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19 The patient with abnormal cervical cytology
Martyn Underwood and William Rhys Parry‐Smith
Department of Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust, Shrewsbury, UK
Case History 1: A 28‐year‐old woman with unexplained infertility is scheduled to have IVF. She has recently undergone cervical screening which has been reported as high‐risk HPV (HRHPV) positive, low‐grade dyskaryosis.
Case History 2: A 30‐year‐old woman with unexplained infertility is referred via her GP to the infertility clinic. As part of a routine appointment, it is discovered this patient has never undergone cervical screening. Screening is offered and performed and is reported as HRHPV with severe dyskaryosis.
Case History 3: A 33‐year‐old woman with infertility is part way through her infertility investigations when she undergoes a routine cervical screening. This is reported as HRHPV and possible glandular abnormality. She is referred to the colposcopy clinic.
Background
Cervical screening programs around the world vary significantly, with vast differences in the frequency and age of commencement of screening, if programs exist at all. Within the UK, the NHS cervical screening is currently offered to all women between the ages of 25–64 years on a 3‐year basis until the age of 50 and then every 5 years until 64 years of age. The screening program has recently changed to offer primary HPV screening first, with cytology testing only in those who are high‐risk HPV positive. The aim of all cervical screening programs is to detect precancerous lesions early to avoid the progression to cervical cancer.
Around the world several countries have introduced the HPV vaccination program, with the aim of immunizing girls against the most common oncogenic HPV strains. In the UK this was introduced in 2008 [1] initially with girls alone, and later boys also. The vaccine consists of two injections over 6 months which offer protection against HPV 16 and 18, which are the most common high‐risk oncogenic strains, and 6 and 11 which are associated with genital warts. This offers protection against approximately 70% of the cervical cancers.
Early detection and treatment of cervical abnormalities can prevent 75% of cervical cancers [1]. For those who have normal HPV screening reports the chances of developing cervical cancer in the subsequent 3 to 5 years is low [1]. It is estimated that approximately 4% of those attending for cervical screening will have an abnormality detected. Those reported as low grade should all ideally be seen within the colposcopy service within 6 weeks or as soon as practicable. Those reported as high grade (moderate or severe dyskaryosis, glandular, or possible invasion) should all be seen within 2 weeks [2].
UK practice and the practice in the wider world have changed over the last few years with a drive towards more conservative management, particularly in those who wish to have children. Several studies have evaluated the rates of preterm birth and miscarriage following cervical treatment. It appears those with abnormal cervical screening have a higher rate of preterm birth compared with those with normal cervical screening even without treatment. This could be due to confounding issues such as smoking status and comorbidities although further research in this field is ongoing.
Research suggests 2.5% of all preterm births in the UK are due to cervical treatment with cervical depths of >10mm or more [3].
A 2017 Cochrane review found that those undergoing excisional