What are the next steps for a 33-year-old female with a recent Pap (Papanicolau) smear showing Human Papillomavirus (HPV) positive result?

From the Guidelines

For a 33-year-old female with an HPV-positive Pap smear, the next steps typically involve additional testing to determine if there are any cervical cell abnormalities, and she should schedule a colposcopy if any cell abnormalities were present, or consider repeat co-testing in 12 months if the Pap was otherwise normal. The management of HPV-positive results depends on various factors including age, test results, and the presence of cellular abnormalities 1. According to the American College of Physicians, the prevalence of high-risk HPV infection peaks shortly after initiation of sexual intercourse, and rates of positive HPV test results are highest among women younger than 25 years, decreasing with advancing age 1.

Given the patient's age and HPV-positive status, it's essential to consider the potential risks and benefits of immediate colposcopy versus repeat co-testing. The likelihood of underlying cervical intraepithelial neoplasia (CIN) grade 2 or a more severe lesion decreases with age, ranging from 12% among women aged 21 to 24 years to 2.4% among those older than 50 years 1. However, the predicted 5-year risk of CIN grade 2 or a more severe lesion is about 10% for women with a normal cytologic test result and a positive HPV test result 1.

Some key points to consider in the management of this patient include:

• The patient's age and the natural history of HPV infection, which often clears without treatment within 1-2 years 1
• The potential risks of colposcopy and biopsy, including pain, bleeding, and infection 1
• The potential long-term risks of excisional treatments, including an increased risk of preterm delivery and neonatal mortality 1
• The importance of regular screenings to monitor for persistent infection or cell changes that might require intervention 1

In terms of specific next steps, if the Pap smear showed cellular abnormalities, a colposcopy should be scheduled sooner, whereas if the Pap was otherwise normal, repeat co-testing in 12 months may be recommended. No medications are typically prescribed for HPV itself, as there is no specific treatment to eliminate the virus 1. The patient should continue regular screenings as directed by her healthcare provider to monitor for any changes or potential complications.

From the Research

Next Steps for a 33-Year-Old Female with HPV Positive Result

• The patient should undergo further testing and evaluation to determine the presence of any high-grade dysplasia or cancer (CIN2+) 2.
• According to the study published in PloS one, women with a positive HPV test result have an increased risk of developing high-grade dysplasia and cancer (CIN2+) compared to women with normal cytology 2.
• The patient's age and HPV positive result indicate a need for close monitoring and potential treatment to prevent the development of abnormal cytology and colposcopic impressions 3.

Triage and Testing Strategies

• The study published in the International Journal of Cancer evaluated 14 triage strategies for HPV DNA-positive women and found that combined cytology and HPV16/18/31/33/45 genotyping gave the highest negative predictive value (NPV) of 98.9% 4.
• Another strategy, cytology triage followed by cytology at 12 months, had a markedly lower colposcopy referral rate of 33.4% and an NPV of 99.3% 4.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with a positive HPV test result undergo colposcopy and potential biopsy to rule out high-grade dysplasia or cancer 5.

Follow-Up and Monitoring

• Women with a positive HPV test result should be monitored closely with repeat cytology and HPV testing at 6-12 months to assess for any changes or development of abnormal cytology 5.
• The study published in Cytopathology found that abnormal cytology at 6 weeks after treatment was significantly correlated with residual/recurrent disease, and that combining abnormal cytology and the presence of high-risk HPV within the first 6 months after treatment gave the best correlation with residual/recurrent disease 6.
• Regular follow-up and monitoring can help identify any potential issues early on and prevent the development of more serious conditions 2, 3, 6, 5, 4.