ALGORITHM 1: PAP & HIGH-RISK HPV SCREENING GUIDELINES

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1 ALGORITHM 1: PAP & HIGH-RISK HPV SCREENING GUIDELINES Women under 30 years not recommended Women 30 years and older Women 30 years and older x3 consecutive screens Women 30 years and older positive and Liquid-based every 1-2 years No previous history of CIN 2 or 3, HIV, immunosuppression or DES exposure in utero Repeat liquid-based & testing There is no role for the use of routine HPV DNA testing in women in this age group Liquidbased and testing every 3 years ASC-US positive Liquid-based and testing every 3 years Rescreen with liquid-based & high-risk HPV DNA * Post-colposcopy follow-up per ASCCP guidelines

2 ALGORITHM 2: SCREENING GUIDELINES FOR WOMEN WITH HYSTERECTOMY OLDER WOMEN Women with supracervical hysterectomy (cervix still intact) Women with complete hysterectomy (cervix removed) Women older than 70 years with an intact uterus and cervix Document & confirm Screen according to the guidelines for women without hysterectomy History of benign disease such as fibroids or endometriosis and no prior abnormal Pap tests or cervical cancer History of DES exposure, pre-cancerous lesions or any GYN cancer x3 consecutive screens and no abnormal Pap tests in the last 10 years* History of cervical cancer, HIV, immunosuppression or DES exposure in utero May choose to discontinue screening Continue Pap testing of the vaginal cuff according to diverse management guidelines May discuss discontinuation of screening with patient Continue Pap tests as long as physically able * Risk factors for the development of cervical carcinoma should be assessed on an ongoing basis and taken into consideration when deciding how often and for how long to screen older Women.

3 ALGORITHM 3: AGE SPECIFIC MANAGEMENT OF ASC-US PAP FINDINGS Women over 20 years ASC-US Women over 20 years ASC-US positive Women over 20 years ASC-US not done Women 20 years and under ASC-US not recommended Repeat liquid-based & DNA Repeat liquid-based at 6 and 12 months Repeat only liquid-based not recommended ASC-US or greater with any positive at 6 and 12 months ASC-US or greater HSIL or greater, ASC-US, ASC-H or LSIL Repeat Routine Screening Repeat only liquid-based not recommended * Post-colposcopy follow-up per ASCCP guidelines ASC-US or greater Routine screening

4 ALGORITHM 4: MANAGEMENT OF AGC PAP FINDINGS Women any age AGC or AIS Women any age AGC or AIS with atypical endometrial cells (with endocervical sampling) DNA testing Endometrial sampling** ** >35 years OR at any age if at risk for endometrial neoplasia Endometrial sampling Endocervical sampling No endometrial pathology Endometrial abnormalities *Close post-colposcopy follow-up per ASCCP guidelines is essential in the management of AGC Pap findings DNA testing Follow-up as appropriate for endometrial pathology

5 ALGORITHM 5: MANAGEMENT OF OTHER PAP FINDINGS - PART I Specimen unsatisfactory for evaluation (unsatisfactory indicates >75% of cells are not interpretable) Endocervical cells/transformation zone not present with intact cervix pregnant Repeat liquid in 3-6 months May repeat in 12 months UNLESS one or more of the following exist Rescreen postpartum Previously obscured by inflammation, attempt to clear inflammatory process prior to repeat repeatedly unsatisfactory Previous abnormal without 3 subsequent s Previous with unexplained glandular abnormality Inability to clearly visualize or sample the endocervical canal A positive Within the past 12 months Immunosuppression Insufficient frequency of previous screening Significant clinical history such as abnormal bleeding, discharge or spotting Manage per guidelines Refer for further gynecologic evaluation, possible colposcopy Repeat In 6 months

6 ALGORITHM 6: MANAGEMENT OF OTHER PAP FINDINGS - PART II Blood or obscuring inflammation Atrophy Trichomonas Infection Benign appearing endometrial cells in a woman over 40 years Review clinical history* positive Normal in postmenopausal women but may show ASC-US Evaluate for symptoms, perform wet mount and/or culture if available evaluation not possible Note LMP. In the absence of risk factors for endometrial cancer, continue routine care per guidelines. otherwise unsatisfactory for evaluation high-risk HPV positive In setting of ASC-US, perform testing unavailable Antibiotic treatment Is reasonable if trichomonas detected on Increased risk of endometrial cancer, perform endometrial biopsy Repeat liquidbased in 12 months if patient does not meet high risk criteria** Repeat liquidbased in 3-6 months ** May administer 0.3mg conjugated estrogen vaginally at bedtime for 4 weeks (if not contraindicated) Repeat one week post treatment * Review clinical history- if significant positives on cancer screening (e.g. abnormal bleeding, spotting, discharge, post coital staining) further evaluation is needed, including possible colposcopy, endocervical curretage or endometrial biopsy ** See Algorithim 4 *** Post-colposcopy follow-up per ASCCP guidelines after estrogen reveals ASC-US or greater, refer for colposcopy* after estrogen is, repeat In 4-6 months, return to regular screening interval ASC-US or greater, refer for colposcopy***