Indications for Colposcopy After Abnormal Pap Smear Results
Colposcopy is definitively indicated for women with atypical squamous cells (both ASC-US and ASC-H), atypical glandular cells, low-grade or high-grade squamous intraepithelial lesion, or squamous carcinoma noted by Pap testing. 1
Specific Indications by Pap Result Type
Atypical Squamous Cells of Undetermined Significance (ASC-US)
- For women aged ≥21 years with ASC-US, three management options exist:
- For women <21 years with ASC-US, colposcopy is not recommended; instead, repeat cytology at 12 months is preferred 1
Low-Grade Squamous Intraepithelial Lesion (LSIL)
- For women aged ≥21 years, immediate colposcopy is recommended 1
- For women <21 years, colposcopy is not recommended due to high rates of spontaneous clearance; repeat cytology at 12 months is preferred 1
High-Grade Squamous Intraepithelial Lesion (HSIL) or ASC-H
- Immediate colposcopy is recommended for all age groups due to high risk of underlying high-grade cervical intraepithelial neoplasia (CIN 2,3) 2
- For ASC-H, the risk of underlying high-grade disease is substantial (up to 50%) 2
- HPV testing alone is not recommended for initial triage of ASC-H 2
HPV-Positive Results
- For HPV-positive results with normal cytology:
- For HPV genotyping positive for types 16 or 18: Immediate colposcopy even with normal cytology 3
Special Populations
HIV-Infected Women
- HIV-infected women should have cervical Pap smear upon initiation of care, repeated at 6 months, and if results are normal, annually thereafter 1
- Any abnormal results (ASC-US or worse) should prompt colposcopy and directed biopsy 1
- More frequent screening is recommended for HIV-infected women with previous abnormal Pap smears, after treatment for cervical dysplasia, with symptomatic HIV infection, or with HPV infection 1
Follow-Up After Colposcopy
- If colposcopy is negative for ASC-H, follow-up should include either repeat cytology at 6 and 12 months or HPV testing at 12 months 2
- After treatment for high-grade precancer, surveillance should continue for at least 25 years 1
- Initial post-treatment testing includes HPV test or cotest at 6,18, and 30 months 1
Common Pitfalls and Considerations
- Normal colposcopy in the presence of a low-grade cervical smear is associated with a very low risk of having or developing high-grade disease 4
- Women with ASC-US who have 3 or more sexual partners, low education, and low income are at increased risk of CIN 2-3 and may benefit from prioritized colposcopy 5
- A negative HPV test in women with ASC-H may predict the absence of HSIL, but current guidelines still recommend colposcopy for all ASC-H results 6
- For non-pregnant patients aged ≥25 years with HSIL cytology and positive HPV 16, expedited treatment may be considered as an alternative to colposcopy 1
Remember that colposcopy is a critical diagnostic step for women with abnormal Pap results, as approximately 40-48% of women with ASC-H or LSIL-H Pap smears have either concurrent or subsequent high-grade cervical pathology 7.