What is the follow-up procedure for an abnormal Pap (Papanicolau) smear?

Follow-Up Management of Abnormal Pap Smear

The follow-up procedure for an abnormal Pap smear depends on the specific cytology result, with high-grade lesions requiring immediate colposcopy, while low-grade abnormalities can be managed with either colposcopy or serial cytology based on risk stratification. 1, 2

Management Algorithm by Cytology Result

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Immediate colposcopy with directed biopsy is mandatory for all women with HSIL. 3, 2
• For patients ≥25 years who are not pregnant, expedited treatment (excision without prior biopsy) is preferred over colposcopy with biopsy after shared decision-making. 2
• If HPV 16 positive with HSIL cytology, expedited treatment should be strongly considered. 2
• Pregnant women should receive colposcopy with biopsy rather than expedited treatment. 2

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• Colposcopy is recommended in most cases for women ≥21 years with LSIL. 3, 2
• Women <21 years should NOT undergo colposcopy due to high spontaneous clearance rates; instead, repeat Pap testing at 12 and 24 months is appropriate. 2
• If preceded by negative HPV test or cotest within the past 5 years, follow-up in 1 year instead of immediate colposcopy may be acceptable. 2
• Alternative management: repeat Pap smears every 4-6 months for 2 years until three consecutive negative results are obtained. 3
• If repeat smears show persistent abnormalities during this surveillance period, colposcopy and directed biopsy are indicated. 3

Atypical Squamous Cells of Undetermined Significance (ASC-US)

Three management options exist for ASC-US: 3, 2

1. High-risk HPV DNA testing (preferred when available):

   • If HPV positive: immediate referral for colposcopy. 3, 2
   • If HPV negative: repeat Pap test at 12 months. 3, 2

2. Repeat Pap tests without colposcopy:

   • Perform repeat Pap smears every 4-6 months for 2 years until three consecutive negative results are obtained. 3
   • If a second report of ASC-US occurs during the 2-year follow-up period, colposcopy should be performed. 3

3. Immediate colposcopy:

   • Appropriate if concerns exist about patient adherence to follow-up or if the patient is at high risk (previous positive Pap tests or poor follow-up history). 3

ASC-US with Severe Inflammation

• Evaluate for infectious processes first. 3
• Re-evaluate with repeat Pap smear 2-3 months after appropriate treatment for identified infections. 3
• Then follow standard ASC-US protocol with repeat Pap smears every 4-6 months for 2 years. 3

Atypical Squamous Cells - Cannot Exclude HSIL (ASC-H)

• Immediate colposcopy is required for all ASC-H results. 2
• Manage similarly to HSIL given the concern for high-grade disease. 2

Atypical Glandular Cells (AGC)

• All subcategories of AGC require colposcopy with endocervical sampling and HPV DNA testing. 2
• This is critical because glandular abnormalities carry higher risk for significant pathology. 2

HPV-Based Management Considerations

HPV 16 or 18 Positive

• Colposcopy is required regardless of cytology results, even if cytology is normal. 2
• For HPV 18 positive cases, endocervical sampling is acceptable at the time of colposcopy due to association with adenocarcinoma. 2

Other High-Risk HPV Types (Non-16/18)

• If cytology is normal, return in 1 year is recommended in most cases. 2
• Colposcopy is always recommended for two consecutive HPV-positive tests, regardless of previous Pap test results. 2

Long-Term Surveillance After Treatment

Initial Post-Treatment Follow-Up

• Testing includes HPV test or cotest at 6,18, and 30 months, OR cytology alone at 6,12,18,24, and 30 months. 2

Extended Surveillance

• Surveillance must continue for at least 25 years after initial treatment for high-grade precancer, even beyond age 65. 2
• Long-term surveillance includes every 3 years if using HPV testing or cotesting, or annual testing if using cytology alone. 2
• If hysterectomy occurs during surveillance period, vaginal screening should continue. 2

Critical Implementation Considerations

Referral Systems for Clinics Without Colposcopy

• Clinics that cannot provide colposcopy services must establish clear referral protocols to facilities that can promptly evaluate and treat patients. 3, 2
• Referral facilities must report evaluation results back to the referring clinic. 3
• Develop protocols to identify and locate women who miss follow-up appointments. 3
• Consider establishing colposcopy services in local health departments where referrals are difficult and follow-up unlikely. 3

Documentation Requirements

• Clearly document Pap results, type and location of follow-up appointments, and results of follow-up in the clinic record. 3, 2

Common Pitfalls to Avoid

• The Pap smear is NOT an effective screening test for STDs. 3, 2
• Postpone conventional cytology Pap smear if the woman is menstruating. 3, 2
• Women with external genital warts do not need more frequent Pap smears unless otherwise indicated. 2
• Never use HPV tests that detect low-risk HPV types (e.g., types 6 and 11) as they are not beneficial in clinical management. 2
• All repeat Pap tests must be interpreted as "satisfactory for evaluation" to count toward the surveillance protocol. 3
• Many women believe they have had a Pap smear after pelvic examination when they actually have not—verify documentation. 3