Managing Abnormal Pap Smears

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When you look at the American Society for Colposcopy and Cervical Pathology (ASCCP) guideline flowsheets, it can seem like an absolute maze, and remembering what to do when is challenging. The ASCCP guidelines are free to review in PDF form and are probably your most useful resource. They also have a very handy smartphone app to help for clinic or problems on the go, but obviously these aren’t available to you in an exam setting. The OBG Project has a ton of helpful articles on Pap smear management as well!

*** It’s also important to know we’re anticipating a change in these guidelines sometime in 2020 from the ASCCP, so stay tuned! ***

Today we’ll try to break it down so mentally, you can remember these algorithms for the exam. We find it helpful to evaluate abnormal Pap management systematically. 

Start by separating Pap cytology results into “low grade,” which are ASC-US and LSIL cytologies, and “high grade,” which are ASC-H and HSIL pathologies. Next, you need to remember the age cut offs: 21-24, 25-29, 30-64, and 65+. Finally, for those over age 30, HPV status will be the next important step in the algorithm.

Let’s break it down:

Normal Cytology. The only potential abnormal in this category is HPV positive. The risk of CIN 2 or greater in this population is approximately 2-6%. It increases if HPV is persistently positive over time.

  • If typed and result is HPV-16 or HPV-18, colposcopy is recommended.

  • If untyped or not 16/18, repeat Pap in 1 year. 

    • If at 1 year, negative HPV and negative cytology, then cotesting in 3 years.

    • If at 1 year, positive HPV and/or abnormal cytology, then perform colposcopy.

      • This intuitively makes sense. If HPV is persistent, it is more likely to cause dysplasia that may be better evaluated with colposcopy. 

 Low Grade (ASC-US, LSIL)

  • In women aged 21-24, ASC-US and LSIL get treated the same, with the recommendation for repeat cytology in 12 months. 

    • This is because the clearance of HPV-caused ASC-US and LSIL is overall high in this group, and colposcopy may lead to overly aggressive management. 

    • As long as there’s no progression to high-grade, there is no indication for colposcopy.

  • In women aged 25-29:

    • LSIL go to colposcopy.

    • ASC-US in this group can have two options: Reflex HPV testing or Repeat Cytology in 12 months.

      • If reflex HPV is positive, management would proceed the same as LSIL with immediate colposcopy.

        • The 5-year CIN3+ risk for both HPV+ ASCUS and LSIL are very similar in this group, approximately 7%.

      • If reflex HPV is negative, then repeat cytology can be performed in 3 years, as HPV-negative ASC-US has very low risk of CIN2+. 

      • If HPV testing is not performed, repeat Pap in 12 months is recommended. A 2nd ASC-US result or worse would then warrant colposocopy.

  • In women aged 30-64, ideally HPV testing is always available! The management algorithm overall doesn’t change much.

    • LSIL or ASC-US, HPV negative: overall low risk of malignant transformation. Thus, with LSIL, can repeat cotesting in 1 year. With ASCUS, repeat in 3 years.

    • LSIL, HPV unknown: get colposcopy, as you would for a 25-29 year old.

    • ASC-US, HPV unknown: repeat cytology, as you would for a 25-29 year old.

    • LSIL or ASC-US, HPV positive: colposcopy should be performed.

  • In women aged 65+, Pap smears are likely only continuing at this point if there have been previous abnormalities, or a lack of screening. ASC-US or LSIL with negative HPV should be treated as abnormal, and thus merit repeat cytology in 1 year. All other abnormalities (i.e., HPV positive) in this age group should receive colposcopy!

Note that in our low grade, we didn’t talk excisional procedures at all; low grade lesions should generally proceed to colposcopy before considering exicsion. 

High Grade (ASC-H, HSIL).

Any ASC-H result merits colposcopy, regardless of HPV status!

  • In women aged 21-24, ASC-H and HSIL get treated the same — colposcopy.

    • If CIN2/3 Not Present: Repeat colpo and cytology q6 months for two years.

      • If no additional high grade abnormalities are noted, then the patient returns to normal screening.

      • If HSIL persists for 24 months, then excision is recommended.

    • If CIN2/3 Is Present: then management is challenging! The risk of excision is the risk of preterm delivery with future pregnancy.

      • With CKC, this can be up to 3.5x greater risk, and with LEEP this risk is approximately 2x greater. 

      • Thus, with CIN2/3, observation or treatment may be pursued after engaging in shared decision-making with your patient.

      • With CIN 2, observation with q6month cytology and colposcopy is preferred.

        • The likelihood of regression spontaneously in this population may be as high as 43%. 

        • If 2x cytology and colposcopy results are normal, the patient may have cotesting in 1 year.

          • If colposcopy or cytology persist as abnormal for 1 year, repeat biopsy is recommended, with treatment with excision recommended by 2 years if not resolved.

      • With CIN 3, treatment is preferred.

        • The likelihood of regression with true CIN3 is much lower, thus prompting recommendation for excision to prevent invasive cancer.

        • If strongly desired, observation may be pursued with the same algorithm as above.

  • In women aged 25-29, women aged 30-64, and women aged 65+ receiving screening, the management of ASC-H and HSIL is the same!

    • ASC-H goes to colposcopy.

    • HSIL results can proceed immediately to excision or perform colposcopy first.

      • Most women with HSIL will have HPV+ testing. Even with negative HPV results, an HSIL test carries a 5-year risk of CIN3 of near 30% and an invasive cancer risk of 7%. Thus, it’s prudent to proceed with further testing in this scenario. 

    • If CIN 2 or 3 is found on colposcopy as result of either of these, then excisional therapy is recommended. 

After colposcopy and biopsies…

We’ve detailed the management of this for 21-24 year olds above, so we’ll leave this group out, as their management varies. Very kindly, if you’ve made it to colposcopy for anyone aged 25 or older, the management is the same.

CIN 2 or 3 on colposcopic biopsy - this will warrant an excisional procedure. 

  • If margins are negative, then cotesting at 12 and 24 months is subsequently recommended, with repeat colposcopy needed for any abnormal result.

  • If margins are positive, then you have three choices:

    • Repeat cytology with endocervical curettage q4-6 months.

    • Repeat excision, if feasible.

    • Hysterectomy.

      • Should only be considered if repeat excision is not feasible, or if high grade abnormalities are persistent after attempted repeat excision. 

CIN 1 or Less on colposcopic biopsies

  • If the initial Pap was low grade (ASC-US or LSIL):

    • Repeat co-testing at 12 months.

      • If normal, then can have repeat testing in 3 years before resuming normal age-appropriate intervals.

      • If there is an abnormality, then colposcopy should be performed.

  • If the initial Pap was high grade (ASC-H or HSIL): 

    • recommend repeat cotesting at 12 and 24 months.

      • If normal at both intervals, then can have repeat testing in 3 years before resuming normal age-appropriate intervals.

      • If there is an abnormality, then colposcopy should be performed.

      • If HSIL is noted, then an excision should be performed versus re-review of prior pathology.

What if the result is “AGC”? Atypical glandular cells can have two categories: “atypical endometrial cells” and then “other.”

  • If any “other” type of AGC, patient should be evaluated with colposcopy and consideration of endometrial sampling. 

    • In patients younger than 35, endometrial sampling may be considered based on risk factors for endometrial cancer. 

    • In patients older than 35, endometrial sampling should be done routinely.

  • If “Atypical endometrial cells,” then endometrial biopsy and endocervical curettage should be performed. Colposcopy should be deferred generally until the results of the endometrial testing is known, and performed if endometrial testing reveals no abnormality.

  • Excisional procedures should be considered if there is concern for neoplasia or adenocarcinoma in situ (AIS). 

    • If no CIN2+, AIS, or cancer, then repeat co-testing should be performed at 12 and 24 months.

What if I get an AIS result from an excisional procedure?

  • In this case, simple hysterectomy is the preferred management. 

  • If future fertility is desired, conservative management with excision may be pursued, though likely should be done alongside GYN oncology!