Type 3 TZ (previously termed ‘unsatisfactory’) colposcopy following LBC prediction of LSIL or HSIL

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Evidence

Systematic reviews were conducted to answer the following questions:

  • For women with a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (or unsatisfactory in previous terminology) colposcopy, what is the safety and effectiveness of 12-month follow-up testing with a HPV test alone, compared with co-testingHPV test and LBC both requested and performed on a cervical sample. (HPV and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory.)?
  • For women with positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, a cytology prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (or unsatisfactory in previous terminology) colposcopy, what is the safety and effectiveness of conservative management, compared with diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone.?

Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (previously termed ‘unsatisfactory’) colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. reported negative or prediction of LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.

No randomised or pseudorandomised controlled trials were identified that compared testing strategies and reported cancer outcomes in women with a positive HPV test result, cytology reported negative or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy. The search strategies and inclusion and exclusion criteria used are described in detail in the Technical report.

In the absence of any direct evidence from the systematic review, a general review of the literature on the management of women with negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology and a type 3 TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. colposcopy was undertaken to inform consensus-based recommendations.

No longitudinal studies were found that followed women with an initial cytology prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy. Three retrospective cross-sectional cohort studies[1][2][3] reported outcomes for women with pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. initial cytology and an unsatisfactory colposcopy:

  • In a cohort of 427 women with ASC-USAtypical squamous cells, undetermined significance or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology who underwent colposcopy (with endocervical curettage) and the entire squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal. was not visible, CIN2+ lesions of the endocervical canal were diagnosed in 18 women (4.2%):[1] eight of these women either had not undergone cervical biopsy or had less than CIN2 disease on cervical biopsy. These also included two women with invasive cancer of the endocervical canal (0.5%), both of whom had a cervical biopsy report of CIN2+.CIN2+ was diagnosed in the endocervical canal in three of 256 women (1.2%) with a normal but unsatisfactory colposcopy, and 15 of 171 women (8.8%) with an abnormal and unsatisfactory colposcopy. The degree to which the findings of this study can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because neither HPV status nor the selection criteria for endocervical curettage was specifically reported.
  • In a cohort of 118 women with ASC-USAtypical squamous cells, undetermined significance or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology who underwent colposcopy (with endocervical curettage) and either the entire squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal. was not visible or a visible lesion not seen in its entirety, CIN2+ was diagnosed on cervical biopsy in 18 women (15.3%).[2] Of these women, six had endocervical as well as ectocervical disease. No additional cases were detected on endocervical curettage. The degree to which the findings of this study can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because neither HPV status nor the selection criteria for endocervical curettage was reported.
  • In a cohort of women with normal, ASCUSAtypical squamous cells, undetermined significanceIn the previous versions of the US Bethesda System, a category of atypical squamous cells of undetermined significance: The nature of the abnormality is uncertain or unequivocal. Included lesions equivalent to both possible low-grade squamous intraepithelial lesion (pLSIL) and possible high-grade squamous intraepithelial lesion (pHSIL) in the Australian Modified Bethesda System. Later versions (including the current version) of the Bethesda System split this category into ASC-H and ASC-US. or LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. cytology who underwent cone biopsy after an unsatisfactory colposcopy (entire squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal. not visible or visible lesion not seen in its entirety) and CIN1mild dysplasia was detected on colposcopically guided biopsy, histologically confirmed CIN2+ was diagnosed in one woman (4.3%).[3] The degree to which the findings of this study can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because HPV status was not reported and 25% of the women were HIV-positive.

A summary of the literature considered can be found in the Technical report.

Overall, this body of evidence suggests that diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. may detect additional clinically significant cervical lesions in women with cytology reported as LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy. In this situation, pre-renewal NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. guidelines recommended repeating cytology in 12 months. In the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears., it is appropriate to apply the same follow-up interval for the repeat HPV test (with reflex LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. if positive for any oncogenic HPV type).

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Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (previously termed ‘unsatisfactory’) colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

No randomised or pseudorandomised controlled trials were identified that compared conservative management with diagnostic excision of the transformation zone and reported cancer outcomes in women with a positive HPV test result, cytological prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy. The search strategies and inclusion and exclusion criteria used are described in detail in the Technical report.

In the absence of any direct evidence from the systematic review, a general review of the literature on the management of women with HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). cytology and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy was undertaken to inform consensus-based recommendations.

No longitudinal studies were found that followed women with an initial cytology prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal (unsatisfactory) colposcopy, with or without cytopathology review. Two retrospective cross-sectional cohort studies[4][5] reported outcomes for women with an initial prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and unsatisfactory colposcopy:

  • In a cohort of 78 women with a cytology prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). and unsatisfactory colposcopy (entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. including squamocolumnar junctionThis is the junction where the ectocervical squamous epithelium and the endocervical columnar epithelium meet, and may be located on the visible ectocervix or may be within the endocervical canal. not visible) who underwent LEEPLoop electrical excision procedureLoop electrical excision procedure, CIN2+ was histologically confirmed in 43 women (55.1%).[4] Of these, one woman (1.3%) had invasive cervical cancer. CIN2+ disease (including the one case of cervical cancer) was found on LEEPLoop electrical excision procedureLoop electrical excision procedure in 35 (74.5%) of 47 women with HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). cytology on review. The degree to which the findings of these studies can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because HPV status was not reported, and review cytology findings could not be compared with initial referral cytology findings or colposcopically directed biopsy findings for individual women. It was not possible to assess how many extra cases of CIN2+ were detected on LEEPLoop electrical excision procedureLoop electrical excision procedure.
  • In a cohort of 65 women with a cytology report of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). who underwent cone biopsy after colposcopy detected no visible lesions and was unsatisfactory (entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. not visible), CIN2+ was diagnosed in 25 women (38.5%) and invasive cervical cancer was diagnosed in three women (4.6%).[5] The degree to which the findings of these studies can be generalised to women in the renewed NCSPNational Cervical Screening ProgramA joint program of the Australian, state and territory governments. It aims to reduce morbidity and mortality from cervical cancer, in a cost-effective manner through an organised approach to cervical screening. The program encourages women in the target population to have regular Pap smears. is limited, because neither HPV status nor the results of cytopathology review (if performed) was reported.

In both of these studies[4][5] a significant number of women were diagnosed with CIN2+ on excisional biopsy. This finding underpins an approach involving excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. when the referral cytology is HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). after cytopathology review and the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. cannot be fully visualised (Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal), irrespective of a HPV test result.

A summary of the literature considered can be found in the Technical report.

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Recommendations

Flowchart 8.4. ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.

Colp T3 TZ after LBC prediction of pLSILLSIL.png












Flowchart 8.5. ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of possible HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

Colp T3 TZ after LBC prediction of pHSIL.png












Flowchart 8.6. ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).

Colp T3 TZ after LBC prediction HSIL.png












Flowchart 8.7. ColposcopyThe examination of the cervix and vagina with a magnifying instrument called a colposcope, to check for abnormalities. Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal and no high grade histology: follow-up or treatment for some women

Colp T3 TZ no high grade histology follow-up or tx for s.women.png










Consensus-based recommendationQuestion mark transparent.png

REC8.9: Repeat HPV test after Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy and referral LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.
For women who have a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result with a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., and colposcopy is reported as Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal, the HPV test should be repeated in 12 months:

  • If oncogenic HPV is not detected at 12 months, the HPV test should be repeated 12 months later.
  • If oncogenic HPV is not detected again at the second repeat HPV test, the woman should be advised to return to routine 5-yearly screening.
  • If the woman has a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result at 12 months, she should be referred directly for colposcopic assessment, with the LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report available to inform the assessment.


Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal indicates failure to visualise the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone., or the entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

Practice pointQuestion mark transparent.png

REC8.10: Cytopathology review prior to observation for pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal at colposcopy
When observation is advised, cytopathology review is recommended to confirm the low-grade cytological abnormality.

  • If pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. is confirmed, observation is appropriate.
  • If pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). is indicated, then diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should be considered.
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REC8.11: Role of ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix in Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category.
Despite a lack of evidence, endocervical curettage can be considered for women who have a positive oncogenic HPV test result (any type) with a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of persistent pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. and colposcopy reported as Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal. A negative ECCEndocervical curettageThe removal of tissue from the endocervical canal of the cervix.The removal of tissue from the endocervical canal of the cervix may provide additional reassurance for a conservative (observational) approach.

Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal indicates failure to visualise the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone., or the entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

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REC8.12: Diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should not be performed if there is no cytological or histological evidence of a high-grade lesion after Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy
For asymptomatic women who have a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result, Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy, and no cytological, colposcopic or histological evidence of a high-grade lesion, further diagnostic procedures (such as diagnostic excision of the transformation zone) should not routinely be performed.

Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal indicates failure to visualise the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone., or the entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

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REC8.13: Role of diagnostic excision: exceptions to recommendation against diagnostic excision of TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. in the absence of high-grade cytology or histology
Diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. can be offered to certain groups of women who have a positive oncogenic HPV test result, a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., and colposcopy reported as Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal:

  • women who have completed childbearing
  • women who are anxious about cancer risk
  • women aged over 50 years
  • women who may not be compliant with recommended surveillance.


Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal indicates failure to visualise the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone., or the entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

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REC8.14: Diagnostic excision: Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy after LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).
For women who have a positive oncogenic HPV (any type) test result, a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology). after cytopathology review, and Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy, diagnostic excision of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. should be performed.

Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal indicates failure to visualise the upper limit of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone., or the entire TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone. is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

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REC8.15: Cytopathology review: Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy following LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology).
Cytopathology review should be considered to confirm a high-grade cytological abnormality before excision, after a positive oncogenic HPV (any type)Women with a positive HPV test result of any oncogenic HPV types detected using routine HPV testing in a pathology laboratory. test result and an initial LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction of pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., when there is a Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy.

This is particularly important when the LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. prediction is pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. because pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system. has a lower PPVPositive predictive value for high-grade disease and the subsequent excision specimens show no evidence of cervical pathology in 45–55% of cases.

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REC8.16: Deferral of treatment following cytopathology review: Repeat HPV test and colposcopy in 6 months
Following cytopathology review, rarely the woman or the clinician wish to defer treatment. In this situation the woman should have a repeat HPV test and colposcopy in 6 months.

  • If HPV detectedWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory. (any type) and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category., repeat HPV test in 12 months.
  • If HPV detectedWomen with a positive HPV test result of any oncogenic HPV types detected using HPV testing platforms in a pathology laboratory. (any type) and LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., the woman should have diagnostic Type 3 excisionType 3 excision (for Type 3 TZ) Equivalent to ‘cone biopsy’ and >15mm length of the TZTransformation zoneThis region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction. In premenopausal women, the transformation zone is fully located on the ectocervix. After menopause through old age, the cervix shrinks with the decreasing levels of estrogen. Consequently, the transformation zone may move partially, and later fully, into the cervical canal.The transformation zone may be described as normal when it is composed of immature and/or mature squamous metaplasia along with intervening areas or islands of columnar epithelium, with no signs of cervical carcinogenesis. It is termed an abnormal or atypical transformation zone (ATZ) when evidence of cervical carcinogenesis such as dysplastic change is observed in the transformation zone. Identifying the transformation zone is of great importance in colposcopy, as almost all manifestations of cervical carcinogenesis occur in this zone..
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Benefits and harms

If these recommendations, including review of cytology, are followed for women who have a Type 3 TZType 3 TZ: part or the entire upper limit of the TZ cannot be seen in the canal colposcopy in the presence of a LBCLiquid based cytology(LBC) is a way of preparing cervical samples for examination in the laboratory. report of negative or prediction of pLSILPossible LSIL in the Australian Modified Bethesda System is broadly equivalent to ASCUS in US Bethesda system./LSILLow-grade squamous intraepithelial lesionThe low-grade squamous intraepithelial lesion (LSIL) category is the morphological correlate of productive viral infection. It is to be used when the scientist/pathologist observes changes that would have been described as ‘HPV effect’ or ‘CIN 1’ in the previous Australian terminology and represents part of the previous ‘low-grade squamous epithelial abnormality’ category. or pHSILPossible HSIL in the Australian Modified Bethesda System is broadly equivalent to ASC-H in US Bethesda system./HSILHigh-grade squamous intraepithelial lesionIn the Australian context, HSIL is used to refer to a cytology predictive of a high grade precancerous lesion (AMBS 2004), or histologically confirmed high grade precancerous lesion (HSIL-CIN2 or HSIL-CIN3 as per LAST terminology)., they will benefit by avoiding over investigation or receiving unnecessary treatment.

See Chapter 5. Benefits, harms and cost-effectiveness of cervical screening in the renewed National Cervical Screening Program (NCSP)

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Health system implications of these recommendations

Clinical practice

It is not anticipated that there will be a significant change to clinical practice, apart from the addition of HPV testing to the recommended surveillance.

Resourcing

No material changes to the costs are anticipated.

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References

  1. 1.01.1 Goksedef BP, Akbayir O, Numanoglu C, Corbacioglu A, Guraslan H, Bakir LV, et al. Evaluation of endocervical canal in women with minimal cervical cytological abnormalities. J Low Genit Tract Dis 2013 Jul;17(3):261-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23422642.
  2. 2.02.1 Poomtavorn Y, Suwannarurk K, Thaweekul Y, Maireang K. Diagnostic value of endocervical curettage for detecting dysplastic lesions in women with atypical squamous cells of undetermined significance (ASC-US) and low grade squamous intraepithelial lesion (LSIL) Papanicolaou smears. Asian Pac J Cancer Prev 2014;15(8):3461-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24870740.
  3. 3.03.1 Day T, Weitzen S, Cooper AS, Boardman LA. Should unsatisfactory colposcopy necessitate treatment of cervical intraepithelial neoplasia 1? J Low Genit Tract Dis 2008 Jan;12(1):11-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18162806.
  4. 4.04.14.2 Massad LS, Tate N, Cejtin E, Collins YC. Quantifying the risk of cervical intraepithelial neoplasia in women with unsatisfactory colposcopy results. J Low Genit Tract Dis 2005 Jan;9(1):23-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15870518.
  5. 5.05.15.2 Veiga FR, Russomano FB, Camargo MJ, Monteiro AC, Tristão A, Silva GV. Prevalence of high-grade squamous intraepithelial lesions and cervical cancer among patients with unsatisfactory colposcopic examination, without visible lesion. Sao Paulo Med J 2009 Sep;127(5):266-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20169274.
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Appendices

Jutta's magnifying glass icon.pngPICO questions 3a & 3b View Systematic review report q 3aView Systematic review report q 3a View Systematic review report q 3bView Systematic review report q 3b View General evidence summary table q 3aView General evidence summary table q 3a
View General evidence summary table q 3bView General evidence summary table q 3b
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