Cytologic Abnormalities

2006 Guidelines for Management of Women with Cytologic Abnormalities Summary


ASCUS – Women > Age 20

• Multiple options (repeat cytology, colposcopy) but HPV testing preferred due to cost effectiveness.
• HPV + referred to colposcopy, if CIN present – manage per guidelines; no CIN identified -  repeat HPV testing @ 12 months or repeat cytology in 6 and 12 months.

Comments:

1. Triage with HPV testing for Hi Risk virus has been further supported with additional studies since its recommendation 6 yrs ago.
2. Colposcopy can have a significant false negative rate even in expert hands (as demonstrated in ALTS) thus in women who are HPV pos and don’t have a colposcopic lesion, further f/u is important.
3. An ECC is recommended at colposcopy in women with no visible lesion and/or unsatisfactory colposcopy.
4. In the follow-up of women with HPV + but no lesion identified, its recommended to not do HPV testing at less than 12 month intervals.

ASCUS in Women 20 years Old and Younger

• Follow-up with annual cytologic testing at 12 months only – no HPV testing.
• If 12 month Pap shows anything less than HSIL – repeat cytology at 12 months later, if result is ASCUS or higher – colposcopy; if negative return to routine screening intervals.

Comments:

1. Evaluation of additional studies have shown that the rate of HPV infection is very high in this age group, the false positive rate is high, and using HPV testing to manage ASCUS would refer too many women to colposcopy to be cost effective.
2. This recommendation also reflects the fact that persistence of Hi Risk HPV is required for neoplasia to develop, the risk of a patient developing invasive cancer in this age group is very low.

ASCUS in HIV + Women

• Manage the same as women in the general population.

Comments:

1. Recent studies have shown a lower rate of CIN II/III and HPV + than previously thought.

ASCUS – H

• Refer for Colposcopic Examination.
• If no CIN identified, follow-up at 12 months with HPV testing or cytology testing at 6 and 12 months. If still HPV positive after 12 months or ASCUS or higher on repeat cytology – re-colposcope.
• If repeat HPV is negative or negative cytology – return to routine screening.

Comments:

1. The risk of a high grade lesion in ASCUS – H is high enough to warrant immediate colposcopy.

Low Grade Squamous Intraepithelial Lesion in Women > 20 Years of Age

• Refer to Colposcopy, perform ECC in non-pregnant women and those with unsatisfactory colposcopy.
• If no CIN II/III, repeat HPV at 12 months or repeat cytology at 6 and 12 months.
• If repeat HPV is positive or ASCCUS or greater on cytology, repeat colposcopy.
• If repeat HPV or cytology is negative, routine screening.

Comments:

1. LSIL is a good marker for hi risk HPV DNA  with 77% patients positive.
2. Risk of having a squamous lesion is same as with ASCUS HPV+ population.
3. Ablative or LEEP not acceptable for women without a histologically demonstrated lesion.

Low Grade Squamous Lesions in Women Aged 20 and Younger

• Follow-up with annual cytologic testing.
• If 12 month cytology less than High Grade Lesion, repeat cytology at 12 months.
• If cytology is HSIL or greater, refer to colposcopy.

Comments:

1. No role for HPV testing in this group.

LSIL in Postmenopausal Women

• Reflex HPV testing, repeat cytology at 6 and 12 months, colposcopy all acceptable; HPV DNA testing preferred.
• If HPV positive or cytology ASCUS or greater, colposcopy.
• If HPV negative or 2 cytologies are negative – routine to routine screening.

LSIL in Pregnant Women

• Refer for Colposcopic Examination.
• ECC is unacceptable.
• If negative – postpartum management.

High Grade Squamous Lesions(HSIL)in Women over age 20

• Refer to Colposcopy.
• Immediate LEEP also acceptable.
• If no HSIL (CIN II/III) seen, either observation with 6 month colposcopy and cytology for 1 year or LEEP excision acceptable.
• Pathologic review of findings (cytology and biopsies) is also recommended. Revised diagnoses may make a management difference.
• If repeat cytologies and colposcopy are negative, return to routine screening.
• If colposcopy unsatisfactory, diagnostic LEEP procedure.

Comments:

1. A single colposcopic exam reveals CIN II/III (HSIL) in 60-65% of individuals.
2. 2% of individuals have invasive cancer.

HSIL in Women aged 20 or Younger

• Refer to colposcopy.
• Immediate LEEP procedure unacceptable.
• If no HSIL (CIN II/III), follow-up colposcopy and cytology at 6 month intervals until one year (assuming adequate colposcopy and negative ECCs).
• If during follow-up HSIL on cytology or colposcopic HSIL, excision recommended.
• If HSIL on cytology persists for 12 months but negative colposcopy, diagnostic excision is recommended.

Comments:

1. Refer to colposcopy.
2. Immediate LEEP procedure unacceptable.

HSIL in Pregnant Women

• Refer to colposcopy.
• Do not perform ECC.
• Diagnostic excision not recommended unless invasive cancer suspected.

Atypical Glandular Cells

• Refer to colposcopy
• Perform ECC, if over 35years of age perform endometrial biopsy.
• Perform HPV testing at time of colposcopy.
• If no abnormalities identified, repeat cytology with HPV testing @ 6 months and at 12 months if HPV negative.
• If ASCUS or more on repeat or positive HPV, refer to colposcopy.
• If SIL (CIN) present on colposcopy but no glandular neoplasia, manage according to ASCCP guidelines.
  

Comments:

1. 10-35% of women will have HSIL or adenocarcinoma.
2. Squamous lesions more frequent than glandular.

Screening in Women over age 30

• ACOG anad the FDA have approved the use of HPV hi risk viral testing, along with a Pap smear in women 30 years of age and older.
• If patient is negative for both cytology and HPV should not be rescreened for 3 years.
• If patient is cytology negative and HPV positive,  repeat cytology and HPV testing in 12 months.
• If persistent HPV positive at 12 months, refer to colposcopy.

Comments:

1. The combined sensitivity and specificity for the detection of high grade squamous lesions for cytology and HPV testing in women 35 or greater is 95% and 93% respectively.
2. The risk of a cytology negative, HPV positive women over 30 of having a high grade lesion is 2-5%.
3. Most patients who are HPV positive in the 30 or over age will convert to negative for HPV, 60% converted in only 6 months in one study.