wHAT IS MILD DYSKARIOSIS?

Answer 1

Cervical smear findings involve "dyskariosis". The word dyskariosis means "abnormal nucleus" and so a mild dyskariosis indicates that the nucleus (middle bit of the cell that carries the important information) has changed a bit. It is not normal but not to worry - just keep an eye on it as it is an early warning sign and not cancer.
The abnormal smear result has different classifications:
Borderline (dyskariosis)
Mild dyskariosis (Cervical Intraepithelial Neoplasia1)
Moderate dyskariosis (CIN 2), and Severe dyskariosis (CIN 3)

Borderline and mild dyskariosis are only treated if they are still there after several smears, because these changes often right themselves without any treatment. A repeat smear should be performed within six months of these changes being found. But if moderate or severe dyskariosis is discovered then it is better to remove the cells so that the new cells beneath grow normally. This is to prevent any cancer from developing in the future.

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Answer 2

Remember first that cervical smears are performed to prevent cancer. They are designed to pick up Early changes in cells. Mild dyskariosis is a long way from cancer. It means that some of the cervical cells taken by the smear test have been affected by human papilloma virus (HPV) and will need to be watched. You will either have been given a smear repeat date, or made an appointment for a gynaecologist to see you.

Answer 3

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Answer 4

"Dyskaryosis is caused by an infection with Human Papilloma Virus (HPV) which exists in a number of different strains."
http://en.wikipedia.org/wiki/Dyskaryosis

Answer 5

Undoubtedly, women with smears showing severe dyskaryosis should have immediate colposcopy; many doctors believe that those with moderate dyskaryosis should be treated in the same way. But what to do about mild dyskaryosis is much less clear cut, and, indeed, the diagnosis is very subjective. According to the NHS cervical screening programme's guidelines, no justification exists for immediate colposcopy for mild dyskaryosis, but the programme wanted further research to determine whether cytological surveillance was as safe and effective as colposcopy.1 Such research is being conducted prospectively by the Aberdeen birthright project and is reported in this week's journal (p 1399).2
The arguments in favour of immediate colposcopy are that it allows early assessment and diagnosis - useful, given the well documented association between mild cytological abnormalities and high grade cervical intraepithelial neoplasia.3,4 In this week's journal, Soutter and Fletcher report that women with mild dyskaryosis are at high risk of developing invasive cervical cancer (p 1421).5 Colposcopy should result in reassurance and should protect against the risk of the patient defaulting from cytological follow up. Disadvantages claimed for immediate colposcopy include the cost, which results in suboptimal use of the procedure. There is also a risk of overtreatment, which has increased with the widespread adoption of a "see and treat" policy after the introduction of large loop excision of the transformation zone.

The Aberdeen group addressed the issue of cost and the use of resources. It reported that only one in four smears obtained from women with mild dyskaryosis undergoing cytological surveillance reverted to normal with time and that most women with mild dyskaryosis eventually required colposcopy. In view of this and the need to take additional smears the group believed that a policy of cytological surveillance was likely to be more expensive and less efficient. This hypothesis is also supported by Johnson and colleagues, who used decision analysis to compare the expected mortality and cost associated with immediate referral with those associated with cytological surveillance.6 The risk of ultimately developing invasive cancer was the same in both groups, but the cost was greater if a conservative policy (cytological surveillance) was adopted.

The other important findings in the paper from Aberdeen were that one third of women with cervical intraepithelial neoplasia grade III had an index smear showing mild dyskaryosis and that one in eight women defaulted from follow up. A previous paper has highlighted the risk of defaulting,7 and in this week's journal Macgregor and colleagues highlight the increased risk of invasive cervical cancer in women who are screened inadequately, or not at all (p 1407).8 Research to identify those women with mild dyskaryosis who may harbour high grade disease has focused mainly on the expression of human papillomavirus types,9 although a recent paper reported a strong association between such lesions and smoking.10 Should women with smears showing mild dyskaryosis therefore be selectively referred?

The remaining potential disadvantage of immediate referral is the risk of overtreatment. The advantages and disadvantages of a see and treat policy are illustrated in the short report by Downey et al in this week's journal in a population at high risk of defaulting (P 1412).11 Although large loop excision of the transformation zone is safe and effective,12 one should aim to avoid unnecessary treatment. Risk factors for overtreatment with large loop excision at the first attendance for colposcopy include minor cytological abnormalities,13 and caution should be exercised in patients with such abnormalities. But I believe that this risk is not an argument favouring cytological surveillance in patients with mild dyskaryosis - rather, an indication for a more complete colposcopic assessment before treatment, including punch biopsy of any lesion.

The time has come to review the recommendations for managing women in whom a smear shows mild dyskaryosis. A case can be advanced for selectively referring smokers with mild dyskaryosis for immediate colposcopy and for continuing with cytological surveillance for non-smokers. The data now available, however, justify a policy of immediate referral of all such patients for colposcopy. This would result in some increase in colposcopic surveillance but is surely preferable to cytological surveillance in a group with a high incidence of important disease who will ultimately need colposcopy, especially when there is a substantial risk of patients defaulting from follow up.

R Hammond



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