What’s new in managing women with unsatisfactory Pap results?
In general, cytology should be repeated in 2 to 4 months.
If the unsatisfactory Pap test is part of a cotest, then the following strategies are appropriate:
- If the HPV test is positive, either repeating the Pap test or moving directly to colposcopy is acceptable
- If HPV genotyping was reported and is positive for type 16 or 18, colposcopy is indicated.
Colposcopy also is recommended when two consecutive Pap tests are unsatisfactory.
What’s new in managing women with normal cytology but no, or insufficient, endocervical cells/transformation-zone component?
The answer varies by age:
- For women 21 to 29 years – routine screening with cytology in 3 years is recommended
- For women 30 years and older:
- When cotesting is done, the HPV result guides management:
- HPV-negative: routine screening with cotesting in 5 years is preferred
- HPV-positive: either cotesting in 1 year or immediate genotyping is recommended
- If HPV testing was not done, then HPV testing is recommended, with management guided by results.
- When cotesting is done, the HPV result guides management:
What’s new in managing women aged 21 to 24 with abnormal cervical cytology or CIN?
Young women of this age are at high risk for HPV infection but very low risk for cancer. Aggressive management usually involves more harm than benefit, promoting observation. Adolescents are no longer screened; management previously reserved for adolescents is now appropriate for women aged 21 to 24 years.
If the Pap result is:
- ASC-US or LSIL:
- No colposcopy is needed. The Pap test should be repeated annually for 2 years, with colposcopy after 1 year only when the finding is HSIL and after 2 years if ASC-US or LSIL findings persist
- HPV triage for ASC-US is not recommended, but if it is done:
- HPV-negative women should continue routine screening with a Pap test in 3 years
- HPV-positive women should have annual cytology for 2 years, with colposcopy after 1 year only if the result is HSIL and after 2 years if ASC-US or LSIL findings persist.
- ASC-H or HSIL:
- Colposcopy is recommended, but immediate treatment (see-and-treat LEEP) is unacceptable
- Women with no CIN 2 or CIN 3 at colposcopy should be followed with colposcopy and cytology every 6 months for as long as 2 years, until two consecutive Pap tests are negative and no high-grade colposcopic abnormality is observed
- Repeat biopsies are indicated if cytology at 1 year is again ASC-H or HSIL
- Diagnostic excision is recommended if HSIL cytology persists for 2 years.
Changes in the management of histologic findings
If CIN 1 is detected, management depends on the antecedent cytology report:
- If the prior Pap finding was ASC-US or LSIL, observation with annual cytology is recommended
- If the prior Pap finding was ASC-H or HSIL, observation for as long as 24 months is recommended, using both colposcopy and cytology at 6-month intervals, provided the colposcopic examination is adequate and endocervical assessment is negative.
If CIN 2 is detected, observation is preferred but treatment is acceptable (see the guidelines for detailed recommendations).
If CIN 2/CIN 3 (not otherwise differentiated) is detected, either observation or treatment is acceptable (see the guidelines for detailed recommendations).
If CIN 3 is detected in a woman of any age, treatment is indicated.
What’s new in managing women 30 years and older who have discordant cotest results?
Use cotesting management recommendations only for women 30 years and older.
If the finding is:
- HPV-positive/Pap-negative (HPV+/ Pap-), the two options are:
- Repeat cotesting in 1 year, with colposcopy if the finding is again HPV+ or the Pap is ASC-US or more severe (including HPV-/ASC-US), and repeat cotesting in 3 years if results for both the HPV test and the Pap are negative (HPV-/Pap-)
- Genotyping, with colposcopy if HPV 16 or 18 is identified and repeat cotesting in 1 year if both HPV 16 and 18 are negative
- HPV-/ASC-US:
- Repeat the cotest in 3 years
- HPV-/LSIL, the options are:
- Cotesting in 1 year (preferred)
- Colposcopy (acceptable)
- HPV+/LSIL or LSIL/no HPV result:
- Colposcopy
- HPV-/HSIL or HPV-/ASC-H:
- Colposcopy
- HPV-/AGC
- Colposcopy, often with endometrial sampling.
New terminology unifies all lower genital tract HPV intraepithelial neoplasia
Darragh TM, Colgan TJ, Cox JT, et al; LAST Project Work Groups. The Lower Anogenital Squamous Terminology Standardization Project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. J Low Genit Tract Dis. 2012;16(3):205–242.
In 2012, the Lower Anogenital Squamous Terminology (LAST) standardization project created new histology terminology for HPV-related lesions of the lower genital tract. The LSIL finding was designated as the all-encompassing term for CIN 1, vaginal intraepithelial neoplasia 1 (VaIN 1), vulvar intraepithelial neoplasia 1 (VIN 1), penile intraepithelial neoplasia 1 (PeIN 1), perianal intraepithelial neoplasia 1 (PAIN 1) and anal intraepithelial neoplasia 1 (AIN 1). Intraepithelial neoplasia (IN) graded 2, 2/3, and 3 from each of these areas is designated HSIL.5