What are the next steps for a patient with a negative result for intraepithelial lesion or malignancy, negative Human Papillomavirus (HPV) test, and an atrophic pattern with predominantly parabasal cells?

Management of Negative Pap Test with Atrophic Pattern and Negative HPV

For a patient with a negative result for intraepithelial lesion or malignancy (NILM), atrophic pattern with predominantly parabasal cells, and negative HPV test, routine age-appropriate screening is recommended with no need for additional follow-up or intervention.

Understanding the Results

• A negative for intraepithelial lesion or malignancy (NILM) result with negative HPV testing indicates a very low risk for cervical cancer or precancerous lesions 1
• An atrophic pattern with predominantly parabasal cells is a common benign finding, particularly in postmenopausal women, and does not require additional evaluation when both cytology and HPV testing are negative 1
• The negative HPV test significantly reduces the risk of developing cervical intraepithelial neoplasia (CIN) in the future 1, 2

Management Recommendations

For Women Ages 30-65 Years:

• Return to routine screening with cotesting (Pap test and HPV) every 5 years 1
• The 5-year risk of CIN3+ in women with negative HPV test and normal cytology is extremely low (0.16% with 5 years follow-up) 1

For Women Ages 21-29 Years:

• Return to routine screening with cytology alone every 3 years 1
• HPV testing is not routinely recommended in this age group due to high prevalence of transient HPV infections 1

Special Considerations

For Postmenopausal Women:

• Atrophic patterns are common due to decreased estrogen levels 1
• No additional evaluation is needed when both cytology and HPV testing are negative 1
• If the patient is symptomatic (vaginal dryness, discomfort), consider topical estrogen therapy for symptom management, but this is not required for cervical cancer prevention 1

For Immunocompromised Women:

• HIV-infected and other immunosuppressed women with negative cytology and negative HPV should be managed the same as women in the general population 1
• More frequent screening may be considered based on individual risk factors 1

Follow-up Considerations

• If the specimen was reported as unsatisfactory for evaluation, a repeat sample would be recommended regardless of HPV status 3
• However, in this case, the specimen was adequate for evaluation with a definitive NILM result, so routine screening is appropriate 1

Evidence Quality and Considerations

• The negative predictive value of a negative HPV test in the setting of normal cytology is extremely high (>99%) 1, 3
• A 2017 study showed that for women with NILM and negative HPV, the progression rate to CIN was only 1.4% over 12 months of follow-up 2
• Even in cases where initial Pap tests showed more concerning findings (ASC-H), a negative HPV test significantly reduced the risk of high-grade lesions 4, 5

Common Pitfalls to Avoid

• Don't confuse atrophic patterns with dysplasia - atrophic changes can sometimes mimic dysplasia cytologically, but the negative HPV test helps confirm the benign nature 1
• Don't recommend unnecessary colposcopy or additional testing when both cytology and HPV testing are negative, as this leads to overtreatment 1
• Don't disregard the significance of the negative HPV test, which substantially reduces the risk of current or future high-grade lesions 1, 2