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Patient context?
Screening/incidentally abnormal test → go to A
Symptoms or visible cervical lesion (postcoital bleeding, malodorous discharge, pelvic pain; friable/exophytic cervix on speculum) → go to B
A) SCREENING & ABNORMAL RESULTS (Risk‑based logic)
A1. Age & routine screening (asymptomatic)
21–29: cytology (Pap) q3y. U.S. Preventive Services Task Force
30–65: choose primary hrHPV q5y (preferred), cotest q5y, or cytology q3y. U.S. Preventive Services Task Force
>65 with adequate prior negative screens & not high‑risk → stop screening. U.S. Preventive Services Task Force
Post‑hysterectomy for benign disease & no CIN2+ history → no screening. (USPSTF text). U.S. Preventive Services Task Force
Immunocompromised (e.g., HIV) → screen more frequently per specialty guidance (risk‑based; test writers expect closer surveillance). (ASCCP risk framework). Lippincott Journals
A2. Abnormal screening result → manage by immediate CIN3+ RISK (ASCCP 2019):
≥60% → Expedited treatment preferred (excisional, e.g., LEEP) if ≥25yo & not pregnant. Classic: HPV‑16+ HSIL, or underscreened with HPV+ HSIL. (First step vs best next step: if classic scenario → go straight to excisional treatment; do NOT wait for colpo biopsy.) PMCACOG
25–<60% → Expedited treatment OR colposcopy acceptable (shared decision‑making). ACOG
4–<25% → Colposcopy. PMC
0.55–<4% (5‑yr risk) → Repeat test in 1 yr. PMC
0.15–<0.55% (5‑yr risk) → Repeat in 3 yrs. PMC
<0.15% (5‑yr risk) → Return to routine screening. PMC
Pearls
Pregnant: No endocervical curettage; defer treatment of CIN to postpartum unless cancer suspected. (ASCCP principles). Lippincott Journals
Vaccination: Routine at 11–12 (start as early as 9). Catch‑up through 26; 27–45 via shared clinical decision‑making. (Vaccine status does not change current screening intervals for adults on exams.) CDC+1
B) SYMPTOMS / VISIBLE LESION (Diagnosis → Staging → Treatment)
B1. First step
Speculum exam. If a visible suspicious cervical lesion → immediate biopsy (don’t “Pap first”). (NBME trap: do not order Pap when a cancerous‑appearing lesion is present—biopsy it.)
B2. Confirmed invasive carcinoma → FIGO staging (clinical + imaging allowed since 2018)
Key 2018 changes: imaging/pathology can assign stage; IB subdivided by size; nodal disease = IIIC. Obstetrics & GynecologyPMC
B3. Initial work‑up after biopsy shows cancer
Pelvic exam (parametria/vaginal involvement), MRI pelvis (local extent), CT chest/abdomen/pelvis or PET/CT(nodes, mets), CBC/CMP; pregnancy test if relevant. (NCCN work‑up). PubMed
B4. Definitive management by stage (NCCN/FIGO‑aligned)
Stage IA1 (≤3 mm depth, ≤7 mm width)
Stage IA2 (3–5 mm depth)
Radical hysterectomy + pelvic nodes or radical trachelectomy + nodes if tumor ≤2 cm and fertility desired. NCCN
Stage IB1 (<2 cm) / IB2 (2–3.9 cm)
Radical hysterectomy + nodes or radical trachelectomy (≤2 cm, node‑neg) vs primary chemoradiationdepending on size/comorbids. PubMed
Stage IB3 (≥4 cm) or IIA2
Primary concurrent chemoradiation (weekly cisplatin + EBRT + brachytherapy). (NBME: ≥4 cm or parametria involved → choose chemoradiation, not primary surgery.) PubMed
Stage IIA1 (≤4 cm, upper 2/3 vagina, no parametria)
Either radical hysterectomy + nodes or chemoradiation (institutional practice). PubMed
Stage IIB (parametrial), III (pelvic wall, lower vagina, hydronephrosis), IIIC (node+), IVA (adjacent organs)
Concurrent chemoradiation. PubMed
Stage IVB / recurrent/metastatic
Systemic therapy (e.g., platinum/taxane ± bevacizumab, and PD‑1 inhibitors for PD‑L1+; tisotumab vedotin options). Palliative radiation for bleeding/pain. (Know that immunotherapy/bevacizumab exist; you won’t be quizzed on lines/doses.) JNCCN
B5. Adjuvant therapy after surgery (high‑risk pathology)
Positive margins, nodes, parametria → adjuvant chemoradiation.
Intermediate‑risk (Sedlis factors) → adjuvant radiation ± chemo per risk. (NCCN). PubMed
B6. Special situations
Pregnancy: biopsy of visible lesion is safe; defer definitive treatment (for preinvasive/CIN) until postpartum; manage invasive cancer with multidisciplinary team (gestational age–dependent). (ASCCP/NCCN principles). Lippincott JournalsNCCN
Post‑treatment surveillance: periodic pelvic exam; imaging if symptomatic/suspicious. (NCCN). NCCN
High‑Yield “First vs Best Next Step” Callouts
Visible friable cervical mass → First step: punch biopsy (not Pap).
ASC‑US in age 21–24 (classic exam framing) → Repeat cytology in 1 year, not immediate colpo (risk‑based systems concur with conservative management here). Lippincott Journals
HSIL + HPV‑16 (nonpregnant, ≥25) → Best next step: expedited excisional treatment. PMC
Tumor ≥4 cm or parametrial involvement → Best next step: concurrent chemoradiation (not radical hysterectomy). PubMed
NBME Traps & Reversal Drills
Don’t Pap a cancer: visible lesion → biopsy now.
No ECC in pregnancy; treat CIN postpartum unless cancer suspected. Lippincott Journals
Post‑hysterectomy (benign, no CIN2+ history) → stop screening. U.S. Preventive Services Task Force
HPV vaccine: great prevention, but doesn’t change adult screening intervals on exams; 27–45 is shared decision‑making, not routine. CDC
Staging is clinical‑imaging (FIGO 2018); node+ = IIIC even if small primary. (Choose chemoradiation.)Obstetrics & Gynecology
