Q. A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management? A. Repeat the Pap smear in 1 year B. Repeat the endocervical portion of the Pap test as soon as possible C. Perform colposcopy with colposcopically directed biopsies D. Perform laparoscopy with laparoscopically directed biopsies E. Perform exploratory laparotomy The answer is B. A Papanicolaou smear should ideally be a sampling of the transformation zone. An adequate sample should show endocervical cells. When endocervical cells are not present, there is some question as to whether the transformation zone was fully sampled. If a woman has no risk factors for cervical dysplasia, has had three normal annual Pap smears in a row, and has a current Pap that shows no abnormality other than the absence of endocervical cells, then the Pap smear can be repeated in 1 year. This patient, however, has significant risk factors for cervical dysplasia, including early initiation of sexual activity, multiple partners, and unprotected intercourse. Therefore, this patient needs the endocervical portion of the Pap test to be repeated as soon as possible. To repeat the Pap smear in 1 year (choice A) would be incorrect management. As noted above, repeating the Pap smear in 1 year is correct only in patients who have no risk factors for cervical dysplasia, three normal annual Pap smears, and a present Pap that is normal except for the lack of endocervical cells. To perform a colposcopy with colposcopically directed biopsies (choice C) would not be correct. This patient has a normal Pap smear overall. The lack of endocervical cells makes the smear incomplete but not abnormal. To perform laparoscopy with laparoscopically directed biopsies (choice D) would not be correct. Laparoscopy does not allow evaluation of the cervix and is not indicated for abnormal or incomplete Pap smears. To perform an exploratory laparotomy (choice E) is not indicated. Again, this patient has a normal but incomplete Pap smear, and major surgery would not be correct management.