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decision pointWhat follow-up will I need if my Pap test shows minor cell changes?

You may be anxious if you have an abnormal Pap test because the thought of cervical cell changes progressing to cancer is very frightening.

This information focuses on your choices of what to do for an abnormal Pap result classified as atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL). If you have other types of abnormal cell changes, your doctor will talk to you about your choices for further testing or treatment.

For ASC-US changes, you have several choices.

  • Watchful waiting with follow-up Pap tests every 4 to 6 months may be an appropriate choice for you. Minor cervical cell changes may never progress and may go away on their own. It is unlikely that minor cell changes would progress to cancer in a short period of watchful waiting. If minor cell changes persist or more severe changes develop in the 4- to 6-month watchful-waiting period, then further testing or treatment can be done right away.
  • You may want to have a human papillomavirus (HPV) test. High-risk types of HPV increase your risk of more severe cell changes. About 50% of women with ASC changes will test positive for high-risk types of HPV.1 For these women, colposcopy will be recommended.
  • If you want a diagnosis right away, you may want more evaluation of the minor cell changes. You may have a procedure called a colposcopy. A cervical biopsy may also be done at the time of colposcopy.

Minor cervical cell changes known as LSIL are nearly always positive for the high-risk types of HPV, so testing for HPV is not helpful. If you have cervical cell changes classified as LSIL, colposcopy is often recommended.

What are minor cervical cell changes?

Minor cervical cell changes classified on a Pap test as atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) are cell changes that have not progressed to more severe abnormalities. They are usually caused by inflammation or infection.

What causes cervical cell changes?

Most cervical cell changes are caused by human papillomavirus (HPV). Other types of infection-such as those caused by bacteria, fungi (yeast), or protozoa (Trichomonas)-may cause ASC-US. Natural cervical cell changes (atrophic vaginitis) related to menopause can also cause an abnormal Pap test.

Smoking has been identified as a factor that may increase your risk of developing abnormal cervical cell changes and cervical cancer.

What are the risks of not monitoring minor cervical cell changes?

Some minor cervical cell changes could, over a long period of time, progress to severe cell changes or cervical cancer, which would require more medical treatment. Follow-up testing to monitor minor cervical cell changes will show whether abnormal cells persist or are progressing to severe cell changes, and appropriate treatment can be done.

What are my follow-up options?

Even though most abnormal Pap tests are caused by HPV infection, which usually goes away on its own, you will need follow-up evaluation to make sure your minor cell changes have resolved.

Your choices for what to do next for ASC-US changes are:

  • Watchful waiting with follow-up Pap tests every 4 to 6 months. Women with ASC-US changes are not likely to develop cervical cancer. More than half of all minor cervical cell changes become normal on their own. Watchful waiting is usually recommended if you can follow through with repeat Pap tests.
  • HPV test to identify high-risk (positive) HPV types. Even if you have a high-risk HPV type, it may never develop more severe cell changes. High-risk HPV infections can also go away on their own. If your test is positive for high-risk HPV, your doctor most likely will recommend colposcopy for further evaluation. If the test is negative, you can go back to a regular Pap test schedule.2
  • Colposcopy. You may want more evaluation of the minor cell changes right away if you:
    • Are not able to return for follow-up.
    • Have several risk factors.
    • Are not comfortable with watchful waiting.

If the results of your Pap test show LSIL:

  • Your doctor may recommend a colposcopy to evaluate the cell changes.
  • Some women, especially those who have already gone through menopause, may be treated for atrophy with estrogen cream and then have a repeat Pap test. Colposcopy is needed only if the repeat test shows cell changes.
  • Watchful waiting may be recommended if you are an adolescent girl. Adolescent girls who have a Pap test that shows ASC-US or LSIL will usually have a repeat Pap test in 6 to 12 months. This is because girls this age are extremely unlikely to develop cervical cancer, and HPV is likely to go away on its own. But if either of the follow-up tests are abnormal, colposcopy is usually the next recommended test.3

What are the side effects or risks of these choices?

If you choose watchful waiting, you will need follow-up Pap tests every 4 to 6 months. It is unlikely, but more severe cervical cell changes could develop during the watchful waiting period. You may worry during the watchful waiting time and may prefer the certainty of having the cell changes evaluated by colposcopy and possibly a cervical biopsy. Or you may be comfortable waiting and prefer to avoid a biopsy procedure.

A colposcopy exam can be done in your doctor's office. It usually is not painful, but it may cause some mild cramping. The instrument used to spread open the sides of the vagina (speculum) is in place longer than during a routine gynecologic exam, which may cause discomfort. Your doctor will be able to tell you what the visual exam shows. The skill of your doctor in doing a colposcopy exam can affect the accuracy of the exam. A colposcopy will be recommended if abnormal Pap test results persist. A cervical biopsy may be done at the time of colposcopy.

What special circumstances affect my options?

If you have any of the following special circumstances, your choices may be different and your doctor can help you decide what is appropriate for you.

  • Menopause. A short treatment period with intravaginal estrogen therapy may be a choice if you are postmenopausal with ASC-US cell changes. A natural decrease in estrogen levels occurs after menopause and may be the cause of your abnormal cervical cell changes. A repeat Pap test after estrogen therapy would determine if treatment was successful or if further treatment is needed because ASC-US changes are still present.
  • A weakened (impaired) immune system. Colposcopy is recommended if you have ASC-US cell changes and an impaired immune system because your cell changes may be more likely to be identified as severe changes than in women with normal immune systems.
  • Pregnancy. If you are pregnant and have ASC-US cell changes, your choices for watchful waiting or further evaluation are the same as for nonpregnant women. Further treatment will be delayed until after delivery unless cervical cancer-which is very rare with minor ASC-US cell changes-is found. If cervical cancer is diagnosed, specialized care for a high-risk pregnancy will be needed.
  • Adolescence. If you are a teenager, minor cell changes are even more likely to go away without treatment. Colposcopy generally is not recommended as a first step.

Should I have HPV testing?

An HPV test can identify high-risk (positive) HPV types. Even if you have a high-risk HPV type, it may never develop more severe cell changes. High-risk HPV infections can also go away on their own.

If you choose HPV testing for ASC-US, you may require a second pelvic exam if cells for HPV testing were not collected or liquid-based cytology was not used at the time of the initial Pap test. If your test is positive for high-risk HPV, your doctor will recommend colposcopy for further evaluation.

Minor cervical cell changes known as LSIL are nearly always positive for the high-risk types of HPV, so testing for HPV is not helpful. If you have cervical cell changes classified as LSIL, colposcopy is often recommended.

If you are a teen and have had an ASC-US or LSIL Pap, your doctor will likely recommend follow-up Pap tests instead of an HPV test.

If you need more information, see the topic Abnormal Pap Test.

Even though most abnormal Pap tests are caused by an HPV infection that will go away or by an inflammation that can be treated, you will need follow-up evaluation to make sure your minor cell changes have gone away. If your cell changes are identified as LSIL, a colposcopy is usually recommended. But for ASC-US changes, you will need to decide whether or not to have a colposcopy right away. Your choices for what to do next for ASC-US changes are:

  • Try a period of watchful waiting with follow-up Pap tests every 4 to 6 months.
  • Have a test for high-risk HPV.
  • Have a colposcopy.

Deciding what to do next after an abnormal Pap test shows ASC-US takes into account your personal feelings and the medical facts. Consider the information below as you make your decision.

Deciding what to do next after an abnormal Pap test shows ASC-US
Follow-up option Reasons to choose this option Reasons not to choose this option

Watchful waiting

  • You prefer to avoid procedures if possible.
  • The abnormal tissue is not extensive enough to be visible on your cervix during an exam.
  • HPV testing shows that the abnormal cells are not a high-risk type.
  • You do not have an impaired immune system.
  • You are a teenage girl.
  • You have already gone through menopause.
  • You are likely to return within 4 to 6 months for a follow-up Pap test.
  • This is your first abnormal result.
  • The abnormal tissue on your cervix is extensive enough to be visible during an exam.
  • HPV testing shows cells of a high-risk type that might progress to cancer.
  • You have an impaired immune system.
  • You are unlikely to be able to have a follow-up Pap test in 4 to 6 months.

HPV test

  • Watchful waiting does not feel comfortable. You want information right away.
  • You are over age 30.
  • Watchful waiting feels comfortable.
  • You are a teenage girl.

Colposcopy

  • Minor cell changes show high-risk HPV types.
  • Abnormal tissue is visible on your cervix.
  • Watchful waiting does not feel comfortable. You want information right away.
  • You have an impaired immune system.
  • You have had abnormal results in the past.
  • You prefer to avoid procedures if possible.
  • HPV test is negative for high-risk HPV.
  • Watchful waiting feels comfortable.
  • You do not have an impaired immune system.
  • This is your first abnormal result.
 

Are there other reasons you might choose a certain follow-up option?

 

Are there other reasons you might not choose a certain follow-up option?

 

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about your choices of follow-up for an abnormal Pap test. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I am comfortable with watchful waiting and follow-up Pap tests at regular intervals. Yes No Unsure
I will feel more certain about what to do if I have a colposcopy exam. Yes No Unsure
I want to avoid medical procedures, such as a colposcopy. Yes No Unsure
I have risk factors for HPV and want to know if I have a high-risk type of HPV. Yes No Unsure

Use the following space to list any other important concerns you have about this decision.

 

 

 

 

 

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to choose or not choose a certain option to evaluate your minor cervical cell changes.

Check the box below that represents your overall impression about your decision.

Leaning toward (you fill in) option

 

Leaning toward (you fill in) option

         

Citations

  1. ASCUS–LSIL Triage Study (ALTS) Group (2003). Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. American Journal of Obstetrics and Gynecology, 188(6): 1383–1392.

  2. Runowicz CD (2007). Approach to the patient with an abnormal Pap smear. In DC Dale, DD Federman, eds., ACP Medicine, section 16, chap. 1. New York: WebMD.

  3. American College of Obstetricians and Gynecologists (2008). Management of abnormal cervical cytology and histology. ACOG Practice Bulletin No. 99. Obstetrics and Gynecology, 112(6): 1419–1444.

Author Sandy Jocoy, RN
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Joy Melnikow, MD, MPH - Family Medicine
Specialist Medical Reviewer Kevin Holcomb, MD - Gynecologic Oncology
Last Updated January 5, 2009

WebMD Medical Reference from Healthwise

Last Updated: January 05, 2009
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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