What is the next step after an abnormal Pap (Papanicolau) smear result?

Management of Abnormal Pap Smear Results

For a patient with an abnormal Pap smear, colposcopy is the recommended next step in most cases, with the specific approach depending on the type of abnormality detected. 1

Management Algorithm Based on Cytology Result

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Immediate colposcopy is mandatory for HSIL results 1
• For patients ≥25 years who are not pregnant, expedited treatment (excision without prior biopsy) is preferred over colposcopy with biopsy after shared decision-making 1
• If HPV 16 is positive with HSIL cytology, expedited treatment should be strongly considered due to the highest risk profile 1

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• Colposcopy is recommended in most cases for LSIL 1
• The exception: if preceded by a negative HPV test or cotest within the past 5 years, follow-up in 1 year instead of immediate colposcopy may be appropriate 1
• For women <21 years with LSIL, colposcopy is NOT recommended; instead, repeat Pap testing at 12 and 24 months is the correct approach due to high spontaneous clearance rates 1

Atypical Squamous Cells of Undetermined Significance (ASC-US)

For women ≥21 years with ASC-US, three management options exist 2, 1:

1. High-risk HPV DNA testing (preferred approach):

   • If HPV positive: refer for colposcopy 1, 3
   • If HPV negative: repeat Pap test in 12 months 1

2. Repeat Pap tests at 6 and 12 months:

   • Continue until two consecutive negative results are obtained 2
   • If subsequent tests show ASC or worse, proceed to colposcopy 2

3. Immediate colposcopy:

   • Appropriate if concerns exist about patient adherence to follow-up 2
   • High-grade histological changes (CIN 2 or higher) are detected in <12% of ASC-US cases at colposcopy, but this risk increases significantly when HPV is positive 2, 3

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

• Immediate colposcopy is required for ASC-H 1

Atypical Glandular Cells (AGC)

• All subcategories of AGC require colposcopy with endocervical sampling and HPV DNA testing 1

HPV-Based Management Considerations

• For HPV 16 or 18 positive cases, colposcopy is required regardless of cytology results, even if cytology is normal 1
• For HPV 18 positive cases, endocervical sampling is acceptable at the time of colposcopy due to association with adenocarcinoma 1
• If cytology is normal with other high-risk HPV types (non-16/18), return in 1 year is recommended in most cases 1
• Colposcopy is always recommended for two consecutive HPV-positive tests, regardless of previous Pap test results 1

Critical Pitfalls to Avoid

• Do not delay colposcopy in women ≥30 years with HPV-positive abnormal results, as this increases the risk of missed high-grade disease 3
• Do not rely on repeat cytology alone for HPV-positive abnormal results in women ≥30 years, as it has lower sensitivity (76.2%) compared to immediate colposcopy 3
• Do not assume low risk despite mild cytologic abnormality; the combination with HPV positivity significantly increases risk 3
• Women with external genital warts do not need more frequent Pap smears unless otherwise indicated 1
• Postpone Pap smear if the woman is menstruating 1

When Reassurance or Repeat Testing is Appropriate

Reassurance alone (Option C) is NOT appropriate for any truly abnormal Pap smear result. The only scenarios where repeat testing without colposcopy is acceptable are:

• ASC-US with negative HPV test: repeat in 12 months 1
• LSIL in women <21 years: repeat at 12 and 24 months 1
• LSIL with negative HPV test or cotest within past 5 years: follow-up in 1 year 1
• Normal cytology with non-16/18 high-risk HPV: return in 1 year 1

Referral Protocols

• Clinics that cannot provide colposcopy services should establish clear referral protocols to facilities that can promptly evaluate and treat patients 1
• Documentation of Pap results, follow-up appointments, and results should be clearly maintained 1