HPV Infection

Koilocytosis on a Pap smear is evidence of an HPV infection, but does not mean that a patient needs routine colposcopic assessment. Often this change will be in conjunction with mildly dyskaryotic cells. If the problem persists then colposcopic examination is recommended. If evidence of a clinical HPV lesion (condyloma is noted on the cervix or upper vagina) is noted, then colposcopic examination may help the assessment of the severity and location of lesions.

CIN I (Mild Dysplasia)
Patients in whom the initial cytological examination shows mild dysplasia are generally followed by repeat smear on a six month basis. Persistence or progression of these lesions should lead to treatment by appropriate methods. In young women with persisting dysplasia of this type and ectocervically located lesions, cryotherapy or laser therapy may be employed to eradicate the lesion.

CIN II (Moderate Dysplasia)
Patients with Pap tests showing moderate dyskaryosis or CIN II should be evaluated by colposcopy. Moderate dysplasia is usually treated with cryotherapy or laser therapy.

A variety of treatment methods are available for the management of these lesions. A decision as to the appropriate treatment method is made after consideration of several factors amongst which is the age of the patient and her desire for future pregnancies.

In women who have completed their families and in whom other gynecological conditions exist simple hysterectomy either by the abdominal or vaginal route remains an acceptable method of treatment with the lowest recurrence or new disease rates for this disorder. This method also precludes further cervical or uterine pathology.

In women who have not yet completed their families and in whom the colposcopic examination has been classified as satisfactory, i.e., visualizing the entire lesion squamocolumnar junction with good cytologic and colposcopic correlation, cryotherapy, electrosurgical loop excision procedures or laser therapy may be employed to eradicate the disease focus. These methods have a negligible complication rate and will not adversely affect fertility or further reproductive function. In addition they have the advantage of being ambulatory treatment methods without the need of anaesthesia and minimal analgesia. For women in whom the lesions extend into the endocervical canal or in whom the colposcopic examination is unsatisfactory, cervical conization becomes the recommended method. We recommend cold-knife conization rather than loop electrosurgical techniques if diagnostic cone biopsy is needed because of the generally superior histological specimen with the former technique. If properly performed, cervical conization will have minimal effects on future reproductive function and will have a complication rate of less than five to ten percent. Patients who have undergone treatment with surgical conization in whom questionable margins or incomplete excision has been reported required meticulous follow-up. Smears and endocervical curettage may help ensure persisting disease or more advanced pathology does not go unrecognized. Routine Pap smear follow-up for these individuals may be somewhat less than ideal as it may be difficult to obtain good quality smears from the area at greatest risk.