What is the management approach for a 23-year-old female with a Pap (Papanicolau) smear result showing Low-grade Squamous Intraepithelial Lesion (LSIL) and no Human Papillomavirus (HPV) testing available?

Management of LSIL in a 23-Year-Old Female Without HPV Testing

For a 23-year-old woman with LSIL on Pap smear, repeat cytology (Pap smear) in 12 months is the recommended management—do not pursue HPV testing or immediate colposcopy. 1, 2

Age-Specific Conservative Approach

Your patient falls into the young adult category (21-24 years) where guidelines explicitly recommend against HPV testing for LSIL management. 1, 2 This conservative approach is based on several key clinical principles:

• Over 90% of LSIL cases in young women regress spontaneously within 24 months without any treatment 1, 2
• 91% of adolescents and young women clear LSIL within 36 months 1, 2
• Young women have extremely high rates of transient HPV infections that clear naturally, making aggressive intervention both unnecessary and potentially harmful 2
• The primary concern is avoiding overtreatment of lesions that would naturally resolve, which could lead to complications in future pregnancies 2

Specific Follow-Up Algorithm

At 12-month follow-up:

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

At 24-month follow-up (if needed):

• Refer to colposcopy if ASC-US or greater is found 1

Critical "Do Not" List

Do NOT perform HPV testing in this patient: 1, 2

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

Do NOT refer for immediate colposcopy: 2

• The high rate of spontaneous clearance makes immediate colposcopy unnecessary and potentially harmful 2
• The risk of progression to CIN 2,3 is relatively low within the first 24 months 1

Common Pitfalls to Avoid

• Ensure proper follow-up tracking: Develop protocols to identify patients who miss their 12-month appointment, as loss to follow-up is a critical failure point 2
• Document clearly: Record the follow-up plan, appointment dates, and results in the medical record 1
• Patient education: Explain why the approach is conservative and emphasize the importance of returning for the 12-month follow-up 2
• Do not confuse with older women's management: Women over 25 years have different management options including HPV testing at 12 months or repeat cytology at 6 and 12 months 1, 2

Why This Differs from Older Women

The management for your 23-year-old patient is intentionally more conservative than for women ≥25 years old, who have acceptable options of either HPV testing at 12 months or repeat cytology at 6 and 12 months. 1, 2 This age-based distinction reflects the biological reality that younger women clear HPV infections at much higher rates and face greater risks from overtreatment than from the LSIL itself. 2