Management of ASCUS with Negative HPV in a 52-Year-Old Woman
For a 52-year-old woman with ASCUS and negative HPV testing, repeat HPV testing (with or without concurrent Pap) in 3 years is recommended. 1
Risk Stratification
- Women with HPV-negative ASCUS have a low but measurable risk of precancer, with a 5-year CIN3+ risk of 0.48%, which is higher than after a completely negative cotest (0.11%) but similar to a negative Pap test alone (0.31%). 2
- The absolute risk remains low, but this result does not carry the same "ultralow" reassurance as a negative cotest. 1, 3
Recommended Management Algorithm
Follow-up interval:
- Return for repeat screening in 3 years with HPV testing (with or without concurrent Pap test). 1
- This represents an update from older 2012 guidelines that recommended 5-year follow-up, based on expanded Kaiser Permanente Northern California data analyzing over 1.1 million women. 1, 3
At the 3-year follow-up visit:
- If HPV test remains negative and cytology is normal (if performed): return to routine age-based screening. 1
- If HPV test is positive OR cytology shows abnormalities: refer to colposcopy. 1
Do NOT:
- Perform immediate colposcopy—this is unnecessary for HPV-negative ASCUS and leads to overtreatment. 3, 4
- Return to screening before 3 years—this is too soon and may result in unnecessary interventions. 3, 4
- Wait 5 years—this interval is too long given the intermediate risk profile. 1, 2
Critical Age-Specific Consideration
This patient cannot exit screening at age 65 based on this result. 1, 4
- HPV-negative ASCUS is insufficient for meeting exit criteria at age 65 years. 1
- She must continue surveillance until achieving either 2 consecutive negative cotests or 3 consecutive negative Pap tests before discontinuing screening. 1
- Women ages 60-65 with HPV-negative ASCUS showed disproportionately higher cancer risk compared to those with negative cotests, despite low dysplasia risk. 1
Evidence Basis
The 2019 ASCCP risk-based management guidelines prioritize management based on CIN3+ risk rather than specific test results, using clinical action thresholds to generate personalized recommendations. 1 The shift from 5-year to 3-year follow-up for HPV-negative ASCUS reflects the principle of "equal management of equal risks"—since the risk profile more closely resembles a negative Pap test alone rather than a negative cotest, the management should align accordingly. 1, 2
Common Pitfalls to Avoid
- Assuming this result equals a negative cotest: The risk is approximately 4-fold higher for CIN3+ and 3-fold higher for cancer compared to a true negative cotest. 2
- Performing HPV genotyping for 16/18: This is not recommended for ASCUS results as it does not alter management. 1
- Allowing screening exit at age 65: This single result does not provide sufficient reassurance to discontinue screening. 1, 4