(Published January 2009)

HPV Screening and Management in Adolescents

HPV Infection in Adolescents

Guidelines for cervical cancer screening and management of abnormal results differ based on age.
Adolescents have a much lower incidence of cervical cancer and higher incidence of HPV infection than older females.^1,2
One study of adolescents 14–17 years old found that 80% of participants had high-risk HPV at some point during the two-year study period.³ Of the eleven adolescents (out of 60) who did not test positive for HPV during the study, three denied any sexual exposure.

Cervical Cancer Screening

Cervical cancer screening should begin three years after initial sexual intercourse or by age 21, whichever occurs first.^4-6
The upper age limit of 21 encourages screening for young women who may be unwilling to disclose sexual activity or abuse. Although the prevalence of ASC-US and LSIL are quite high in adolescents because of the high prevalence of HPV, cervical cancer is rare.^2,7
Use of the HPV DNA test to triage these results in adolescents would refer many to colposcopy despite the low risk of cervical cancer.
Most high-risk HPV infections and associated abnormal cellular changes will resolve in a short time.
Delaying the onset of screening until three years after initiation of sexual intercourse allows time for the clearance of these cellular changes, reducing unnecessary diagnostic procedures and treatment.
2006 Consensus Guidelines recommend one-year follow-up for adolescents (ages 20 and under) who have ASC-US.⁸ If a woman with ASC-US inadvertently receives an HPV test for triage and the test result is positive, it should not alter the recommendations for management of the abnormal Pap test result.⁹

Combined HPV and Cytology Testing

Combined HPV and cytology testing for primary screening is NOT recommended in adolescents.
The ideal age to start screening with combined HPV testing and cytology is at 30 years of age.¹⁰
The rationale for this recommendation is based on several factors:
- HPV infections are very common in young women and frequently result in abnormal Pap results.
- There is a high prevalence of HPV infection in younger women, which drops considerably as women age. At the same time, the incidence of cervical cancer increases with age and is relatively rare in younger age groups.
- As the prevalence of HPV declines with age, the incidence of CIN-3 and cancer increases.
- The evaluation of minor cytological abnormalities in young women is expensive, causes considerable anxiety, and can result in unnecessary exams and tests for follow-up.

Management of Abnormal Cytology Results in Adolescents

All adolescents who have ASC-US, LSIL, or CIN-1 should have repeat cytology in 12 months regardless of HPV status.⁸
All adolescents who have HSIL should undergo colposcopy.⁸

For a list of resources that provide detailed management guidelines, see Appendix B.

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.
HPV tests detect the virus that causes cell changes and cancer of the cervix.
Testing for HPV infection in adolescents would frequently show positive results, but most of these infections go away on their own.
Pap tests are used to detect cell changes and precancer that are caused by HPV.
Pap tests are used starting three years after the first episode of intercourse or by age 21.
A sexually active adolescent needs cervical cancer screening with the Pap test, even if she has received the HPV vaccine.

References

SEER Cancer Statistics Review 1975-2003.
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.
Brown DR. A longitudinal study of genital human papillomavirus infection in a cohort of closely followed adolescent women. J Infect Dis. 2005;191:182-92.
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.
U.S. Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Pub No. 03-515A.
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.
Wright JD, Rader JS, Davila R, Powell MA, Mutch DG, Gao F, et al. Human papillomavirus triage for young women with atypical squamous cells of undetermined significance. Obstet Gynecol. 2006;107(4):822-9.
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.
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.
ACOG Committee on Gynecologic Practice. ACOG Committee Opinion No. 356: Routine cancer screening. Obstet Gynecol. 2006;108(6):1611-3.