Dr. Naana Afua Jumah (Student, Harvard Medical School): A 23-year-old woman was
seen in the gynecology clinic of this hospital because of a high-grade squamous intraepithelial
lesion seen on pathological examination of a Papanicolaou (Pap) smear.
Four weeks earlier, the patient had come to the adolescent and young adult
medicine clinic of this hospital to establish care and to receive counseling regarding
oral contraception, screening for sexually transmitted infections, and vaccination for
the human papillomavirus (HPV).
Menarche had occurred at the age of 13 years, and menses had been monthly and
regular. She had been sexually active since the age of 21 and had had 18 male
partners, most of whom had had other sexual partners, and she had no history of
sexually transmitted infections or pelvic infections. She had used oral contraceptives
for 3 months, when she first became sexually active, and reported consistent condom
use for both contraception and protection against sexually transmitted infections,
except on three occasions. Physical and gynecologic examination 20 months
earlier had been normal; the Pap smear was normal, with endocervical cells present.
Testing of cervical secretions for gonorrhea and chlamydia were negative. Five
months later, a viral culture of a genital specimen and serologic tests for herpes
simplex virus (HSV) type 1 and type 2 IgG and IgM antibodies were reportedly
negative. Three months before this evaluation, she had been seen in the emergency
department of this hospital for a possible accidental overdose of acetaminophen,
which she had been taking for dental pain. The blood acetaminophen level was
25.9 mg per liter (reference range, 10 to 25; toxic level, >120); the level 3 hours
later was normal. She was instructed on proper dosing of the drug and discharged.
She had had multiple atypical nevi, and one of two previous excisions had reportedly
shown dysplastic changes. She had had an adenoidectomy at the age of 10 years.
The patient worked in an office and lived with roommates. She had been without
health insurance since graduating from college 1 year earlier. She drank 5 to 10
alcoholic beverages 2 to 3 days per week, including during sexual activity, and
reported several episodes of blackouts while drinking; she had smoked marijuana
on a few occasions in the past and did not smoke tobacco. Her mother had a history
of vitiligo and alcohol abuse; her father and two sisters had irregular nevi. There
was no family history of coagulopathy or gynecologic cancer. She was allergic to
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