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Managing HPV: A New Era in Patient Care

(Published June 2009)

HPV and the Adolescent

Guidelines for cervical cancer screening and management of abnormal results in adolescents differ in important ways from those recommended for nonadolescent women. These differences reflect the relatively low incidence of cervical cancer and the high incidence of human papillomavirus (HPV) infection in adolescents, compared with older females.1,2

Cervical Cancer Screening

National guidelines from ACOG, USPSTF, and ACS all recommend that cervical cancer screening begin three years after initial vaginal intercourse or by age 21, whichever occurs first.3-5

Management of Atypical Squamous Cells of Undetermined Significance

The prevalence of HPV infection is higher in adolescents than in older females. If HPV testing were used to manage ASCUS in adolescents, the practice would result in colposcopy referral for many women at low risk for cervical cancer.6 The ASCCP guidelines specifically state that HPV testing should not be used in management of ASCUS in adolescents. In fact, if the testing is performed for some reason, the results should not affect management. The guidelines recommend initial observation regardless of HPV status, with repeat cytology in 12 months.6

Subsequent management is dependent on the results of Pap testing:

  • If the Pap test result at 12 months shows HSIL, the patient should be referred for colposcopy.
  • If the Pap test result at 12 months shows any other result, the test should be repeated in 12 months. If the repeat Pap test result (at 24 months) shows ASC or greater, the patient should be referred for colposcopy. If the result is negative, she can return to routine screening.

Management of Low-Grade Squamous Intraepithelial Lesion

LSIL lesions will regress in more than 90 percent of adolescents and young women over the course of 36 months.7 For this reason, ASCCP guidelines recommend initial observation regardless of HPV status, with repeat cytology in 12 months.6 Subsequent management is identical to that for ASCUS, as outlined above.

  • If the Pap test result at 12 months shows HSIL, the patient should be referred for colposcopy.
  • If the Pap test result at 12 months shows any other result, the test should be repeated in 12 months. If the repeat Pap test result (at 24 months) shows ASC or greater, the patient should be referred for colposcopy. If the result is negative, she can return to routine screening.

Management of High-Grade Squamous Intraepithelial Lesion

In contrast with recommendations for older females, immediate loop electrosurgical excision (“see and treat”) is not an acceptable management option for HSIL in adolescents. Instead, ASCCP guidelines recommend colposcopy for all adolescents with HSIL.6

Subsequent follow-up depends on biopsy results:6 If the colposcopy is unsatisfactory or endocervical curettage is positive, an excisional procedure is recommended.

  • If the colposcopy is satisfactory and the biopsy shows no CIN-2,3, patients should have Pap testing and colposcopy every six months for up to 24 months. If both Pap test results are negative and the colposcopy is normal, she may return to routine screening.

Management of Cervical Intraepithelial Neoplasia Grade 1

ASCCP guidelines recommend initial observation regardless of HPV status, with repeat cytology in 12 months.8 Subsequent management is identical to that for ASCUS, as outlined above.

Counseling Points

When counseling an adolescent patient about cervical cancer screening, make sure she understands these points before she leaves your office or clinic:

  • HPV infection is very common among sexually active adolescents.
  • Testing for HPV infection in adolescents would show positive results so frequently that it would not be helpful in determining whether cervical cell abnormalities are present.
  • For this reason, other types of tests, such as the Pap test, are used to check for the effects of HPV infection.

Management of Cervical Intraepithelial Neoplasia Grade 2 or 3

National guidelines recommend two management options for CIN-2,3 in adolescents: treatment or observation with colposcopy and cytology every six months for up to 24 months.8 If CIN-2 is specified, the guidelines suggest that observation is preferred, but treatment is acceptable. If CIN-3 is specified, treatment is recommended. Treatment also is recommended when colposcopy is deemed unsatisfactory.

References:

  1. SEER Cancer Statistics Review 1975-2003. 
  2. Sherman ME, Schiffman M, Cox JT. Effects of age and human papilloma viral load on colposcopy triage: data from the randomized Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS). J Natl Cancer Inst. 2002;94:102-7.
  3. Saslow D, Runowicz CD, Solomon D, Moscicki AB, Smith RA, Eyre HJ, et al. American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin. 2002;52;342-62.
  4. U.S. Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality. Publ. No. 03-515A. 2003.
  5. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists. Number 45, August 2003. Cervical cytology screening (replaces committee opinion 152, March 1995). Obstet Gynecol. 2003;102(2):417-27.
  6. Wright TC, Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests. Am J Obstet Gynecol. 2007;197(4):346-55.
  7. Moscicki AB, Shiboski S, Hills NK, Powell KJ, Jay N, Hanson EN, et al. Regression of low-grade squamous intra-epithelial lesions in young women. Lancet. 2004;364(9446):1678-83.
  8. Wright TC, Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. 2006 Consensus Guidelines for the Management of Women with Cervical Intraepithelial Neoplasia or Adenocarcinoma in situ. Am J Obstet Gynecol. 2007;197(4):340-5.