyLology lnLerpreLaLlon (or unA probe LesLlng) (21), Lhus Lhe speculum should be lubrlcaLed Lo mlnlmlze paLlenL dlscomforL. Slnce conLamlnaLlon wlLh blood may lnLerfere wlLh unA probe LesLlng, buL has been shown noL Lo affecL cyLology lnLerpreLaLlon (8), S1u LesLlng should be performed flrsL. 1here are Lwo ma[or Lechnlques used Lo obLaln cervlcal cyLologlcal speclmens. ln boLh Lechnlques, lL ls lmporLanL Lo sample Lhe LransformaLlon zone, as mosL cervlcal cancer orlglnaLes ln Lhe squamocolumnar [uncLlon.
- Llquld-based cyLologlc sampllng. A speclally deslgned plasLlc brush (or "broom") ls used, Lhe cenLer of whlch ls lnserLed lnLo Lhe endocervlcal canal and Lhen roLaLed flve full clockwlse roLaLlons. 1he enLlre brush ls Lhen placed ln a llquld medlum conLalner. lor older women wlLh a sLenoLlc os or whose prevlous samples lacked endocervlcal cells, lL may be helpful Lo subsequenLly also sample Lhe os wlLh Lhe LradlLlonal endocervlcal brush, Lhen swlshlng lL ln Lhe llquld medlum Lo release addlLlonal cells. Cne advanLage of llquld-based sampllng ls LhaL cells are cenLrlfuged and dlspersed more evenly on Lhe sllde, decreaslng screenlng error and Lhereby LheoreLlcally lmprovlng senslLlvlLy. Also, llquld-based LesLlng allows for reflex LesLlng for hlgh-rlsk Pv from Lhe same sample, enabllng Lrlage of paLlenLs wlLh ASCuS Lo colposcopy vs.resumpLlon of rouLlne screenlng. - ConvenLlonal brush/scrape Lechnlque. llrsL, Lhe ecLocervlx ls scraped wlLh a wooden or plasLlc spaLula, roLaLlng Lhe spaLula 360 degrees, and Lhen Lhe sample ls spread onLo a sllde. nexL, an endocervlcal brush ls lnserLed lnLo Lhe os and roLaLed, Lhen removed and rolled across Lhe sllde. 8apld flxaLlon ls vlLal, as Lhe sample can become alr-drled ln a maLLer of seconds. lf deslred, a separaLe speclmen can be obLalned for Pv LesLlng, uslng Lhe proprleLary cervlcal swab and LransporL medlum.
nV Vacc|ne A vacclne (Cardasll) conLalnlng 4 Pv Lypes (16, 18, 6 and 11) has been shown Lo be hlghly effecLlve ln prevenLlng cervlcal Pv lnfecLlon (22) and ls expecLed Lo slgnlflcanLly reduce (buL noL ellmlnaLe) Lhe rlsk of cervlcal dysplasla and cancer as well as genlLal warLs (23). Crlglnally approved for glrls and women, Lhls was expanded ln 2010 Lo lnclude boys and men. 1he LargeL group for Lhls serles of Lhree vacclnaLlons (glven aL 0, 2 and 6 monLhs) ls young adolescenLs age 11-12, before Lhey are sexually acLlve, however, "caLch-up" vacclnaLlons are lndlcaLed and Lhe vacclne ls approved for boLh genders age 9-26. A recenL sLudy of proLracLed vacclnaLlon schedules (wlLh Lhe longesL belng 0, 12 and 24 monLhs) demonsLraLed LhaL sLrlcL adherence Lo Lhe sLandard schedule ls noL essenLlal (24). ln parL because noL all oncogenlc Pv seroLypes are lncluded ln Lhe vacclne, reclplenLs are sLlll aL rlsk, albelL greaLly lowered, for cervlcal cancer, and screenlng recommendaLlons remaln unchanged. A second vacclne LhaL conLalns only Pv Lypes 16 and 18 (Cervarlx) ls also avallable. PealLh lnsurance coverage of Lhe vacclne ls mandaLed ln some buL noL all sLaLes and Lhe vacclne ls expenslve. noLe LhaL Lhe CuC suggesLs LhaL Lhe paLlenL remaln seaLed (ln offlce or walLlng area) for 13 mlnuLes followlng vacclnaLlon Lo help decrease Lhe rlsk of falnLlng. 1he Pv vacclne ls revlewed ln more deLall ln Lhe lmmunlzaLlons arL 2 module.
Case 10: In|t|a| cons|derat|ons |n prescr|b|ng comb|ned ora| contracept|ves ?our nexL paLlenL ls a 23-year-old woman wlLhouL slgnlflcanL pasL medlcal hlsLory who presenLs for rouLlne evaluaLlon. She menLlons LhaL she and her boyfrlend have been uslng condoms for blrLh conLrol and she would llke Lo learn more abouL comblned oral conLracepLlves. She asks whaL would happen lf she were Lo forgeL Lo Lake a plll. ?ou open your dlscusslon wlLh lnsLrucLlons abouL chooslng an oral conLracepLlve, lnlLlaLlng oral conLracepLlves and managemenL of accldenLal lapses ln doslng. Whlch CnL of Lhe followlng sLaLemenLs ls correcL? A. Comblned oral conLracepLlves are Lyplcally lnlLlaLed aL or shorLly followlng Lhe onseL of menses, buL can be sLarLed aL any Llme as long as one ls confldenL Lhe woman ls noL pregnanL. 8. Comblned oral conLracepLlves are usually composed of boLh an esLrogen and a progesLln componenL (l.e. Lhe "comblned" plll), some are esLrogen only (l.e. Lhe "mlnl-plll"). C. lf a woman mlsses Lwo consecuLlve days of her comblned oral conLracepLlve, she should sLop Laklng lL, use an alLernaLlve meLhod of conLracepLlon unLll Lhe nexL cycle beglns and Lhen resLarL Lhem. u. 1he esLrogen componenL of a comblned oral conLracepLlve ls deslgned Lo prevenL endomeLrlal developmenL whlle Lhe progesLln componenL prevenLs ovulaLlon. L. All comblned oral conLracepLlves lnduce mensLrual bleedlng monLhly Lo prevenL Lhe healLh rlsks assoclaLed wlLh endomeLrlal hyperplasla. op Up Answers A. CorrecL! Comblned oral conLracepLlves are Lyplcally lnlLlaLed on Lhe flrsL day of menses, or cusLomarlly Lhe flrsL Sunday LhereafLer. AlLernaLlvely, Lhey may be sLarLed aL any Llme of Lhe mensLrual cycle, as long as one ls confldenL Lhe woman ls noL pregnanL. noLe LhaL one should noL rely excesslvely on offlce pregnancy LesLlng ln Lhls lnsLance, as lL does noL deLecL very early pregnancy or lmpendlng ovulaLlon. 8. lncorrecL. All hormonal conLracepLlon conLalns a progesLln, comblned conLracepLlon adds an esLrogen. C. lncorrecL. When a woman reallzes she has mlssed one or Lwo days of her oral conLracepLlve, she should Lake one lmmedlaLely and Lhen Lake one LableL 8lu unLll all mlssed LableLs have been Laken. lf more Lhan Lwo consecuLlve days are mlssed, Lhen addlLlonal conLracepLlon (l.e. condoms) should be used unLll Lhe nexL cycle. u. lncorrecL. ln currenLly avallable low dose pllls, Lhe esLrogen componenL malnly provldes cycle conLrol, Lhe progesLln componenL boLh suppresses ovulaLlon and Lhlckens cervlcal mucus. L. lncorrecL. Some comblned oral conLracepLlves lnduce a wlLhdrawal bleed once every Lhree monLhs (Seasonale and oLhers), and one new conLracepLlve (Lybrel) has no scheduled bleedlng, Lhere ls no harm ln ellmlnaLlng or reduclng Lhe frequency of wlLhdrawal bleedlng. Summary Answer 1he correcL answer ls A. Comb|ned ora| contracept|ves are typ|ca||y |n|t|ated on the f|rst day of menses, or the f|rst Sunday thereafter. A|ternat|ve|y, they may be started at any t|me of the menstrua| cyc|e, as |ong as one |s conf|dent that a woman |s not pregnant.
Introduct|on Cral conLracepLlves remaln Lhe mosL common form of conLracepLlon ln Lhe u.S. (17 of women are currenL users) (26). 1he slde effecLs, beneflLs and poLenLlal rlsks of oral conLracepLlves, dlscussed ln Lhe followlng secLlons, are only Lhree of many facLors LhaL may play lnLo a woman's cholce of conLracepLlve meLhod. Whlle space consLralnLs do noL permlL revlew of all forms of conLracepLlon, lL ls lmporLanL for Lhe generallsL physlclan Lo be aware of Lhe array of opLlons ln order Lo provlde approprlaLe counsellng (see 1ables 6 and 7).
1ab|e 6. Lstrogen-Conta|n|ng Contracept|on 1. Comblned oral conLracepLlves 1aken dally 2. 1oplcal aLch (CrLho Lvra) 1 paLch placed each week for 3 weeks, Lhen no paLch for 1 week
3. vaglnal 8lng (nuva8lng) 1 rlng lnLravaglnally for 3 weeks, Lhen 8emoved for 1 rlng-free week
Ster|||zat|on 1. vasecLomy 2. 1ransabdomlnal 1ubal Cccluslon a. osL arLum-Mlnllap wlLh elLher llgaLlon, cllps or rlngs b. lnLerval (remoLe from pregnancy) l. Mlnllap as above ll. Laparoscopy 3. 1ranscervlcal 1ubal Cccluslon Lssure
8arr|er Methods 1. Condom (male, female) 2. ulaphragm 3. Cervlcal cap 4. Pybrlds a. Lea's Shleld b. lem Cap 3. Spermlclde
Iert|||ty Awareness Methods Lactat|ona| Amenorrhea *lmplanLs and luus are Lhe mosL effecLlve forms of reverslble conLracepLlon, whlle barrler and ferLlllLy awareness meLhods are assoclaLed wlLh Lhe hlghesL pregnancy raLes.
Comblned oral conLracepLlves (l.e. conLracepLlve pllls conLalnlng boLh esLrogen and progesLln) are among Lhe safesL and mosL common medlcaLlons prescrlbed. A parLlcular advanLage of oral conLracepLlves ls LhaL, unllke many hormonal meLhods, Lhey are hlghly reverslble. upon dlsconLlnuaLlon of Lhe plll, ferLlllLy Lyplcally reLurns wlLhln 3 monLhs -- someLlmes as early as Lhe nexL cycle.
1he dose of sex sLerolds ln comblned oral conLracepLlves has been reduced dramaLlcally slnce Lhey flrsL became avallable ln Lhe 1960s. 1he reducLlon ln dose allows for Lhe same conLracepLlve efflcacy wlLh fewer adverse effecLs. 1oday, "low-dose" conLracepLlves, conLalnlng 30 or 33 mlcrograms of esLrogen, are Lyplcally prescrlbed, more recenLly "exLra low-dose" formulaLlons LhaL conLaln only 20 mlcrograms have become avallable. ConLracepLlves conLalnlng 30 mlcrograms of eLhlnyl esLradlol are now reserved for selecL lndlcaLlons.
1here are many dlfferenL formulaLlons of low-dose comblned oral conLracepLlves on Lhe markeL, buL Lhere ls no convlnclng evldence LhaL Lhelr dlfferences are cllnlcally slgnlflcanL. 1herefore, Lhe cholce of formulaLlon can be gulded by such facLors as physlclan or paLlenL famlllarlLy and cosL. Some excepLlons Lo Lhls generallLy lnclude Lhe oral conLracepLlves conLalnlng Lhe progesLln drosplrenone (l.e. F)*'#(, F)G, @4/)GH ?)9/")- and generlcs), whlch has anLl-mlneralocorLlcold effecLs LhaL can predlspose Lo hyperkalemla. Such formulaLlons musL be avolded ln women wlLh chronlc renal or adrenal lnsufflclency and used wlLh cauLlon ln women Laklng angloLensln converLlng enzyme (ACL) lnhlblLors, angloLensln recepLor blockers (A88's), hlgh doses of nonsLeroldal anLl-lnflammaLory drugs (nSAlus), or heparln.
AnoLher newer (Lhlrd generaLlon") progesLln lsdesogesLrel (conLalned ln CrLho-CepL, CrLho 1rl-cyclen, Cyclessa, uesogen, MlrceLLe and some generlcs), a progesLln developed Lo have less androgenlc effecL. uesogesLrel lncreases Lhe rlsk of venous Lhromboembollsm Lwo-fold over Lhe rlsk of conLracepLlves conLalnlng Lhe older progesLln, levonorgesLrel (26), alLhough Lhe absoluLe rlsk for v1L remalns low aL 10 per 10,000 woman-years 1hls lncrease ln rlsk ls surprlslng glven LhaL v1L rlsk has always been aLLrlbuLed Lo Lhe esLrogen componenL, noL Lhe progesLln. Some cllnlclans choose Lo prescrlbe only Lhe older, levonorgeLrel-conLalnlng, oral conLracepLlves for reasons of safeLy.
Monophaslc comblned oral conLracepLlves have a consLanL dose of esLrogen and progesLln ln each of Lhe 21 LableLs of acLlve hormones ln each cycle pack (Lhe remalnlng 7 days of a 28-day pack ls merely placebo). haslc comblned oral conLracepLlves alLer Lhe dose of Lhe progesLln and (ln some formulaLlons) Lhe esLrogen componenL among Lhe 21 acLlve LableLs ln each pack (agaln, Lhe remalnlng 7 pllls are placebo). haslc formulaLlons were developed Lo beLLer mlmlc normal physlology, buL cllnlcal superlorlLy has noL been demonsLraLed. An advanLage of Lhe monophaslc form ls LhaL Lhe Llmlng of "menses" can be manlpulaLed by Laklng Lhe acLlve hormones for longer Lhan 21 days before Laklng 7 days of lnacLlve LableLs. Cccaslonally Lhls sLraLegy ls used for managlng medlcal condlLlons LhaL ln some women are aggravaLed by mensLruaLlon, such as asLhma, buL ls more commonly employed Lo posLpone "menses" for vacaLlons, eLc. Longer-cycle comblned oral conLracepLlves have been packaged (e.g. Seasonale and oLhers) LhaL conLaln 12 weeks of hormone followed by 7 days of lnerL LableLs, Lhus reduclng Lhe frequency of "menses" Lo once every Lhree monLhs, one brand (Lybrel) has no placebo LableLs.
Adm|n|strat|on, effect on pregnancy, eff|cacy Comblned oral conLracepLlves are Lyplcally lnlLlaLed on elLher Lhe flrsL day of menses (for lmmedlaLe conLracepLlve efflcacy) or Lhe flrsL Sunday afLer menses beglns (wlLh back-up conLracepLlon [l.e. condoms or absLlnence] advlsed for Lhe flrsL 7-10 days of Lhe flrsL pack). AlLernaLlvely, one can sLarL oral conLracepLlves aL any Llme durlng a women's cycle as long as pregnancy ls noL suspecLed. 1hls approach can be used for amenorrhelc women swlLchlng from oLher meLhods. ln general, one should noL rely solely on offlce pregnancy LesLlng when lnlLlaLlng hormonal conLracepLlon. Such LesLlng ls unable Lo deLecL early pregnancy and wlll noL predlcL lmpendlng ovulaLlon. ln Lhe evenL LhaL oral conLracepLlves are accldenLally Laken durlng Lhe flrsL LrlmesLer of pregnancy, however, Lhe woman can be reassured LhaL Lhey are noL LeraLogenlc.
lallure raLes assoclaLed wlLh comblned oral conLracepLlve use relaLe Lo lndlvldual compllance: Lhey range from less Lhan 1/100 woman-years ln women who are hlghly compllanL Lo greaLer Lhan 13/100 woman- years among lnner-clLy Leens. When lnlLlaLlng comblned oral conLracepLlves, lL ls Lherefore crlLlcal Lo revlew plll-Laklng sLraLegles. 1he plll should be Laken aL Lhe same Llme each day (ofLen bedLlme). lf a woman mlsses one or Lwo LableLs, she should Lake one LableL as soon as posslble. She should Lhen conLlnue Lo Lake one LableL Lwlce dally (Laklng more Lhan one LableL aL once may cause nausea and vomlLlng ln some paLlenLs) unLll each of Lhe mlssed LableLs has been Laken. Women who have mlssed more Lhan Lwo consecuLlve days should be advlsed Lo use an addlLlonal form of conLracepLlon (e.g., condoms and spermlclde) whlle Lhey compleLe Laklng Lhe currenL pack of pllls. AnoLher common source of error ls "walLlng for menses Lo end" prlor Lo sLarLlng Lhe nexL plll pack. ln cerLaln slLuaLlons lL may beneflL Lhe paLlenL Lo revlew LhaL a plll ls Laken each day wlLhouL excepLlon, and LhaL lL ls common for "menses" Lo perslsL lnLo Lhe flrsL few days of Lhe new plll pack.
Women who conslsLenLly mlss Lhree or more LableLs each cycle should conslder oLher conLracepLlve cholces LhaL do noL requlre dally compllance. Such women may have beLLer success wlLh meLhods LhaL are less user-dependenL such as Lhe paLch, ln[ecLlon, vaglnal rlng, lmplanLable meLhods, or luu, Lhese Loplcs are beyond Lhe scope of Lhls dlscusslon.
Case 11: S|de effects and hea|th benef|ts of comb|ned ora| contracept|ves An 18-year-old sLudenL who uses condoms lnconslsLenLly ls lnLeresLed ln sLarLlng oral conLracepLlves. Per moLher has warned her LhaL she may develop slde effecLs from Laklng Lhe plll and her frlends have Lold her LhaL lL can cause dangerous mensLrual aberraLlons. Whlch CnL of Lhe followlng sLaLemenLs abouL slde effecLs and healLh rlsks of comblned oral conLracepLlve use ls correcL? A. Amenorrhea ls common wlLh conLlnued plll usage, as long as Lhe paLlenL Lakes her pllls rellably she can be confldenL she's noL pregnanL. 8. lnLermensLrual ("breakLhrough") bleedlng due Lo comblned oral conLracepLlves ls normal LhroughouL Lhe flrsL year of use. C. Women who develop amenorrhea whlle on comblned oral conLracepLlves are aL lncreased rlsk for endomeLrlal hyperplasla and should dlsconLlnue Lhem. u. llbrocysLlc changes worsen wlLh comblned oral conLracepLlve use. op Up Answers A. CorrecL! 8ecause comblned oral conLracepLlves are progesLln-domlnanL, Lhey cause aLrophy of Lhe endomeLrlum, whlch someLlmes leads Lo amenorrhea. 8. lncorrecL. lnLermensLrual bleedlng LhaL perslsLs or sLarLs greaLer Lhan Lhree monLhs lnLo Lherapy requlres furLher evaluaLlon. C. lncorrecL. Amenorrhea LhaL develops whlle Laklng comblned oral conLracepLlves ls due Lo aLrophy of Lhe endomeLrlum and ls noL harmful. u. lncorrecL. llbrocysLlc breasL changes ofLen lmprove wlLh comblned oral conLracepLlves. Summary Answer 1he correcL answer ls A: Amenorrhea |s common w|th cont|nued p||| usage, as |ong as the pat|ent takes her p|||s re||ab|y she can be conf|dent she's not pregnant.
Comblned oral conLracepLlves confer a very lmporLanL healLh beneflL: Lhe prevenLlon of unlnLended pregnancy. WlLh Lhls beneflL come some slde effecLs, buL also oLher non-conLracepLlve beneflLs.
S|de effects of ora| contracept|ves Slde effecLs of oral conLracepLlves are a ma[or source of paLlenL noncompllance and dlsconLlnuaLlon. Cllnlclans can enhance Lhelr paLlenLs' conLracepLlve success by fully dlscusslng slde effecLs wlLh Lhem prlor Lo lnlLlaLlng Lherapy and reassurlng Lhem LhaL mosL Lyplcally resolve afLer a few monLhs of Lherapy ("as Lhelr body ad[usLs Lo Lhe medlcaLlon"). nausea and breasL Lenderness, caused by Lhe esLrogen componenL, commonly occur ln comblned oral conLracepLlve users. lorLunaLely, nausea can ofLen be averLed by Laklng Lhe medlcaLlon aL bedLlme and Lhese sympLoms usually lmprove or resolve by Lhe fourLh monLh. Cccaslonally, lnLolerable slde effecLs may be relleved by swlLchlng Lo anoLher comblned oral conLracepLlve LhaL conLalns a dlfferenL synLheLlc progesLln.
MensLrual changes from comblned oral conLracepLlve use can cause paLlenL anxleLy and are a common reason for dlsconLlnuaLlon. lnLermensLrual ("breakLhrough") spoLLlng and bleedlng occur ln approxlmaLely one-quarLer of women durlng Lhe flrsL 3 monLhs of use. Counsellng paLlenLs Lo anLlclpaLe breakLhrough bleedlng ls lmporLanL. When lnLermensLrual bleedlng occurs afLer 3 monLhs of use, Lhe paLlenL should be evaluaLed for causes of bleedlng unrelaLed Lo oral conLracepLlve use, lncludlng cervlcal or endomeLrlal lnfecLlon, neoplasla and pregnancy. When Lhese causes are excluded, Lhe spoLLlng ls aLLrlbuLed Lo sheddlng of an endomeLrlum rendered unsLable from progesLln-relaLed aLrophy (comblned oral conLracepLlves conLaln boLh esLrogen and a progesLln buL are progesLln-domlnanL). A shorL course of nSAlu such as lbuprofen 800 mg 3 Llmes dally for 3 days sLarLed aL Lhe flrsL slgn of spoLLlng ls someLlmes adequaLe LreaLmenL. AlLernaLlvely, swlLchlng Lo a dlfferenL plll formulaLlon wlLh greaLer esLrogen conLenL (l.e. from a 20 g plll Lo a 30 g or 33 g plll), or Lo a monophaslc formulaLlon lf uslng a Lrlphaslc one, may resLore a sLable endomeLrlum.
SomeLlmes amenorrhea resulLs from plll-relaLed endomeLrlal aLrophy - parLlcularly ln long-Lerm users. AlLhough such amenorrhea ls noL medlcally harmful, lL may cause paLlenL anxleLy regardlng Lhe posslblllLy of pregnancy. Cfferlng pregnancy LesLlng and reassurance can help relleve paLlenL anxleLy. lf paLlenLs conLlnue Lo be dlsLurbed by amenorrhea, oral esLrogen Laken wlLh each of Lhe acLlve oral conLracepLlve LableLs (l.e. Lhe flrsL 21 LableLs ln a pack of pllls) ofLen wlll resLore wlLhdrawal bleedlng. SwlLchlng Lo a dlfferenL low-dose plll ls anoLher opLlon.
Peadaches are occaslonally reporLed by women uslng comblned oral conLracepLlves and requlre approprlaLe evaluaLlon and managemenL. new onseL mlgralne and progresslon of mlgralne are each reason for dlsconLlnuaLlon of esLrogen-conLalnlng conLracepLlon (due Lo Lhe rlsk of sLroke). ln some seLLlngs, exlsLlng mlgralne represenLs a conLralndlcaLlon Lo sLarLlng comblned conLracepLlves (see "SLroke" secLlon under "ConLralndlcaLlons Lo LsLrogen-ConLalnlng ConLracepLlon" below). 1enslon headaches are unrelaLed Lo oral conLracepLlve use.
Comblned oral conLracepLlves cause an lncrease ln blood pressure ln some suscepLlble women. revlously lL was sLandard Lo ask paLlenLs Lo reLurn for blood pressure evaluaLlon 3 monLhs afLer lnlLlaLlon and Lhen annually ln all paLlenLs Laklng comblned oral conLracepLlves. Powever, Lhls problem ls relaLlvely uncommon, and evldence lndlcaLes LhaL provlslon of a year's worLh of refllls of CCCs aL Lhe Llme of lnlLlaLlon lmproves conLlnuaLlon raLes (a perpeLual problem wlLh conLracepLlon) and decreases pregnancy raLes. ConsequenLly Lhe CuC now recommends LhaL paLlenLs be provlded wlLh 12 refllls when CCCs are prescrlbed, and be advlsed Lo monlLor Lhelr own blood pressure ln noncllnlcal seLLlngs such as a pharmacy or flre sLaLlon (27). 1hey should be lnsLrucLed Lo reLurn for any quesLlons or concerns, buL no follow-up vlslL need be scheduled (27).
8y conLrasL, Lhe CuC cauLlons agalnsL prescrlpLlon of comblned oral conLracepLlves Lo women wlLh esLabllshed hyperLenslon, mosLly due Lo a lack of daLa. CLher auLhorlLles, lncludlng ACCC, supporL Lhe use of comblned oral conLracepLlves ln women wlLh well-conLrolled hyperLenslon lacklng evldence of end- organ damage lf Lhey are wlLhouL oLher slgnlflcanL coronary rlsk facLors, lncludlng obeslLy. Powever, women wlLh hyperLenslon need close monlLorlng, lnlLlally 2-3 monLhs afLer sLarLlng Lhe conLracepLlve and Lhen Lwlce yearly lf lL remalns conLrolled. (28)
MosL women do noL galn welghL whlle Laklng oral conLracepLlves and for Lhose who do, lL ls llkely due Lo an anabollc response Lo Lhe progesLln componenL (l.e. lncreased appeLlLe).
LasLly, Lhe mosL lmporLanL slde effecL of comblned oral conLracepLlves ls Lhe rlsk of arLerlal and venous LhromboLlc evenLs (see D"74"#)- I C4(&5* !%"&'>&4'>&-#*' secLlon below).
nea|th benef|ts of ora| contracept|ves AlLhough ofLen overlooked, Lhe healLh beneflLs assoclaLed wlLh hormonal conLracepLlon are subsLanLlal. Comblned oral conLracepLlves confer a varleLy of non-conLracepLlve healLh beneflLs, lncludlng quallLy-of- llfe beneflLs and proLecLlon from ovarlan and endomeLrlal mallgnancles. lor mosL women who Lake comblned oral conLracepLlves, menses become more regular and predlcLable and Lhe number of days and amounL of flow decllne. Cral conLracepLlves reduce Lhe severlLy of dysmenorrhea and can lmprove anemla and lron sLores ln women wlLh menorrhagla. use of comblned oral conLracepLlves can also resLore regular menses ln women wlLh abnormal bleedlng caused by chronlc anovulaLlon. Comblned oral conLracepLlves can also confer proLecLlon from several benlgn buL common condlLlons, such as flbroadenoma and cysLlc changes of Lhe breasL. (29) 1he use of comblned oral conLracepLlves ls also assoclaLed wlLh a reduced rlsk of pelvlc lnflammaLory dlsease (30) and ecLoplc pregnancy. AlLhough older llLeraLure suggesLed LhaL comblned oral conLracepLlve use suppressed funcLlonal ovarlan cysL formaLlon, lL ls unclear wheLher Loday's low-dose formulaLlons have Lhls effecL. AlLhough lL seems obvlous Lo Lhe physlclan, lL ls lmporLanL Lo counsel Lhe paLlenL LhaL hormonal conLracepLlon offers no proLecLlon from S1us, condom use should be encouraged ln approprlaLe seLLlngs.
Case 12: Contra|nd|cat|ons to comb|ned ora| contracept|ves ?our nexL paLlenL of Lhe afLernoon ls new Lo you: a 33-year-old woman who ls here for a rouLlne examlnaLlon. She has occaslonal mlgralnes wlLh aura, buL oLherwlse no medlcal hlsLory. She works as an accounLanL, ls marrled wlLh Lhree chlldren and smokes one pack per day. Per only medlcaLlon ls "Lhe plll", for whlch she requesLs a reflll. Per blood pressure ls normal. ?ou declde Lo: A. 8eflll her prescrlpLlon and schedule her Lo follow-up ln one year. 8. Advlse LhaL slnce she wlshes Lo conLlnue uslng comblned oral conLracepLlves, she should lmmedlaLely reduce or cease smoklng, and schedule close follow-up ln 1 monLh. C. Advlse her Lo swlLch Lo condoms. u. Advlse her LhaL all hormonal conLracepLlon ls conLralndlcaLed slnce she smokes. L. Advlse her LhaL she has Lwo unaccepLable healLh rlsks for Lhe use of comblned conLracepLlon, buL elLher a progesLln-only meLhod or lnLrauLerlne devlce (luu) would be rellable and safe conLracepLlon for her. op Up Answers A. lncorrecL. 8ecause she suffers mlgralne wlLh aura she should noL use esLrogen-conLalnlng conLracepLlves. Also, slnce lncreaslng age and Lobacco use boLh conLrlbuLe Lo Lhe rlsk of Ml assoclaLed wlLh comblned oral conLracepLlves, women age 33 or older who smoke > 13 clgareLLes/day should noL use Lhe plll. 8. lncorrecL. AlLhough managemenL of her Lobacco use ls approprlaLe, esLrogen-conLalnlng conLracepLlon should noL be used by women who suffer mlgralne wlLh aura. C. lncorrecL. lallure Lo counsel your paLlenL abouL Lhe avallablllLy of oLher, more effecLlve meLhods of blrLh conLrol LhaL would be safe for her would be lnapproprlaLe. u. lncorrecL. Cnly conLracepLlves LhaL conLaln esLrogen are conLralndlcaLed ln older (l.e. age > 33 years) smokers and women who suffer mlgralne wlLh aura. rogesLln-only conLracepLlon (e.g. uepo-rovera, lmplanon and Lhe "mlnl-plll") has few conLralndlcaLlons and would be safe ln Lhls paLlenL. L. CorrecL. Mlgralne wlLh aura aL any age and smoklng > 13 clgareLLes/day by a woman age 33 or older are each a conLralndlcaLlon Lo comblned hormonal conLracepLlon. Summary answer 1he correcL answer ls L: Adv|se her that the m|gra|ne w|th aura h|story represents an unacceptab|e hea|th r|sk (stroke) to the use of estrogen-conta|n|ng contracept|on, even |f she were to reduce or qu|t her smok|ng.
ln Lhls secLlon, we revlew conLralndlcaLlons Lo oral conLracepLlves. 1he CuC has publlshed "u.S. Medlcal LllglblllLy CrlLerla for ConLracepLlve use, 2010" (31), whlch asslgns common medlcal condlLlons a gradlng sysLem of 1 Lo 4 regardlng Lhe safeLy of a parLlcular conLracepLlve meLhod, wlLh 1 represenLlng no resLrlcLlons and 4 essenLlally deflned as a conLralndlcaLlon. 1he recommendaLlons are evldence-based and updaLed regularly and of greaL value ln Lhe prescrlblng of conLracepLlon Lo women wlLh chronlc medlcal condlLlons.
Arter|a| and venous thrombos|s 1he LhromboLlc (boLh venous and arLerlal) rlsks assoclaLed wlLh comblned hormonal conLracepLlon sLem from Lhe esLrogen componenL and are relaLed ln a dose-dependenL manner. MosL of Lhe avallable daLa assesslng Lhe rlsks for LhromboLlc evenLs come from sLudles of oral conLracepLlves, buL are llkely appllcable Lo Lhe oLher forms of esLrogen-conLalnlng conLracepLlon (l.e. Loplcal paLch [CrLhoLvra], vaglnal rlng [nuva8lng], and monLhly ln[ecLlon [Lunelle - presenLly unavallable ln Lhe u.S]). aLlenLs aL rlsk for Lhese evenLs remaln candldaLes for progesLln-only conLracepLlon, such as uepo-rovera, lmplanon (an lmplanLable agenL effecLlve for 3 years) and Lhe progesLln-only plll ("mlnl-plll"). ln addlLlon, lnLrauLerlne devlces (copper or progesLln-releaslng) are hlghly rellable meLhods LhaL are safe for Lhese women.
Myocard|a| |nfarct|on ArLerlal evenLs (speclflcally myocardlal lnfarcLlon) are lncreased ln women who Lake comblned oral conLracepLlves. A recenL case-conLrol sLudy deLermlned LhaL comblned oral conLracepLlve use was assoclaLed wlLh an lncreased rlsk of myocardlal lnfarcLlon ln all age groups of women, excepL Lhose beLween ages 18-24, and Lhls was furLher lncreased by Lhe presence of Lobacco use, dlabeLes or hyperllpldemla. 1he overall odds raLlo for developlng a myocardlal lnfarcLlon on oral conLracepLlves was 2.0 (32, 33), wlLh sllghLly lower rlsk assoclaLed wlLh Lhe exLra-low dose" (20 mcg) formulaLlons. 1he absoluLe rlsk of Ml ls exLremely low (1 per 10,000 person-years), buL noneLheless needs Lo be consldered ln women wlLh rlsk facLors for coronary arLery dlsease, especlally slnce effecLlve alLernaLlve modes of conLracepLlon LhaL do noL conLaln esLrogen are avallable. 1he r|sk of coronary events |s the pr|mary reason that estrogen-conta|n|ng contracept|on |s not recommended for smokers age 3S and o|der. noLe LhaL Lhere ls evldence of a dose-response relaLlonshlp beLween smoklng and rlsk of cardlovascular evenLs wlLh use of comblned oral conLracepLlves. lor Lhls reason, Lhe CuC currenLly recommends agalnsL esLrogen-conLalnlng conLracepLlon for women age 33 and older who smoke > 13 clgareLLes a day, whereas smoklng fewer Lhan 13 clgareLLes a day by a woman age 33 or older represenLs a relaLlve conLralndlcaLlon (31). 1hls dlsLlncLlon ls noL unlversally accepLed, however, and many pracLlLloners advlse all smokers Lo swlLch Lo a progesLln-only meLhod or luu upon reachlng age 33 (27).
Stroke A recenL large uanlsh sLudy demonsLraLed LhaL use of comblned oral conLracepLlves approxlmaLely doubles Lhe rlsk of LhromboLlc sLroke, alLhough, once agaln, Lhe absoluLe rlsk remalns very small (33). 8ecall LhaL Lhe CuC (buL noL ACCC) conslders even well-conLrolled hyperLenslon a relaLlve conLralndlcaLlon Lo Lhe use of comblned conLracepLlon (31). Mlgralne wlLh aura and complex mlgralne (mlgralne wlLh neurologlc deflclL) are assoclaLed wlLh greaLer LhromboLlc Lendency and sLroke, and Lherefore esLrogen-conLalnlng conLracepLlon ls conLralndlcaLed ln such hosLs (34). Such use ls accepLable ln Lhe seLLlng of common mlgralne (mlgralne wlLhouL aura), alLhough Lhese paLlenLs requlre careful educaLlon and close monlLorlng, and alLernaLlve meLhods are recommended for such hosLs age 33 and older.
Venous thromboembo||sm 1he rlsk of venous Lhromboembollsm (v1L) ln comblned oral conLracepLlve users ls lncreased by Lhree Lo slx cases per 10,000 users among users compared Lo non-users (26). LsLrogen-conLalnlng conLracepLlon ls parLlcularly dangerous ln women wlLh lncreased rlsk of deep venous Lhrombosls (such as Lhose wlLh procoagulanL sLaLes) and should noL be used by women wlLh a hlsLory of v1L. AlLhough obeslLy ls a rlsk facLor for v1L, Lhe rlsk ln Lhese paLlenLs does noL appear Lo be lncreased wlLh Lhe addlLlon of comblned oral conLracepLlves, Lherefore, obeslLy ls noL a conLralndlcaLlon Lo Lhelr use. Slmllarly, Lhe presence of varlcose velns does noL preclude oral conLracepLlve use. Powever, a paLlenL wlLh a personal hlsLory of even *584"9#$#)- LhrombophleblLls should be consldered aL lncreased rlsk for developmenL of v1L on comblned oral conLracepLlves. Women wlLh a famlly hlsLory of v1L who deslre esLrogen-conLalnlng conLracepLlon should flrsL conslder undergolng screenlng for Lhrombogenlc muLaLlons. LasLly, Lhe rlsk of cerebral veln Lhrombosls ls clearly lncreased ln some women who Lake comblned oral conLracepLlves. (33)
AlLhough Lhe foregolng dlscusslon revlews Lhe slgnlflcanL morbldlLy and morLallLy LhaL comblned oral conLracepLlve use may lmparL, lL ls lmporLanL Lo remember LhaL whlle Lhe relaLlve rlsk may be slgnlflcanL, Lhe absoluLe rlsk of Lhese evenLs remalns qulLe low. Moreover, numerous sLudles have documenLed LhaL ln Lhe Lyplcal young and healLhy hosL oral conLracepLlves are remarkably safe agenLs. 1he followlng Lables summarlze Lhe conLralndlcaLlons Lo esLrogen-conLalnlng and progesLln-only conLracepLlves.
1ab|e 9: Contra|nd|cat|ons to estrogen-conta|n|ng contracept|on
1ab|e 10: Contra|nd|cat|ons to progest|n-on|y contracept|on
2J!BK !%4 )>&+4 7)>-4* L I MN -#*7 7%&*4 '40#$)- $&(0#7#&(* A%#$% 7%4 .:. $-)**#9#4* )* .)74,&"/ OPO &" OQ;P3O R")04 P #* ) O$&(0#7#&( 7%)7 "48"4*4(7* )( 5()$$487)>-4 %4)-7% "#*S #9 7%4 $&(7")$487#+4 '47%&0 #* 5*40OT R")04 Q #* O) $&(0#7#&( 9&" A%#$% 7%4 7%4&"47#$)- &" 8"&+4( "#*S* 5*5)--/ &57A4#,% 7%4 )0+)(7),4* &9 5*#(, 7%4 '47%&03O ?44 %4"4 9&" 95"7%4" 047)#-*H )(0 &7%4" "4-)7#+4 $&(7")#(0#$)7#&(*3 Case 13: Comb|ned ora| contracept|ves and cancer ?our nexL paLlenL ls a healLhy 23-year-old woman who ls lnLeresLed ln sLarLlng comblned oral conLracepLlves, buL sLaLes LhaL her moLher has breasL cancer and she ls concerned LhaL she may also develop breasL cancer lf she Lakes oral conLracepLlves. She also menLlons LhaL slnce her mensLrual perlod began yesLerday she wlll need Lo posLpone her ap smear. Per lasL ap smear, performed four years ago, was normal. Pow wlll comblned oral conLracepLlve use affecL her rlsk of cancer? A. SLudles have demonsLraLed an lncreased rlsk of breasL cancer when new-generaLlon comblned oral conLracepLlves are used ln women who have a flrsL-degree relaLlve wlLh breasL cancer. 8. Comblned oral conLracepLlves are causally llnked Lo Lhe developmenL of cervlcal cancer. C. Comblned oral conLracepLlves reduce Lhe rlsk of ovarlan cancer. u. Comblned oral conLracepLlves have no effecL on Lhe rlsk of endomeLrlal cancer. L. ?ou should noL prescrlbe Lhls paLlenL oral conLracepLlves unLll her ap smear ls performed. op Up Answers: A. lncorrecL. Whlle flrsL generaLlon oral conLracepLlves, wlLh Lhelr hlgh esLrogen componenL, were assoclaLed wlLh an lncreased rlsk of breasL cancer ln women wlLh a flrsL-degree relaLlve wlLh breasL cancer, no deflnlLe lncreased rlsk has been found wlLh recenL generaLlon comblned oral conLracepLlves 8. lncorrecL. 1he causal llnk beLween oral conLracepLlves and cervlcal cancer has noL been demonsLraLed. C. CorrecL! Women who have ever used comblned oral conLracepLlves decrease Lhelr rlsk of developlng ovarlan cancer. Women who use Lhem for more Lhan 10 years have an 80 rlsk reducLlon. u. lncorrecL. Cral conLracepLlves are assoclaLed wlLh a reduced rlsk of endomeLrlal cancer. L. lncorrecL. rovlslon of conLracepLlon ls unrelaLed Lo cancer screenlng. Summary Answer 1he correcL answer ls C: Comb|ned ora| contracept|ves reduce the r|sk of ovar|an cancer.
Whlle many are concerned abouL Lhe rlsks of cancer assoclaLed wlLh oral conLracepLlves, Lhe lncldence of cerLaln cancers ls acLually reduced ln women who use Lhem. revenLlon of eplLhellal ovarlan and endomeLrlal cancer ls an lmporLanL non-conLracepLlve beneflL of comblned oral conLracepLlves. (37)
Cra| Contracept|ves and Cvar|an, Lndometr|a|, 8reast and Cerv|ca| Cancers aLlenLs someLlmes mlsLakenly belleve LhaL oral conLracepLlves lncrease Lhelr rlsk of cancer. Powever, Lhelr Lyplcal use leads Lo a 40 reducLlon ln ovarlan cancer rlsk, a proLecLlon LhaL appears Lo lasL for aL leasL 13 years followlng dlsconLlnuaLlon. Women who Lake oral conLracepLlves for a decade or longer en[oy an 80 rlsk reducLlon (36). Slmllarly, oral conLracepLlves use leads Lo a halvlng of Lhe rlsk of endomeLrlal cancer, 1he currenL low-dose" comblned oral conLracepLlves have no effecL on breasL cancer rlsk (37,38), lncludlng for Lhose women wlLh a famlly hlsLory of breasL cancer (39).
1he relaLlonshlp beLween oral conLracepLlve use and cervlcal cancer remalns conLroverslal. Some buL noL all epldemlologlc sLudles have found a sllghLly lncreased rlsk for cervlcal cancer wlLh oral conLracepLlve use. Powever, poLenLlal blases have been clLed, among Lhem Lhe observaLlon LhaL oral conLracepLlve use may be a marker for greaLer exposure Lo Pv lnfecLlon. lf oral conLracepLlve use ls causally assoclaLed wlLh any lncreased rlsk of cervlcal neoplasla, lL ls of small magnlLude. Cne should noLe LhaL a hlsLory of cervlcal lnLraeplLhellal neoplasla ls noL a conLralndlcaLlon Lo oral conLracepLlves.
Improv|ng Access to Contracept|on 8oLh Lhe WPC and ACCC expllclLly sLaLe LhaL a pelvlc examlnaLlon ls noL necessary before prescrlblng comblned oral conLracepLlves (40, 41). Also, alLhough screenlng LesLs for S1us and cervlcal cancer have proven beneflL, Lhey are unrelaLed Lo Lhe use of hormonal conLracepLlon and, ln Lhe lnLeresL of opLlmlzlng access Lo conLracepLlon, should noL be consldered mandaLory before provldlng or conLlnulng Lhese meLhods. Moreover, paLlenLs have Lhe rlghL Lo choose whlch prevenLlve screenlng measures Lhey undergo.
Powever, one should Lake a hlsLory Lo conflrm LhaL Lhe paLlenL has no conLralndlcaLlon or serlous precauLlon Lo Lhelr use. Cne should also lnqulre abouL LhromboLlc Lendencles ln Lhe famlly and assess for Lobacco use. 1he paLlenL's blood pressure should be measured, buL no physlcal examlnaLlon ls requlred. ln 2012 ACCC publlshed a commlLLee oplnlon LhaL comblned oral conLracepLlves should be made avallable over Lhe counLer Lo lmprove access Lo conLracepLlon, as Lhe beneflLs of reduclng unwanLed pregnancles ouLwelgh Lhe poLenLlal rlsks. Women would screen Lhemselves for conLralndlcaLlons by uslng checkllsLs. luA approval llkely remalns a few years away (42).
Case 14: Lmergency Contracept|on A 20-year-old woman calls you whlle you are on call SaLurday mornlng and says LhaL she had unproLecLed lnLercourse Lhe nlghL before. Per lasL mensLrual perlod was one week ago, she has been pregnanL once before and had an elecLlve aborLlon. She has no medlcal problems. She wanLs Lo know lf emergency conLracepLlon would be approprlaLe. WhaL would be Lhe besL course of acLlon? A. Counsel her on Lhe efflcacy and posslble slde effecLs and recommend she purchase levonogesLrel 1.3 mg "over-Lhe-counLer". 8. 1ell her she musL come Lo your offlce on Monday for an evaluaLlon before Laklng emergency conLracepLlon. C. Advlse her LhaL she has Lo go Lo Lhe Lmergency 8oom, so she can have a pelvlc exam and pregnancy LesL before recelvlng emergency conLracepLlon. u. 8efuse Lo recommend emergency conLracepLlon, because dolng so would encourage furLher lrresponslble behavlor. L. Call ln a prescrlpLlon for comblned oral conLracepLlves and lnsLrucL her Lo Lake four LableLs lmmedlaLely, Lhen conLlnue Lhe medlcaLlon Lo prevenL furLher need for emergency conLracepLlon. op Up Answers: A. CorrecL! Lmergency conLracepLlon would be safe and effecLlve ln Lhls slLuaLlon. 8. lncorrecL. no furLher evaluaLlon ls necessary and delaylng Lhe prescrlpLlon could dlmlnlsh Lhe effecLlveness of emergency conLracepLlon. C. lncorrecL. AlLhough esLabllshed pregnancy ls a relaLlve conLralndlcaLlon (because Lhe medlcaLlon ls no longer "effecLlve"), Lhere ls no danger Lo Lhe pregnanL woman or Lhe feLus, oLher Lhan Lhe rlsks of slde effecLs, such as nausea and vomlLlng. elvlc exam ls llkewlse unnecessary. u. lncorrecL. AlLhough some are concerned LhaL Lhe provlslon of emergency conLracepLlon would encourage women Lo have unproLecLed lnLercourse, Lhere ls no evldence LhaL Lhls ls Lhe case, and denylng her Lhe LreaLmenL ln Lhls slLuaLlon would be negllgenL. L. lncorrecL. 1he ?uzpe meLhod (2 doses of comblned oral conLracepLlves Laken 12 hours aparL) has been replaced by levonorgesLrel and ullprlsLal reglmens, whlch are more effecLlve and assoclaLed wlLh fewer slde effecLs. lurLhermore, alLhough malnLenance conLracepLlon can be begun lmmedlaLely followlng a dose of emergency conLracepLlon, Lhe declslon Lo sLarL comblned oral conLracepLlves should noL be made wlLhouL furLher medlcal hlsLory-Laklng and blood pressure measuremenL. Summary answer 1he correcL answer ls A: Counse| her on the poss|b|e s|de effects and ca|| |n a prescr|pt|on for Levonorgestre| 1.S mg ("|an 8 Cne-Step "or "Next Cho|ce").
unlnLended pregnancy ls ma[or healLh problem LhaL can adversely affecL lndlvldual women and socleLy aL large. Lmergency conLracepLlon (or posL-colLal conLracepLlon) ls one measure LhaL can reduce Lhe rlsk of unlnLended pregnancy (and Lhe need for aborLlon). 1hls refers Lo Lhe use of hormone pllls afLer lnLercourse Lo prevenL pregnancy, someLlmes called "Lhe mornlng afLer plll".
lL has been known for years (buL llLLle publlclzed) LhaL pregnancy can be prevenLed by Laklng elghL low- dose comblned conLracepLlve pllls (four pllls conLalnlng 30-33 g eLhlnyl esLradlol Laken Lwelve hours aparL), up Lo 72 hours afLer lnLercourse. 1hls ls referred Lo as Lhe "?uzpe meLhod".
SubsequenL sLudles showed LhaL a reglmen of a progesLln alone, levonorgesLrel ls more effecLlve and assoclaLed wlLh fewer slde effecLs Lhan Lhe ?uzpe meLhod. (43, 44) 1he orlglnal reglmen of Lwo doses of levonorgesLrel Laken 12 hrs aparL (lan 8-no longer avallable) has now been replaced by a slngle dose of 1.3 mg (lan 8 Cne-SLep) wlLhouL lncrease ln slde effecLs (43). lL ls esLlmaLed LhaL Lhe levonorgesLrel reglmen prevenLs aL leasL 74 of expecLed pregnancles. AlLhough Lhe luA package lnserL clLes a llmlL of 72 hrs, per ACCC lL can be lnlLlaLed up Lo 120 hrs (3 days) afLer lnLercourse. Powever, effecLlveness decllnes wlLh lncreaslng delay beLween lnLercourse and LreaLmenL, and Lhe avallablllLy of Lhe new emergency conLracepLlve medlcaLlon, ullprlsLal, llkely alLers Lhls recommendaLlon.
ullprlsLal (Llla 30 mg, Laken once) ls a selecLlve progesLerone recepLor modulaLor LhaL became avallable ln 2010. lL ls superlor Lo Lhe levonorgesLrel and ?uzpe reglmens ln LhaL lL reLalns effecLlveness beyond 72 hrs and ls approved for use up Lo 3 days (120 hrs) afLer lnLercourse (46, 47). 8ecause more daLa are avallable for levonorgesLrel and a prescrlpLlon ls noL requlred, some auLhorlLles have suggesLed LhaL levonorgesLrel be recommended for emergency conLracepLlon ln mosL seLLlngs, excepL where admlnlsLraLlon ls delayed beyond 72 hours, aL whlch Llme ullprlsLal demonsLraLes superlor effecLlveness. More recenLly, however, evldence has lndlcaLed LhaL Lhe levonorgesLrel emergency conLracepLlon reglmen has decreased efflcacy ln obese women (48). lL has been recommended LhaL ullprlsLal (or emergenL copper luu lnserLlon) be uLlllzed for overwelghL or obese women wlLh a welghL exceedlng 70 kg (134 lb) (27). Powever, many pharmacles do noL sLock ullprlsLal, and arranglng urgenL luu placemenL ls ofLen noL feaslble, and Lhus Lhe levonorgesLrel reglmen remalns Lhe malnsLay of emergency conLracepLlon.
1he slde effecLs of Lhe progesLerone reglmens are mlld, wlLh Lhe mosL common belng nausea, headache and abdomlnal paln. 1he ?uzpe meLhod ls more ofLen assoclaLed wlLh vomlLlng, and some cllnlclans prescrlbe an anLl-emeLlc (preferably mecllzlne) (27) Lo be Laken one hour prlor Lo Lhe flrsL dose of Lhe ?uzpe reglmen, and for Lhe levonogesLrel reglmen lf severe nausea ls anLlclpaLed. lf vomlLlng occurs wlLh 3 hours of an emergency conLracepLlve dose, lL should probably be repeaLed. ln Lhe evenL of severe vomlLlng, emergency conLracepLlon may be admlnlsLered vaglnally. 1he only conLralndlcaLlon Lo LreaLmenL wlLh any of Lhese reglmens ls esLabllshed pregnancy. regnancy can be screened for over Lhe Lelephone (by lnqulrlng abouL LM), and Lhere ls no need for an offlce vlslL, examlnaLlon, or laboraLory LesLs. (43) 1he CuC speclflcally sLaLes LhaL, ln conLrasL Lo rouLlne use of hormonal conLracepLlon, Lhere are no medlcal condlLlons for whlch emergency conLracepLlon ls conLralndlcaLed (31). 1he mechanlsm of acLlon ls a delay ln or lnLerference wlLh ovulaLlon. Slnce a woman ls ferLlle durlng Lhe 3 days precedlng and Lhe day of ovulaLlon, emergency conLracepLlon ls beneflclal when Laken durlng LhaL Llme frame (approxlmaLely days 9-14 ln a classlc 28-day mensLrual cycle, alLhough Lhls frequenLly varles and more llberal prescrlblng ls [usLlfled). 1he paLlenL should be advlsed LhaL Lhe meLhod does noL proLecL agalnsL pregnancy from any subsequenL colLal acLs--lncludlng durlng Lhe same cycle. She can be assured LhaL emergency conLracepLlon cannoL lnduce an aborLlon and Lhere ls no evldence LhaL lL can harm a feLus.
AfLer Laklng emergency conLracepLlon a paLlenL should anLlclpaLe mensLruaLlon aL lLs usual Llme, or up Lo one week early or laLe. lallure Lo mensLruaLe wlLhln 21 days of LreaLmenL should prompL Lhe paLlenL Lo seek medlcal care. noLe LhaL a rouLlne meLhod of hormonal conLracepLlon can elLher be lnlLlaLed lmmedlaLely afLer Lhe emergency conLracepLlon, or aL Lhe onseL of menses, alLhough Lhls requlres assessmenL of relevanL medlcal hlsLory and knowledge of blood pressure. Lven lf rouLlne conLracepLlon wlLh oral conLracepLlves ls begun lmmedlaLely followlng Lhe emergency conLracepLlon (brldglng"), Lhe paLlenL remalns aL rlsk for pregnancy and musL use barrler conLracepLlon for Lhe flrsL 7-10 days.
rovldlng women wlLh emergency conLracepLlon has noL been found Lo lncrease Lhelr sexual acLlvlLy (49) - a concern ralsed by some. Many experLs argue LhaL physlclans could make emergency conLracepLlon more accesslble Lo women Lhrough such sLraLegles as prescrlpLlons ln advance (30). AlLhough prevlously lan 8 Cne SLep (and lLs generlcs such as nexL Cholce Cne uose, My Way and 1ake AcLlon) were avallable across Lhe counLer" followlng presenLaLlon of paLlenL lu (Lo verlfy age > 17) and Lhen dlscusslon wlLh Lhe pharmaclsL, lL ls now Lruly over-Lhe-counLer and on Lhe shelves ln pharmacy alsles, avallable for purchase by persons of any age wlLhouL resLrlcLlon. 1hese reglmens are covered by some buL noL all lnsurance plans, and are currenLly relaLlvely expenslve (Lyplcal reLall prlce $33-$30). AlLhough no longer ln common use, famlllarlLy wlLh Lhe ?uzpe meLhod and provlslon of a sample pack of CCCs ls someLlmes be helpful ln slLuaLlons of flnanclal hardshlp.
lL should be noLed LhaL Lhe mosL effecLlve form of emergency conLracepLlon ls Lhe emergenL lnserLlon of a copper lnLrauLerlne devlce (buL noL Lhe levonorgesLrel-releaslng luu) wlLhln 3 days of colLus.
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LonglLudlnal sLudy of human paplllomavlrus perslsLence and cervlcal lnLraeplLhellal neoplasla grade 2/3: crlLlcal role of duraLlon of lnfecLlon3 ! naLl Cancer lnsL 2010,102:313-3243 8. Saslow u, Solomon u, Lawson PW eL al. Cervlcal Cancer Culdellne CommlLLee. Amerlcan Cancer SocleLy, Amerlcan SocleLy for Colposcopy and Cervlcal aLhology, and Amerlcan SocleLy for Cllnlcal aLhology screenlng guldellnes for Lhe prevenLlon and early deLecLlon of cervlcal cancer. CA Cancer ! Clln 2012,62:147-172. 9. Massad LS, LlnsLeln MP, Puh Wk, eL al. 2012 ASCC Consensus Culdellnes Conference. 2012 updaLed consensus guldellnes for Lhe managemenL of abnormal cervlcal cancer screenlng LesLs and cancer precursors. ! Low CenlL 1racL uls. 2013,17(3 Suppl 1):S1-S27. 10. 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CbsLr Cyn 2004,190(Suppl 1):S30-S38. 46. llne , MaLh P, Clnde S, Culllns v, eL al. ullprlsLal aceLaLe Laken 48-120 hours afLer lnLercourse for emergency conLracepLlon. CbsLeL Cynecol 2010,113:237-63. 47. Clasler Al, Cameron S1, llne M, eL al. ullprlsLal aceLaLe versus levonorgesLrel for emergency conLracepLlon: a randomlsed non-lnferlorlLy Lrlal and meLa-analysls. LanceL 2010,373:333-62. 48. Clasler A, Cameron 1, 8llLhe u, eL al. Can we ldenLlfy women aL rlsk of pregnancy desplLe uslng emergency conLracepLlon? uaLa from randomlzed Lrlals of ullprlsLal aceLaLe and levonorgesLrel. ConLracepLlon. 2011,84(4):363-7. 49. Craham A, Moore L, Sharp u, ulamond l. lmprovlng Leenagers' knowledge of emergency conLracepLlon: clusLer and randomlsed conLrolled Lrlal of a Leacher led lnLervenLlon. 8M! 2002,324:1179-84. 30. Crlmes uA, 8aymond LC. Lmergency conLracepLlon. Ann lnLern Med 2002,137:180-9.