Management of a 42-Year-Old Female with ASCUS and HPV Positive E6/E7
For a 42-year-old female with ASCUS and HPV positive E6/E7, immediate colposcopic evaluation is strongly recommended due to the increased risk of underlying high-grade cervical disease. 1
Rationale for Colposcopy Referral
- Women with ASCUS who are HPV DNA positive should be managed in the same fashion as women with LSIL and be referred for colposcopic evaluation 1
- HPV E6/E7 mRNA positivity indicates active viral oncogene expression, which is associated with a significantly higher risk of progression to CIN2+ compared to women with negative results (pooled RR = 3.08) 2
- Women positive for HPV E6/E7 mRNA have a greater risk of malignant progression of cervical lesions and therefore require more vigilant follow-up 3
Colposcopy Procedure Details
- During colposcopy, the cervix should be examined with a colposcope (10x-16x magnification) after application of 3-5% acetic acid solution 1
- Endocervical sampling is preferred for women in whom no lesions are identified during colposcopy or those with an unsatisfactory colposcopy 1
- Colposcopically directed biopsies should be taken from any suspicious areas to rule out invasive disease and determine the extent of preinvasive disease 1
Post-Colposcopy Management
If CIN is not identified during colposcopy:
- HPV DNA testing at 12 months or repeat cytologic testing at 6 and 12 months are acceptable follow-up options 1
- HPV DNA testing should not be performed at intervals less than 12 months 1
If CIN is identified:
- Management depends on the grade of CIN detected
- For CIN 2,3: treatment options include excision (loop electrosurgical excision procedure, cold-knife conization) or ablative procedures (laser ablation, cryotherapy) 1
- For CIN 1: follow-up with HPV DNA testing at 12 months or repeat cytology at 6 and 12 months 1
Special Considerations for HPV E6/E7 Testing
- HPV E6/E7 mRNA testing has a high positive predictive value (70.0%) for detecting underlying CIN2+ in women with abnormal cytology 4
- The PPV increases with age, reaching 83.7% for HPV 16 positive women above 40 years of age 4
- Women with positive HPV E6/E7 mRNA tests should be considered at high risk for progression and managed accordingly with prompt colposcopy and potentially more aggressive follow-up 2
Common Pitfalls to Avoid
- Do not delay colposcopy referral for women with ASCUS who are HPV positive, as this could lead to missed high-grade lesions 5
- Avoid routine use of diagnostic excisional procedures (like LEEP) without histologically diagnosed CIN 2,3, as this could lead to overtreatment 1
- Do not perform HPV DNA testing at intervals less than 12 months as this could lead to unnecessary procedures 1
- Ensure proper documentation of all test results and follow-up appointments to prevent loss to follow-up 5
By following this evidence-based approach, you can ensure appropriate management of this patient with ASCUS and HPV positive E6/E7, minimizing both the risk of progression to invasive disease and unnecessary procedures.