1. Cervical Cancer Screening and Sexually Transmitted Infections Case Studies

2. VETERANS HEALTH ADMINISTRATION Joyce, a 32-year-old returning veteran, comes in for a Well Woman visit. She has a history of an “abnormal Pap” before her deployment which was two years ago. Vital signs: 5 feet 6 inches tall, 141 lbs., HR 75, RR 17, temp 97.9 F, BP 122/82, non-smoker. 2 Case Study 1

3. VETERANS HEALTH ADMINISTRATION Q1: Joyce’s Pap smear results come back as “ASC- US (atypical squamous cells of undetermined significance)”. What would you do next? A.If liquid-based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy. B.Refer immediately to colposcopy. C.Repeat Pap test in 6 months. 3

4. VETERANS HEALTH ADMINISTRATION Q1: Joyce’s Pap smear results come back as “ASC- US (atypical squamous cells of undetermined significance)”. What would you do next? A.If liquid based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy. B.Refer immediately to colposcopy C.Repeat Pap test in 6 months 4

5. VETERANS HEALTH ADMINISTRATION Discussion Points Option A: Reflex testing for HPV (if liquid cytology is used, or if a separate sample is collected at time of Pap) is preferred for patient convenience and cost-effectiveness − Women who test HPV negative: risk of harboring CIN 2/3+ is less than 2%; can perform co-testing in 3 years − Women who test HPV positive: refer for colposcopy due to 15-27% chance of CIN 2/3+ (unless under the age of 25 where repeat testing in 1 year is suggested) Option B: Proceeding immediately to colposcopy is no longer recommended 5

6. VETERANS HEALTH ADMINISTRATION Discussion Points Option C: If reflex HPV testing is not available, a follow-up Pap in 1 year is an option. If one-year FU is ASCUS or worse, colposcopy is recommended. − The rate of loss to follow-up is substantial: 1.Loss of 15–25% in research settings 2.Loss of 54–81% in clinical practice settings 6

7. VETERANS HEALTH ADMINISTRATION Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond? A.<1% B.1-5% C.6-10% D.>10% 7

8. VETERANS HEALTH ADMINISTRATION Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond? A.<1% B.1-5% C.6-10% D.>10% 8

9. VETERANS HEALTH ADMINISTRATION The risk of cancer is very low (0.1–0.2%), and the risk of CIN 2/3+ for any individual patient is also low (2%) Discussion 9

10. VETERANS HEALTH ADMINISTRATION Q3: What if Joyce’s Pap smear results come back as “L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step? Use the table on the next slide to guide your decision. 10 A.Repeat Pap smear immediately B.Repeat Pap smear in 6 months C.Refer for colposcopy

11. 11 Pap resultCIN1CIN2/3Cancer Normal Papup to 10%<1%0.25% ASC-US, HPV neg<10%<1.5%<0.01% Normal Pap, HPV+<1.1%<0.08% ASC-US, HPV+50-60%7-18%<0.1% LGSIL50-60%2-19%0.16% HGSIL20%up to 70%7% Management options for L-SIL result, no co-testing: A.Repeat Pap smear immediately B.Repeat Pap smear in 6 months C.Refer for colposcopy

12. VETERANS HEALTH ADMINISTRATION 12 A.Repeat Pap smear immediately B.Repeat Pap smear in 6 months C.Refer for colposcopy Q3: What if Joyce’s Pap smear results come back as “L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step?

13. VETERANS HEALTH ADMINISTRATION An L-SIL diagnosis is associated with a positive test result for high- risk HPV in most women (83% of the women with L-SIL cytology according to the ALTS study*). Therefore, reflex HPV testing is of limited value for triaging colposcopy. There is a high incidence of CIN 2 and 3 in patients with L-SIL (15% and 30% respectively). However, for women under the age of 25 with L-SIL, regardless of HPV status, immediate colposcopy is not recommended. Discussion *The ASCUS/LSIL Study (ALTS) Group. J Natl Cancer Inst, 2000: 92:397-402. 13

14. VETERANS HEALTH ADMINISTRATION Q.4: What if Joyce’s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)? What is your next step? Use the table on the next slide to guide your decision. A.Repeat Pap smear immediately B.Repeat Pap smear in 6-12 months C.Refer to Gynecology for colposcopy and/or other procedures 14

15. 15 Pap resultCIN1CIN2/3Cancer Normal Papup to 10%<1%0.25% ASC-US, HPV neg<10%<1.5%<0.01% Normal Pap, HPV+<1.1%<0.08% ASC-US, HPV+50-60%7-18%<0.1% LGSIL50-60%2-19%0.16% HGSIL20%up to 70%7% Management options for H-SIL result: A.Repeat Pap smear immediately B.Repeat Pap smear in 6-12 months C.Refer to Gynecology for colposcopy and/or other procedures

16. VETERANS HEALTH ADMINISTRATION A.Repeat Pap smear immediately B.Repeat Pap smear in 6-12 months C.Refer to Gynecology for colposcopy and/or other procedures 16 Q.4: What if Joyce’s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)”? What is your next step?

17. VETERANS HEALTH ADMINISTRATION Among women with H-SIL cytology results, greater than 70% have been reported to have CIN2 or CIN3, and 1-5% harbor invasive cancer. Therefore, a referral to a gynecologist for colposcopy is essential. Discussion 17

18. VETERANS HEALTH ADMINISTRATION Joyce, continued… Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are possible diagnoses? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) F.All of the above 18

19. VETERANS HEALTH ADMINISTRATION Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are the possible diagnoses? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) F.All of the above 19

20. VETERANS HEALTH ADMINISTRATION Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities? 20

21. VETERANS HEALTH ADMINISTRATION Sexual history to distinguish between infections that are sexually transmitted and other reproductive tract infections Query any recent antibiotic use, diabetes, or immunosuppression (make candida more likely) Inspect the vulva, looking for areas of erythema, edema, ulceration or chronic vulvar skin changes. Palpate with a cotton- tipped applicator to elicit areas of tenderness. Inspect the vagina and cervix Assess the color, consistency, and odor of discharge Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities? 21

22. VETERANS HEALTH ADMINISTRATION Q7. What are the next diagnostic steps? A.Vaginal pH B.Amine (whiff test) C.Potassium hydroxide (KOH) smear D.Normal saline microscopy E.BD Affirm TM point of care testing F.All of the above 22

23. VETERANS HEALTH ADMINISTRATION A.Vaginal pH B.Amine (whiff test) C.Potassium hydroxide (KOH) smear D.Normal saline microscopy E.BD Affirm TM testing F.All of the above Q7. What are the next diagnostic steps? 23

24. VETERANS HEALTH ADMINISTRATION Obtain specimens from lateral vaginal wall for laboratory evaluation. Evaluations should include vaginal pH, amine (whiff) test, saline and 10% potassium hydroxide (KOH) smears for microscopic examination. Normal pH ( 4.5 has a limited differential diagnosis. Perform whiff test for amines by placing a drop of 10% KOH on vaginal secretions and checking for fishy odor. Saline microscopy permits identification of trichomonads and clue cells. BD Affirm TM can identify candida species, trichomonas vaginalis, and gardnerella vaginalis. Turnaround time may vary by facility. Discussion 24

25. VETERANS HEALTH ADMINISTRATION Q8. Your exam reveals a positive whiff test and a pH >5. What is the most likely diagnosis? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) 25

26. VETERANS HEALTH ADMINISTRATION Q8. Your exam reveals a positive whiff test and a pH >5. What is the most likely diagnosis? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) 26

27. VETERANS HEALTH ADMINISTRATION Q9. What treatment is least effective? A. Oral Metronidazole B. Topical Metronidazole C. Clindamycin D. Tinidazole E. Triple sulfa 27

28. VETERANS HEALTH ADMINISTRATION Q9. What treatment is least effective? A. Oral Metronidazole B. Topical Metronidazole C. Clindamycin D. Tinidazole E. Triple sulfa 28

29. VETERANS HEALTH ADMINISTRATION Q10. Which of the following would you NOT do if Joyce’s symptoms don’t improve? A. Re-evaluate for cure B. Re-evaluate for another cause of vaginitis C. Recommend douching D. Query about unprotected sex 29

30. VETERANS HEALTH ADMINISTRATION Q10. Which of the following would you NOT do if Joyce’s symptoms don’t improve? A. Re-evaluate for cure B. Re-evaluate for another cause of vaginitis C. Recommend douching D. Query about unprotected sex 30

31. VETERANS HEALTH ADMINISTRATION Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) 31

32. VETERANS HEALTH ADMINISTRATION Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge (diagnosis of exclusion) E.Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP) 32

33. VETERANS HEALTH ADMINISTRATION Q12. Which treatment would you NOT consider? A. Topical imidiazole B. Topical metronidazole C. Oral fluconazole 33

34. VETERANS HEALTH ADMINISTRATION A. Topical imidiazole B. Topical metronidazole C. Oral fluconazole Q12. Which treatment would you NOT consider? 34

35. VETERANS HEALTH ADMINISTRATION Discussion Point Oral fluconazole is good if Joyce has already tried topical imidiazole Also, topical treatment is messy and the oral fluconazole is a one-dose pill 35

36. VETERANS HEALTH ADMINISTRATION Q13. Which of the following would you do if Joyce’s symptoms don’t improve? A. Obtain a culture to confirm type of candida B. Assess for risk factors that potentially promote candida C. Treat the infection for longer period of time 36

37. VETERANS HEALTH ADMINISTRATION Q13. Which of the following would you do if Joyce’s symptoms don’t improve? A. Obtain a culture to confirm type of candida B. Assess for risk factors that potentially promote candida C. Treat the infection for longer period of time All options are feasible. 37

38. VETERANS HEALTH ADMINISTRATION Option A: May be dealing with another type of candida (candida tropicalis or candida glabrata) which doesn’t respond well to fluconazole. Obtain a culture to confirm type of candida. Option B: Many women have risk factors that could promote candida. Assess for antibiotic use (e.g., acne treatment), change to a different/low-dose OCP, assess for diabetes mellitus and confirm that she is well controlled. Options C and D: May need to treat infection for a longer period of time (repeat doses of fluconazole on day 4/7). Consider treating Joyce’s partner. Discussion Points 38

39. VETERANS HEALTH ADMINISTRATION Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and pH is normal. What is the most likely diagnosis? A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge E.Atrophic vaginitis 39

40. VETERANS HEALTH ADMINISTRATION A.Bacterial vaginosis B.Candidiasis C.Trichomoniasis D.Physiologic discharge E.Atrophic vaginitis Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and pH is normal. What is the most likely diagnosis? 40

41. VETERANS HEALTH ADMINISTRATION Q15. What treatment would you provide? A. Metronidazole 2gm oral dose x 1 B. Tinidazole C. Topical Metronidazole D. Oral fluconazole 41

42. VETERANS HEALTH ADMINISTRATION A. Metronidazole 2gm oral dose x1 B. Tinidazole C. Topical Metronidazole D. Oral fluconazole Q15. What treatment would you provide? Joyce’s partner should also be treated as trichomonas is a sexually transmitted infection 42

43. VETERANS HEALTH ADMINISTRATION Q16. What would you do if Joyce’s symptoms don’t improve? 43

44. VETERANS HEALTH ADMINISTRATION Query about unprotected sex, other partners, and adherence to medication by Joyce and her partner. Reassess for other cause of vaginitis after treatment (i.e., candida after exposure to ABX). Q16. What would you do if Joyce’s symptoms don’t improve? 44

45. VETERANS HEALTH ADMINISTRATION Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI? 45

46. VETERANS HEALTH ADMINISTRATION There are three major concerns… 1.Discuss her sexual practices: Address the issue of multiple sexual partners in a sensitive fashion. Ensure you understand the following: Are all of her sexual encounters consensual? This addresses the possibility of rape or sexual abuse. What are Joyce’s motives for having multiple sexual partners? This can reveal possible psychological problems, low self- esteem, substance use, etc. 2.Discuss her high risk of further STI exposure from unprotected sex 3.Discuss contraception Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI? 46