What are the next steps for a 32-year-old female with a normal Pap (Papanicolau) smear but positive for Human Papillomavirus (HPV)?

Management of 32-Year-Old Female with Normal Pap and Positive HPV Test

For a 32-year-old female with a normal Pap smear but positive HPV test, the recommended next step is to repeat co-testing (Pap and HPV test) in 12 months. 1

Rationale and Management Algorithm

The presence of HPV with normal cytology represents a common clinical scenario that requires appropriate follow-up due to the risk of developing cervical intraepithelial neoplasia (CIN) or cancer over time.

Initial Assessment

• Normal Pap smear with positive HPV indicates HPV infection without current cytological abnormalities
• At age 32, this patient falls into the age group (≥30 years) where specific management protocols apply
• The risk of developing CIN3 or cancer within 10 years for women with normal cytology but positive HPV test is approximately 21% in women over 30 2

Management Steps

1. Repeat co-testing (Pap and HPV test) in 12 months 1

   • This is the preferred approach for women with normal cytology but positive HPV test
   • Allows time to determine if the HPV infection will clear spontaneously

2. Follow-up based on 12-month results:

   • If HPV test becomes negative and cytology remains normal: Return to routine screening 1
   • If HPV test remains positive OR cytology shows ASC-US or greater: Refer for colposcopy 3, 1

3. Colposcopy indications:

   • Two consecutive positive HPV tests (even with normal cytology)
   • Any cytological abnormality on follow-up testing

Important Considerations

Risk Assessment

• HPV infection is often transient, with most infections clearing spontaneously within 1-2 years 4, 5
• However, persistent HPV infection is the primary risk factor for developing cervical cancer 4
• The 10-year risk of CIN3+ in women with normal cytology but positive HPV test is significant (13.6-21.2%) 2

Common Pitfalls to Avoid

1. Immediate colposcopy is not indicated

   • For women with normal Pap and positive HPV, immediate colposcopy is not recommended as the first step
   • Exception: If the HPV test specifically identifies types 16 or 18, colposcopy would be indicated 3

2. Avoid under-follow-up

   • Simply returning to routine screening without follow-up testing is inappropriate due to the increased risk of developing cervical abnormalities 6
   • All women with a positive HPV test require follow-up, even with normal cytology

3. Avoid over-treatment

   • No treatment is indicated at this stage without histological evidence of CIN
   • Diagnostic excisional procedures are not recommended without histologically diagnosed CIN 2/3 1

HPV Type Considerations

If HPV genotyping was performed:

• HPV 16 or 18 positive: Consider immediate colposcopy due to higher risk of progression 3
• Other high-risk HPV types: Follow the 12-month co-testing protocol 3, 1

By following this evidence-based approach, the risk of developing cervical cancer can be minimized while avoiding unnecessary procedures for transient HPV infections that may resolve spontaneously.