ACOG發表常規骨盆腔檢查、子宮頸細胞學篩檢的建議

作者：Fran Lowry  
出處：WebMD醫學新聞

　　April 22, 2009 — 美國婦產科醫學會（ACOG）發表了一項常規骨盆腔檢查與子宮頸細胞學篩檢的委員會意見，這將發表於5月號的婦產科醫學期刊上。
　　
　　ACOG的產科執業委員會寫到，ACOG委員會意見代碼431號的建議，該文件反映出新興的臨床與科學進步，且應該做出改變了。該資訊不應被解釋為要求進行特定治療或是處置療程。
　　
　　由於人類乳突狀病毒疫苗的進展造成了何時、哪些女性應該接受定期評估等困惑，因此ACOG決定發表這項指引。
　　
　　該建議提供有關何時應該開始進行篩檢、篩檢的頻率、以及根據年齡，何時應該停止常規骨盆腔檢查以及子宮頸細胞學檢驗等建議。
　　
　　從未有性經驗、21歲以下的女性，並不需要接受常規骨盆腔檢查、子宮頸細胞學檢驗或是性傳染病（STD）的檢驗。然而，ACOG建議，如果這些女性有性經驗，ACOG建議在性行為3年後開始進行子宮頸細胞學篩檢，且之後每年進行一次。常規的骨盆腔檢查應根據病患的病史決定何時進行。
　　
　　針對21~29歲女性，ACOG建議每年進行一次骨盆腔檢查與子宮頸細胞學檢查。25歲以下有性生活的女性應該接受披衣菌的篩檢，且所有有性生活的青少年都應該接受淋病的篩檢。根據ACOG表示，尿液篩檢就已經足夠了，不需要進行擴張器檢查。
　　
　　ACOG也表示，所有有性生活的青少年與19~64歲女性都應該接受HIV篩檢。
　　
　　對於30~64歲的女性，建議每年進行一次骨盆腔篩檢與子宮頸細胞學檢驗。然而，在3次檢驗結果正常後，如果病患沒有子宮頸上皮內異常增生（CIN）2或是CIN 3，且非免疫功能不全、也非HIV陽性病患、且在胚胎時期沒有暴露在乙烯雌酚（DES），篩檢頻率可以調整至每2~3年一次。
　　
　　對於65歲以上女性，ACOG建議每年進行骨盆腔檢查。然而，如果這些女性連續3次檢查結果正常、或10年內沒有異常檢查結果、沒有子宮頸癌病史、沒有暴露在DES下、HIV陰性、免疫功能正常、且沒有其他STD危險因子，則可以停止篩檢。何時重新開始篩檢則應該在每年的定期檢查中決定。
　　
　　對13~18歲女性而言，骨盆腔篩檢並非每年健康檢查的常規項目，除非有醫療需求。當有無月經症、異常出血、陰道炎、骨盆疼痛、STD、骨盆腔腫塊、或是其他狀況下才進行這項檢查。
　　
　　對於無症狀且已經因良性原因接受子宮摘除、或是雙側卵巢切除的女性，雖然應該繼續進行年度外生殖器的檢查，但停止進行擴張器與徒手骨盆腔檢查是合理的。
　　
　　ACOG建議，當年齡或其他健康議題達到女性可能不會選擇治療於常規檢驗中發現的病灶時，應該停止骨盆腔檢查。這樣的決定應該在病患與她們的醫師之間討論後進行。

ACOG Issues Recommendations on Routine Pelvic Exam, Cervical Cytology Screening

By Fran Lowry
Medscape Medical News

April 22, 2009 — The American College of Obstetricians and Gynecologists (ACOG) has issued a committee opinion on routine pelvic examination and cervical cytology screening that will be published in the May issue of Obstetrics and Gynecology.

The recommendations of ACOG Committee Opinion Number 431 come with the caveat that the document "reflects emerging clinical and scientific advances as of the date issued and is subject to change," writes ACOG's Committee on Gynecologic Practice. "The information should not be construed as dictating an exclusive course of treatment or procedure to be followed."

ACOG decided to issue the guidelines because the advent of the human papillomavirus vaccine has given rise to some confusion about when, and in whom, to perform periodic health assessments in women.

The recommendations on when to start screening, how often to continue screening, and when to stop routine pelvic examination and cervical cytology are based on age.

For women younger than 21 years who have never been sexually active, no routine pelvic examination, cervical cytology, or testing for sexually transmitted disease (STD) is needed. If the women have ever been sexually active, however, ACOG recommends cervical cytology be performed 3 years after the onset of sexual activity, and annually thereafter. Routine pelvic examination should be performed only when indicated by the patient's medical history.

For women aged 21 to 29 years, ACOG recommends an annual pelvic examination and cervical cytology. Sexually active women aged 25 years or younger should be screened for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Urine-based screening without a speculum examination is sufficient for such screening, according to ACOG.

ACOG also says that all adolescents and women aged 19 to 64 years who are sexually active should be screened for HIV.

For women aged 30 to 64 years, the recommendation is for annual pelvic examination plus cervical cytology. However, screening can be decreased to every 2 to 3 years after 3 normal test results if the patient has no history of cervical intraepithelial neoplasia (CIN) 2 or CIN3, is not immunosuppressed, is not HIV-positive, and was not exposed to diethylstilbestrol (DES) in utero.

For women older than 65 years, ACOG recommends an annual pelvic examination. However, cervical cytology may be discontinued if the woman has had 3 or more normal test results in a row, no abnormal test results in 10 years, no history of cervical cancer, no DES exposure in utero, is HIV-negative and immunocompetent, and does not have other risk factors for STDs. The need to begin screening again should be evaluated at each annual examination.

The pelvic examination is not a routine part of the annual health examination in girls aged 13 to 18 years, unless it is medically indicated. It should be performed when it is likely to yield information about amenorrhea, abnormal bleeding, vaginitis, pelvic pain, an STD, a pelvic mass, or other conditions.

It is also reasonable to stop speculum and bimanual pelvic examinations in asymptomatic women who have had a total hysterectomy and bilateral oophorectomy for benign indications, although annual examination of the external genitalia should continue.

It would also be reasonable to stop pelvic examination when a woman's age or other health issues reach a point where the woman would not choose to treat conditions detected during the routine examination. Such a decision should be discussed between the patient and her physician, ACOG recommends.

Obstet Gynecol. 2009;113:1190–1193.