Most abnormal pap smears are a result of an infection of the cervix, vagina or vulva with the human 
        papillomavirus ( HPV ).  Some strains of the virus are more dangerous than others and are associated
       with the development of cancer. High grade HPV subtypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 
       and 68 have been associated with severe forms of pre-cancerous lesions and invasive cancer of
       the cervix, vagina and vulva. DNA testing is available to detect if there is a Low Grade HPV subtype
       ( non-cancerous) or a High Grade HPV subtype.  Approximately 2—5% of all pap smears will have an
       abnormal result. Some abnormal pap smears are as a result infection and inflammation. Yeast infections,
       herpes, trichomonas, and recent sexual activity may cause an abnormal Pap smear.                                                                                

                                                             Abnormal Pap Smear Classification

                        ASCUS  -   Atypical cells of undetermined significance

                       LGSIL  -     Low grade squamous intra-epithelial neoplasia or Mild  dysplasia   

                       HGSIL  -    High grade squamous intraepithelial neoplasia or Moderate or Severe dysplasia  

                       CIS   -     Carcinoma in Situ is one stage before cancer of the cervix

                       Cancer of the cervix  -  abnormal cells invading deep layers of cervix

       What is cervical dysplasia?

The term "plasia" means growth. Cervical dysplasia means disordered growth. It is easier
to understand cervical dysplasia if we first examine the normal cervix. When we look at the
lining of the normal cervix under a microscope we see layers of cells. The normal distribution
is that the bottom layer is made of round young cells. As the cells mature they rise to the
surface and flatten out, so that on the surface the cells are flat.

In cervical dysplasia there is a lack of this organized growth process. In mild dysplasia
 (CIN I) only a few cells are abnormal, while in moderate dysplasia (CIN II)the abnormal cells
 involve about one-half of the thickness of the surface lining of the cervix.

In severe dysplasia or carcinoma-in-situ  (CIN III) the entire thickness of cells is disordered,
 but the abnormal cells have not yet spread below the surface. Carcinoma-in-situ means
 "cancer in place". If this condition is not treated, it often will grow into an invasive
 cervical cancer.

In dysplasia and carcinoma-in-situ, all of the abnormalities are confined to the surface
lining (or "skin") of the cervix. In invasive cancer, the cells are not only disordered
throughout the entire thickness of the lining, but they invade the tissue underlying
the surface. Invasive cancer is treated entirely differently than dysplasia.

              HPV, human papillomavirus, infection is the most common reason for dysplasia and abnormal pap
      smears of the cervix.  In ASCUS only very few of the cells of the cervix are abnormal. As is demonstrated in
      the diagram above, in a pap smear with LGSIL or Mild Dysplasia only a few cervical cells are abnormal,
      while in Moderate Dysplasia the abnormal cells involve about halfof the thickness of the surface lining
      of the cervix. In Severe Dysplasia, or Carcinoma In-Situ the entire thickness of the cervix is disordered
      but the abnormal cells have not yet spread below the surface of the cervix. In Invasive Cancer the cells are
      not only disordered throughout the entire thickness of the lining, but they invade the tissue underlying the
      surface of the cervix.

              
                     Symptoms and Signs of Abnormal Cells of the Cervical, Vaginal and Vulvar Areas

          Vaginal bleeding, drainage and discharge, vaginal odor, irritation, vulvar itching, sores or ulcers,
      raised lesions, and discoloration are many of the symptoms and signs occurring with the presence of
      pre-cancerous and cancerous cells.Blood vessels in the cervical tissue are disrupted and often
      heavy bleeding occurs between menstrual periods because of the presence of these abnormal cells. 
      Most times no symptoms occur.                                  

                                                               
                                                               
       Pelvic Infection—is often associated with irregular, heavy bleeding and abnormal pap smears.
      Bacteria in the vagina often migrate up into the cervix, uterus, and fallopian tubes causing infection of the
      lining of these structures. Swelling and inflammation of the lining in the uterus causes large amounts
      of tissue to fall or break off, thus causing heavy bleeding during and between menstrual periods.
      Inflammation of the cervix may also cause cervical cells to appear abnormal microscopically, thus leading
      to abnormal pap smear readings.                    

      Sexually transmitted diseases such as trichomonas, bacterial vaginosis and gonorrhea are often
      associated with irregular bleeding and abnormal pap smears. Proper diagnosis and early antibiotic
      treatment help to avoid severe infection in the cervix, uterus, tubes and ovaries that can lead to scarring
      of the pelvis and difficulty in getting pregnant.

             Endometrial cancer is another common cause of abnormal pap smears and heavy bleeding.
       Abnormal cells in the lining of the uterus multiply out of control and form very thick tissue called
       endometrial hyperplasia. Further growth of these abnormal cells forms cancer cells and is often
       associated with heavy bleeding. These cells may come through the cervix and be found in the cells
       of a pap smear. This cancer is often seen in women over fifty who have hypertension, are overweight,
       and often have a past history of using estrogen hormone replacement therapy ( Premarin, Estrogen, etc.).
       Months and years of high estrogen levels stimulate the cells in the lining of the uterus to multiply and produce
       endometrial hyperplasia, pre-cancerous cells and endometrial cancer. Any mature women, who stops
       her normal monthly menses for one year or more and then starts to bleed again, should immediately visit her
       gynecologist to be evaluated for possible abnormal cells in the uterus. Treatment for early endometrial
       cancer is very successful and usually involves removal of the uterus via a hysterectomy. Advanced
       cases may require chemotherapy and radiation therapy.

                                                                  Diagnosis and Treatment

                Colposcopy is a procedure utilizing a powerful magnifying device or digital camera with video capabilities
      ( Digital Colposcopy) to examine the vulva, vagina, and cervix. It is done most often to diagnose the severity
      of the abnormality of the pap smear, and helps directs the doctor to areas that need biopsy samples.
      Digital colposcopy allows providers to photograph and document abnormal areas for future reference 
      ( i.e.– genital warts, vaginal infections, pre-cancerous and cancerous lesions of the cervix, vagina
      or vulva, or any other abnormality). This process allows both the patient and the doctor to observe the
      benefits of treatment or the progression of a disease process. Colposcopy is also utilized to inspect the
      cervix and genital region if a DNA test reveals a High Risk Type of HPV is present or an abnormal biopsy
      result occurs.

                                                                    Digital   Colposcopy

           To perform the procedure, treatment consents are signed, a routine pelvic exam set-up is utilized, and then
      the doctor places some vinegar and sometimes some iodine on the vagina and cervix with a cotton swab to
      see the problem area. A television screen is beside the patient’s bed to allow the patient, and a family member
      or partner, to see exactly what the doctor sees. Abnormal areas often appear as white areas on the cervix,
      vagina, and vulva.

             Treatment involves early diagnosis and removal of these abnormal cells of the cervix before the
      development of cancer. Excision of these abnormal cells is performed with local anesthesia. Hysterectomy
      may be suggested if carcinoma in- situ or invasive cancer is present.

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                               KENNETH GOODRICH, M.D.  -  OBSTETRICIAN- GYNECOLOGIST  
     
                                           Certified by the American Board of Obstetrics and Gynecology

           Specializing in General Obstetrics and Gynecology, Minimally Invasive Gynecological Surgery- Hysterectomies
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