What are the next steps after receiving abnormal Pap (Papanicolaou) test results?

Management of Abnormal Pap Test Results

The next step after receiving abnormal Pap test results depends on the specific abnormality, but generally requires either colposcopy, HPV testing, or follow-up testing based on risk stratification according to the 2019 ASCCP Risk-Based Management Consensus Guidelines. 1

Initial Management Based on Pap Result Type

For ASC-US (Atypical Squamous Cells of Undetermined Significance):

• HPV testing is recommended for triage of women aged ≥21 years with ASC-US results 2
• Three options are available for follow-up management:
  1. HPV DNA testing (preferred approach)
  2. Repeat Pap tests at 6 and 12 months
  3. Immediate colposcopy (if concerns about adherence to follow-up)

For LSIL (Low-Grade Squamous Intraepithelial Lesion):

• Direct referral for colposcopy is recommended 2, 1
• Exception: For patients with a negative HPV test or cotest within the past 5 years, follow-up in 1 year instead of immediate colposcopy is acceptable 2

For HSIL (High-Grade Squamous Intraepithelial Lesion):

• Immediate colposcopy is mandatory 2, 1
• Expedited treatment should be considered for non-pregnant patients aged ≥25 years 2

For HPV-Positive Results:

• If HPV 16/18 positive: Immediate colposcopy regardless of cytology results 1
• If positive for other high-risk HPV types with normal cytology: Follow-up in 1 year 2, 1
• Two consecutive HPV-positive tests always warrant colposcopy, even with normal cytology 2, 1

Colposcopy Management

If Colposcopy is Normal or Shows CIN 1:

• Repeat cytology at 6 and 12 months or HPV testing at 12 months 1
• If HPV negative at 12 months or two consecutive negative cytology results: Return to routine screening 1
• If HPV positive or abnormal cytology persists: Refer back for colposcopy 1

If Colposcopy Shows CIN 2/3:

• Treatment is indicated with LEEP, cryotherapy, cold knife conization, or laser ablation 1
• Exception: CIN 2 may be followed without treatment in young women desiring fertility 1

If Colposcopy is Unsatisfactory:

• Endocervical sampling in addition to directed cervical biopsy is recommended 1
• If ECC shows CIN 2/3: LEEP or cold knife conization is required 1

Post-Treatment Surveillance

After treatment for high-grade precancer:

• Initial testing: HPV test or cotest at 6,18, and 30 months 2, 1
• Long-term surveillance: Testing at 3-year intervals if using HPV testing/cotesting, or annual testing if using cytology alone 2
• Surveillance should continue for at least 25 years after treatment, even beyond age 65 2, 1

Important Considerations

• HPV 16/18 carry the highest risk (17-21% for CIN3+) compared to other high-risk HPV types (approximately 3% risk) 1
• Approximately 15.6% of women with non-16/18 high-risk HPV can develop HSIL 1
• The sensitivity of Pap smear alone for detecting HPV infection is relatively low (39%), highlighting the importance of appropriate follow-up of abnormal results 3
• Almost one-third of women do not have follow-up colposcopy within 12 months after an abnormal Pap test, which is concerning especially for high-risk populations 4
• Clear documentation of all test results, follow-up appointments, and management decisions is crucial 1

Common Pitfalls to Avoid

• Don't delay colposcopy for HSIL results - these represent significant risk for high-grade disease
• Don't ignore persistent inflammatory Pap smears - studies show they can harbor a high proportion (20.9%) of CIN 5
• Don't use HPV testing inappropriately - HPV testing should not be performed for deciding whether to vaccinate, testing persons <25 years as part of routine screening, or testing oral/anal specimens 2
• Don't miss follow-up - establish clear referral protocols if colposcopy services aren't available locally 1
• Don't assume a negative HPV test eliminates need for colposcopy in patients under surveillance for previous abnormal results 2