What are the next steps for a patient with Atypical Squamous Cells of Undetermined Significance (ASCUS) and a positive Human Papillomavirus (HPV) test?

From the Guidelines

For patients with ASCUS (Atypical Squamous Cells of Undetermined Significance) and positive HPV test results, the recommended next step is colposcopy with directed biopsies, as indicated by the most recent guidelines 1. This approach is based on the 2021 sexually transmitted infections treatment guidelines, which emphasize the importance of colposcopy in managing abnormal cervical cancer screening tests and cancer precursors. The guidelines recommend colposcopy for patients with ASCUS or LSIL and positive HPV test results, as this combination indicates a higher risk for underlying high-grade cervical disease compared to ASCUS alone 1. During colposcopy, the cervix is examined with a magnifying instrument after application of acetic acid and Lugol's iodine to highlight abnormal tissue. If colposcopy reveals concerning areas, biopsies should be taken from these sites for histological evaluation. If colposcopy is negative (no visible lesions), follow-up with repeat co-testing (Pap and HPV testing) is recommended in 12 months. Some key points to consider in management include:

• The presence of HPV with abnormal cells increases the likelihood of a clinically significant lesion 1.
• For patients under 25 years old, management may be more conservative with observation, as most HPV infections clear spontaneously in younger women 1.
• Patients should be advised that colposcopy is generally well-tolerated with minimal discomfort, though they may experience light spotting afterward.
• Primary HPV testing is recommended for screening, with cytology testing performed for all positive HPV test results to help determine the next steps in management 1.
• Colposcopy is recommended if HPV genotyping is positive for types 16 or 18, and it can be considered if it is infeasible for the patient to return for cytology alone 1.

From the Research

Next Steps for ASCUS and Positive HPV

• For women with atypical squamous cells of undetermined significance (ASCUS) and positive human papillomavirus (HPV) results, the next steps involve further testing and potential treatment to rule out cervical intraepithelial neoplasia grade 2 or 3 (CIN2+) 2.
• Studies have shown that HPV-based detection methods, alone or in combination with cytology, may be useful in post-treatment management strategies for women with ASCUS and positive HPV results 2, 3.
• The use of local estrogen therapy has been suggested as a potential tool to increase the specificity of HPV testing in post-menopausal women with ASCUS and positive HPV results 4, 5.
• Colposcopy and biopsy are recommended for women with ASCUS and positive HPV results, as they can help identify women at risk of CIN2+ 2, 3, 6.
• Repeat Pap testing with cotesting for HPV is also a recommended strategy for women with ASCUS and negative HPV results 3.
• The sensitivity and specificity of different testing strategies, including repeat Pap smears, HPV testing, and combination testing, have been evaluated in various studies 2, 3, 6.

Management Strategies

• The American Society for Colposcopy and Cervical Pathology guidelines recommend high-risk HPV testing for patients 30 to 64 years of age with a low-grade squamous intraepithelial lesion on Papanicolaou (Pap) tests 3.
• A study published in the Journal of the American Society of Cytopathology found that colposcopy and biopsy were necessary for 37% of women with ASCUS and positive HPV results 3.
• Another study published in the Virology journal found that the use of local estrogen therapy increased the specificity of HPV testing in post-menopausal women with ASCUS and positive HPV results 5.
• A study published in the Journal of Reproductive Medicine found that a combination of repeat cytology and HPV testing was a promising strategy for identifying women with concomitant CIN2/3 6.

Diagnostic Testing

• HPV testing has been shown to be a useful tool in identifying women at risk of CIN2+ 2, 3, 6.
• The sensitivity and specificity of different HPV testing methods, including Hybrid Capture and polymerase chain reaction (PCR), have been evaluated in various studies 2, 6.
• Colposcopy and biopsy are recommended for women with ASCUS and positive HPV results, as they can help identify women at risk of CIN2+ 2, 3, 6.