What is the management of Low-grade Squamous Intraepithelial Lesion (LSIL) on Pap smear?

From the Guidelines

For patients with LSIL on Pap smear, the recommended approach is to perform colposcopy to evaluate the cervix more thoroughly, especially for those 25 years and older, as this approach is supported by the most recent and highest quality evidence 1.

Management of LSIL

The management of Low-grade Squamous Intraepithelial Lesion (LSIL) on Pap smear involves:

• Colposcopy for patients 25 years and older to evaluate the cervix more thoroughly
• For patients younger than 25, LSIL can often be managed with repeat cytology in 12 months without immediate colposcopy, as these lesions frequently resolve spontaneously in younger women due to robust immune responses 1
• If LSIL persists for two years or progresses to HSIL (High-grade Squamous Intraepithelial Lesion), treatment may be necessary, typically with excisional procedures like LEEP (Loop Electrosurgical Excision Procedure) or cryotherapy

Key Considerations

• Approximately 60-80% of LSIL cases will regress spontaneously within 1-2 years without treatment 1
• Regular follow-up is essential to monitor for persistence or progression
• Patients should be counseled about smoking cessation and condom use, as these factors can influence HPV clearance and lesion regression

Special Populations

• Pregnant women with LSIL can be managed with colposcopy, but treatment should be deferred until after delivery unless invasive cancer is suspected 1
• For women under 21 years, referral to colposcopy for LSIL is not recommended due to high rates of spontaneous clearance in this population 1

From the Research

LSIL on Pap Management

• The management of low-grade squamous intraepithelial lesion (LSIL) Pap results is a topic of interest in the medical field, with various studies exploring the best approaches for triage and follow-up 2, 3, 4, 5, 6.
• A study published in 2013 found that HPV positivity among women with LSIL decreased only slightly with age, and that the 5-year risks of CIN 2+ and CIN 3+ were higher among women testing HPV-positive/LSIL compared to those testing HPV-negative/LSIL 2.
• Another study from 2009 suggested that delaying colposcopy to repeat cytology resulted in a significant loss to follow-up in a population at high risk for poor compliance, and recommended immediate colposcopy for women with LSIL over 20 years of age when optimal patient compliance cannot be ensured 3.
• The use of HPV DNA testing and HPV E6/E7 mRNA testing has been explored as a potential tool for triaging women with LSIL Pap results, with studies suggesting that these tests may be useful in identifying women at higher risk of developing CIN 2+ or worse lesions 4, 5, 6.
• A meta-analysis published in 2017 found that a positive HPV E6/E7 mRNA test result was associated with a higher risk of progressing to CIN 2+ in the future, and suggested that women with a positive result should be referred for colposcopy and strengthen follow-up promptly 6.
• The American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP) have guidelines for the management of LSIL Pap results, which include options for repeat cytology, HPV DNA testing, and colposcopy 2, 3, 4.

Triage and Follow-up

• The choice of triage and follow-up approach for women with LSIL Pap results depends on various factors, including the patient's age, HPV status, and medical history 2, 3, 4, 5, 6.
• A study published in 2018 found that women with LSIL and positive HPV E6/E7 mRNA results had a higher risk of developing CIN 2+ or worse lesions, and suggested that these women should be prioritized for colposcopy and follow-up 5.
• The use of HPV E6/E7 mRNA testing has been shown to be a useful tool in identifying women with LSIL Pap results who are at higher risk of developing CIN 2+ or worse lesions, and may help to guide triage and follow-up decisions 5, 6.