What is the appropriate management for a 21‑year‑old woman whose Pap smear shows atypical squamous cells of undetermined significance (ASC‑US) and Candida species?

Management of ASC-US with Candida in a 21-Year-Old Woman

For this 21-year-old woman with ASC-US and Candida on Pap smear, repeat cervical cytology in 12 months is the recommended management—HPV testing should not be performed at this age, and the Candida should be treated only if symptomatic. 1

Age-Specific Management Algorithm

Women under 21 years require special consideration because HPV prevalence is extremely high in this age group (most sexually active young women become HPV-positive within several years of first intercourse), and the vast majority of low-grade lesions regress spontaneously. 1 Progression to cervical cancer is extraordinarily rare before age 21, and most CIN III lesions are detected on subsequent screening rather than requiring immediate intervention. 1

Primary Management Pathway

• Repeat Pap smear at 12 months is the sole recommended next step for this patient. 1
• Do not perform HPV testing—the guidelines explicitly state that HPV testing is not recommended in women younger than 21 years because it cannot meaningfully triage management in this population. 1
• Treat the Candida infection only if the patient is symptomatic (vaginal itching, discharge, dyspareunia). 1 The presence of Candida does not alter cervical cytology management or require treatment before repeat cytology unless clinically indicated. 1

Follow-Up at 12 Months

The management pathway depends entirely on the 12-month cytology result:

• If negative or benign cellular changes: Repeat cytology again at 24 months (total 2-year follow-up from initial ASC-US). 1
• If persistent ASC-US or LSIL: Repeat cytology again at 24 months. 1
• If ASC-H or HSIL: Proceed immediately to colposcopy. 1

Follow-Up at 24 Months (3 Years Total)

• If negative: Resume routine screening (next Pap at age 21 or per standard guidelines). 1
• If ASC-US, LSIL, or HSIL: Proceed to colposcopy. 1

Rationale for Conservative Management

The high regression rate in young women justifies observation rather than immediate colposcopy. Research demonstrates that approximately 73% of ASC-US cases in young women regress to normal without intervention. 2 Although 24.3% of women with ASC-US may develop SIL over time, the risk of progression to cancer remains negligible in this age group, and aggressive intervention causes more harm (through overtreatment and psychological distress) than benefit. 1, 3

Immediate colposcopy—which is standard for women ≥21 years with ASC-US—is deliberately avoided in younger patients to prevent unnecessary procedures and potential cervical trauma that could affect future pregnancies. 1

Critical Pitfalls to Avoid

• Never order HPV testing in women under 21 years—this is explicitly contraindicated by multiple guidelines because the test lacks clinical utility in this population. 1
• Do not proceed directly to colposcopy unless repeat cytology shows ASC-H, HSIL, or persistent abnormality after the full 3-year observation period. 1
• Do not treat asymptomatic Candida before repeat cytology—underlying infection should be treated "if indicated" (meaning if symptomatic), but treatment is not required before obtaining subsequent cytology. 1
• Ensure the patient understands the importance of follow-up—approximately 29-33% of patients are lost to follow-up in real-world practice, which represents the primary failure mode of this conservative strategy. 4, 3 Emphasize that the 12-month repeat Pap is mandatory, not optional.

Documentation and Patient Education

• Document that HPV testing was deliberately not performed due to age-based guidelines. 1
• Counsel the patient that ASC-US in young women usually resolves without treatment and that observation is safer than immediate intervention. 1
• Provide written instructions for the 12-month follow-up appointment and ensure the patient has a reliable method of contact for appointment reminders. 4
• If Candida is symptomatic, treat with standard antifungal therapy (e.g., fluconazole 150 mg single dose or topical azole), but document that this does not change cervical cytology management. 1