Should a 55-year-old female who tests positive for Human Papillomavirus (HPV) undergo genotyping?

HPV Genotyping for a 55-Year-Old Female with Positive HPV Test

Yes, HPV genotyping should be performed for a 55-year-old female who tests positive for HPV, as this can help stratify her risk and determine the appropriate management pathway.

Rationale for HPV Genotyping

HPV genotyping provides valuable risk stratification for HPV-positive women. According to current guidelines, there are two main management options for women over 30 who test HPV-positive but have negative cytology:

1. Option 1: Repeat co-testing (cytology and HPV) in 12 months
2. Option 2: Immediate HPV genotype-specific testing for HPV16 alone or for HPV16 and HPV18 1

Risk Assessment Based on HPV Type

• Women with HPV 16/18 have substantially higher risk of cervical intraepithelial neoplasia (CIN):
  • Among cytology-negative women 30 years and older, CIN 3 was identified in 21% of those with HPV 16 and 18% of those with HPV 18 during 10-year follow-up
  • In contrast, the risk of CIN 3 among women with other high-risk HPV types was only 1.5% 1

Management Algorithm Based on Genotyping Results

1. If HPV 16/18 positive:

   • Refer directly to colposcopy due to higher risk of high-grade lesions 1

2. If positive for other high-risk HPV types (not 16/18):

   • Repeat co-testing (cytology and HPV) in 12 months
   • If either test is positive at follow-up, refer for colposcopy
   • If both tests are negative, return to routine screening 1

This approach allows for more targeted management, directing women at highest risk (HPV 16/18 positive) to immediate colposcopy while avoiding unnecessary colposcopy for women with other high-risk types who have a lower risk of progression.

Evidence Quality and Considerations

The recommendation for HPV genotyping is supported by high-quality evidence from large cohort studies showing that HPV16 and HPV18 confer significantly higher risk of cervical precancer and cancer compared to other HPV types 1.

Recent guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology support the use of HPV genotyping for risk stratification in women 30 years and older who test HPV positive but have negative cytology 1.

Important Caveats

• HPV genotyping should only test for high-risk (oncogenic) HPV types; there is no clinical utility in testing for non-oncogenic types 1
• The genotyping test should specifically identify HPV types 16 and 18, as these confer the highest risk of progression to cervical cancer 1
• For women with HPV 16/18, direct referral to colposcopy is warranted despite negative cytology due to the elevated risk of underlying high-grade lesions 1

By implementing HPV genotyping for this 55-year-old HPV-positive woman, you can provide more personalized risk assessment and potentially avoid unnecessary procedures while ensuring appropriate surveillance for those at higher risk of cervical cancer.