Management of 21-Year-Old Woman with ASCUS, HPV-Negative, and Candida on Pap Smear
For this 21-year-old woman with ASCUS and negative HPV testing, return to routine annual cytology screening is recommended; the candida finding should be treated only if she is symptomatic. 1
Cervical Management: ASCUS with Negative HPV
Primary Recommendation for Young Women
Women aged 21-24 years with HPV-negative ASCUS have extremely low risk of high-grade cervical disease (1.4% risk of CIN3+) and should return to routine screening intervals rather than accelerated surveillance. 2 This represents a risk comparable to women with completely normal cytology. 3
The 2006 ASCCP consensus guidelines specifically state that for women over age 20 with HPV-negative ASCUS, repeat cytologic testing at 12 months is the recommended follow-up strategy. 1 However, given her young age (21 years), annual screening aligns with standard screening intervals for this age group.
Colposcopy is not indicated for HPV-negative ASCUS, as the negative predictive value approaches 99.7-100% for subsequent detection of CIN3 or worse over the next 2 years. 2
Why HPV-Negative Status Changes Management
The combination of ASCUS with negative HPV testing reduces the risk of underlying CIN2+ to approximately 1.4%, compared to 15.2% risk when HPV is positive. 2 This 10-fold difference in risk justifies conservative management.
Only 22 of 1,559 (1.4%) HPV-negative ASCUS women developed CIN3+ during 2-year follow-up in the landmark ASCUS-LSIL Triage Study, with only 7 cases diagnosed between 12-24 months. 2
Age-Specific Considerations
At age 21, this patient is at the lower boundary of the screening age range where HPV infections are extremely common but typically transient, with the vast majority clearing spontaneously within 2 years. 1
The prevalence of high-risk HPV infection in women with ASCUS decreases dramatically with age: 74% in women <30 years versus only 19% in women ≥50 years. 4 Her negative HPV status at age 21 is particularly reassuring.
Management of Incidental Candida Finding
Treatment Indications
Candida identified on Pap smear is a colonization finding and requires treatment only if the patient has symptoms of vulvovaginal candidiasis (itching, burning, abnormal discharge, dyspareunia). 5
If symptomatic, a single 150 mg oral dose of fluconazole is the recommended first-line treatment for uncomplicated vulvovaginal candidiasis. 6 This FDA-approved regimen achieved 55% therapeutic cure rates (clinical resolution plus mycologic eradication) in controlled trials. 6
Alternatively, topical azole therapy for 1-7 days (such as clotrimazole or miconazole intravaginally) is equally effective for acute uncomplicated vulvovaginal candidiasis. 5
If Asymptomatic
- Asymptomatic candida colonization does not require antifungal treatment, as treatment of colonization does not prevent future symptomatic episodes and may promote resistance. 5, 7
Common Pitfalls to Avoid
Do not perform repeat HPV testing before 12 months, as guidelines explicitly state that HPV testing should not be performed at intervals less than 12 months. 1, 8
Do not refer to colposcopy based solely on the ASCUS finding when HPV is negative—this represents overtreatment and exposes the patient to unnecessary procedures. 1, 2
Do not treat candida empirically without assessing for symptoms, as this does not improve outcomes and may lead to unnecessary medication exposure. 5
Do not use the candida finding as justification for more aggressive cervical surveillance—the two findings are completely unrelated, and vaginal flora does not influence cervical cancer risk. 3
Practical Next Steps
Schedule routine annual Pap smear in 12 months (at age 22). 1
Ask specifically about vulvovaginal symptoms (itching, burning, discharge, dyspareunia). 5
If symptomatic for candidiasis, prescribe fluconazole 150 mg PO as a single dose or topical azole therapy. 6
If asymptomatic, provide reassurance that candida colonization is normal and does not require treatment. 5
Educate the patient that her HPV-negative ASCUS result carries very low risk and that she can return to routine screening. 2