Am Fam Physician. 2006;74(8):1431-1434
New information about the natural history of cervical dysplasia and the role of human papillomavirus (HPV) in cervical cancer, as well as the development of new technologies for cervical cancer screening, prompted the American College of Obstetricians and Gynecologists (ACOG) to develop new guidelines for the management of abnormal cervical cytology and histology. Because management in some instances differs for adolescent patients, ACOG also created guidelines specific to this population. These recommendations were published in the April 2006 issue of Obstetrics & Gynecology.
Aggressive management of benign lesions in adolescents should be avoided because most cervical intraepithelial neoplasia (CIN) grades 1 and 2 lesions regress spontaneously. Surgical excision or destruction of cervical tissue in nulliparous adolescents may harm fertility and cervical competency. Destruction of normal cervical tissue should be minimized when possible, and observation may be sufficient for many adolescents. Treatment recommendations for adults and adolescents are summarized in Table 1.
Atypical squamous cells of undetermined significance (ASC-US) may indicate HPV infection. Women with ASC-US who have had liquid-based cytologic screening should be tested for high-risk HPV, and those with positive results (i.e., presence of high-risk HPV DNA) should have colposcopy. However, the risk of invasive cancer in adolescents is almost zero, and the likelihood of HPV clearance is high; most infections in adolescents resolve within two years. Therefore, as an alternative to immediate colposcopy, adolescents with ASC-US and a positive high-risk HPV test result may be monitored with cytologic screening at six and 12 months or a single high-risk HPV test at 12 months. Colposcopy should be performed if repeat test results are abnormal or if there is evidence of persistent HPV infection. Adolescents with ASC-US and a negative high-risk HPV test result should have a Papanicolaou test after 12 months.
Adolescents with ASC when high-grade squamous intraepithelial lesions (HSIL) cannot be ruled out (ASC-H) should undergo immediate colposcopy. Higher rates of CIN 2 and 3 and cervical cancer have been found in persons with ASC-H, but no studies have addressed ASC-H in adolescents.
Adolescents with low-grade squamous intraepithelial lesions (LSIL) can be monitored with cytologic screening at six and 12 months or a high-risk HPV test at 12 months as an alternative to immediate colposcopy. Those with cytologic abnormalities or persistent HPV infection at one year should undergo colposcopy.
Adult and adolescent women with HSIL should have colposcopy with endocervical assessment. The “see and treat” alternative using the loop electrosurgical excision procedure (LEEP) is not recommended in adolescents. Adolescents with HSIL and biopsy-confirmed CIN 2 may be monitored without intervention if they have adequate colposcopy and normal histology test results on endocervical assessment. Follow-up should be individualized, but cytology or colposcopy at intervals of four to six months is reasonable. Adolescents with HSIL cytology and a postcolposcopy diagnosis of CIN 1 or less with adequate colposcopy and negative results on endocervical assessment may be monitored with colposcopy and cytology at four to six months. Excision is an acceptable alternative, but it increases the risk of cervical stenosis and preterm labor.
Atypical glandular cells (AGC) in adolescents are rare. Adolescents with AGC should be referred to a subspecialist with expertise in managing cervical dysplasia and should have colposcopy and endocervical sampling. Endometrial sampling typically is not used in adolescents unless they are morbidly obese or have abnormal uterine bleeding, oligomenorrhea, or possible endometrial cancer.
|Diagnosis||Recommendation for adults||Alternative recommendation for adolescents|
|ASC-US, high-risk HPV-positive||Immediate colposcopy||Repeat Pap test in six and 12 months or high-risk HPV test alone in 12 months|
|ASC-US, high-risk HPV-negative||Repeat Pap test in 12 months||Repeat Pap test in 12 months|
|LSIL||Colposcopy||Repeat Pap test in six and 12 months or high-risk HPV test alone in 12 months|
|AGC||Colposcopy, endocervical assessment, possible endometrial evaluation||Colposcopy, endocervical assessment, possible endometrial evaluation|
|Cancer||Colposcopy with endocervical assessment||Colposcopy with endocervical assessment|
|CIN 1||Pap test at six and 12 months or high-risk HPV test at 12 months; colposcopy for any abnormality||Pap test at six and 12 months or high-risk HPV test at 12 months; colposcopy for any abnormality|
|CIN 2||Ablative or excisional therapy||Close follow-up at four- to six-month intervals (cytology or colposcopy)*|
|CIN 3||Ablative or excisional therapy||Ablative or excisional therapy|
For adolescents with CIN 1, management without therapy provides the best balance between risk and benefit. These adolescents should be monitored with cytologic testing at six and 12 months or high-risk HPV testing at 12 months. Colposcopy should be performed if cytology results are abnormal or high-risk HPV results are positive. For those who require therapy, options include cryotherapy, laser therapy, and LEEP, determined by the geometry of the lesion and the clinical recommendations of the physician. The least amount of cervical tissue necessary to eradicate the lesion should be removed.
In adolescents, CIN 2 can be managed with observation or with ablative or excisional therapy. Patients monitored without therapy should be reliable for follow-up and should understand the risks. Follow-up can be individualized; a conservative approach would be colposcopy or cytology every four to six months.
Therapy is recommended for all women with CIN 3. Cryotherapy, laser therapy, and LEEP are equally effective treatments; excision has been recommended for biopsy-confirmed CIN 3. Choice of therapy is determined by the geometry of the lesion and the clinical recommendations of the physician.
Cervical cytology in minors often is obtained during contraception counseling or confidential screening for sexually transmitted diseases (STDs), which may take place without the knowledge of the parent or guardian. Colposcopic examination is considered an STD evaluation, and parental consent is preferred but should not be required; in the absence of parental consent, consent should be obtained from the minor and noted in the medical record. Parental consent requirements for biopsy and cervical dysplasia therapy depend on whether these procedures are considered part of STD evaluation and treatment and on state law. Physicians who provide care without parental consent should be aware of their state law and local standards of care.