When to repeat a Pap smear in a 59-year-old patient with a Human Papillomavirus (HPV) positive result?

From the Guidelines

For a 59-year-old woman with a positive HPV test on Pap smear, follow-up testing should be conducted in 12 months, as per the American Cancer Society's 2020 guideline update 1. This recommendation applies specifically to women aged 25-65 who have a positive HPV test but normal cytology (Pap smear). During the follow-up visit at 12 months, both HPV testing and cytology (co-testing) should be performed. If both tests are negative at that time, the woman can return to routine screening. However, if either test remains positive, a colposcopy is recommended for further evaluation. This approach allows time to see if the immune system will clear the HPV infection naturally, which often occurs, while still monitoring for potential progression. Persistent HPV infection at this age carries a higher risk for developing cervical abnormalities compared to younger women, so adherence to follow-up is particularly important. Women with abnormal cytology results along with HPV positivity would need more immediate colposcopy rather than the 12-month follow-up approach. The American Cancer Society's guidelines prioritize the use of primary HPV testing alone every 5 years as the preferred method for cervical cancer screening in women aged 25-65 years 1. It is essential to note that these guidelines are based on the latest available evidence and are subject to change as new research emerges. In this case, the 2020 guideline update from the American Cancer Society provides the most recent and highest-quality evidence for guiding clinical practice 1.

Some key points to consider:

• The American Cancer Society recommends that women aged 25-65 years with a positive HPV test but normal cytology should have follow-up testing in 12 months 1.
• Co-testing with both HPV testing and cytology is recommended for follow-up evaluation 1.
• Women with persistent HPV infection or abnormal cytology results require more immediate evaluation and potential colposcopy 1.
• The guidelines prioritize primary HPV testing alone every 5 years as the preferred method for cervical cancer screening in women aged 25-65 years 1.

Overall, the American Cancer Society's 2020 guideline update provides clear guidance for the management of women with positive HPV test results, emphasizing the importance of follow-up testing and co-testing to ensure timely detection and treatment of potential cervical abnormalities 1.

From the Research

HPV Positive Pap Smear in 59-Year-Old Women

• The management of HPV positive Pap smear results in women, including those aged 59, is guided by various studies and guidelines 2, 3, 4, 5, 6.
• A study published in 2021 found that all women testing positive for HPV, regardless of Pap smear result, should be referred to colposcopy 2.
• Another study from 2009 evaluated the efficacy of HPV DNA testing with cytology triage and/or repeat HPV DNA testing in primary cervical cancer screening, and found that primary HPV DNA-based screening with cytology triage and repeat HPV DNA testing of cytology-negative women appears to be the most feasible cervical screening strategy 3.
• The degree of agreement between HPV testing, Pap smear, and colposcopy in cervical dysplasia diagnosis was analyzed in a 2012 study, which found a fair agreement between Pap smear and colposcopic biopsy 4.
• A 2022 study found that post-menopausal status was not significantly associated with abnormal Pap smear cytology or cervical dysplasia, and recommended continuing with current cervical cancer guidelines of screening for all women regardless of menopausal status 5.
• The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, as discussed in a 2020 article, emphasize the importance of considering patient risk factors for high-grade cervical intraepithelial neoplasia (CIN) and cancer in the management of abnormal cervical cancer screening results 6.

Repeat Pap Smear Timing

• The optimal timing for repeating a Pap smear in a 59-year-old woman with an HPV positive result is not explicitly stated in the provided studies.
• However, the studies suggest that referral to colposcopy is recommended for all women with positive HPV results, regardless of age or Pap smear result 2.
• The 2009 study found that repeat HPV DNA testing of cytology-negative women increased the sensitivity for detection of CIN3+ by 30% 3.
• The 2020 article emphasizes the importance of following ASCCP guidelines for the management of abnormal cervical cancer screening results, which may include repeat Pap smears or colposcopy 6.

Risk Assessment and Management

• The management of HPV positive Pap smear results in women, including those aged 59, should take into account individual risk factors for high-grade CIN and cancer 6.
• The 2022 study found that high-grade dysplasia was significantly associated with high-grade Pap smear results, and recommended considering this association in the management of abnormal Pap smear results 5.
• The 2012 study found that incorporation of HPV testing into the present Pap screening program has the potential to make screening for cervical cancer more effective 4.