Management of the patient with an abnormal Papanicolaou test. Recent developments

Based on available data, virtually all cervical cancers and the majority of their high-grade precursors (Hi-SIL/CIN 2-3) contain sexually transmitted oncogenic HPV types, among these the most common type is HPV type 16. In current practice, the most cost-effective diagnostic and therapeutic means for Hi-SIL/CIN lesions is LEEP. Judgment must be exercised, however, to tailor the depth of electroexcision of cervical cancer precursors, particularly with respect to the low-grade variants, according to the position of their endocervical lesional margin. About half of the low-grade lesions also carry intermediate- to high-risk oncogenic viruses; unfortunately, morphology cannot identify them unless abnormal mitotic figures are present on the histologic sections. When sophisticated, low-cost viral probing tests and perhaps Cervicography become available, it may be pertinent to determine whether a low-grade lesion contains low-risk virus or is associated with a high- to intermediate-risk virus group. Indeed, the former are unlikely to progress to invasion and may, in fact, regress without therapy other than multiple biopsies, whereas the latter carry high-risk carcinoma potential. Treating long-term monogamous men with asymptomatic, subclinical lesions who are partners of HPV-infected women is not considered cost effective, for they do not seem to reinfect each other. Management strategies for patients with HPV infections should not only be therapeutic but also educative, encouraging patients to practice sexual monogamy.