Practice Guidelines

ACOG Releases Guidelines for Managing Abnormal Cervical Cytology and Histology in Adolescents

Liz Smith

New information about the natural history of cervical dysplasia and the role of human papillomavirus (HPV) in cervical cancer, as well as the development of new technologies for cervical cancer screening, prompted the American College of Obstetricians and Gynecologists (ACOG) to develop new guidelines for the management of abnormal cervical cytology and histology. Because management in some instances differs for adolescent patients, ACOG also created guidelines specific to this population. These recommendations were published in the April 2006 issue of Obstetrics & Gynecology.

Aggressive management of benign lesions in adolescents should be avoided because most cervical intraepithelial neoplasia (CIN) grades 1 and 2 lesions regress spontaneously. Surgical excision or destruction of cervical tissue in nulliparous adolescents may harm fertility and cervical competency. Destruction of normal cervical tissue should be minimized when possible, and observation may be sufficient for many adolescents. Treatment recommendations for adults and adolescents are summarized in Table 1.

ASC-US. Atypical squamous cells of undetermined significance (ASC-US) may indicate HPV infection. Women with ASC-US who have had liquid-based cytologic screening should be tested for high-risk HPV, and those with positive results (i.e., presence of high-risk HPV DNA) should have colposcopy. However, the risk of invasive cancer in adolescents is almost zero, and the likelihood of HPV clearance is high; most infections in adolescents resolve within two years. Therefore, as an alternative to immediate colposcopy, adolescents with ASC-US and a positive high-risk HPV test result may be monitored with cytologic screening at six and 12 months or a single high-risk HPV test at 12 months. Colposcopy should be performed if repeat test results are abnormal or if there is evidence of persistent HPV infection. Adolescents with ASC-US and a negative high-risk HPV test result should have a Papanicolaou test after 12 months.

ASC-H. Adolescents with ASC when high-grade squamous intraepithelial lesions (HSIL) cannot be ruled out (ASC-H) should undergo immediate colposcopy. Higher rates of CIN 2 and 3 and cervical cancer have been found in persons with ASC-H, but no studies have addressed ASC-H in adolescents.

LSIL. Adolescents with low-grade squamous intraepithelial lesions (LSIL) can be monitored with cytologic screening at six and 12 months or a high-risk HPV test at 12 months as an alternative to immediate colposcopy. Those with cytologic abnormalities or persistent HPV infection at one year should undergo colposcopy.

HSIL. Adult and adolescent women with HSIL should have colposcopy with endocervical assessment. The "see and treat" alternative using the loop electrosurgical excision procedure (LEEP) is not recommended in adolescents. Adolescents with HSIL and biopsy-confirmed CIN 2 may be monitored without intervention if they have adequate colposcopy and normal histology test results on endocervical assessment. Follow-up should be individualized, but cytology or colposcopy at intervals of four to six months is reasonable. Adolescents with HSIL cytology and a postcolposcopy diagnosis of CIN 1 or less with adequate colposcopy and negative results on endocervical assessment may be monitored with colposcopy and cytology at four to six months. Excision is an acceptable alternative, but it increases the risk of cervical stenosis and preterm labor.

AGC. Atypical glandular cells (AGC) in adolescents are rare. Adolescents with AGC should be referred to a subspecialist with expertise in managing cervical dysplasia and should have colposcopy and endocervical sampling. Endometrial sampling typically is not used in adolescents unless they are morbidly obese or have abnormal uterine bleeding, oligomenorrhea, or possible endometrial cancer.

CIN 1. For adolescents with CIN 1, management without therapy provides the best balance between risk and benefit. These adolescents should be monitored with cytologic testing at six and 12 months or high-risk HPV testing at 12 months. Colposcopy should be performed if cytology results are abnormal or high-risk HPV results are positive. For those who require therapy, options include cryotherapy, laser therapy, and LEEP, determined by the geometry of the lesion and the clinical recommendations of the physician. The least amount of cervical tissue necessary to eradicate the lesion should be removed.

CIN 2. In adolescents, CIN 2 can be managed with observation or with ablative or excisional therapy. Patients monitored without therapy should be reliable for follow-up and should understand the risks. Follow-up can be individualized; a conservative approach would be colposcopy or cytology every four to six months.

CIN 3. Therapy is recommended for all women with CIN 3. Cryotherapy, laser therapy, and LEEP are equally effective treatments; excision has been recommended for biopsy-confirmed CIN 3. Choice of therapy is determined by the geometry of the lesion and the clinical recommendations of the physician.

consent

Cervical cytology in minors often is obtained during contraception counseling or confidential screening for sexually transmitted diseases (STDs), which may take place without the knowledge of the parent or guardian. Colposcopic examination is considered an STD evaluation, and parental consent is preferred but should not be required; in the absence of parental consent, consent should be obtained from the minor and noted in the medical record. Parental consent requirements for biopsy and cervical dysplasia therapy depend on whether these procedures are considered part of STD evaluation and treatment and on state law. Physicians who provide care without parental consent should be aware of their state law and local standards of care.

Practice Guideline Briefs

AAP Examines Prevention of Childhood Obesity Through Lifestyle Changes

Societal, financial, technologic, and commercial factors have caused childhood obesity in the United States to triple since the 1960s. The American Academy of Pediatrics (AAP) policy statement, "Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity," was published in the May 2006 issue of Pediatrics and addresses how physicians can encourage physical activity in children and adolescents who are currently or are at risk of becoming overweight or obese.

Children who are overweight or obese are more likely to have diabetes mellitus, insulin resistance, obstructive sleep apnea, hypertension, nonalcoholic steatohepatitis, or low self-esteem compared with children of normal weight. These health implications are profound, particularly because 80 percent of children and adolescents who are obese continue this trend into adulthood.

To address the obesity epidemic in children, it is recommended that physicians assess and accurately measure the body fat in their young patients. Some children may be genetically predisposed to obesity, but insufficient infant breastfeeding, the consumption of sugar-sweetened beverages and oversized fast-food meals, and reduced intake of fiber, fruit, and vegetables also contribute to childhood obesity.

Twenty-six percent of children and adolescents in the United States spend more than four hours a day watching television, and they have become even more sedentary with access to computers and video games. Sixty-two percent of children nine to 13 years of age do not participate in organized physical activities, and 23 percent do not participate in nonorganized physical activities outside of school hours. However, inactive role models, unsafe play environments, or inadequate access to physical education also may explain the lack of physical activity in children.

Treatment programs that combine nutritional intervention and exercise are recommended over diet modification alone because they have better success rates. Regular physical activity should be made available to children during school hours because it is important in weight reduction and improves insulin sensitivity in children and adolescents with type 2 diabetes. It also is psychologically beneficial to children regardless of weight and is associated with increased self-esteem and reduced depression and anxiety.

Aerobic exercise is suggested because it can reduce systolic and diastolic blood pressure measurements. However, lifestyle-related physical activity programs should be tailored to each child, and the physician should not measure the child's progress through weight loss alone but in terms of the effects on associated morbidities.

Adolescents and children older than two years should watch no more than two hours of television per day. It is recommended that physicians ask parents to record the number of hours a day their child spends in front of the television or how long he or she plays computer or video games; however, giving the child a pedometer may be a more accurate measure of activity. A goal of at least 11,000 steps a day is recommended for children.

SHERRI DAMLO