Ms Y, a 30-year-old Caucasian, is self-referred for an annual examination. She reports a history of abnormal Pap test results and wants to establish care with a provider in the city to which she has relocated. She has no other complaints.


Ms Y started undergoing annual Pap tests prior to her 18th birthday. She reports that her mother also came to her appointments because of her history of dysmenorrhea. Ms Y’s first menses (menarche) was at age 12; menses was every 28 days, 5- to 7-day duration, with moderate cramping, and heavy, light, or normal bleeding. Ms Y’s first sexual experience was at age 21, she has had 8 lifetime partners, and she has never been pregnant. Her first abnormal Pap test was performed by her previous provider in 2007 when she was 23 years old. The result was atypical squamous cells of undetermined significance (ASCUS) and positive for human papillomavirus (HPV). A colposcopy was performed, and her provider at that time recommended against the cervical cancer vaccine because she was already HPV-positive. Socially, Ms Y has never smoked, does not use drugs, drinks 5 cups of caffeinated beverages per day, and has 1 or 2 alcoholic drinks per month.

Ms Y reports a surgical history related to abnormal Pap test results that include multiple colposcopies with biopsy, cryocautery of the cervix, and loop electrical excision procedure (LEEP).  She has a history of migraine and herpes simplex virus, has no known allergies, and takes the following medications: Excedrin Migraine as needed for migraine headache, Lutera (28) once per day for contraception, and Valacyclovir 500 mg for herpes. There is no family history of gynecologic cancer, but her father and paternal grandmother have type 2 diabetes.

Continue Reading

Physical examination

 Ms Y’s initial vital signs are: blood pressure 112/79 mm Hg, heart rate 76 beats per minute, and body mass index (BMI) 27.76. Physical examination of the neck, chest, breasts, and skin, as well as the cardiovascular, gastrointestinal, genitourinary, neurologic, and psychiatric areas and systems, is negative.

Evaluation and tests

Based on Ms Y’s history of abnormal Pap test results, a repeat Pap test with HPV testing was performed. In addition, she was screened for sexually transmitted infections. The Pap test result was high-grade squamous intraepithelial lesion (HSIL), whereas HPV high-risk, chlamydia, and gonorrhea tests were negative. A colposcopy with biopsy and endocervical curettage were performed within 3 weeks. Ms Y’s evaluation and results are shown in Table 1. The specimen type for her Pap tests was Thin Prep, and the statement of adequacy for her Pap tests was “satisfactory for interpretation. Endocervical cells/transformation zone component present.”

Because her result was low-grade SIL and high-grade SIL could not be ruled out, the pathologist recommended “repeat cytology testing in six months.” A decision was made by her current provider to repeat cytology in 3 months instead of 6 months due to the result of “high-grade SIL could not be ruled out.” The cytology result was high-risk HPV-positive.

Table 1. Evaluation and results with current provider

Date Evaluation Results
10/27/14 Pap smear HSIL
11/19/14 HPV test Negative
Colposcopy Negative
Biopsy Negative
Endocervical curettage Negative
2/23/15 Pap smear Atypical squamous cells of undetermined significance
HPV test Positive high-risk HPV