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

Management of Abnormal Pap Test Results

Immediate colposcopy is recommended for high-grade abnormalities (HSIL, ASC-H, AGC), while ASC-US results can be managed with HPV testing (preferred), repeat Pap tests, or colposcopy depending on risk factors. 1, 2

Management Based on Specific Abnormal Results

Atypical Squamous Cells of Undetermined Significance (ASC-US)

• For women ≥21 years with ASC-US, three management options exist: high-risk HPV DNA testing (preferred), repeat Pap tests at 6 and 12 months, or immediate colposcopy 1, 2
• If HPV testing is positive with ASC-US, refer for colposcopy 1
• If HPV testing is negative with ASC-US, repeat Pap test in 12 months 1
• Colposcopy is appropriate if there are concerns about follow-up adherence or other clinical indications 3

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• Colposcopy is recommended in most cases for LSIL 1
• For women <21 years with LSIL, repeat Pap testing at 12 and 24 months is recommended instead of colposcopy due to high rates of spontaneous clearance 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, 2

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Immediate colposcopy is recommended for patients with HSIL 1, 4
• For non-pregnant patients ≥25 years with HSIL, 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

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

• Immediate colposcopy is recommended for ASC-H 1

Atypical Glandular Cells (AGC)

• All subcategories of AGC require colposcopy with endocervical sampling and HPV DNA testing 1
• Endometrial sampling is recommended in conjunction with colposcopy for women ≥35 years with AGC 2

HPV-Based Management

• Colposcopy is recommended regardless of cytology results for HPV 16 or 18 positive cases, even if cytology is normal 1
• For HPV 18 positive cases, endocervical sampling is recommended at the time of colposcopy due to association with adenocarcinoma 1
• If cytology is normal with other high-risk HPV types (non-16/18), return in 1 year is recommended 4, 1
• Colposcopy is always recommended for two consecutive HPV-positive tests, regardless of previous Pap test results 1
• HPV tests that detect low-risk HPV types should not be used as they are not beneficial in this setting 3

Follow-Up After Initial Management

• After treatment for high-grade precancer, surveillance should continue for at least 25 years, even beyond age 65 4, 1
• Initial post-treatment 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 includes testing every 3 years if using HPV testing/cotesting, or annual testing if using cytology alone 4, 1
• If hysterectomy occurs during surveillance period, vaginal screening should continue 1

Special Considerations

• Expedited treatment is not recommended for pregnant women; colposcopy with biopsy is the appropriate management 1
• For non-sexually active females with abnormal Pap results, colposcopy is still recommended as HPV transmission can occur through non-sexual routes 4
• HPV testing is not recommended for women <21 years 4

Practical Considerations and Common Pitfalls

• Clinics that cannot provide colposcopy services should establish clear referral protocols to facilities that can promptly evaluate and treat patients 3, 1
• Documentation of Pap results, follow-up appointments, and results should be clearly maintained 3, 1
• Pap test should not be considered a screening test for STDs 3, 1
• Postpone Pap test if the woman is menstruating 3, 1
• Women with external genital warts do not need more frequent Pap tests unless otherwise indicated 1
• Women who have had a hysterectomy do not require annual Pap tests unless the hysterectomy was related to cervical cancer or its precursor lesions 1
• Patient adherence to follow-up is a significant concern, with studies showing that almost one-third of high-risk patients may not complete recommended colposcopy within 12 months 5
• Patients with a history of abnormal results and severe Pap test abnormalities are at risk of misreporting recommendations for follow-up 6
• For unsatisfactory Pap tests with negative HPV cotesting, the negative predictive value for high-grade lesions is very high (99.6%), suggesting that longer follow-up intervals may be safe 7