From the Guidelines
For a patient with ASCUS (Atypical Squamous Cells of Undetermined Significance) on Pap smear with positive HPV testing, the recommended next step is colposcopy with directed biopsies. This procedure allows for direct visualization of the cervix using a colposcope and application of acetic acid and Lugol's solution to identify abnormal areas for targeted biopsies. The colposcopy should be scheduled within 4-6 weeks of the abnormal Pap result. During the procedure, the physician will take small tissue samples from any suspicious areas for histological examination to determine if there are precancerous or cancerous changes. This recommendation is based on the increased risk of underlying high-grade cervical dysplasia or cancer when both ASCUS and HPV positivity are present, as supported by the 2021 guidelines from the MMWR Recommendations and Reports 1. The HPV positivity, particularly with high-risk strains, significantly increases the likelihood that the ASCUS finding represents a true precancerous lesion rather than benign changes.
Some key points to consider in the management of ASCUS with positive HPV include:
- The risk of underlying high-grade cervical dysplasia or cancer is increased when both ASCUS and HPV positivity are present 1.
- Colposcopy with directed biopsies is the recommended next step for managing ASCUS with positive HPV, as it allows for direct visualization and sampling of suspicious areas 1.
- Patients should be advised that the procedure may cause mild cramping and light spotting for 1-2 days afterward, but serious complications are rare.
- The 2021 guidelines from the MMWR Recommendations and Reports provide the most recent and highest quality evidence for managing ASCUS with positive HPV, superseding earlier guidelines and studies 1.
In contrast to earlier studies, such as those from 2004 1 and 2014 1, the 2021 guidelines provide more specific and updated recommendations for managing ASCUS with positive HPV, taking into account the latest evidence on HPV testing and colposcopy. Therefore, these guidelines should be followed in clinical practice to ensure the best possible outcomes for patients with ASCUS and positive HPV.
From the Research
Next Steps for ASC-US with Positive HPV
- The current American Society for Colposcopy and Cervical Pathology guidelines recommend high-risk human papillomavirus (hr-HPV) testing for patients with a low-grade squamous intraepithelial lesion on Papanicolaou (Pap) tests 2.
- For women with atypical squamous cells of undetermined significance (ASCUS) and positive HPV, colposcopy is recommended as the next step 2, 3.
- HPV genotyping for HPV16/18 can improve risk assessment for women with ASCUS Pap results and may be used to predict the risk of cervical intraepithelial neoplasm grade 2 or worse (CIN2+) 4.
- A study found that hr-HPV testing with HPV 16/18 genotyping and reflex cytology (atypical squamous cells of undetermined significance - ASCUS threshold) presented the optimal combination of sensitivity and specificity relative to cytology alone 5.
- For post-menopausal women with ASC-US and positive HPV, the use of local estrogen therapy may increase the specificity of the HPV test, and colposcopy is recommended as the next step 6.
Considerations for Colposcopy and Biopsy
- Colposcopy and biopsy are essential for diagnosing CIN2+ in women with ASCUS and positive HPV 2, 3.
- The sensitivity and specificity of colposcopy and biopsy for detecting CIN2+ vary depending on the population and the specific testing methods used 3, 5.
- HPV testing with HPV 16/18 genotyping can help identify women at higher risk of CIN2+ and guide the decision to perform colposcopy and biopsy 4, 5.