What are the next steps after an abnormal Pap (Papanicolau) smear result?

Management of Abnormal Pap Smear Results

The next steps after an abnormal Pap smear should be determined by the specific cytology result, HPV status, and patient history, with colposcopy recommended for most significant abnormalities to prevent progression to cervical cancer. 1

Initial Management Based on Abnormal Pap Result

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Immediate colposcopy is always recommended 1
• For patients ≥25 years who are not pregnant, expedited treatment is preferred over colposcopy with biopsy (after shared decision-making) 1
• If HPV 16 positive with HSIL cytology, expedited treatment should be strongly considered 1

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• Colposcopy is recommended in most cases 1
• Exception: For women <21 years, colposcopy is not recommended due to high rates of spontaneous clearance; repeat Pap testing at 12 and 24 months is recommended instead 1
• If preceded by negative HPV test or cotest within past 5 years, follow-up in 1 year instead of immediate colposcopy may be appropriate 1

Atypical Squamous Cells of Undetermined Significance (ASC-US)

• For women ≥21 years, three management options exist 1:
  1. High-risk HPV DNA testing (preferred approach)
  2. Repeat Pap tests at 6 and 12 months
  3. Immediate colposcopy (if concerns about follow-up adherence exist)
• If HPV positive, refer for colposcopy 1
• If HPV negative, repeat Pap test in 12 months 1

Atypical Squamous Cells - Cannot Exclude HSIL (ASC-H)

• Immediate colposcopy is recommended 1

Atypical Glandular Cells (AGC)

• All subcategories of AGC require colposcopy with endocervical sampling and HPV DNA testing 1
• Endometrial sampling is also recommended in women ≥35 years or younger women with risk factors for endometrial cancer 1
• If initial evaluation is unremarkable and HPV positive, repeat cytology and HPV testing in 6 months 1
• If initial evaluation is unremarkable and HPV negative, repeat cytology and HPV testing in 12 months 1

HPV-Based Management

HPV 16 or 18 Positive

• Colposcopy is recommended regardless of cytology results, even if cytology is normal 1
• For HPV 18 positive cases, endocervical sampling is acceptable at the time of colposcopy due to association with adenocarcinoma 1

Other High-Risk HPV Types (non-16/18)

• If cytology is normal, return in 1 year is recommended in most cases 1
• If cytology is abnormal, follow management based on cytology result 1

Two Consecutive HPV-Positive Tests

• Colposcopy is always recommended, regardless of previous Pap test results 1

Follow-Up After Initial Management

After Normal Colposcopy

• For low-grade cervical smear with normal colposcopy, risk of developing high-grade disease is very low 2
• Follow-up should be based on the initial abnormality that prompted colposcopy 1

After Treatment for High-Grade Precancer

• Surveillance should continue for at least 25 years after initial treatment, even beyond age 65 1
• Initial testing includes:
  • HPV test or cotest at 6,18, and 30 months, OR
  • Cytology alone at 6,12,18,24, and 30 months 1
• Long-term surveillance:
  • Every 3 years if using HPV testing or cotesting
  • Annual testing if using cytology alone 1
• If hysterectomy occurs during surveillance period, vaginal screening should continue 1

Special Considerations

Pregnant Women

• Expedited treatment is not recommended; colposcopy with biopsy is the appropriate management 1

History of High-Grade Lesions

• Colposcopy may be warranted for patients with history of high-grade lesions (CIN 2/3, histologic or cytologic HSIL, ASC-H, AGC, or AIS) 1

Practical Considerations

• HPV testing or cotesting is preferred to cytology testing alone for follow-up after abnormal results 1
• Cytology testing is recommended more frequently than HPV testing/cotesting for follow-up (annually when HPV testing is recommended at 3-year intervals) 1
• Clinics that cannot provide colposcopy services should establish clear referral protocols to facilities that can promptly evaluate and treat patients 1
• Documentation of Pap results, follow-up appointments, and results should be clearly maintained 1

Common Pitfalls to Avoid

• Pap smear is not an effective screening test for STDs 1
• Postpone Pap smear if the woman is menstruating 1
• Mucopurulent discharge might compromise interpretation; remove carefully before testing if follow-up is unlikely 1
• Women with external genital warts do not need more frequent Pap smears unless otherwise indicated 1
• Women who have had a hysterectomy do not require annual Pap smears unless the hysterectomy was related to cervical cancer or its precursor lesions 1
• Never use HPV tests that detect low-risk HPV types (e.g., types 6 and 11) as they are not beneficial in this setting 1