Management of ASCUS with Negative HPV in a 33-Year-Old Woman
Return to routine screening with co-testing in 3 years. 1
Primary Recommendation
For a 33-year-old woman with ASCUS and negative high-risk HPV testing, no immediate colposcopy or accelerated follow-up is needed; she should return to routine screening intervals. 1, 2 The combination of ASCUS cytology with a negative HPV test places her at very low risk for high-grade cervical intraepithelial neoplasia (CIN 3+), comparable to women with completely normal screening results. 2, 3, 4
Evidence-Based Rationale
The ASCCP consensus guidelines (updated 2014) specifically state that HPV-negative ASCUS results have a 5-year CIN3+ risk of only 0.48%, which is closer to the risk after a negative Pap test alone (0.31%) than after negative co-testing (0.11%). 3
Women with HPV-negative ASCUS have only a 1.4% risk of developing CIN 3 or worse during 2-year follow-up, compared to 15.2% for HPV-positive ASCUS women. 4
The negative predictive value for CIN3+ after HPV-negative ASCUS approaches 99.7-100%, making immediate colposcopy unnecessary overtreatment. 2, 4
Specific Follow-Up Protocol
Schedule repeat co-testing (Pap + HPV) in 3 years, not 5 years. 1 This is a critical update from earlier guidelines:
The 2012 ASCCP consensus initially recommended 5-year follow-up for HPV-negative ASCUS, but updated data from the Kaiser Permanente Northern California cohort showed that cancer risk remained disproportionately elevated despite low dysplasia risk. 1
The current recommendation is co-testing at 3 years rather than 5 years for HPV-negative ASCUS in women aged 30-65. 1
If co-testing is unavailable, repeat Pap testing alone in 3 years is acceptable. 1
Age-Specific Considerations
At age 33, this patient falls into the 30-65 age group where co-testing is the preferred screening strategy. 1
Co-testing every 5 years is preferred for routine screening in this age group, but the presence of a prior ASCUS result (even with negative HPV) warrants the shorter 3-year interval. 1
HPV testing is appropriate for women ≥25 years with ASCUS for triage purposes, unlike younger women where HPV prevalence is high and often transient. 1
What NOT to Do: Common Pitfalls
Do not perform repeat HPV testing before 12 months from the initial negative result, as this leads to unnecessary testing and potential false-positive results. 2
Do not refer for immediate colposcopy, as the negative predictive value of HPV-negative ASCUS is 99.7-100% for CIN3+. 2, 4
Do not use the 5-year interval that applies to completely negative co-testing; HPV-negative ASCUS requires the 3-year interval. 1
Do not perform HPV 16/18 genotyping, as it does not alter management for ASCUS results and the patient is already HPV-negative. 1
Do not allow this patient to exit screening at age 65 based solely on this HPV-negative ASCUS result; she will need 2 consecutive negative co-tests or 3 consecutive negative Pap tests before discontinuing screening. 1
Alternative Management if Co-Testing Unavailable
If HPV testing is not available for follow-up:
- Repeat Pap testing alone in 12 months is acceptable. 2
- If that repeat Pap shows ASCUS or worse, refer for colposcopy. 2
- If negative, continue routine 3-year Pap screening. 1
Documentation and Patient Education
Document that the patient had ASCUS with negative high-risk HPV testing at age 33. 2
Counsel the patient that her current risk is very low but she must return for screening in 3 years (not 5 years) due to the prior ASCUS finding. 1
Emphasize that this 3-year interval applies even though her HPV test was negative, as updated guidelines recognize a slightly elevated long-term cancer risk. 1, 3