Management of Atrophic Pap Smear with Negative HPV and No Dysplasia
Return to routine age-appropriate cervical cancer screening is recommended for patients with an atrophic pattern showing predominantly parabasal cells when both cytology is negative for intraepithelial lesion or malignancy (NILM) and HPV testing is negative. 1
Clinical Context and Risk Assessment
The scenario described represents a benign finding with extremely low cancer risk:
- Atrophic changes with negative cytology and negative HPV carry the same minimal risk as any negative cotest result 1
- The 5-year risk of CIN3+ in HPV-negative, cytology-negative women is approximately 0.16-0.3%, which does not warrant increased surveillance 1
- Atrophic cellular patterns commonly occur in postmenopausal women due to estrogen deficiency and can create diagnostic challenges, but when definitively interpreted as NILM, they require no special management 2, 3
Recommended Management Algorithm
For women aged 30-65 years:
- Resume cotesting (cytology + HPV) at 5-year intervals 1
- Alternatively, cytology alone at 3-year intervals is acceptable 1
For women aged 21-29 years:
- Resume cytology screening at 3-year intervals 1
Important Clinical Pitfalls to Avoid
Do not perform colposcopy for atrophic smears with negative cytology and negative HPV:
- Colposcopy is only indicated when cytology shows ASC-US or greater abnormalities, regardless of HPV status in the setting of LSIL or higher 1, 4
- The presence of atrophic changes alone does not warrant colposcopic evaluation when both cytology and HPV are negative 1
Do not prescribe empiric estrogen therapy when the cytology is already definitively negative:
- Estrogen therapy is reserved for cases where atrophic changes create diagnostic uncertainty (e.g., atypical cells that may represent either atrophy or dysplasia) 2, 5, 6, 7
- When cytology is clearly interpreted as NILM, estrogen treatment serves no diagnostic purpose 5, 6
Do not repeat testing at shortened intervals:
- HPV testing should not be performed at intervals less than 12 months 4
- There is no indication for accelerated screening in this low-risk scenario 1
Special Considerations
If the patient is symptomatic from atrophy (vaginal dryness, dyspareunia, irritation):
- Topical vaginal estrogen may be offered for symptom management, but this is a quality-of-life intervention, not a cancer screening intervention 1
- Symptomatic treatment does not change the screening interval recommendations 1
For HIV-infected women:
- Even in HIV-positive patients, if both cytology and HPV are negative with CD4 count >500 cells/µL, consideration can be given to extending screening intervals to 3 years, similar to HIV-negative women 1
- However, standard practice for HIV-infected women remains annual screening after two consecutive normal results 6 months apart 1