From the Guidelines
A colposcopy is recommended after two positive HPV tests with normal Pap smears. This procedure allows for direct visualization of the cervix with magnification and the application of acetic acid and Lugol's solution to identify abnormal areas that may require biopsy. The recommendation stems from the understanding that persistent high-risk HPV infection, even with normal cytology, increases the risk of developing cervical dysplasia or cancer over time, as indicated by the 2021 guidelines for the management of abnormal cervical cancer screening tests and cancer precursors 1.
Key Points to Consider
- The 2019 ASCCP risk-based management consensus guidelines recommend colposcopy for women with two consecutive HPV-positive tests, regardless of the Pap test result 1.
- The guidelines emphasize that previous Pap test results do not modify the recommendation for colposcopy in the case of two consecutive HPV-positive tests 1.
- Colposcopy is a crucial step in the management of women with persistent HPV infection, as it allows for the identification and biopsy of potentially abnormal areas, which can help prevent the development of cervical cancer 1.
- The procedure is generally well-tolerated, with minimal discomfort and no requirement for anesthesia, and it can be performed in an outpatient setting 1.
Procedure and Follow-up
During the colposcopy, the provider will examine the cervical tissue and may take small biopsies from any suspicious areas for further evaluation. The procedure typically takes 10-15 minutes and requires no anesthesia. After colposcopy, you may experience light spotting for 1-2 days. If biopsies are taken, it is recommended to avoid tampons, sexual intercourse, and douching for about a week to allow healing. This approach balances the need for further evaluation of persistent HPV infection while avoiding unnecessary procedures for transient infections that would likely clear on their own. The most recent guidelines from 2021 support this approach, emphasizing the importance of colposcopy in the management of women with persistent HPV infection 1.
From the Research
Indications for Colposcopy
- Colposcopy is indicated in patients with normal cytology and two HR HPV DNA positive tests performed at a nine month interval 2.
- The study suggests that colposcopy is necessary for women with two positive Human Papillomavirus (HPV) tests, even if the Pap smear is normal 2, 3.
HPV Testing and Colposcopic Examination
- HPV DNA testing is the preferred approach in women with an ASC-US result, and colposcopic examination is recommended for those who test positive for high-risk HPV 2.
- The incorporation of HPV testing into the present Pap screening program has the potential to make screening for cervical cancer more effective 4, 5.
Follow-up and Diagnostic Procedures
- For the follow up of untreated patients with ASC-US/LSIL and CIN I, colposcopy carried out at one year after a single HR HPV DNA positive test is as sensitive as colposcopy after two or three abnormal cytology tests 2.
- Women with persistent HPV infection remained at high risk for grade 2 or 3 lesions or cancer after referral for colposcopy 5, 3.
Clinical Guidelines and Recommendations
- Therapeutic decisions must not be based solely on the results of HPV DNA testing except in specific cases 2.
- All women testing positive for HPV, regardless of Pap smear result, should be referred to colposcopy 3.
- Patients with minimal Pap smear abnormalities such as HPV changes or atypia are likely to have a worse histologic diagnosis, with approximately two thirds showing dysplasia 6.