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Re: Gyn: Recurrent dysplasiaFrom: Joanne Bulley, MD (islesannie@yahoo.com)Mon Oct 30 12:06:48 2006
Garry I have a few of these cases testing my expertise! As a friend (dermatologist) said to me 15 -18 years ago "HPV is going to put our kids through college" Not to mention making all of us crazy! This is a long answer - but I bet each of us have a hadful of these patients at any one time and it is tough to answer all their questions. I have gone to doing the HRHPV for women at or over 30 yo. But I wonder what headaches that will give me once I get a few "normal Pap" but "+HRHPV". For those I am telling the woman she needs to have a colpo looking for occult disease and then has to be sure to come in for annual Paps. The neg-neg folks can go to Q 3 year paps. But the +HR HPV patients are going to be a difficult management - like your patient! For this one: ASCUS + HRHPV with adequate colpo, biopsy CIN 1: if I was certain of her complaince and willingness to come back, I would offer Q 6 month colpos until clears or progresses (or she says I am tired of this, can't you cut it out?) IF she wants another LEEP I sould consider it, but likely encourage the watchful observation. I have the following three cases now: 1. 84 yo (had one partner after being widowed and got the HRHPV and we hvae been chasing it since 1996): Cone 1996 (margins all clear) LEEP 2004 (I think) with minimal lesion, margins all clear. Paps in between and some normal most ASCUS. After LSIL was evaluated with colpo no disease) treated with Extrogen Vaginal cream. Pap back to ASCUS. Quit Estrogen and then recently had HSIL Pap. Very difficult colpo. No lesion visible. Consulted with Gyn Onc. She said daily Estrace Cream 1 gm and if vaginal access improve, consider another cone. So we did that. Pap went back to LSIL (all remain positive for HR HPV). Cone - remove the centrla core as high as possible (difficult access remains) Path - some reactive atypia no dysplasia, ECC negative. Plan: Extrace Vaginal cream 1 gm 3 times per week and Pap in 6 months. Hyst if returns to HSIL. Watchful waiting if stays at or below LSIL. 2. 50-ish woman. Current long term partner gave her HPV: both external and Cervical - upper vagina. Leep or cone would not treat the vaginal. After various colpos and follow up - consult with Gyn Onc - estrogen vaginal cream recommended. Paps and colpos still bounce around the various LSIL / ASCUS etc. Colpo - still had disease onto vaginal fornices. Repeat consult with Gyn Onc: suggest Efudex (5-FU) Treated once weekely X 10 weeks (with 2 weeks off in the middle due to vulvar and vaginal burning) concomitant Premarin Vaginal Cream 1 gm weekly. Next Pap & colpo normal. Now on 1 gm estrogen cream twice weekly with colpo Q 6 months for the tiem being. 3. approximately 40 yo with Hysterectomy for DUB / pelvic pain with normal Pap 6 months before hyst. Hyst Path: Mild dysplasia of cervix. Pap 6 months after hyst LSIL. Colpo: vaginal lesions biopsy VaIN (I forget the level I think moderate dysplasia). OR for laser ablation of the vaginal dysplasia. Next pap - LSIL; colpo - continued disease and tested out + HRHPV. Has just finished a similar course of 5 FU (after review with my friendly gyn onc) but has not yet had her f/u colpo (no show) (I have cared for this patient for the last 20 years - and she will come in - we just have to hound her. She has an autistic son and she is rather marginal herself in social skills) Joanne
At Mon, 30 Oct 2006, Garry E. Siegel, M.D. wrote:
>
-- Joanne Bulley, MD Keene, NH, USA
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