What is the recommended management for a 65-year-old female with atypical squamous cells of undetermined significance (ASC-US) and cellular changes associated with atrophy on a Pap test?

Management of ASC-US with Atrophic Changes in a 65-Year-Old Female

For a 65-year-old female with atypical squamous cells of undetermined significance (ASC-US) and cellular changes associated with atrophy, the recommended management is HPV testing, with colposcopy if HPV-positive or repeat cytology in 12 months if HPV-negative. 1, 2

Initial Management Algorithm

• For women with ASC-US, reflex HPV DNA testing is the preferred initial management strategy 3
• If HPV testing is positive, colposcopy is recommended due to increased risk of cervical intraepithelial neoplasia (CIN) 3, 1
• If HPV testing is negative, repeat cytology in 12 months is recommended 2, 4
• Women over 65 years with ASC-US should not exit screening without additional negative tests, even with HPV-negative results 1

Rationale for Management

• The risk of CIN3+ after an HPV-negative/ASC-US result is higher than after a completely negative co-test (0.48% vs 0.11%) 4
• Studies show that approximately 9.7% of women with ASC-US have CIN 2 or more serious abnormality, necessitating further evaluation 3
• Atrophic changes can mimic dysplasia, but should not alter the management algorithm for ASC-US 1
• The 5-year cancer risk after HPV-negative/ASC-US (0.043%) is closer to that after a negative Pap test alone (0.031%) than after a negative co-test (0.014%), supporting a 3-year rather than 5-year follow-up interval 4

Follow-up Recommendations

• If HPV testing is positive, follow-up after colposcopy depends on colposcopy results 3
• If HPV testing is negative, repeat co-testing (Pap and HPV) in 3 years is recommended 1, 2, 4
• Women should not exit screening at age 65 with a recent ASC-US result, even if HPV-negative 1
• Continued screening is necessary until the patient has 2 consecutive negative co-tests or 3 consecutive negative Pap tests 1

Special Considerations for Older Women with Atrophic Changes

• Atrophic changes in postmenopausal women can lead to ASC-US interpretations due to cellular changes that mimic dysplasia 5
• Despite atrophic changes, the management algorithm remains the same as for other ASC-US results 1
• Women over 60 years with HPV-positive ASC-US may have a higher risk for cervical cancer during follow-up than younger women 1
• Risk estimates for cancer among women with HPV-positive ASC-US test results in this age group suggest caution is warranted 1

Common Pitfalls to Avoid

• Do not allow exit from screening at age 65 with a recent ASC-US result, as this is insufficient for exiting screening 1
• Do not extend screening interval beyond 3 years for HPV-negative ASC-US, as the previous 5-year interval recommendation has been revised based on newer evidence 1, 4
• Do not assume that an HPV-negative ASC-US result carries the same ultralow risk as a negative co-test 2
• Do not perform colposcopy immediately for all ASC-US results regardless of HPV status, as it can lead to unnecessary procedures 2

Considerations for HIV-Infected Women

• For HIV-infected women, more frequent screening is recommended regardless of age 3
• Women with atypical squamous cells should undergo colposcopy and directed biopsy 3
• Abnormal cervical cytology is 10–11 times more common in HIV-infected women compared with the general female population 3