Managing low grade and borderline cervical abnormalitiesBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3014 (Published 29 July 2009) Cite this as: BMJ 2009;339:b3014
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The error into which this debate has drifted over the many years of
its currency is plain to see. Whilst the figures adduced are no doubt
flawless, the inferences drawn are too narrow. Cervical screening is but
one small element of reproductive health care and the target population
age range is so wide that results at one end cannot prudently be
translated to the other. Furthermore the entire terrain is a complex mesh
of dynamically interacting and varying factors.
HPV infection is not a static phenomenon. Predicating future
screening policy on retrospective analysis is fraught with risk.
In 2005 I had a letter in BJOG
in which I made just this point.
The natural histories of HPV infection and CIN are becoming known but
will change with time, immunisation and the social environmental
variation. Age at first intercourse and numbers of partners are factors
moving in a direction which presupposes an increase in incidence of HPV
transmission and CIN development in the future.
Ideally, we should be encouraging young people to treat regular
comprehensive sexual health checks as an innocuous routine - of no greater
threat than routine dental hygiene - and starting before first
intercourse. The coherent provision of advice, knowledge, contraception,
STD/HPV screening, cervical cytology, etc. is essential to combat
unplanned pregnancy and infectious disease incidence.
The greatest barrier to rational service development is the morbid
delicacy that still grips the population, the media and the profession
when addressing sexual behaviour, especially amongst the young.
The message needs to be direct, utilitarian and consistent - no more
excruciatingly politically correct euphemisms and posturing. We all need
to be vastly more grown up about the whole thing.
For practical purposes everyone has sex. This has consequences.
Concerns, anxieties, misunderstandings and ignorance are excessively
common. Getting the parts down to your local service provider and up onto
the ramp for MOT regularly, as the mileage increases or problems arise,
will go a long way to ensuring a long and trouble free sex life. Once this
pattern of routine care is securely in place the details of which tests
are done and when can vary but patterns of behaviour of infectious disease
are known to change capriciously - continuous surveillance ought to allow
us to remain a step ahead or at least abreast of those changes.
There is no substitute for regular and, if necessary, frequent
examination and testing - life-long. I despair at the lengths to which
some of my erstwhile colleagues will go to avoid examining patients.
Genital (or breast or rectal) examination is or should be a banal,
mundane, sexless interaction with no greater psychological overlay than a
snap of the fingers. If the professionals cannot get the thing right then
what hope has the laity?
Competing interests: No competing interests