Feature

GPs’ guide to completing a cervical screening pathology request form


Lara Roeske


10/01/2018 1:14:02 PM

Dr Lara Roeske outlines important details for completing a pathology request form in the context of the renewed National Cervical Screening Program.

News teaser
The renewed National Cervical Screening Program is for sexually active, asymptomatic women who are vaccinated and unvaccinated for HPV.

Asymptomatic women aged 25–74 with no previous screen-detected abnormality who are due for cervical screening
GPs can request a cervical screening test (CST). They should not request a Pap smear, cervical cytology or Pap test.
 
GPs can also consider requesting a test for chlamydia infection either:

  • annually for asymptomatic women who have ever been sexually active and are aged 30 or younger
  • selectively for women aged 30 or older according to risk (sexual history and examination findings) or request.
If requesting a CST and a chlamydia test, both can be done on the liquid-based cervical sample. The patient must sign the Medicare assignment on the request form for the test to be bulk-billed.
 
Asymptomatic women of any age with a previous screen-detected abnormality returning for follow up
GPs can request a follow-up human papillomavirus (HPV) test for women with a previous low-grade squamous intraepithelial lesion (LSIL).
 
Alternatively, GPs can request a co-test – HPV and liquid-based cytology (LBC) – as part of commencing or continuing test of cure follow-up management of women treated for a histologically confirmed high-grade squamous intraepithelial lesion (HSIL).
 
Women at any age with symptoms or signs suggestive of cervical cancer
GPs can request a co-test (HPV and LBC). They can also consider adding ‘abnormal symptoms/signs, not for routine screening’ to the request form.
 
Women with signs or symptoms suggestive of cervical cancer should have further investigation regardless of their age. This includes a co-test (HPV and LBC). A referral for appropriate investigation to exclude genital tract malignancy should also be considered.
 
Symptoms suggestive of cervical cancer include unexplained, persistent or unusual bleeding, dyspareunia and discharge (offensive and/or blood-stained). Signs such as an abnormal appearance of the cervix or significant contact bleeding should be documented on the request form and in the medical record.
 
Abnormal vaginal bleeding includes post-coital bleeding (PCB), unexplained inter-menstrual bleeding (IMB) or post-menopausal bleeding (PMB), and requires further investigation and appropriate referral if clinically indicated.
 
Any bleeding in a post-menopausal woman should be investigated with a co-test (HPV and LBC) and referral for gynaecological assessment.
 
Pre-menopausal women with a single episode of post-coital bleeding should be investigated with a co-test (HPV and LBC). If the cervix is clinically normal and the co-test negative, the woman should be advised that no further investigation is necessary; however, if the post-coital bleeding recurs or persists she should be referred for gynaecological assessment (which should include colposcopy).
 
The co-test is a diagnostic test, rather than a screening test, requiring the pathology laboratory to perform both an HPV and an LBC test on the same sample. GPs should indicate that the sample is not being collected as part of routine screening by noting the presence of symptoms or signs on the form. Relevant clinical information may also be added to the request form by selecting the relevant tick box from the checklist under clinical findings.
 
Co-testing is not indicated in the vast majority of women presenting with vaginal discharge and/or dyspareunia, as almost all will have benign gynaecological disease and cervical cancer in these women is very uncommon. If due for cervical screening, a CST would be most appropriate.
 
Persistence of any unexplained gynaecological symptoms/signs should always warrant further investigation and referral as appropriate.
 
Repeat testing for an unsatisfactory CST result (HPV or LBC)
A repeat sample can be collected 6–12 weeks after an unsatisfactory result. GPs can request either a repeat HPV test for the follow-up of a previous unsatisfactory HPV result, or a repeat LBC test for the follow-up of a previous unsatisfactory LBC result.
 
Asymptomatic sexually active women aged younger than 25 with a previous negative Pap test result
Sexually active, asymptomatic women aged younger than 25 are not eligible for a cervical screening test, and GPs should not request a CST or cervical screening test.
 
Young sexually active women should be offered an annual chlamydia test, contraceptive counselling and safe-sex advice. These women will receive an invitation to screen from the National Cancer Screening Register three months prior to turning 25.
 
In the case of women who have experienced first sexual activity at a young age (<14 years ), and who had not received the HPV vaccine before this experience, GPs can consider requesting a single CST or cervical screening test between ages 20–24 on an individual basis.
 
Asymptomatic women aged 75 or older who request screening
GPs can request a CST or cervical screening test for women aged 75 or older and have never had a cervical screening test, or who have not had one in the previous five years.
 
Asymptomatic women aged 30 or older who are under-screened (at least two years overdue for cervical screening) and decline a speculum examination
Self-collection is a vaginal swab taken by a woman for HPV testing. The sample contains vaginal, not cervical, cells. The vaginal HPV test is sufficiently accurate and includes partial genotyping for HPV 16 and HPV 18. LBC cannot be performed on the vaginal sample. Self-sampling must be performed in a healthcare setting – it is not available as a home-based test or mail out kit.
 
Note: VCS Pathology is currently able to process these samples following successful accreditation. It is anticipated that wider accreditation will become available (your laboratory will advise you). In the meantime, VCS Pathology can receive self-collected samples from eligible Australian women. VCS Pathology offers bulk billing for any eligible Australian woman not residing in Victoria. Eligible Victorian women will be tested free of charge.
 
For all cervical screening episodes and follow-up testing of screen-detected abnormalities
GPs should record:
  • Aboriginal and/or Torres Strait Islander/cultural and linguistic diversity (CALD) status
  • country of birth
  • language spoken at home.
This information will assist in assessing cervical screening participation rates and inform efforts to improve access to appropriate services for under-screened and unscreened women.
 
Resources
Visit RACGP.TV to view Changes to cervical screening, a video resource presented by Dr Lara Roeske and Dr Stella Heley designed to support GPs and their practice teams in the transition to the new guidelines. In addition, resources supporting the renewed National Cervical Screening Program are available at VCS Pathology.



cervical cervical-screening National-Cervical-Screening-Program



Assoc Prof Louise Owen   12/01/2018 8:21:37 AM

Hi Laura,
Thanks for the comprehensive document which will be very handy. Could I suggest that in the section "pre-menopausal women with a single episode of post coital bleeding '.... should have the CO= test..." - could you include Chlamydia PCR into that section as the conclusion is that if the co test is negative then 'no further investigation is necessary' however the most common cause of PCB in young women would be CT and this has not been tested for in this scenario. Thanks , Director Sexual Health Service Tasmania.


Dr Das Devidas   12/01/2018 10:43:49 AM

Message is Clear


Dr Lara Roeske   12/01/2018 4:31:10 PM

Thank you Louise.
A differential diagnosis of Chlamydia infection can be considered by the GP for women at any age presenting with symptoms including abnormal vaginal bleeding ( PCB, IMB, PMB) discharge and dyspareunia. And a request for a Chlamydia test may be included as part of the investigation of the presenting symptom, informed by the history and examination findings. The article assists GPs to identify when a co-test is clinically indicated according to the national guideline recommendations.


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