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):
- Because human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing is more sensitive than cervical cytology in detecting cervical intraepithelial neoplasia (CIN) 2 and CIN 3, women with negative concurrent test results can be reassured that their risk of unidentified CIN 2 and CIN 3 or cervical cancer is approximately 1 in 1,000.
- Studies using combined HPV testing with cervical cytology have reported a negative predictive value for CIN 2 and CIN 3 of 99 to 100%.
- HPV DNA testing is not recommended in women with low-grade squamous intraepithelial lesions (LSIL), atypical squamous cells (ASC) that cannot exclude high-grade squamous intraepithelial lesions, or atypical glandular cell cytology.
- The triage of women with ASC of undetermined significance (ASC-US) cytology using reflex HPV DNA testing for high-risk types when liquid-based cytology was used at the time of the initial visit eliminates the need for a repeat office visit and is a more sensitive triage tool than repeat cytology while referring fewer women to colposcopy.
- Women with high-risk HPV who have ASC-US or LSIL cytology but are not found to have CIN 2 or CIN 3 at their initial colposcopy have approximately a 10% risk of having CIN 2 or CIN 3 within 2 years.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Although evidence is lacking that condoms offer complete protection from HPV infection, condom use may reduce the risk of HPV-related disease, such as genital warts and cervical neoplasia.
- Studies show that condoms may be effective in the clearance of HPV or HPV-associated lesions.
- Use of a combination of cervical cytology and HPV DNA screening is appropriate for women aged 30 years and older. If this combination is used, women who receive negative results on both tests should be rescreened no more frequently than every 3 years.
- Because of a similar risk of recurrence, no single treatment for external genital warts can be recommended over another.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Women older than 30 years with a negative cytology result who have high-risk HPV DNA positive test results should have both tests repeated in 6 to 12 months. Those with persistent high-risk HPV (on repeat testing) should undergo colposcopy regardless of the cytology result.
- Human papillomavirus DNA testing could be used as a test of cure for women with CIN 2 or CIN 3 at 6–12 months following excision or ablation of the transformation zone. Those with high-risk HPV should be referred for colposcopy.
- Treatment for genital warts should be guided by the preference of the patient and the experience of the heath care provider.
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.
