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Dr. Andrew Rynne

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Got abnormal pap results. Had laser surgery for vaginal lessons. Done colonoscopy and biopsy. What should be done now?

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Dr. Aarti Abraham

OBGYN

Practicing since :1998

Answered : 6011 Questions

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Posted on Thu, 31 Jan 2013 in Women's Health
Question: I have a question about abnormal pap results. A little background: I am 40 years old, have 3 children, and have a long term history of abnormal pap results, which are almost always a low grade abnormality. I have had numerous, numerous paps and colposcopies, have had HPV testing since I turned 30, and had laser surgery to address vaginal lesions when I was 31. (There were no cervical lesions at that time, only vaginal). I have had some normal results (though not many, and never 3 in a row, ever).

I am very faithful to my follow up appointments, and try to understand what my results mean. I consider myself healthy and "health literate". While I know that there can be many causes of an abnormal pap, it is hard to imagine anything that would consistently cause abnormal results for 20 years! I also understand that HPV can be in your system, and dormant, and therefore a negative HPV test does not necessarily mean that you are, in fact, negative for HPV.

My most recent pap was ASC-H, I had a colposcopy and biopsies (though my doctor did not see any abnormalities). I don't have those results yet.

I am not terribly concerned about any one test result here or there, and I will dependably go to follow up (and I have a good partnership with my doctor). I just don't really understand the big picture: 20 years of abnormal paps, no identified HPV, and a previous surgery. How can I help myself get to "normals"?
doctor
Answered by Dr. Aarti Abraham 36 minutes later
Hello
Thanks for writing in.
I have gone through your query at length, and appreciate your robust interest in the issue.
It would help me tremendously if you elaborate on what you meant by 20 years of abnormal pap results - could you give me more details please ?
Also, somewhere along the way, I think you have already understood the conundrum.
Most low grade abnormalities are attributed to HPV infection, particularly the ones which persist over years, as has happened in your case. The other causes of low grade abnormalities regress with time.
Also, in women with good immunity, the HPV infection clears up with time, so it might not show up on tests.

SO the answer lies there - consistently abnormal Paps, caused by subclinical HPV infection, which is not always picked up on testing.

If the Paps do not revert to " normals ", there is still no room for worry, as long as you are on regular surveillance with regular pap smears , and do not cross the zone of low grade abnormalities, and your HPV and Colposcopy reports are normal.

Its heartening to see you so aware and involved in your body and its well being, as you should rightly be.

Please do feel free to discuss further and it would be nice to have your recent biopsy reports too

Take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Aarti Abraham 32 minutes later
Thank you! That was fast!

Well, I wish I had my 20 years of abnormal results in detail...and the reporting system has changed during that time (I think...is that right?). In my 20s, I consistently had results that said "mild to moderate dysplasia", but my colposcopy almost never showed any visible problem (except for the time I had laser ablation for the vaginal lesions....and that was right after the birth of my first child, when I was 30). During my 20s, I would follow up after an abnormal pap every 4 months, usually with a re-pap, and a colposcopy at least once a year. The reason I remember that I have never had 3 normal results in a row is because at that time, I kept thinking that, if I could only get 3 normal results, then I would be able to go once a year! And, that never happened! (And now that some women can have a pap every 3 years, I just think, "that will probably never be me!") I am a little bit discouraged. I am married, and have been monogomous for the last 18 years...but, I realize that HPV can be tricky and stay with you for a long time, even at an undetectable level.

For the last 3 years, my results have been:
Nov. 2010: ASCUS, HPV negative. Follow up with repeat pap in one year.

Nov. 2011: ASCUS, HPV negative. Follow up with repeat pap in one year.

December 2012: ASC-H, HPV negative. Follow up with Colpo.

January 2013: Colpo. No abnormalities seen. Random punch biopsy and ECC taken. (Don't have results yet).

So, the subclinical HPV is what confuses me. If HPV is subclinical (I assume that means that it is not detectable, but that it is there), can it cause cellular changes of the cervix? I wasn't sure about that: if it had to be detectable in order to be able to cause cervical changes.

And, is it safe to assume that a high risk form of HPV would not stay subclinical? In other words, by virtue of it being high risk, is it more likely to be detectable?

Thank you!
doctor
Answered by Dr. Aarti Abraham 36 minutes later
Thank you,
Am honoured by the extensive and meticulous reply.
Yes, the reporting system has undergone many changes during the past 20 years.

Another thing - the details of those vaginal lesions? What kind of lesions were they, and why did they necessitate surgery ?

Subclinical infection means that it is not detectable, yes, but that it has been there in the cervical cells in the past, and caused cellular changes. In order to cause cellular changes, it is not a prerequisite for the HPV virus to be detectable.

Certain subtypes of HPV virus are high risk and more virulent - the more aggressive virus would cause more cellular and more abnormal changes, but it is not likely to be more detectable per se, other than that it would infect more cells and in a more aggressive way.

Hope I have been of some help !
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Aarti Abraham 2 hours later
Yes, thank you, that has been very helpful.

I do not remember the pathology of my vaginal lesions (I was so sleep deprived and post partum with my first sweet baby!). But, I do know that I had the colpo that identified it right after my post partum appt. So, right after my delivery, my pap was abnormal, and my colpo showed the vaginal lesions. My doctor thought that was important because sometimes birth helps you "shed" some of the problem spots. (I hope I am remembering that correctly). And, she thought I had some auto-immune troubles in that pregnancy, so it kind of makes sense to me that my results were a bit more urgent (we did not "watch and wait", which is what we had been doing for quite a long time! I did have a laser ablation (not LEEP or cryo).

I was hopeful that maybe that surgery (almost 10 years ago now) would give me a "clean slate" so to speak, and that my results would begin to be more normal. But, that has not been the case!

Right now my plan, recommended by my doctor, (as long as the biopsy results of my colpo are normal), is to return for a repeat pap at 6 months and 12 months. I think I need both of them to be normal before I can go back to once a year...and I just don't have a history of 2 normals in a row, so, darn.

I am not really worried that I am about to have cancer (especially since I am good about my follow up). But I would just like to stop having such repeated low level abnormal results! I almost wish that it would flare up just enough to require treatment that could get me back to a clean slate!

And, is it likely that if a woman does have subclinical HPV that it can become problematic for her as she ages (and presumably her immune system weakens?)

You have been such a help! Thank you!
doctor
Answered by Dr. Aarti Abraham 2 hours later
Hi,
You normally would not have a LEEP for vaginal lesions, only cervical ones.
ALso, your doctor's plan is perfect, and not to be improved upon, but that you already know.
Also, since the surgery was vaginal in nature, it wouldnt affect the outcome of the cervical abnormalities that are consistently giving you altered Pap results.
Its perfectly alright to be on the surveillance, the flare up need not always be something to wish for, as it could be precancerous/cancerous !
Yes, a weakened immune system can definitely lead to flare up of the HPV infection and cervical lesions.
But with your description of your background health and the age of 40, alongwith a positive attitude, I think you need not worry about it for a long time to come, as long as you maintain your general well being.
Visiting a gynecologist every 6 months might not be such a bad idea overall !

Take care, and interacting with you has been a pleasure.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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