[NP-Clinical] endometrial cells on PAPs

Thu Mar 15 19:03:56 PDT 2007

Kim,

Thank you so much.  This helps tremendously as I do try to practice 
evidence-based-care.  I believe that the algorithim does confirm my current 
strategy of evaluating the menstrual cycle phase and the woman's risk and 
making recommendations accordingly.  My collaborating doc and I have 
discussed this numerous times over the last couple of years.  While liquid 
based technology helps with improved identification of abnormal pathology, 
the flip-side is false-positive findings and the risks associated with 
further evaluation.  You are the first person to provide me with a 
documented standard-of-care regarding this issue.

Thanks again,
Sue Wiers FNP

>From: "Kimberly Spering" <crnp2001 at westgateoptical.com>
>Reply-To: NP Clinical <np-clinical at nurse.net>
>To: "NP Clinical" <np-clinical at nurse.net>
>Subject: Re: [NP-Clinical] endometrial cells on PAPs
>Date: Thu, 15 Mar 2007 21:45:07 -0400
>
>
>
>
>
>Benign Endometrial Cells Algorithm Annotations
>
>2-6. Benign Endometrial Cells (BEC) Present
>
>Key Points:
>
>  a.. The Bethesda System 2001 reports the presence of normal, 
>cytologically benign-appearing exfoliated endometrial glandular cells only 
>in women age 40 or greater.
>  b.. Benign-appearing endometrial cells are noted in up to 12% of cervical 
>cancer screenings performed over one year, more commonly in premenopausal 
>than in postmenopausal women.
>The presence of benign endometrial glandular cells on cervical screening 
>tests may reflect physiologic shedding or shedding in response to a 
>pathological process. In women over age 40, the presence of 
>benign-appearing endometrial cells on cervical cytology has been found to 
>be less than 2%. Benign-appearing endometrial cells are more likely to be 
>identified on cervical cytology in the first 10 to 12 days of the menstrual 
>cycle (prevalence 21% to 24%) than in the remainder of the cycle 
>(prevalence 2%). The presence of benign endometrial cells on cervical 
>cytology are reported so that a clinician can determine the significance of 
>the finding in an individual woman.
>
>Eighty-four percent (84%) of pre- and postmenopausal women who underwent 
>endometrial sampling due to findings of benign endometrial cells on 
>cervical pathology had no pathology, benign pathology or nondiagnostic 
>pathology. Sixteen percent (16%) of these women were found to have 
>significant pathology (simple or complex hyperplasia with or without atypia 
>or carcinoma) at the time of their endometrial sampling.
>
>If a woman has symptoms of endometrial cancer (abnormal uterine 
>bleeding/spotting) or she is at increased risk of endometrial cancer (i.e., 
>postmenopausal; family or personal history of ovarian, breast, colon or 
>endometrial cancer; tamoxifen use; chronic anovulation; obesity; or prior 
>endometrial hyperplasia), a sampling of the endometrium with endometrial 
>biopsy or dilation and curettage (D & C) is suggested to rule out 
>endometrial cancer. If the above symptoms or risk factors are not present, 
>routine gynecological care should be continued, as women have not been 
>proven to be at increased risk of endometrial cancer based on the presence 
>of benign endometrial cells on cytology alone.
>
>Evidence supporting this recommendation is of classes: B, C, D, R
>
>http://www.guideline.gov/summary/summary.aspx?doc_id=10041&nbr=005341&string=endometrial+AND+cells+AND+PAP+AND+smear
>
>
>
>
>Initial Evaluation. Colposcopy with endocervical sampling is recommended 
>for women with all subcategories of AGC, with the exception that women with 
>atypical endometrial cells should initially be evaluated with endometrial 
>sampling (AII). Endometrial sampling should be performed in conjunction 
>with colposcopy in women older than 35 years with AGC and in younger women 
>with AGC who have unexplained vaginal bleeding (AII).
>
>http://www.guideline.gov/summary/summary.aspx?doc_id=3286&nbr=002512&string=endometrial+AND+cells+AND+PAP+AND+smear
>----- Original Message ----- From: "Sue Wiers" <sgwiers at hotmail.com>
>To: <np-clinical at nurse.net>
>Sent: Thursday, March 15, 2007 7:10 AM
>Subject: Re: [NP-Clinical] (no subject)
>
>
>>Kim,
>>
>>I did a lot of research into this a couple of years ago which included a 
>>literature search, discussing with three ob-gyns, and a pathologist.  In a 
>>nutshell, I could not find definitive guidelines or an established 
>>standard-of-care  Do you know if any exist now?  One gyn and the 
>>pathologist felt that this interpretation is now included due to someone 
>>probably getting sued at some point and that too many unncessary 
>>endometrial biopsies are probably being done.
>>
>>My approach has been to evaluate the findings within the context of the 
>>woman's risk for endometrial cancer (relative age, whether the cells were 
>>found in-phase or out-of-phase, whether or not she has been on OCs, etc). 
>>In the relatively younger woman who is having regular menstrual cycles, 
>>whose pap was done within 10 days of her last period I discuss with her 
>>the risk of missing an endometrial cancer vs the risk associated with 
>>endometrial biopsy (while not particularly risky, still not risk free).  I 
>>give them the option of ruling out cancer with biopsy or repeating a pap 
>>out-of-phase.  I don't believe that there is a right or wrong answer. In 
>>the older patient without regular or with no menses, we do the endometrial 
>>biopsy.
>>
>>Sue Wiers, FNP
>>
>>
>>>From: "Kimberly Spering" <crnp2001 at westgateoptical.com>
>>>Reply-To: NP Clinical <np-clinical at nurse.net>
>>>To: "NP Clinical" <np-clinical at nurse.net>
>>>Subject: Re: [NP-Clinical] (no subject)
>>>Date: Thu, 15 Mar 2007 06:44:23 -0400
>>>
>>>My opinion is for #3:
>>>
>>>She needs an endometrial biopsy.  It may just be proliferative 
>>>endometrium, but you definitely want to rule out hyperplasia, CA, etc.  
>>>On occasion, I've heard comments from others who mention that perhaps the 
>>>cytobrush sampled "too far" into the cervix, but since usual cervical 
>>>lengths are longer than the size of that brush, I don't agree with that 
>>>opinion.  It would be hard to get into the main body of the uterus with a 
>>>cytobrush, IMO, unless you were speaking of a patient post-op cold cone 
>>>biopsy (with a BIG wedge removal).
>>>
>>>Kim Spering
>>>OB-GYN
>>>   ----- Original Message -----
>>>   From: arezendes at aol.com
>>>   To: np-clinical at nurse.net
>>>   Sent: Wednesday, March 14, 2007 6:01 PM
>>>   Subject: [NP-Clinical] (no subject)
>>>
>>>
>>>   I am looking for some expert opinions on a couple of issues,
><snip>
>>>   3. Woman who is 44 having usual periods but had endometrial cells on 
>>>her pap. LMP was 2/22 and pap done 3/1.  Any guidelines?
>>>
>>>   Thanks to all ahead of time.
>>>   Ann, NP
>
>
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