Management of 56-Year-Old Female with Negative PAP and Positive HPV
Repeat HPV testing with or without concurrent PAP test in 1 year is the recommended next step for this patient. 1
Rationale for 1-Year Follow-Up
This management approach is based on the 2019 ASCCP risk-based guidelines, which recognize that a negative PAP (NILM - negative for intraepithelial lesion or malignancy) with positive HPV represents a relatively low-risk scenario. 1 The key determining factor is whether this patient had negative screening results within the previous 5 years:
- If she had negative HPV testing or co-testing within the past 5 years: The guidelines specifically allow deferral of colposcopy in favor of repeat testing at 1 year. 1
- If she had a previous HPV-positive result: Immediate colposcopy is indicated, as two consecutive HPV-positive tests warrant direct referral regardless of cytology. 1
Critical Decision Point: HPV Genotyping
If HPV genotyping is available and shows HPV 16 or 18, proceed directly to colposcopy regardless of negative cytology. 1 This is because:
- HPV 16 carries the highest risk for progression to high-grade disease 1
- HPV 18 has relatively high association with adenocarcinoma, and endocervical sampling should be performed at colposcopy 1
- For non-16/18 high-risk HPV types with negative cytology, the 1-year follow-up strategy remains appropriate 2
Follow-Up Protocol at 1 Year
At the 1-year visit, perform repeat HPV testing (with or without PAP): 1
- If HPV negative or both tests negative: Return to routine age-appropriate screening 2
- If HPV remains positive: Refer to colposcopy 1, 2
- If cytology shows ASC-US or worse: Refer to colposcopy 1, 2
Important Caveats
Do not extend the initial follow-up interval beyond 12 months. 2 While some data suggest safety in longer intervals for postmenopausal women, the first surveillance visit should occur at 1 year to ensure appropriate risk stratification. 3
HPV testing alone or repeat cytology alone is preferred over cytology-only follow-up because negative HPV testing has higher negative predictive value for excluding high-grade disease compared to cytology alone. 1
Avoid common pitfalls:
- Do not perform immediate colposcopy unless HPV 16/18 positive or there is a history of consecutive HPV-positive results 1
- Do not recommend excisional procedures or hysterectomy based solely on a single positive HPV test with negative cytology 2
- Ensure the patient understands this is active surveillance, not dismissal of the finding 2