When cytology results are more severe than ASC-US
If results are ASC-H, AGC, LSIL, or HSIL, manage with colposcopy regardless of HPV results.
Negative cytology and positive for high-risk HPV
This scenario is more difficult for both the physician and patient. High-risk HPV is a clear risk factor for subsequent dysplasia.21 While most HPV infections are transient, the risk of dysplasia increases when they persist.24 A reasonable course is to repeat both Pap and HPV in 6 to 12 months. This allows time for transient HPV infections to clear and for persistent infections to be identified on the repeat test.
The ultimate prognosis and management are determined by the repeat cytology plus HPV. If both repeat tests are negative, further repeat screening should be delayed for 3 years.
If the cytology is ASC-US, but HPV is negative, the patient may safely be screened again in 1 year with Pap plus HPV. Colposcopy is indicated if the cytology is worse than ASC-US and/or if the HPV remains positive.
Counseling HPV-positive patients
Perhaps the most difficult aspect of screening with cytology plus HPV DNA is what to advise patients whose Pap test is normal but whose HPV is positive.
Many women are aware that HPV is sexually transmitted, and a positive HPV test conjures fears of spousal infidelity, concerns about spreading the infection, and fear of other sexually transmitted infections.
Long latency. I have found it useful to defuse the infidelity concern by pointing to the long latent period associated with HPV infections. A recently diagnosed HPV infection may have been acquired years in the past from a prior partner, or from her current partner early in their relationship.
Neither partner should construe a positive test for high-risk HPV as an indicator of promiscuity. It is just as likely that a temporary change in her immune status allowed a previously latent infection to become productive.
Highly prevalent. The patient may be reassured by knowing that HPV is exceedingly common; up to 75% of women will have one or more subtypes of HPV in their lower genital tract at some time in their lives. Pointing out that it can be considered a marker of ever having had vaginal intercourse may help to eliminate the stigma of a sexually transmitted disease.
Let her know her partner probably carries the same HPV type, or has cleared it in the past.
Low risk of cancer for the partner. Male partners of women who test positive for high-risk HPV DNA do not require any testing. Reassure the couple that the male’s risk of cancer is very low since the penis lacks a transformation zone, the substrate for efficient neoplastic transformation.
Reassure her of low risk without neoplastic changes. The presence of HPV on the cervix is of little clinical importance unless the cervical epithelium has begun to undergo neoplastic changes. Reassure the patient that as long as she has no squamous intraepithelial lesions on Pap testing or a persistently positive HPV DNA test over time, she has a low risk developing cancer.
What’s the harm in yearly testing?
Will our patients skip annual gynecologic exams if we tell them they no longer need an annual Pap test? If Paps are performed only every 3 years, will many women wait 4 or 5 years between screenings?
These and other concerns make it difficult to change an ingrained routine, despite data that support new practice guidelines.
Besides, the Pap test is inexpensive, so what’s the harm in doing it annually? While the Pap test itself remains relatively inexpensive, the wide popularity of the liquid-based Pap test has doubled or tripled the cost of the test in many markets. And annual testing in low-risk women has a high rate of false positives, which require costly follow-up testing.13
Though future studies must determine the optimal interval for gynecologic examinations in asymptomatic women, periodic examinations are certainly important—even if a Pap test is not done each year. As primary-care providers, gynecologists offer periodic screenings for conditions such as diabetes, cardiac disease, and colon cancer, in addition to gynecologic evaluations. And it makes good sense to encourage frequent periodic exams for patients at risk, such as young women in need of contraceptive counseling or evaluation for sexually transmitted disease, and older women in need of breast surveillance.
But if we provide periodic screening without the “Pap-smear prompt,” we’ll need to redouble our efforts to teach patients the value of the annual exam for other health assessments, not cervical cytology screening alone.
The authors report no relevant financial relationships.