What is the recommended management for a 26-year-old female patient with a history of Low-grade Squamous Intraepithelial Lesions (LSIL) on previous colposcopy, who now has a current Pap smear showing LSIL and is Human Papillomavirus (HPV) negative?

Management of 26-Year-Old with LSIL Cytology and Negative HPV

This patient should undergo colposcopy regardless of the negative HPV status, as women with LSIL cytology have too great a risk of CIN3+ and cancer to warrant a return to routine screening. 1

Primary Recommendation

• Women with abnormal cytology more severe than ASC-US (including LSIL) should be referred to colposcopy regardless of their HPV status. 1
• The risks of CIN3+ and cancer following HPV-negative LSIL cytology results are too great to warrant a return to routine screening. 1
• This recommendation applies to all women aged 21-65 years with LSIL cytology, including this 26-year-old patient. 1

Why HPV-Negative Status Does NOT Change Management

• While HPV-negative ASC-US has very low risk (less than 2% risk of CIN3+ at 2 years), LSIL cytology represents a higher-risk category that requires colposcopic evaluation even when HPV testing is negative. 1
• The 2012 American Cancer Society/ASCCP guidelines explicitly state that LSIL+ cytology warrants colposcopy regardless of HPV status, distinguishing it from the management of ASC-US. 1

Critical Distinction from Younger Women

• Although this patient is 26 years old (close to the 21-24 age group), the conservative "annual cytology only" approach recommended for women aged 21-24 with LSIL does not apply here. 2, 3
• For women aged 25 and older with LSIL, colposcopy is the appropriate next step, particularly when there is a history of previous LSIL on colposcopy. 2, 3

Follow-Up After Colposcopy

• If CIN 1 is found at colposcopy: Follow-up with either HPV DNA testing every 12 months or repeat cervical cytology every 6-12 months is recommended. 1
• If HPV DNA test is positive or repeat cytology shows ASC-US or greater, repeat colposcopy is indicated. 1
• If CIN 1 persists for at least 2 years, either continued follow-up or treatment is acceptable. 1
• If CIN 2,3 is found: Treatment with excision or ablation is recommended (if colposcopy is satisfactory). 1

Common Pitfalls to Avoid

• Do not be falsely reassured by the negative HPV test - LSIL cytology itself is the indication for colposcopy, not the HPV status. 1
• Do not confuse this scenario with ASC-US/HPV-negative, which can return to routine screening. 1
• Ensure proper documentation and follow-up protocols to prevent loss to follow-up after colposcopy. 2, 3
• The previous colposcopy showing LSIL makes continued surveillance even more important, as this represents persistent or recurrent disease. 1