What is the next best step for a 22-year-old female with a Low-grade Squamous Intraepithelial Lesion (LSIL) Pap smear result and no previous history of abnormal results?

Management of LSIL in a 22-Year-Old Female

For a 22-year-old woman with LSIL and no previous abnormal history, the next best step is annual cytologic testing (repeat Pap smear in 12 months), NOT colposcopy or HPV testing. 1

Age-Specific Management for Young Women (Ages 21-24)

The management of LSIL differs dramatically based on age, and this patient falls into a critical age group where conservative management is strongly recommended:

Why Conservative Management?

• High spontaneous regression rates: Over 90% of LSIL cases in young women regress within 24 months without treatment, and 91% of adolescents and young women clear LSIL within 36 months. 1

• Transient HPV infections are common: Young women have a high prevalence of transient HPV infections that clear spontaneously, making aggressive intervention unnecessary and potentially harmful. 1

• Risk of overtreatment: The primary concern in this age group is avoiding overtreatment of lesions that would naturally regress, which could lead to complications in future pregnancies. 1

Recommended Follow-Up Algorithm

At 12-month follow-up:

• Repeat Pap smear 2, 1
• Refer to colposcopy ONLY if HSIL or greater is found 2, 1
• Do NOT refer for ASC-US or persistent LSIL at this visit 2, 1

At 24-month follow-up:

• If ASC-US or greater is found, then refer to colposcopy 2, 1

What NOT to Do

HPV DNA testing is unacceptable for this patient: 2, 1

• HPV testing should NOT be performed in women aged 21-24 with LSIL 1
• If HPV testing is inadvertently performed, the results should NOT influence management 2, 1
• Cotesting (cytology plus HPV) is not recommended for cervical cancer screening in women aged 21-29 years 1

Immediate colposcopy is NOT indicated: 2, 1

• Colposcopy is unacceptable for adolescents and young women (≤24 years) with LSIL 2
• The high rate of spontaneous clearance makes immediate colposcopy unnecessary and potentially harmful 1

Key Differences from Older Women

This conservative approach contrasts sharply with management in women ≥25 years, where either HPV testing at 12 months or repeat cytology at 6 and 12 months would be acceptable options, with colposcopy for HPV-positive results. 2, 1 However, age 22 specifically mandates the more conservative annual cytology approach. 1

Common Pitfalls to Avoid

• Do not order reflex HPV testing: Many laboratories automatically perform HPV testing on abnormal Pap smears, but this should be avoided or ignored in this age group. 2, 1

• Ensure proper follow-up: Develop protocols to identify patients who miss their 12-month follow-up appointment, as loss to follow-up is a significant concern. 2

• Patient education is critical: Many women believe they've had a Pap smear when they haven't, so provide clear documentation that a Pap smear was obtained and explain the follow-up plan. 2

• Do not treat based on cytology alone: The risk of progression to CIN 2,3 is relatively low within the first 24 months in this age group. 1