Snap shot A 37-year-old G4P4 woman underwent a routine cervical Pap smear during an annual exam. The cytological evaluation showed a high-grade squamous intraepithelial lesion (HSIL/CIN2/3). She was referred for colposcopy and directed biopsies. Introduction Screening Pap smear most important screening tool USPSTF recommends screening women ages 21-65 every 3 years, or every 5 years if combined with cytology and HPV testing. has dramatically lowered rates in developed countries Histology cervical intraepithelial neoplasia (CIN) is precursor lesion to invasive cancer 85% squamous cell carcinoma 15% adenocarcinoma arising from endocervical glands Average age of diagnosis is 50 yrs, but can occur much earlier Risk factors include HPV infection (especially types 16 and 18) multiple sexual partners intercourse early in life tobacco use immunocompromised diethylstilbestrol exposure Presentation Symptoms (invasive cancer) postcoital bleeding malodorous discharge pelvic pain asymptomatic diagnoses often made by Pap smear, colposcopy, or biopsy Physical exam (invasive cancer) cervical discharge ulceration Evaluation Positive Pap smear/colposcopy must be followed with cone biopsy Diagnosis between invasive cervical carcinoma and cervical intraepithelial neoplasia (CIN) CIN biopsy classification CIN I mild dysplasia only involves lower 1/3 of epithelium CIN II moderate dysplasia involves lower 2/3 of epithelium CIN III carcinoma in situ severe dysplasia involves entire epithelial thickness may progress to invasive cancer Colposcopy dysplasia may show white areas with mosaic pattern with acetic acid application may appear "warty" Prognosis, Prevention, and Complications Complications may invade rectum, bladder, ureters, and vagina may metastasize to lungs