What is the next step in management for a 45-year-old woman with a history of cryotherapy of the cervix, showing atypical cells of undetermined significance on her PAP smear, with a negative HPV status?

Management of ASC-US with Negative HPV in a 45-Year-Old Woman

For a 45-year-old woman with ASC-US and negative HPV testing, repeat co-testing (Pap plus HPV) in 1 year is the recommended next step. 1

Rationale for 1-Year Follow-Up

The 2021 CDC guidelines explicitly state that for patients with positive HPV status initially but then showing NILM (negative for intraepithelial lesion or malignancy) with unknown or HPV-negative status, repeat Pap plus HPV testing should occur in 1 year. 1 While your patient presents with ASC-US rather than NILM, the HPV-negative status is the critical risk stratifier that determines management timing.

Risk Assessment Context

• The 5-year risk of CIN3+ after HPV-negative/ASC-US is only 0.48%, which is substantially lower than HPV-positive ASC-US (18% risk). 2
• This low risk profile is closer to a negative Pap test alone (0.31% CIN3+ risk) than to a negative co-test (0.11% risk), supporting conservative management. 2
• HPV status is the most important risk stratifier for women with ASC-US, and negative HPV testing provides strong reassurance against high-grade disease. 3

Management Algorithm

Primary Recommendation

• Repeat co-testing (Pap + HPV) in 1 year 1

At 1-Year Follow-Up, Three Possible Outcomes:

1. If both tests negative: Return to routine screening per age-appropriate guidelines 1

2. If HPV positive OR cytology shows ASC-US or greater: Proceed to colposcopy 1, 4

3. If persistent ASC-US with negative HPV: Continue annual surveillance until resolution 4

Why Not Immediate Colposcopy?

Immediate colposcopy is not indicated for HPV-negative ASC-US because:

• The detection rate of significant lesions with colposcopy in this population is low 5
• Guidelines reserve immediate colposcopy for HPV-positive ASC-US or qualified ASC-US favoring neoplasia 1, 4
• The prior cryotherapy history does not change this recommendation unless there was a history of high-grade lesions (CIN 2/3, HSIL), which is not indicated in this case 1

Important Caveats

Prior cryotherapy consideration: The 2021 guidelines note that colposcopy may be warranted for patients with a history of high-grade lesions (CIN 2, CIN 3, histologic or cytologic HSIL). 1 However, since the question states "no colonization abnormal" (presumably meaning no prior high-grade lesions), this exception does not apply.

Avoid these common pitfalls:

• Do not simply repeat cytology alone without HPV testing—co-testing is preferred for follow-up after abnormal results 1
• Do not wait 3 years as you would for a completely negative co-test—the ASC-US finding requires earlier reassessment 2
• Ensure the patient understands the importance of returning for follow-up, as failure to follow up on ASC-US is a common cause of delayed cervical cancer diagnosis 3

Special Circumstances That Would Change Management

If any of the following apply, immediate colposcopy would be indicated instead:

• ASC-US qualified as "cannot exclude HSIL" or "favoring neoplasia" 4
• Severe inflammation requiring evaluation for infectious processes first, then re-evaluation 4
• Patient is high-risk (poor adherence to follow-up, immunocompromised) 4
• History of previous high-grade cervical lesions 1