What are the next steps for a 31-year-old with a positive Human Papillomavirus 16 (HPV16) result and an abnormal Liquid-Based Cytology (LBC) Pap smear?

Management of 31-Year-Old with HPV16-Positive and Abnormal LBC

Proceed directly to colposcopy, as HPV 16 is the highest-risk HPV type and warrants colposcopy regardless of the specific cytology result. 1

Immediate Next Steps

Colposcopy Referral

• Colposcopy is mandatory for all HPV 16-positive results, even if cytology were completely normal, because HPV 16 carries a 17-21% 10-year cumulative risk of CIN 3+ 2
• The CDC explicitly states that HPV 16 is the highest-risk HPV type and colposcopy is recommended in all cases 1
• Do not delay colposcopy or attempt repeat testing—immediate referral is the standard of care 1

During Colposcopy

• Perform thorough examination of the transformation zone with directed biopsies of any suspicious areas 3
• Consider endocervical curettage (ECC) to evaluate the endocervical canal, particularly if adenocarcinoma is a concern 3
• Take biopsies from all abnormal-appearing areas identified during colposcopic examination 4

Management Based on Colposcopy/Biopsy Results

If CIN 1 or Less

• Repeat HPV testing with or without concurrent Pap test in 1 year 2
• Refer back to colposcopy if HPV remains positive or cytology becomes abnormal at follow-up 2

If CIN 2+ (High-Grade Dysplasia)

• Treatment is indicated with either ablative or excisional procedures (loop electrosurgical excision procedure [LEEP] is most common) 2, 5
• For HSIL cytology specifically with HPV 16, expedited treatment should be considered for non-pregnant patients ≥25 years 1

If Colposcopy is Negative

• HPV testing or cotesting at 12 months is recommended 3
• HPV testing or cotesting is preferred over cytology alone for follow-up 1, 3

Long-Term Surveillance After Treatment

If high-grade precancer (CIN 2/3) is treated:

Initial Surveillance Phase

• HPV test or cotest at 6,18, and 30 months post-treatment 1, 2
• If using cytology alone, test at 6,12,18,24, and 30 months 1

Long-Term Surveillance Phase

• Continue surveillance for at least 25 years after initial treatment, even if this extends beyond age 65 1, 2
• Test at 3-year intervals if using HPV testing or cotesting 1, 2
• Test annually if using cytology testing alone 1, 2
• If hysterectomy occurs during surveillance period, vaginal screening should continue 1

Critical Clinical Context

Why HPV 16 Requires Aggressive Management

• HPV 16-positive women with normal cytology still have substantial risk: studies show 13.6% develop CIN3+ within 10 years 6
• Research demonstrates that 48.2% of cytologically normal but HPV 16-positive women had HSIL on colposcopic biopsy 7
• HPV 16-related CIN2+ lesions are detected at younger age (mean 35.1 years) compared to other high-risk types (39.1 years) 4

Common Pitfalls to Avoid

• Do not attempt "watchful waiting" or repeat testing in 1 year for HPV 16-positive results—this is only appropriate for non-16/18 high-risk HPV types with normal cytology 2
• Do not skip colposcopy based on minimally abnormal cytology—HPV 16 status overrides cytology-based algorithms 1
• Do not discontinue surveillance early after treatment—the 25-year surveillance requirement is absolute 1, 2