Atypical Results on a Pap Test

Frederick R. Jelovsek MD

A call from the doctor's office about an abnormal Pap smear ranks as a bad news day in anyone's book. While the first thought is possible cancer of the cervix, there a many grades of abnormal that are not cancerous. Cancer is certainly the worst grade of an abnormal Pap; atypical squamous cells of undetermined significance (ASCUS) is the least abnormal grade. In between, is mild, moderate and severe dysplasia. All of these classifications refer to the squamous cells that line the outside of the cervix and vagina. These are the cells that are exposed to sexual intercourse and whatever bacteria, viruses and irritants that accumulate over the years.

There is one other type of abnormal cervical cells, glandular cells on the inside of the cervical canal. The extreme abnormality of these is adenocarcinoma of the cervix rather than the more usual squamous cell carcinoma of the cervix. The mildest abnormality of these glandular cells is atypical glandular cells of undetermined significance (AGCUS or AGCUS). This is an infrequent category of abnormal Pap but it is more worrisome than squamous cell atypia (ASCUS).

In a recent article, Cox JT: AGUS Pap smears - A follow-up strategy. OBG Management 1998;July:74-87, a diagnostic strategy was outlined to evaluate AGUS Pap smears. It's work up is quite different than the squamous cell atypia because 20-50% of women with this Pap result have a more severe, hidden lesion that requires diagnosis lest it progress into, or already represents, an existing cancer. Doctors currently have a tendency to treat this category without the respect that it deserves, because the more commonly occurring squamous abnormality, ASCUS, is much less frequently associated with more advanced lesions. In addition, glandular lesions can progress to a cancer more rapidly than a squamous lesion. They are also more difficult to detect by colposcopy.

The evaluation process for a squamous atypia, ASCUS, is just to repeat the Pap in 3-6 months. For AGUS, Dr. Cox and the American Society of Colposcopy and Cervical Pathology, recommend an immediate colposcopy and, at that time, an endocervical curetting (scraping) to diagnose any worse changes up inside the cervical canal where you can't see with the colposcope. If there are any abnormal changes on the curetting, a conization of the cervix should be done. That can be a LEEP (loop electrical excision procedure) conization in the office or a "cold knife" conization in the outpatient surgery unit.

Women need to know that there is intense physician disagreement about the best way to work-up both ASCUS and AGUS, but also, they need to know that they are two different Pap abnormalities -- one, AGUS being much more worrisome and needing more aggressive diagnosis, than the other, ASCUS. Make sure you know which pap abnormality you have.