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Difficulty: MediumClinical Preventive Services and Screening

A 22-year-old female university student visits the ambulatory care center for an annual wellness check. She has a history of Crohn disease involving the colon, which was diagnosed 2 years ago and is currently in clinical remission. Her daily medications include azathioprine and intravenous infliximab infusions every 8 weeks. She recently became sexually active with a single male partner and relies on oral contraceptives for birth control. She feels well and denies abdominal pain, diarrhea, or intermenstrual bleeding. Her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mmHg, and body mass index is 22 kg/m². Her immunization records indicate she completed all routine pediatric vaccines, but she has not received any clinical preventive services since age 17. Which of the following is the most appropriate next step in preventive care for this patient?

  1. A
    Administration of live-attenuated influenza vaccine
  2. B
    Cervical cytology combined with human papillomavirus testing
  3. C
    Routine endometrial biopsy
  4. Performance of cervical cytology aloneAnswer
  5. E
    Referral for screening colonoscopy

Answer

Performance of cervical cytology alone
The correct answer is the performance of cervical cytology alone. According to current preventive guidelines, routine cervical cancer screening should commence at age 21 for all women, regardless of sexual activity history. For women between the ages of 21 and 29, the recommended screening modality is cervical cytology (Pap smear) every 3 years. This patient is 22 years old and has not received any preventive care since age 17; therefore, she is due for her initial cervical cytology screening.

Step-by-Step Solution

1
Evaluate the patient's age and sexual history to determine cervical cancer screening requirements.
The patient is a 22-year-old female. USPSTF guidelines recommend starting cervical cancer screening at age 21.
To identify if she is due for primary preventive screening for cervical cancer.
2
Determine the appropriate modality for cervical cancer screening in this age group.
Cytology (Pap smear) alone every 3 years is indicated. HPV co-testing is not indicated until age 30.
Transient HPV infections are highly prevalent in women under 30, and co-testing would lead to unnecessary invasive follow-up.
3
Assess the patient's medical history for other indicated screenings or contraindications.
She has Crohn disease diagnosed 2 years ago (too early for colonoscopy) and is on immunosuppressants (contraindicating live vaccines like the live-attenuated influenza vaccine).
To rule out alternative preventive measures or identify potential harm from contraindicated interventions.

Key Concept

Cervical cancer screening with cytology alone is recommended for women aged 21 to 29 years every 3 years. Additionally, live-attenuated vaccines are contraindicated in patients on biologic therapies.
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Topics

Clinical Preventive Services and Screening

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