Chapter 06Promoting Reproductive Health Through an Understanding

of Cervical Cytology Screening, Human Papillomavirus, and

Cervical Cancer

DNA tumor virus Associated with premalignant/malignant

cervical disease and other cancers Over 100 virus types with various

manifestations (common warts, plantar warts, skin cancers, anal/genital warts)

Most common STD in the U.S.

Human Papillomavirus

Squamous epithelium Columnar epithelium Meet at the squamocolumnar junction Squamous metaplasia: process of change

from columnar to squamous cellls Transformation zone: area between old and

new SCJ

The Uterine Cervix

Papanicolaou (Pap) test - 1940s◦ Cytological study for detecting cancer◦ Worldwide, most widely used cancer screening

method◦ Can detect 95% of all cervical cancers and

precancerous abnormalities◦ Dramatically reduces cervical cancer death rates

Cervical Cancer Screening

Begin at age 21 Every 2 years ages 21–29 Age 30+: if three consecutive negative

results, screen every 3 years unless special risk factors◦ HIV+ or DES or previous cervical cancer◦ Immunosuppressed

Cervical Cancer Screening

Collect cytology sample at mid-cycle Teach patients: for 24–48 hours prior to

testing◦ Avoid intercourse◦ Avoid vaginal medications◦ Avoid douching

Document all communication re: Pap testing

Optimizing Cervical Cancer Screening

May discontinue after age 65–70 if three consecutive negative tests and no abnormal test findings in previous 10 years (ACS,USPSTF, ACOG)

Cervical Cancer Screening in Older Women

Cryosurgery Laser ablation Conization

◦ Cold knife ◦ Laser◦ Loop electrosurgical excision procedure

Management of Abnormal Cervical Cytology Results

Produces no symptoms Detected by DNA testing Primary cause of cervical neoplasia Persistent infection associated with cervical

cancer

High Risk HPV

Performed on vaginal/cervical cell sample collected for a Pap test

Assesses for one or more potentially cancer-causing HPV types

Recommended for women 30+ years old

HPV DNA Testing

Abnormal Pap test results External genital warts (1%)

◦ Condyloma acuminata, smooth papular warts, keratotic genital warts, flat warts

Cervical lesions (10%)◦ Majority heal through natural immune response◦ Some persist and progress to cervical cancer

HPV Infection: Manifestations

Cigarette smoking Greater than three lifetime sex partners New sex partner within past 12 months Drug use within past 12 months Intercourse while alcohol-impaired Never married

HPV Infection/HPV-Related Cervical Disease: Risk Factors

Healthy lifestyle◦ Diet◦ Avoid chemical/environmental hazards◦ Sexual health awareness (e.g., condoms,

monogamous relationship)◦ Prophylactic HPV vaccination

Patient Teaching to Reduce Cervical Cancer Risk

Gardasil – HPV types 6, 11, 16, 18◦ Also approved for use in males

Cervarix – HPV types 16, 18 Three intramuscular injections Ideally administered before initiation of

sexual activity Avoid during pregnancy

HPV Vaccines

Squamous cell carcinoma (80%–90%) Adenocarcinoma Typically slow growing, begins as dysplasia

(pre-cancerous condition)◦ Detected by Pap test◦ 100% curable

Cervical Cancer

HPV infection, immunosuppression Cigarette smoking, alcoholism, poor nutrition Co-infection with other STDs Early onset of sexual activity, multiple sexual

partners, early age first full-term pregnancy Inadequate cervical screening In utero DES exposure Family history of cervical cancer

Cervical Cancer Risk Factors

When present, may include◦ Continuous vaginal discharge◦ Abnormal vaginal bleeding ◦ Heavier, longer menstrual periods◦ Loss of appetite, weight loss◦ Fatigue◦ Pelvic pain, back pain, leg pain

Cervical Cancer Symptoms

To determine spread, testing may include◦ X-ray computed tomography◦ Magnetic resonance imaging◦ Positron emission tomography◦ Cystoscopy◦ Chest x-ray◦ Intravenous pyelogram

Cervical Cancer Work-Up

Dependent upon cancer stage May include

◦ Surgery◦ Radiation therapy◦ Chemotherapy◦ Biological therapy

Cervical Cancer Treatment

Used for metastatic or recurrent cancer May be oral or intravenous May be used in combination with other

chemotherapeutic agents May be combined with RT or surgery

Chemotherapy for Cervical Cancer

Common side effects◦ Nausea and vomiting◦ Change in appetite, oral lesions◦ Vaginal sores◦ Temporary hair loss◦ Fatigue◦ Anemia, bruising, skin rash, infection

susceptibility◦ Menstrual cycle changes, infertility◦ Pain, swelling in legs and feet

Chemotherapy Patient Teaching

Used for metastatic cancer Interferon most common therapy Sometimes combined with chemotherapy Usually administered on outpatient basis Counsel about side effects: flu-like

symptoms, rash, anorexia, bruising

Biological Therapy

Education – all ages◦ Cervical cancer screening◦ Cervical cancer symptoms◦ Relationship between HPV and cervical cancer◦ Strategies to reduce HPV risk

Support for state, federal funding

Nursing Role in Cervical Health Promotion