Abnormal Pap Test

Treatment Overview

Even though most abnormal Pap tests are caused by an HPV infection that will go away or an inflammation that can be treated, you will need a follow-up evaluation to make sure your abnormal cell changes have resolved. Your need for treatment will vary depending on whether your abnormal cell changes are mild, moderate, or severe. Abnormal Pap test results may show minor cell changes (most common), moderate to severe cell changes (less common), or cervical cancer (rare). Depending upon the cause and severity of the cervical cell changes, treatment may be necessary.

Human papillomavirus (HPV) infection is the most common cause of an abnormal Pap test. There are many types of HPV. High-risk types can cause cell changes that could develop into cancer.

Evaluation of minor cell changes (ASC-US and LSIL)

An abnormal Pap test result is not uncommon because HPV infection is very common. Most cell changes seen in abnormal Pap test results will not progress to cervical cancer. If your abnormal Pap test shows minor cell changes, you may have several choices of what to do next.

If your Pap test shows that a vaginal infection or a treatable sexually transmitted disease (STD) is present, you can be treated with medicine.

Evaluation of ASC-US.If you have had a Pap test only and your test results show atypical squamous cells of undetermined significance (ASC-US), you can:

• Choose watchful waiting, which includes repeat Pap tests every 4 to 6 months. Watchful waiting will not be harmful if the abnormal tissue is not visible on the cervix or a type that is not likely to progress to cancer and you do not have an impaired immune system. Regular use of condoms during this time will increase the chance that abnormal cells will go away on their own.²
• Have a test for high-risk human papillomavirus (HPV) types. The natural course of most types of HPV is to resolve on their own within 18 months. HPV in women younger than 30 usually goes away on its own. HPV in women older than 30 is more likely to persist. Minor cell changes not related to high-risk HPV may not be significant and often go away. Even if you have a high-risk HPV type, more severe cell changes may never develop because high-risk HPV infections can also go away on their own. But if testing shows a high-risk HPV, your doctor will probably recommend a colposcopy and possibly cervical biopsy to look at the abnormal cells. If you do not test positive for a high-risk HPV, you can return to a normal screening schedule.⁷
• Have a colposcopy so your doctor can look at the abnormal cells. A cervical biopsy may be done at the same time to confirm the colposcopy findings. Women with HIV infection will most likely be evaluated with colposcopy and then treated for any abnormal cervical cells.

Women over 30 can have a Pap test and an HPV test at the same time. If you have had a Pap test and an HPV test as part of your regular exam, you will have two results to consider. The following are recommendations for these test results.

• Normal Pap and negative for high-risk HPV: Return to routine Pap test screening schedule every 3 years.
• Normal Pap and positive for high-risk HPV: Repeat Pap and HPV in 6 to 12 months. If both repeat tests are normal, return to routine Pap screening schedule. If either of the repeat tests is abnormal, colposcopy is recommended.
• Pap result of atypical squamous cells of undetermined significance (ASC-US) and negative for high-risk HPV: Repeat Pap test in 12 months.
• Pap result of ASC-US or more severe changes and positive for high-risk HPV: Have a colposcopy.

HPV testing or colposcopy may be included in a watchful waiting period of time because they are diagnostic tests, not treatments. Watchful waiting is usually recommended only for women who will follow through with repeat Pap tests every 4 to 6 months.

Evaluation of LSIL.If the results of your Pap test show the minor cell changes called low-grade squamous intraepithelial lesions (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.

Adolescent girls with a Pap test that shows ASC-US or LSIL will usually have a repeat Pap test at 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.⁸

It is very unlikely that minor cervical cell changes would progress to cancer in a short period of watchful waiting. Atypical squamous cells of undetermined significance (ASC-US) cell changes usually remain the same or return to normal after the first abnormal result. Low-grade squamous intraepithelial lesions (LSIL) cell changes may be more likely to progress to more severe cell changes over time, but most LSIL cell changes return to normal or are not identified as more severe cell changes.¹

Minor changes found by a repeat Pap test and confirmed by colposcopy or biopsy can remain under observation (watchful waiting) or be treated to destroy or remove the abnormal tissue.

For more information, see:

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

Treatment for moderate to severe cell changes (HSIL)

Treatment decisions for an abnormal Pap test that shows moderate to severe cell changes are based on the Pap test results, colposcopy, and cervical biopsy. A larger tissue sample may be removed by a cone biopsy. In some cases, this procedure may serve as treatment so you are cured. Follow-up to evaluate and treat moderate to severe cervical cell changes is recommended sooner than for minor cell changes. If not treated, about 40% of women with untreated high-grade squamous intraepithelial lesions (HSIL) will progress to invasive cancer over a period of 10 years.⁹

• For moderate or severe precancerous cell changes confirmed by biopsy, treatment will focus on destroying or removing the abnormal tissue. Treatment choices include LEEP, a surgery that uses a thin wire loop to remove the abnormal tissue; cryotherapy, which destroys tissue by freezing it; laser therapy, which destroys tissue with a laser beam; or cone biopsy (conization), in which a cone-shaped piece of abnormal tissue is removed from the cervix.
• For cervical cancer, treatment will focus on destroying or removing the cancerous tissue. Treatment choices include a hysterectomy, radiation therapy, chemotherapy, or a combination of these therapies.

Treatment for an abnormal Pap during pregnancy

A Pap test may be done during pregnancy if a woman is due for her regular screening test. A pregnant woman with an abnormal Pap test is monitored closely throughout her pregnancy. Monitoring may include evaluation by colposcopy. The goal of evaluation is to rule out cervical cancer, a rare diagnosis. Treatment for abnormalities other than cancer is done after delivery.

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Author:	Sandy Jocoy, RN	Last Updated: January 5, 2009
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Kevin Holcomb, MD - Gynecologic Oncology
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