AGUS Pap Smear

1. Epidemiology
   1. Incidence: 0.18 to 0.74% of Pap Smears
2. Pathophysiology
   1. Not equivalent to ASCUSPap Smear
   2. Much higher likelihood of associated Cervical Dysplasia
      1. No abnormality on Colposcopy: 50 to 80%
         1. See benign causes below
      2. Significant abnormality on Colposcopy: 20 to 50%
         1. See significant causes below
3. Causes: AGUS Pap Smear
   1. Significant abnormalities
      1. Cervical Dysplasia associated with squamous lesions
      2. Adenocarcinoma in situ
      3. Adenocarcinoma
   2. Benign abnormalities
      1. Metaplasia
      2. Endometriosis
      3. Arias-Stella reaction associated with pregnancy
      4. Endocervical polyps
4. Signs: Colposcopy of Adenocarcinoma and AIS (subtle)
   1. Typical squamous Cervical Dysplasia findings not seen
   2. Findings (observe before acetic acid application)
      1. Dull orange or yellow (adenocarcinoma)
      2. Occurs in transition zone under columnar epithelium
      3. Variegated red and white lesions
      4. Papillary lesions
      5. Large gland openings
      6. Unusual vascular patterns
         1. Vessels in pattern of tendrils or roots
         2. Vessels in pattern of written characters
5. Evaluation
   1. Colposcopy with directed biopsy in all endocervical sample in all AGUS and
   2. Endometrial Biopsy indications
      1. Age over 35 years or
      2. Abnormal Uterine Bleeding or
      3. Atypical endometrial cells on Pap Smear cytology
6. Management: AGUS Favor Reactive or NOS
   1. Positive Colposcopy
      1. Abnormal findings:
         1. CIN 1-3
         2. Glandular Neoplasia
      2. See 'Favor Neoplasia' below
   2. Negative Colposcopy and ECC
      1. HPV status unknown
         1. Repeat Pap Smears at 6 month intervals for 2 years
      2. HPV negative
         1. Repeat Pap Smear and HPV test in 12 months
         2. Colposcopy if HPV positive or ASCUSPap Smear or worse
      3. HPV positive
         1. Repeat Pap Smear and HPV test in 6 months
         2. Colposcopy if HPV positive or ASCUSPap Smear or worse
      4. Special circumstance: Repeat Pap Smear with AGUS
         1. Consider conization
         2. See 'Favor Neoplasia' below
7. Management: AGUS Pap Smear Favor Neoplasia or AIS
   1. Perform Colposcopy
      1. Negative ECC: Cone biopsy as below
      2. Positive ECC: Consider Hysterectomy
   2. Perform Cone Biopsy (Cold-knife conization)
      1. Cone Biopsy positive for Cervical Cancer
         1. Radical Hysterectomy with or without radiation
      2. Cone Biopsy positive for Adenocarcinoma in situ
         1. Simple Hysterectomy
      3. Cone Biopsy negative
         1. Consider Endometrial Biopsy (esp. age over 35)
8. References
   1. Apgar (2009) Am Fam Physician 80(2): 147-55
   2. Cox (1997) J Low Genit Tract Dis 1:41-5
   3. Kaferle (2001) Am Fam Physician 63(11):2239-44
   4. Dinh (1999) J Low Genit Tract Dis 3:73-6
   5. Wright (2002) J Low Genit Tract Dis 6:127-43