From the Guidelines
The management of Low-Grade Intraepithelial Lesion (LSIL) typically involves surveillance rather than immediate treatment, with the recommended approach being to perform colposcopy to evaluate the cervix more thoroughly for women 25 years and older, and repeat cytology in 12 months for women under 25. The rationale for this approach is based on the high rate of spontaneous regression of LSIL, with 70-80% of cases resolving within 1-2 years as the immune system clears the underlying HPV infection 1.
Key Considerations
- For women 25 years and older with LSIL on Pap test, colposcopy is recommended to evaluate the cervix more thoroughly, and if colposcopy is adequate with no evidence of high-grade disease, follow-up with co-testing (Pap and HPV testing) in 12 months is appropriate 1.
- For women under 25, LSIL often resolves spontaneously due to robust immune responses, so repeat cytology in 12 months is recommended without immediate colposcopy 1.
- If LSIL persists for two years or progresses to high-grade lesions, then further evaluation with colposcopy and possible treatment is warranted 1.
- Treatment options for persistent LSIL include excisional procedures (LEEP or conization) or ablative procedures (cryotherapy or laser ablation), but these are generally reserved for persistent or progressive disease 1.
Rationale for Conservative Management
The conservative management approach is supported by the fact that most LSIL cases will spontaneously regress, and unnecessary treatment can lead to potential complications including cervical stenosis, bleeding, infection, and adverse pregnancy outcomes 1.
Special Considerations
- Pregnant women with LSIL can have colposcopy, but treatment during pregnancy is unacceptable unless invasive carcinoma is identified 1.
- Adolescents with LSIL can be managed conservatively, with repeat cytology in 12 months, as they have a high rate of spontaneous regression 1.
From the Research
Management of Low-Grade Intraepithelial Lesion (LSIL)
The management of LSIL varies, and several strategies have been proposed:
- Colposcopy immediately after cytologic diagnosis of low-grade SIL or at the same time the smear is taken, with HPV testing as a triage option in some countries 2
- Colposcopy only after a repeated abnormal cytologic result within a 6-month interval or after an optional test positive for high-risk HPV 2
- Management taking into account the socio-economic status of the patient, with 'see and treat' management recommended for patients with poor compliance, and follow-up by cytology and colposcopy for patients with assured compliance 2
- HPV testing at 12 months as a sensitive test for detection of CIN grade 2 or 3, with a referral rate to repeat colposcopy of 55.0% 3
- Repeat semiannual cytology with referral to colposcopy at an ASCUS threshold, demonstrating similar sensitivity but with a higher rate of referral to colposcopy 3
Treatment and Follow-up
- Treatment of high-grade lesions is generally recommended once diagnosed, while the management of low-grade lesions is more complex and depends on various factors, including local circumstances and patient compliance 4
- Surveillance may be offered to patients with low-grade lesions, with treatment recommended if the lesion persists for 2 years or worsens in grade or size 4
- The American Society for Colposcopy and Cervatory Pathology developed guidelines for the management of cervical cytologic abnormalities, including recommendations for colposcopy, repeat cytology, and HPV DNA testing 5
- Avoiding treatment while continuing to monitor patients for clearance of disease or a change to a more severe diagnosis is a proposed approach for managing LSIL 6