From the Guidelines
For a patient with a positive HPV test and ASC-H result, immediate referral for colposcopy with possible biopsy is recommended. This is considered urgent as ASC-H suggests possible high-grade squamous intraepithelial lesion (HSIL), which carries a significant risk of cervical precancer or cancer 1. During colposcopy, the cervix is examined under magnification after application of acetic acid and Lugol's iodine to identify abnormal areas for targeted biopsies. The procedure typically takes 15-30 minutes in an outpatient setting. If precancerous lesions are found, treatment options may include excisional procedures such as LEEP (Loop Electrosurgical Excision Procedure) or conization.
The recommendation for immediate colposcopy is based on the understanding that HPV positivity combined with ASC-H cytology indicates a higher risk of underlying significant cervical disease, with approximately 50% of these cases having CIN 2 or higher on further evaluation 1. According to the 2021 guidelines for managing abnormal cervical cancer screening tests, colposcopy is recommended for patients with high-risk results, including those with ASC-H and positive HPV test results 1. Patients should be advised that colposcopy is a diagnostic procedure, not treatment, and follow-up will depend on biopsy results.
Some key points to consider in the management of abnormal cervical cancer screening tests include:
- Colposcopy can be deferred for patients at low risk, but is recommended for those with high-risk results such as ASC-H and positive HPV test results 1
- Referral to colposcopy is recommended if cytology test results are abnormal or the HPV test is positive at the 1-year follow-up visit 1
- Treatment can be expedited for high-risk patients, including those with high-grade cytology results and positive HPV test results 1
From the Research
Follow-up Recommendations for Positive HPV Test and ASC-H Result
- A positive Human Papillomavirus (HPV) test and an Atypical Squamous Cells - High grade (ASC-H) result indicate a high risk of cervical intraepithelial neoplasia grade 3 or more severe diagnoses (CIN3+) 2.
- The 5-year risk of CIN3+ following a positive HPV test and ASC-H result is higher compared to those with a negative testing history 2.
- Studies suggest that women with an antecedent HPV-positive/ASC-H have a higher risk of developing CIN2+ lesions compared to those with antecedent HPV-positive/ASC-US or LSIL 3.
- For women with an antecedent ASC-H, one negative cotest 1 year after colposcopy predicted lower subsequent 5-year risk of CIN2+ (2.2%) than 1 negative HPV test (4.4%) or 1 negative Pap (7.0%) 3.
- Reflex human papillomavirus (HPV) testing with ASC-H cytologic diagnosis may improve accuracy in detection of CIN2+ lesions, especially in postmenopausal women 4.
- High-risk HPV (hrHPV) testing can help identify women with ASC-H who are at higher risk of developing CIN2+ lesions, and triaging ASC-H postmenopausal women with cotesting or hrHPV genotyping may be considered as optimal clinical practice 4.
- Outreach colposcopy clinics and HPV self-sampling can improve follow-up rates and reduce loss to follow-up in community-based cervical cancer screening programs 5.
- HPV E6/E7 mRNA testing may be more specific than cytology in post-colposcopy follow-up of women with negative cervical biopsy, and a positive mRNA test post-colposcopy could justify treatment in women above 40 years 6.