Two definitions need to be explained here. “lesser abnormalities” (lesser abnormalities), HPV16 or HPV18(+), persistent untyped HPV infection, cytologically reported ASC-US, LSIL. “young women Young women” (young women), women who present for consultation on the pros and cons of treating abnormal findings for subsequent pregnancy or continuing with conservative observation, with no specific age limit. Special populations refer to pregnant women and young women. The guidelines include “recommended”, “acceptable”, “not recommended” and “unacceptable”. ” and “unacceptable” are self-explanatory. The “return HPV test” (reflex HPV test) is a test that uses residual cytosolic fluid base, or HPV specimens that were retained at the same time as the last cytology, in a move to save money and reduce the economic burden.
Based on the level of evidence, the ACOG makes the following recommendations.
Level A Evidence (good and consistent evidence)
Cytology ASC-US with return HPV testing.
For ASC-US with HPV(+), colposcopy should be performed.
Cytology suggestive of LSIL, regardless of HPV result, perform colposcopy.
Except in pregnant women and young women, adequate colposcopy to diagnose CIN2, CIN3, or CIN2,3 with excision and ablation is the appropriate option.
Level B evidence (limited and inconsistent evidence)
For women ≥30 years of age, if HPV(+) and cytology(-) at the time of concurrent testing, re-testing at the same time in one year is acceptable. For ASC-US with HPV(-) (either concurrent HPV or return HPV), it is recommended that both tests be repeated after 3 years.
For ASC-US with HPV(+), concurrent testing for both tests is recommended after 12 months if colposcopy fails to detect CIN. If both tests are (-) at the same time, it is recommended to return to the screening protocol according to age within 3 years.
For women 21-24 years of age, it is best to repeat cytology after 12 months if cytology suggests ASC-US, but return HPV testing is also acceptable.
ASC-US for HPV(-) should be considered abnormal in women ≥65 years of age when they are ready to stop screening.
For women with cytology suggestive of LSIL between the ages of 21-24 years, follow-up cytology at 12 months is recommended and colposcopy is not recommended.
For pregnant women with LSIL, colposcopy is preferable.
Colposcopy is recommended for women with ASC-H, regardless of HPV results. Return HPV testing is not recommended.
Except for special populations, immediate LEEP or colposcopy is acceptable for cytology with HSIL results.
Except in pregnant women, diagnostic excision is recommended if cytology HSIL and colposcopy are inadequate.
Colposcopy is recommended for women between 21 and 24 years of age with ASC-H or HSIL. Immediate treatment (immediate investigation and treatment) is not acceptable.
Colposcopy and endothelial biopsy are recommended for all subcategories of AGC and AIS, except for atypical endothelial cells, regardless of HPV results. Endometrial biopsy and colposcopy are recommended simultaneously, and endocervical canal biopsy is recommended for all subcategories of AGC and AIS at ≥35 years of age. Endometrial biopsy is recommended for all women ≥35 years of age with clinical indications, as these women are at risk for endometrial carcinoma.
No further evaluation is recommended for asymptomatic premenopausal women with cytologically benign endometrial cells, benign endometrial mesenchymal cells, or histiocytes. For postmenopausal women with benign endothelial cell cytology results, the endothelium should be evaluated regardless of the presence or absence of symptoms.
For women ≥25 years of age with CIN1 or colposcopy for “unlikely abnormal” cytologic findings that do not reveal a lesion, reexamination in 1 year is recommended. If both HPV and cytology are (-), retesting is recommended after 3 years based on age. If either test is abnormal, a vaginal examination is recommended. If CIN persists for at least 2 years, continued follow-up or treatment is acceptable.
In cases where CIN1 is found on endocervical canal biopsy after an unlikely abnormal result, but CIN2+ is not found on direct colposcopic biopsy, management should follow ASCCP guidelines regarding CIN1 and repeat endocervical canal biopsy within 12 months.
For women between 21-24 years of age with prior cytologic findings of ASC-US or LSIL and histologically confirmed CIN1, repeat cytology in 12 months is recommended. Follow-up HPV testing is not acceptable.
Treatment is not recommended for women between 21-24 years of age with CIN1 regardless of prior cytologic findings.
Treatment of pregnant women with CIN1 is unacceptable.
Total hysterectomy at the first diagnosis of CIN2, CIN3 or CIN2,3 is unacceptable.
For women treated for CIN2, CIN3 or CIN2,3, concurrent testing is recommended after 12 months and after 24 months. If all concurrent tests are (-), retesting after 3 years is recommended. If either test is abnormal, colposcopy in combination with endovascular biopsy is recommended. If all tests are (-), continued routine screening for 20 years is recommended (continued screening is recommended even if over 65 years of age).
Level C evidence (conference or expert opinion)
For unsatisfactory cytology, where HPV testing is absent, unknown, or negative, repeat cytology is recommended in 2-4 months.
For women between 21-29 years of age, cytology (-) but no or inadequate component of the migratory zone in the cervical canal, routine screening is recommended. For women ≥30 years of age with cytology (-), no or inadequate component of the migrating band in the cervical canal, and no or unknown results for HPV, HPV testing is preferred.
For postmenopausal women with postmenopausal LSIL but no HPV screening, acceptable options include: HPV screening; repeat cytology at 6 and 12 months; and colposcopy.
In women aged 21-24 years with cytology for HSIL, a combination of colposcopy and cytology (every 6 months) is recommended for observation up to 24 months if histology fails to detect a CIN2+ lesion, provided there is assurance that colposcopy is adequate and that the cervical canal assessment is negative or CIN1.
If histology fails to detect a CIN2+ lesion, diagnostic excision is recommended, or observation at 12 and 24 months with a combined examination (provided that colposcopy is assured to be adequate and that the cervical canal assessment is negative). In this case, a review of cytological, histological and colposcopic findings is acceptable.
In women between 21 and 24 years of age with cytologic findings of ASC-H or HSIL followed by histologic confirmation of CIN1 or no lesions, a regimen of combined colposcopy and cytology (every 6 months) is recommended for observation up to 24 months, provided that assurance is given that colposcopy is adequate and that the results of cervical canal evaluation are negative.
If the presence of CIN2, CIN3 or CIN2,3 in the margins of the diagnostic resected specimen or in the endocervical canal specimen is detected immediately after operative treatment, a re-evaluation using cytology and endocervical canal biopsy is advisable at 4-6 months after treatment.
Either treatment or a combination of colposcopy and cytology (every 6 months) is acceptable in young women with a histologic diagnosis of CIN2,3 but no other specific findings, provided that the cytology is adequate. If a young woman is histologically diagnosed with CIN2, observation is preferable, but treatment is also acceptable. Total hysterectomy is preferable in women who have completed their reproductive requirements and in women with AIS found in the diagnostic resection specimen.