What are the next steps for a patient with a Pap smear showing cervical dysplasia?

Management of Cervical Dysplasia on Pap Smear

The appropriate next step depends on the specific grade of dysplasia and patient age, but in general: women with high-grade squamous intraepithelial lesions (HSIL) should undergo immediate colposcopy with directed biopsy, while management of low-grade lesions (LSIL) or atypical squamous cells (ASC-US) varies by age and can include colposcopy, HPV testing, or repeat cytology. 1

Management Algorithm by Cytology Result

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Immediate colposcopy with directed biopsy is mandatory for all women with HSIL cytology 1
• Expedited treatment ("see and treat") is preferred for nonpregnant patients aged ≥25 years, though colposcopy with biopsy remains acceptable after shared decision-making 1
• Endocervical assessment should be performed during colposcopy 1
• This approach is critical because HSIL carries up to a 50% risk of CIN 2 or higher on histology 1

Atypical Squamous Cells - Cannot Exclude HSIL (ASC-H)

• Colposcopy is recommended for all women with ASC-H, regardless of age 1
• The prevalence of CIN 2,3 in ASC-H cases can be as high as 50%, warranting immediate colposcopic evaluation 1

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• For women aged ≥21 years: Colposcopy with directed biopsy is the preferred approach 1
• Alternative management includes repeat cytology every 4-6 months for 2 years until three consecutive negative smears are obtained 1
• For women aged <21 years: Colposcopy is NOT recommended due to high spontaneous clearance rates; instead, repeat Pap testing at 12 and 24 months is appropriate 1
• HPV testing is not useful for LSIL triage because 86% of women with LSIL will be HPV-positive 1

Atypical Squamous Cells of Undetermined Significance (ASC-US)

For women aged ≥21 years, three management options exist 1:

1. High-risk HPV DNA testing (preferred): If HPV-positive, proceed to colposcopy; if HPV-negative, repeat Pap at 12 months 1
2. Repeat Pap smears: At 6 and 12 months until two consecutive negative results, then resume routine screening 1
3. Immediate colposcopy: Appropriate if concerns exist about patient adherence or other clinical indications 1

For women aged <21 years: Repeat Pap testing at 12 and 24 months; colposcopy is not recommended 1

• ASC-US with severe inflammation should prompt evaluation for infectious processes, with reevaluation 2-3 months after treatment 1
• If ASC-US is qualified as suspicious for neoplasia, manage as LSIL 1

Atypical Glandular Cells (AGC) and Adenocarcinoma In Situ (AIS)

• Colposcopy with endocervical sampling is mandatory for all women with AGC or AIS 1
• Reflex HPV testing or repeat cytology alone is unacceptable for initial triage 1

Key Colposcopy Principles

• A satisfactory colposcopy requires visualization of the entire squamocolumnar junction and margins of any visible lesion 1
• Directed biopsies should be performed on any abnormal areas identified during colposcopic examination 1
• Endocervical curettage is not required if the entire transformation zone is visualized 1
• In pregnant women, biopsy of lesions suspicious for cancer or CIN 2,3 is preferred, but endocervical curettage is unacceptable 1

Post-Treatment Surveillance

• After treatment for high-grade precancer, surveillance must continue for at least 25 years, even if this extends beyond age 65 1
• Initial testing includes HPV test or cotest at 6,18, and 30 months (or cytology alone at 6,12,18,24, and 30 months) 1
• Long-term surveillance involves testing at 3-year intervals with HPV/cotesting or annually with cytology alone 1

Critical Pitfalls to Avoid

• Never use HPV testing as a stand-alone screening test without cytology 1
• Do not perform colposcopy for ASC-US or LSIL in adolescents (<21 years) due to high spontaneous regression rates 1
• Ensure adequate referral systems are in place if your clinic cannot provide colposcopic follow-up; protocols must identify patients who miss appointments 1
• Document all results clearly: initial Pap findings, referral location, and follow-up outcomes 1
• High-grade histological changes are detected in <12% of ASC-US cases at colposcopy, but missing these cases has significant mortality implications 1