What is the appropriate management for a 61‑year‑old woman with a Pap smear showing low‑grade squamous intraepithelial lesion (LSIL) and a negative high‑risk human papillomavirus (HPV) test?

Management of 61-Year-Old Woman with LSIL and Negative HPV

For a 61-year-old postmenopausal woman with LSIL cytology and a negative high-risk HPV test, the recommended management is repeat cytology at 12 months OR HPV DNA testing at 12 months, with colposcopy reserved only if repeat testing shows ASC-US or greater (for cytology) or becomes HPV-positive. 1

Why Conservative Management is Appropriate

The combination of LSIL with negative HPV testing in a postmenopausal woman represents a very low-risk scenario for high-grade disease:

• Research specifically examining postmenopausal women with LSIL and negative HPV found zero cases of CIN 2 or higher among 54 women who underwent immediate colposcopy, with 61% showing only CIN 1 and 39% showing no dysplasia at all 2
• The negative predictive value of HPV testing for excluding high-grade lesions in LSIL patients approaches 99.6% 3
• This risk profile justifies avoiding immediate colposcopy and its associated costs, discomfort, and potential complications 2

Specific Follow-Up Algorithm

At 12-month follow-up, you have two acceptable options 1:

1. Repeat cytology alone: If ASC-US or greater is found, refer to colposcopy 1
2. HPV DNA testing: If positive, refer to colposcopy; if negative, return to routine age-appropriate screening 1

If two consecutive cytology tests are negative for intraepithelial lesion or malignancy, the patient can return to routine screening intervals 4

Important Distinctions from Younger Women

This management differs significantly from younger age groups 1, 5:

• Women under 25 years: Repeat cytology at 12 months only, with colposcopy reserved for HSIL or greater (not for persistent LSIL or ASC-US) 5
• Women 25-29 years: Similar to your patient—either repeat cytology at 6 and 12 months OR HPV testing at 12 months 1
• Women 30-65 years with LSIL and unknown HPV status: Immediate colposcopy is recommended because LSIL in this age group without HPV testing carries higher risk 6

The key difference here is that your patient already has a negative HPV test, which substantially lowers her risk and makes conservative management appropriate 2

Critical Pitfalls to Avoid

• Do not perform immediate colposcopy simply because the patient is over 30 years old—the negative HPV test changes the risk stratification and makes this unnecessary 2
• Ensure proper follow-up systems are in place, as loss to follow-up is a major concern in cervical cancer screening; develop protocols to identify patients who miss their 12-month appointment 1, 5
• Document the plan clearly and ensure the patient understands the importance of returning for follow-up testing, as approximately 29% of patients with abnormal cytology are lost to follow-up in real-world practice 7
• Do not confuse cytologic LSIL with histologic CIN I—they are not equivalent, and management decisions should be based on cytology results at this stage 6

Why HPV Testing Matters in LSIL

While routine HPV testing is not recommended for initial LSIL triage in younger women (because over 80% of LSIL patients are HPV-positive, making it non-discriminatory) 5, when HPV testing has already been performed and is negative, this information is highly valuable for risk stratification 2. The negative HPV result in your postmenopausal patient provides strong reassurance that high-grade disease is unlikely 2.