Pap Smears and the Teenage Girl
Recent developments in understanding the natural history of human papilloma virus (HPV) virus & its role in cervical cancer have led to significant changes in recommendations for Pap smears in teens.
It’s been generally accepted for years that certain HPV viruses (the “high-risk” types) cause cervical cancer. Recently, however, studies have shown that many teens have transient HPV infections that do not lead to cervical dysplasia or cancer. This has lead to the recommendation that Pap smear screening begin no later than 21 years old; although sexually active teens should be screened at least yearly for chlamydia. However, the American College of Obstetricians & Gynecologists strongly recommends that teens have their first gyn visit before they are sexually active. An initial visit, usually without a pelvic exam, is recommended between ages 13-15 with the gynecologist for establishing a relationship and beginning health education.
Even when teenage girls have low-grade lesions on Pap smears, in most cases they will resolve without treatment. Management of the low-grade squamous intraepithelial lesion (LGSIL) Pap has traditionally been colposcopy with biopsies to rule out a high-grade lesion, with follow-up Pap smears every four months for a year. Newer guidelines also allow for delaying colposcopy and obtaining an HPV-DNA test in a year, with colposcopy at that time if the patient is positive for high-risk HPV-DNA. Another option is to repeat the Pap at 6 and 12 months and perform a colposcopy if the repeat Pap remains abnormal. For the high-grade Pap (HGSIL) immediate colposcopy is still recommended.
The “grey-zone” in Pap results, now categorized as abnormal squamous cells of uncertain significance (ASCUS-US), is evaluated further with HPV-DNA testing. A test positive for “high-risk HPV” leads to colposcopy, a negative test is reassuring – with only a follow-up Pap in 6-12 months recommended.
Endometriosis is surprisingly common in adolescent girls. Studies show that greater than 50% of girls who undergo laparoscopy for pelvic pain not responding to OCP’s & NSAID’s have endometriosis. It has even been found in young girls who have only entered puberty with breast development, but are not yet menstruating. More than two thirds of adult women with endometriosis report onset of their symptoms before age twenty, with almost half seeing a physician at least five times before being diagnosed.
The goals of therapy for adolescent endometriosis are suppression of pain, slowing disease progression, & preserving fertility. Adolescents under age 18 with persistent pelvic pain who have failed medical therapy should undergo operative laparoscopy for diagnosis of possible endometriosis & concurrent treatment by ablation or excision of the lesions. Those older than eighteen can be treated with 6 months empiric therapy with a Gn RH agonist (Depo Lupron) with add back therapy of low dose progestin or HRT to minimize bone loss. After therapy, the adolescent patient should be maintained on continuous suppression with OCP’s until child bearing is completed.