What is the follow-up protocol for a Papanicolaou (Pap) smear after a negative colposcopy?

From the Guidelines

After a negative colposcopy, follow-up Pap smear testing should typically be performed in 12 months, as recommended by the most recent guidelines 1. This approach allows for the monitoring of potential persistent HPV infection, which often clears naturally within 1-2 years. The 12-month interval is supported by the 2021 sexually transmitted infections treatment guidelines, which suggest that patients with a minimally abnormal test result can be followed up in 1 year instead of undergoing colposcopy immediately 1.

Key Considerations

• The risk of recurrent or persistent cervical intraepithelial neoplasia (CIN) after a negative colposcopy is relatively low, but it is essential to continue follow-up indefinitely 1.
• HPV DNA testing can be a useful tool in posttreatment surveillance, and it is recommended to perform this test at least 6 months after treatment 1.
• The 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors provide a framework for managing abnormal cervical cancer screening tests, including the use of patient-level risk data and clinical action thresholds 1.

Follow-Up Care

• During the follow-up period, patients should continue routine healthcare and report any concerning symptoms like abnormal bleeding or discharge.
• If the follow-up Pap smear is normal, most patients can return to routine screening (every 3-5 years depending on age and screening method).
• However, if abnormalities persist on the follow-up Pap, additional evaluation, including repeat colposcopy, may be necessary.
• This surveillance approach balances the need to detect potential progression of disease while avoiding unnecessary procedures for transient HPV infections that the immune system will likely clear.

From the Research

Follow-up Pap Smear after Negative Colposcopy

• The management of women with abnormal Pap smear results and negative colposcopy findings is a topic of interest in cervical cancer screening 2.
• A study published in 2004 found that women with low-grade squamous intraepithelial lesion (LGSIL) and normal colposcopy do not need further therapeutic measures during the first year after the initial smear 2.
• The study suggested that a follow-up Pap smear at 12 months after the initial smear is sufficient for women with LGSIL and normal colposcopy 2.
• Another study published in 2019 found that routine cytological follow-up may be an appropriate method in the management of atypical squamous cell of undetermined significance (ASCUS) instead of immediate colposcopy 3.
• The use of human papillomavirus (HPV) genotyping in cervical cancer screening has been shown to discriminate risk of high-grade cervical intraepithelial neoplasia (≥CIN 3) to a clinically significant degree, regardless of cytology result 4.
• A systematic review published in 2020 found that HPV genotyping can be used to estimate the risk of CIN 3 or worse, and that the evidence supports a clinical utility for HPV genotyping in risk discrimination during cervical cancer screening 4.

Recommendations for Follow-up

• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with a negative colposcopy result after an abnormal Pap smear should have a follow-up Pap smear at 12 months 5.
• The ACOG also recommends that women with a history of cervical cancer or high-grade cervical intraepithelial neoplasia (CIN 2 or 3) should have more frequent follow-up Pap smears, typically every 6 months for the first 2 years after treatment 5.
• The use of HPV genotyping can help guide follow-up recommendations, with women who are HPV-positive being at higher risk of developing CIN 3 or worse 4.