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Managing Abnormal Cervical Cytology in the Postmenopausal Patient

In 2012 the ACS, USPSTF and ACOG released updated recommendations for cervical cancer screening, and the ASCCP issued revisions of the earlier guidelines for management of abnormal Pap smears.  The following incorporates these recommendations and guidelines.  Visible lesions of the cervix require biopsy regardless of cytology results.

CLINICAL ACTIONS:

ASC-US

  • Management is identical to that for premenopausal women (either repeat cytology in one year or HPV followed by colpo if HPV positive)
    • When considering discontinuation of screening at age 65, the finding of HPV neg/ASC-US should be considered abnormal
      • Additional surveillance is recommended
      • Cotesting is recommended but cytology acceptable

LSIL

  • HPV testing not done
    • Obtain HPV testing or
    • Repeat cytologic testing at 6 and 12 months or
    • Colposcopy
  • HPV negative or CIN not identified on colposcopy
    • Repeat cytology in 12 months
  • HPV positive or repeat cytology ≥ ASC-US
    • Colposcopy
  • If 2 consecutive repeat cytology tests are normal
    • Return to routine screening

HSIL

  • Management is identical to that for premenopausal women
    • Immediate loop or electrosurgical excision acceptable or
    • Colposcopy with ECC regardless of HPV status
  • Note: Repeat cytology or reflex HPV testing is “not acceptable”

AGC and AIS

  • Colposcopy with ECC plus endometrial sampling
  • HPV testing is not recommended

Endometrial Cells, Stromal Cells or Histiocytes on Cervical Cytology

  • Endometrial assessment regardless of symptoms, even if cells are benign
    • In postmenopausal women, even benign findings are associated with an approximately 5% risk for pathology (e.g., endometrial adenocarcinoma)

SYNOPSIS:

Management of the postmenopausal woman with abnormal cervical cytology in general follows the same guidelines as for the premenopausal woman.  Any abnormality, including ASC-US should be factored into the equation when deciding on when to stop performing Pap smears.  Per USPSTF recommendations: “Women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer are not at risk for cervical cancer and should not be screened. As part of the clinical evaluation, clinicians should confirm through review of surgical records or direct examination that the cervix was removed.”

KEY POINTS:

  • Hysterectomy is the recommended treatment for women with AIS
  • A colposcopy inconclusive for cancer should be followed by a diagnostic excisional procedure
  • Hysterectomy is acceptable for recurrent or persistent CIN 2+ or if repeat diagnostic procedure is not feasible (e.g. minimal residual cervix)

Diagnosis codes:

ASC-US: R87.610

ASC-H:  R87.611

LSIL:  R87.612

HSIL: R87.613

Learn More – Primary Sources:

ASCCP Colposcopy Standards: Risk-Based Colposcopy Practice

ASCCP Guidelines 2012

ACOG Practice Bulletin 140: Management of abnormal cervical cancer screening test results and cervical cancer precursors 

USPSTF: Cervical Cancer Screening