What are the next steps after receiving an Atypical Squamous Cells of Undetermined Significance (ASCUS) Pap result?

Management of ASCUS Pap Result

For women aged 21 years or older with an ASCUS Pap result, high-risk HPV DNA testing is the preferred next step, with immediate colposcopy recommended for HPV-positive patients and repeat Pap testing at 12 months for HPV-negative patients. 1

Age-Based Management Algorithm

For Women Under 21 Years

• Repeat Pap testing at 12 months and 24 months is recommended
• Colposcopy is NOT recommended due to high rates of spontaneous clearance 1
• Only proceed to colposcopy if repeat cytology shows ASC-H or HSIL

For Women 21 Years and Older

Three management options are available, with HPV testing being preferred:

1. High-risk HPV DNA testing (preferred):

   • If HPV positive: Immediate colposcopy
   • If HPV negative: Repeat Pap test at 12 months 1

2. Repeat Pap tests:

   • Perform at 6 and 12 months
   • If two consecutive negative results: Return to normal screening
   • If persistent ASCUS or worse: Follow ASCCP guidelines for management 1

3. Immediate colposcopy:

   • Appropriate if concerns about follow-up adherence exist
   • Note that high-grade histological changes (CIN 2+) are found in <12% of ASCUS cases 1

HPV Testing Methods

If HPV testing is chosen, it can be performed by:

• Collecting a specimen for Pap and HPV DNA on the same swab
• Using a supplied swab at the time of the Pap test
• Reflex testing if liquid-based cytology was used
• Scheduling a separate follow-up appointment 1

Clinical Considerations

• The risk of CIN3+ after an HPV-negative/ASCUS result is closer to that of a negative Pap test than a negative cotest, supporting a 3-year return interval for HPV-negative ASCUS 2
• High-grade histological changes are detected in <12% of ASCUS cases after colposcopy 1
• HPV tests that detect only low-risk HPV types are not recommended as they provide no clinical benefit in this setting 1
• HPV type 16 is the most common high-risk type found in ASCUS patients 3

Special Populations

HIV-Infected Women

• For HIV-infected women with ASCUS, follow-up by Pap tests without colposcopy is acceptable when ASCUS is not qualified further 1
• Repeat Pap tests every 4-6 months for 2 years until three consecutive negative smears 1
• Consider colposcopy if a second ASCUS report occurs during follow-up 1

Women with Inflammation

• Women with unqualified ASCUS associated with severe inflammation should be evaluated for infectious processes
• Re-evaluation should be performed after appropriate treatment, preferably after 2-3 months 1

Common Pitfalls to Avoid

1. Don't ignore ASCUS results: Although most ASCUS does not progress to cancer, more than one-third of high-grade lesions are initially identified from ASCUS Pap results 4

2. Don't perform colposcopy on all ASCUS patients: This leads to unnecessary procedures as only 5-10% of women with ASCUS harbor serious cervical disease 4

3. Don't use HPV tests for low-risk types: These tests provide no benefit in management decisions 1

4. Don't fail to document and follow up: Ensure clear documentation of Pap results, follow-up appointments, and results of follow-up to prevent patients from being lost to follow-up 1