Obgyn · Year 3 · from Obgyn
Case 1: Abnormal Pap Smear with HSIL
Patient Demographics
- Age: 32 years
- Sex: Female
- Occupation: Dental hygienist
Chief Complaint
"I got a call that my Pap smear was abnormal and I need to come in for more testing."
History of Present Illness
The patient is a 32-year-old G2P2 who presents for colposcopy after an abnormal Pap smear. Her routine cervical cancer screening performed 2 weeks ago revealed high-grade squamous intraepithelial lesion (HSIL). She is understandably anxious and wants to know what this means and what to expect today.
Gynecologic History
- Menarche: Age 12
- Menstrual cycles: Regular, 28-day cycles, 5 days of flow
- Last menstrual period: 10 days ago
- Prior Pap smears: Normal at ages 25, 28, 30
- HPV vaccination: Not vaccinated (not available during adolescence)
- Contraception: Copper IUD placed after last pregnancy
- STI history: Treated for chlamydia at age 22
- Sexual history: 3 lifetime partners, currently monogamous
Obstetric History
- G2P2002
- Two uncomplicated vaginal deliveries at term
Pap Smear Result
- Cytology: High-grade squamous intraepithelial lesion (HSIL)
- HPV testing: Positive for high-risk HPV (type 16 detected)
Pre-Colposcopy Counseling
Explained to patient:
- HSIL indicates precancerous changes that require further evaluation
- Colposcopy involves magnified examination of the cervix
- Biopsies may be taken, which causes mild cramping
- This is NOT cancer, but needs treatment to prevent cancer
Colposcopy Procedure
Visualization:
- Adequate colposcopy (transformation zone fully visible)
- IUD strings visualized, not removed
After Acetic Acid (3-5%) Application:
- Large area of dense acetowhite epithelium at 12-3 o'clock
- Sharp, distinct margins
- Punctation pattern visible (stippled appearance)
- Mosaic pattern at 2 o'clock
- No atypical vessels
Schiller's Iodine (Lugol's):
- Non-staining area corresponding to acetowhite lesion
- Confirms abnormal epithelium (lacks glycogen)
Biopsies Taken
- Directed biopsies x 3 from most abnormal-appearing areas
- Endocervical curettage (ECC) performed
Histopathology Results (1 week later)
Cervical Biopsies:
- CIN 3 (carcinoma in situ) at 12 o'clock position
- CIN 2 at 2 o'clock position
- CIN 2 at 3 o'clock position
Endocervical Curettage:
- Negative for dysplasia
Diagnosis
Cervical Intraepithelial Neoplasia 3 (CIN 3)
- High-grade precancerous lesion
- HPV 16 positive (highest-risk type)
- No invasion on biopsy
Treatment Recommendation
Loop Electrosurgical Excision Procedure (LEEP)
Procedure Discussion:
- Outpatient procedure under local anesthesia
- Wire loop removes transformation zone
- Provides tissue for histologic evaluation
- Confirms margins and rules out invasion
- High cure rate (>90%)
LEEP Procedure (performed 2 weeks later)
Findings:
- Local anesthesia: Lidocaine with epinephrine
- Cervix visualized with colposcope
- Transformation zone excised with single pass
- Specimen oriented and sent to pathology
- Hemostasis with Monsel's solution
- EBL <5 mL
LEEP Pathology:
- CIN 3 present
- Margins: Negative (clear ectocervical and endocervical margins)
- No invasive carcinoma
Post-Treatment Surveillance
- Counseled on importance of follow-up
- HPV/Pap co-testing at 6 months
- If negative, annual co-testing for 3 years
- Then return to routine screening if all negative
- Elevated cancer risk persists for 25 years; continued screening essential
Clinical Image
Image Description: Colposcopic image of the cervix after application of acetic acid demonstrating a large area of dense acetowhite epithelium with sharp borders and punctation pattern, characteristic of high-grade cervical intraepithelial neoplasia.
Attribution: Image from Wikimedia Commons. Educational colposcopy image. Licensed under CC BY-SA 4.0.