Management of ASC-US with Positive High-Risk HPV in a 58-Year-Old Woman
This patient requires colposcopy with endocervical sampling. 1
Immediate Management
Refer for colposcopy immediately rather than pursuing repeat cytology or observation, as women with ASC-US who are HPV-positive should be managed identically to women with LSIL. 1 The 2006 ASCCP Consensus Guidelines explicitly state that HPV-positive ASC-US warrants colposcopic evaluation regardless of age. 1
Key Points About Colposcopy
- Endocervical sampling is preferred when no lesions are identified on colposcopy and is mandatory for unsatisfactory colposcopy. 1
- The colposcopy must visualize the entire transformation zone to be considered satisfactory. 1
- Directed biopsies should be obtained from any suspicious lesions. 1
Risk Stratification Context
At age 58, this patient's 3-year risk of CIN3+ with HPV-positive ASC-US is approximately 5.2%, which exceeds the threshold for immediate colposcopic referral. 2 While HPV infections are less common in this age group (only 19% of women ≥50 years with ASC-US are HPV-positive), those who test positive have significant risk for high-grade lesions. 3
Post-Colposcopy Management Depends on Findings
If No CIN or Only CIN1 Identified
Two acceptable options exist: 1
Option 1 (Preferred): Repeat HPV testing at 12 months
- If HPV remains positive → repeat colposcopy
- If HPV negative → return to routine screening
Option 2: Repeat cytology at 6 and 12 months
- If ASC-US or greater on either test → colposcopy
- If both negative → return to routine screening
Do not repeat HPV testing before 12 months, as approximately 60% of HPV-positive women will clear the virus during follow-up, and earlier testing provides no clinical benefit. 1
If CIN2 or CIN3 Identified
Treatment with excisional or ablative procedures (LEEP, cryotherapy, cold knife conization, or laser ablation) is indicated. 1
Common Pitfalls to Avoid
Do not use repeat cytology or observation as initial management for HPV-positive ASC-US in women over age 20. 1 This is a critical error that leads to delayed diagnosis—research shows that 52.6% of women with HPV-positive ASC-US who should receive colposcopy do not get appropriate referral. 4
Do not perform HPV genotyping (HPV 16/18 testing) to decide about colposcopy in the setting of ASC-US. 1 While genotyping has a role in cytology-negative/HPV-positive women aged ≥30, it is not recommended for triage of ASC-US because approximately 50% of CIN2+ lesions are associated with non-16/18 high-risk types, and the risk of CIN2+ with other oncogenic HPV types is still approximately 20%. 1
Avoid excisional procedures without histologic confirmation of CIN2+, as this represents overtreatment. 1