Education module for GPs, nurse Pap providers, sexual health physicians and general gynaecologists Question 1a answer

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Question 1a answer

b) Recommend Kate return at age 25 for a cervical screening test.

c) Check that Kate is up to date with her annual Chlamydia test.


Explanation

Routine cervical screening is not recommended in women under the age of 25 years (REC15.1).

HPV is a very common and highly infectious virus that is transmitted through sexual contact. Approximately 30% of all sexually active women test positive for HPV within the first 12 months of becoming sexually active. This increases to 48% within 3 years. Most women clear their HPV infection within 12-36 months and only persistent infection over many years will increase a woman’s risk of developing cervical cancer.

It is important to explain that the HPV vaccine (Gardasil) contains 4 strains of HPV (6, 11, 16 and 18). HPV types 16 and 18 are included for their oncogenic potential, while 6 and 11 are included as these strains cause more than 90% of anogenital warts. Evidence demonstrates that there is significant herd immunity obtained with the HPV vaccine. There has been a significant decrease in high-grade cervical disease (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). or CIN2+), HPV 16/18Only HPV types 16 and or 18 detected using routine HPV screening tests in laboratory. positivity and genital warts in individuals from the vaccinated cohort (born on or after 1 July 1980). Although Kate has not been vaccinated she is from this cohort (born on or after 1 July 1980) and will therefore benefit from herd immunity.

Despite already being sexually active Kate could be offered the HPV vaccine. It is important to discuss with her the cost of the three dose regime; the possibility that she may already have natural immunity to the HPV strains covered by the vaccine; and the fact that even after vaccination she will still need to commence screening at age 25.

This initial consultation provides an excellent opportunity to discuss key concepts of the new cervical screening program as well as offering opportunistic sexually transmissible infections (STI) screening and education. A sexual history should be obtained and all sexually active women under the age of 30 should be offered annual Chlamydia testing.

The key messages are:

  1. From 1 December 2017 the cervical screening test will replace the Pap test.
  2. Routine screening for asymptomatic women will commence at age 25.
  3. HPV is usually transient and is an extremely common infection in men and women under the age of 30, but the risk of developing cervical cancer is low.
  4. Evidence demonstrates that herd immunity has been achieved since the introduction of the HPV vaccine with a significant decrease in high-grade cervical disease (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). or CIN2+), HPV 16/18Only HPV types 16 and or 18 detected using routine HPV screening tests in laboratory. prevalence and genital warts in individuals from the vaccinated cohort (born on or after 1 July 1980).
  5. Test for Chlamydia annually in all women under the age of 30 who have ever been sexually active. ([the Guidelines for preventive activities in general practice 9th edition 6.2.1])


The key recommendation is:

REC15.1: Routine cervical screening is not recommended in young women

Routine cervical screening is not recommended in women under the age of 25 years.
Next question: question 1b