recommend having this app on your phone. And recommendations for these are mostly based on risk of CIN3 or worse in the next five years. So I'm gonna do this as a case-based. There are questions in here, but given the number of people, I think it'll just be easier if I keep going rather than pausing for someone to answer all of these questions. So this is a 35-year-old G5P5 non-pregnant female who presents to you for a routine gynecologic exam. She has a history of five prior vaginal deliveries and she has never had a pap smear. What are the appropriate tests to perform during this visit? So for any routine gynecologic visit, she'd need a complete history and physical, both a pelvic and a breast exam. Given that she's never had a pap smear, she would be due for a pap smear with HPV co-testing if available. You can offer her STI screening and then you can consider checking a CBC, TSH, and glucose as part of her routine exam. So she has a pap smear as indicated and it shows the following histopathology. And we'll go over what this means in a second, but you can see these cells kind of going all the way up. And so her pathology report reads high-grade squamous intraepithelial lesion and her HPV test is positive for HPV16. So given that this patient had this particular pap smear as well as never having a pap smear before in her life, her risk of CIN3 based on this information alone is about 60%. So when looking at the preferred next step in the workup, the thing that mainly drives her treatment is that 60%. So the first question is, what is their immediate risk of CIN3 or higher? And the threshold is 4%. So hers is definitely higher than 4%. And then the next threshold is all the way up here. So her risk is 64%, in which case we would recommend expedited treatment if possible. I think it's important to note that the only reason that her risk goes all the way up to 60% in this algorithm is because she's never been tested before. So you perform a leap with final pathology showing CIN3 with negative margins and no invasive carcinoma. What is the appropriate follow-up for this patient? So as we kind of already talked about with the patient that you presented earlier today, she needs follow-up within six months, and that would be a pap smear with HPV co-testing. If that's normal, then she needs to be tested every year for three years, at which point, if those are normal, she can go back to routine screening. So what if this patient had had regular pap screening and her previous pap was L-cyl HPV18 positive with a normal Colpo? So in a patient who's actually had routine screening, that changes her level of risk. So in this case, you would actually start with a Colposcopy rather than going straight to treatment. Does anyone have any questions about the first case before we move on? Okay. So the next case is a 45-year-old P3, non-pregnant perimenopausal female who presents to you for a repeat pap smear. One year ago, her pap smear was L-cyl HPV18 positive and a negative Colposcopy. Her pap smear today shows H-cyl HPV18 positive. Based on the ASCCP guidelines, you decide to perform a Colposcopy and ECC. Visually, her cervix looks like this. You perform a biopsy of the kind of wider areas as well as an ECC. Pathology from the biopsy and ECC demonstrate adenocarcinoma in situ. What is the recommended next step? So in this case, as we've already talked about, the recommendation would be for a leap or a cold knife cone, but we generally prefer the cold knife cone if possible because it allows for a greater depth, less artifact, and an intact and oriented specimen. This procedure allows us to both confirm the diagnosis as well as to rule out any underlying carcinoma. So you perform the cold knife cone and ECC. Her final pathology demonstrates AIS without evidence of carcinoma and her ECC is negative. What is the recommended next step? So as we kind of already talked about today, the recommendation in this patient who is done with trial bearing would be for a hysterectomy, which allows you to definitively rule out any underlying carcinoma and prevent recurrence of her AIS.

abnormal pap smears

follow-up procedures

high-grade squamous intraepithelial lesion

loop electrosurgical excision procedure

cervical intraepithelial neoplasia grade 3