The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The following recommendations are based on good and consistent scientific evidence (Level A):
- Women with atypical squamous cell (ASC) cytology results may undergo immediate colposcopy, triage to colposcopy by high-risk human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing, or repeat cytology screening at 6 and 12 months. Triage to colposcopy should occur after positive HPV test results or ASC or higher-grade diagnosis. Women with ASC who test negative for HPV or whose HPV status is unknown and test negative for abnormalities using colposcopy should have a repeat cytology test in 1 year.
- Most women with ASC who are HPV positive or women with ASC for which high-grade squamous intraepithelial lesion (HSIL) cannot be excluded (ASC-H), low-grade squamous intraepithelial lesion (LSIL), or HSIL test results should undergo colposcopy.
- For women with an ASC HPV-positive test result or ASC-H or LSIL cytology result and a negative initial colposcopy or a histologic result of cervical intraepithelial neoplasia grade 1 (CIN 1), optimal follow-up is repeat cervical cytology tests (not screening) at 6 and 12 months or an HPV test at 12 months; a repeat colposcopy is indicated for a cytology result of ASC or higher-grade abnormality or a positive high-risk HPV test.
- The recommendation for follow-up of untreated CIN 1 includes cytology tests at 6 and 12 months with colposcopy for an ASC or higher-grade result, or a single HPV test at 12 months, with colposcopy if the test result is positive.
The following recommendations are based on limited and inconsistent scientific evidence (Level B):
- Endocervical sampling using a brush or curette may be undertaken as part of the evaluation of ASC and LSIL cytology results and should be considered as part of the evaluation of atypical glandular cells (AGC), adenocarcinoma in situ (AIS), and HSIL cytology results.
- Endocervical sampling is recommended at the time of an unsatisfactory colposcopy or if ablative treatment is contemplated.
- Endocervical sampling is not indicated in pregnancy.
- Endometrial sampling is indicated in women with atypical endometrial cells and in all women aged 35 years or older who have AGC cytology results, as well as in women younger than 35 years with abnormal bleeding, morbid obesity, oligomenorrhea, or clinical results suggesting endometrial cancer.
- Women with HSIL cytology results and negative or unsatisfactory colposcopy results should undergo excision unless they are pregnant or adolescent.
- Women with AGC favor neoplasia or AIS cytology results and negative or unsatisfactory colposcopy results should undergo excision unless they are pregnant. A colposcopic examination negative for abnormalities after two AGC not otherwise specified (NOS) cytology results is also an indication for excision in the absence of pregnancy.
- Pregnant women with CIN 2 or CIN 3 may undergo follow-up with colposcopy during each trimester and should be reevaluated with cytology and colposcopy examinations at 6-12 weeks postpartum or thereafter. Treatment of CIN 2 and CIN 3 in pregnancy is not indicated.
- Women with CIN 2 or CIN 3 should be treated (in the absence of pregnancy) with excision or ablation. Management of CIN 2 in adolescents may be individualized.
- Women treated for CIN 2 or CIN 3 with a positive margin on excision may be followed by repeat cytology testing, including endocervical sampling every 6 months for 2 years or HPV DNA testing at 6 months; if these test results are negative, annual screening may be reestablished.
- Women with a cervical biopsy diagnosis of AIS should undergo excision to exclude invasive cancer. Cold-knife conization is recommended to preserve specimen orientation and permit optimal interpretation of histology and margin status.
- After treatment of CIN 2 or CIN 3, women may be monitored with cytology screening three to four times at 6-month intervals or undergo a single HPV test at 6 months before returning to annual follow-up.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Colposcopic examination during pregnancy should have as its primary goal the exclusion of invasive cancer. Excisions in pregnant women should be considered only if a lesion detected at colposcopy is suggestive of invasive cancer.
- Cervical cytology screening lacking endocervical cells may be repeated in 1 year when testing was performed for routine screening. Cytology screening performed for a specific indication (i.e., AGC follow-up or posttreatment follow-up after LEEP with a positive margin) may need to be repeated.
- Adolescents with ASC who are HPV positive or with LSIL results may be monitored with repeat cytology tests at 6 and 12 months or a single HPV test at 12 months, with colposcopy for a cytology result of ASC or higher-grade abnormality or a positive HPV test result.
- After treatment of AIS, when future fertility is desired and cervical conization margins are clear, conservative follow-up may be undertaken with cytology and endocervical sampling every 6 months.
- Women should not be treated with ablative therapy unless endocervical sampling test results are negative for abnormalities and the lesion seen and histologically evaluated explains the cytologic finding.
- In the absence of other indications for hysterectomy, excisional or ablative therapy for CIN 2 or CIN 3 is preferred.
Definitions:
Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendations
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
