This month, Risa Denenberg, RN, FNP, an expert in gynecological care and a longtime advocate for women with HIV, discusses the Pap smear results of AIDS activist Marlene Diaz.
When Marlene went to her gynecologist for a routine pelvic exam, she reported no unusual symptoms, and her doctor found nothing wrong during the physical. But her Pap smear, a standard screening test for cervical cancer, came back showing cell changes, a worrisome problem more common in HIV positive women.
A Pap smear samples cells from the cervix (the passageway between the vagina and the uterus) by gently scraping its surface with a small, flat wooden stick, or by twirling a small brush just inside the cervical canal. Technique is key, since it is relatively easy to miss an area of abnormal cells. Improper technique can also damage the cells when they’re collected or when the slide is prepared for the lab.
Choosing the best slide preparation method is also crucial. Marlene’s doctor ordered a comparatively new technique called thinprep pap that disperses the cells into a liquid preservative. This method—slightly more expensive than a traditional Pap—prevents cells from being heaped on top of one another, which makes them difficult to examine.
In Marlene’s case, the finding was epithelial cell abnormality, meaning that there are abnormal cervical cells. The descriptive diagnosis adds that this is a low grade squamous intraepithelial lesion (SIL), and that a more advanced lesion may be present. This means that cellular changes were found that may or may not indicate a precancerous condition.
Some women’s Pap smears—but not Marlene’s—find white blood cells that could indicate inflammation or infection (if confirmed and treated, a Pap would then be repeated). Another possible finding is cell changes that suggest the presence of human papillomavirus (HPV), some strains of which are linked to development of cervical cancer. This result usually indicates an earlier stage of cell changes, and thus a less serious condition.
Cellular abnormalities are graded according to their severity and potential for turning into cancer. Marlene’s low-grade SIL (also called cervical intraepithelial neoplasia, grade 1 [CIN 1]) is the least serious. A high-grade SIL (sometimes labeled as CIN 2 or CIN 3) would be more worrisome. A CIN 3 may also be called carcinoma in situ (CIS), meaning a very early and treatable form of cancer.
In any case, a further examination is needed to determine the actual stage of an abnormality. Marlene will next receive an examination of her cervix under magnification (a colposcopy) during which tissue samples (biopsies) will be taken from the affected areas. It is important to understand that this abnormal Pap finding does not mean that Marlene has cervical cancer. She just needs follow-up diagnostic testing that, although uncomfortable, will likely result in a negative—and thus reassuring—biopsy report.
If the problem turns out to be serious, it can usually be treated effectively by a variety of methods, even in a woman with HIV. (When diagnosed late, cervical cancer can be fatal—in fact, the majority of deaths occur in women who’ve never had a Pap.) And since Marlene is doing well right now with her CD4 cell count and viral load, treatment (if needed) will probably be successful. While the usual recommendation for women HIVers is twice-annual Pap smears, Marlene will need follow-up exams every three months for at least a year (or longer if more cell changes appear).
For both initial and follow-up cervical cancer screening, some new tests are on the scene: PPS (Pap Plus Speculoscopy; see “Cervix Service,” POZ, June 1998) is a procedure said by its manufacturer to be almost as sensitive as a colposcopy. Some women may want to obtain a computer-generated review of a Pap smear (called PAPNET), or receive testing for HPV in addition to the Pap. These tests may turn out to be more accurate than the standard Pap alone, but they have not been around long enough to know for sure. In the meantime, regular Pap smears and follow-up care can prevent cervical cancer in women like Marlene.
Risa Denenberg’s book, Gynecological Care Manual for HIV Positive Women, is available from EMIS at 800.225.0694. Women with HIV can call the Women Alive hotline at 800.554.4876 with medical questions, or obtain Project Inform’s fact sheets for women HIVers at 800.822.7422 or www.projectinform.org