What treatments are available if a Pap smear is abnormal?
If a Pap smear is interpreted as abnormal, there are several different management and treatment options including colposcopy, conization, cryocauterization, laser therapy, and large-loop excision of the transformation zone.
All of these procedures have essentially the same overall cure rate of over 90%. However, the procedures do vary considerably in several other respects and so will be discussed separately.
Colposcopy is a procedure that allows the doctor to take a closer look at the cervix. The colposcope is essentially a magnifying glass for the cervix. For colposcopy to be adequate, the whole cervical lesion, as well as the whole transformation zone (the transition between the vagina-like lining and the uterus-like lining), must be seen.
During colposcopy, the cervix is cleaned and soaked with 3% acetic acid (vinegar). This mild acid not only cleans the surface of the cervix but also allows cellular abnormalities to show up as white areas (called acetowhite epithelium or acetowhite lesions).
If suspicious areas of cervical tissue are seen during colposcopy, a biopsy (tissue sampling) is often done. The sample is sent to the laboratory for analysis by a pathologist, and the biopsy results determine the next step in the treatment.
The procedure is essentially painless and quite simple, usually taking only several minutes to perform. Generally, the woman is instructed not to have intercourse, douche, or use tampons for about a week afterward if a biopsy is done. Pregnancy is not a contraindication to colposcopy. Colposcopy can adequately evaluate 90% of women who have abnormal Pap smear results.
Conization allows the entire area of abnormal tissue to be removed and provides the maximum amount of cervical tissue for laboratory evaluation to rule out the presence of invasive cancer. After the cervical area is visualized, generally by colposcopy, a small cone-shaped specimen of tissue is taken from around the endocervical canal.
Conization is usually done on an out-patient basis under anesthesia in a hospital or surgical facility. For three weeks after the procedure, the woman needs to avoid douching, using tampons, and refrain from sexual intercourse.
Cure rates close to 100% are achieved with conization as long as the cells along the margins of treatment are normal.
With conization, there are associated risks from anesthesia and postoperative hemorrhage (bleeding in about 10% of cases) as well as possible future adverse effects on fertility. Conization is generally performed only on women who have had severe changes on biopsy, have adenocarcinoma in situ (a diagnosis of cancer in the inner portion of the cervix), or whose Pap smears suggest they may have some invasion of cancer into the nearby tissue.
Large-loop excision (LEEP) of the transformation zone
Large-loop excision of the transformation zone (LEEP) removes the cervical transformation zone (the area where the vaginal-type lining changes to the uterine-type lining) using a thin-wire loop to administer electrocautery. It allows samples to be collected for additional tissue analysis and can be performed in the office under local anesthesia.
Specialized (more frequent) follow-up is necessary after LEEP. This follow-up includes Pap smears, colposcopy, and sometimes other techniques. This is now the most commonly used treatment for Pap smear abnormalities.
A hysterectomy for the treatment of abnormal Pap smears is appropriate only for those women who are finished with childbearing and have severe pre-cancerous abnormalities that have persisted despite other treatments.