ALGORITHM 1: PAP & HIGH-RISK HPV SCREENING GUIDELINES

Women under 30 years

Women 30 years and older Women 30 years and older Women 30 years and older
Cytology negative
Cytology negative Cytology negative x3 Cytology negative
High-risk HPV not
High-risk HPV negative consecutive screens High-risk HPV positive
recommended

and
yes yes

Liquid-based No previous history of

cytology CIN 2 or 3, HIV, Repeat liquid-based cytology
every 1-2 years immunosuppression or & high-risk HPV testing
DES exposure in utero in 12 months

yes
result result
result

There is no Liquid- Cytology Cytology Cytology

role for the use based cytology negative
negative ASC-US
of routine HPV DNA and high-risk HPV High-risk HPV High-risk HPV High-risk HPV
testing in women in this testing every 3 years positive
negative negative
age group

yes yes yes

Liquid-based Rescreen with

cytology and liquid-based
high-risk HPV cytology & high-risk Colposcopy*
testing every HPV DNA
3 years in 12 months

* Post-colposcopy
follow-up per ASCCP
guidelines
 ALGORITHM 2: SCREENING GUIDELINES FOR WOMEN WITH
HYSTERECTOMY AND OLDER WOMEN

Women with supracervical Women with complete

Women older than 70 years
hysterectomy hysterectomy
with an intact uterus and cervix
(cervix still intact) (cervix removed)

If If
If If
Document &
confirm

History of benign disease such as Cytology negative

Screen according to the History of DES exposure, History of cervical cancer, HIV,
fibroids or endometriosis and no x3 consecutive screens and
guidelines for women without pre-cancerous lesions immunosuppression or
prior abnormal Pap tests or no abnormal Pap tests
hysterectomy or any GYN cancer DES exposure in utero
cervical cancer in the last 10 years*

yes yes yes yes

Continue
May discuss Continue
Pap testing of
May choose to discontinuation Pap tests as
the vaginal cuff
discontinue of screening with long as physically
according to diverse
screening patient able
management guidelines

* Risk factors for the development of cervical carcinoma should

be assessed on an ongoing basis and taken into consideration
when deciding how often and for how long to screen older
Women.
 ALGORITHM 3: AGE SPECIFIC MANAGEMENT OF ASC-US PAP
FINDINGS
Women 20 years
Women over 20 years Women over 20 years Women over 20 years and under
Cytology ASC-US Cytology ASC-US Cytology ASC-US Cytology ASC-US
High-risk HPV negative High-risk HPV positive High-risk HPV not done High-risk HPV not
recommended
yes yes yes
yes

Repeat Repeat only

Repeat
liquid-based cytology & liquid-based cytology
Colposcopy* liquid-based cytology
high-risk HPV DNA in 12 months
at 6 and 12 months
in 12 months High-risk HPV not recommended
result
result result
result
result

Cytology
ASC-US Cytology Cytology Cytology
Cytology Cytology
or greater with any result negative Cytology at negative,
ASC-US or HSIL or
High-risk HPV High-risk HPV High-risk HPV 6 and 12 ASC-US,
greater greater
negative positive negative months negative ASC-H or LSIL

yes yes
yes yes yes

Repeat only
Routine liquid-based cytology
Repeat cytology Colposcopy* Colposcopy* in 12 months
Colposcopy* Screening
in 12 months High-risk HPV
not recommended

Cytology
Cytology
ASC-US or
negative
greater
* Post-colposcopy follow-up
per ASCCP guidelines

yes yes

Routine
screening Colposcopy*
 ALGORITHM 4: MANAGEMENT OF AGC PAP FINDINGS

Women any age

Women any age
Cytology AGC or AIS
Cytology AGC or AIS
with atypical endometrial cells

yes yes

Endometrial sampling
Colposcopy* (with endocervical sampling) AND
AND Endocervical sampling
High-risk HPV DNA testing
AND
Endometrial sampling** result result
**If >35 years OR at any age if at risk for endometrial neoplasia

No
endometrial Endometrial
pathology abnormalities

yes yes

*Close post-colposcopy follow-up per ASCCP guidelines is essential in the

management of AGC Pap findings
Colposcopy* Follow-up as
AND appropriate for
high-risk HPV endometrial
DNA testing pathology
 ALGORITHM 5: MANAGEMENT OF OTHER PAP FINDINGS - PART I

Specimen
Endocervical
unsatisfactory for evaluation
cells/transformation zone not
(unsatisfactory indicates >75%
present with intact cervix
of cells are not interpretable)

yes yes If pregnant

Repeat liquid cytology

in 3-6 months
May repeat cytology in Rescreen postpartum
12 months UNLESS one or
If If
more of the following exist

Previously
obscured by
inflammation,
Cytology
attempt to clear
inflammatory repeatedly
process prior to repeat unsatisfactory

Inability
Previous Previous Significant
to clearly A positive
abnormal cytology clinical
visualize or high-risk HPV Insufficient
cytology without with history such as
sample the result Within the Immuno- frequency of
3 subsequent unexplained abnormal bleeding,
endocervical canal past 12 months suppression previous screening
negative results glandular abnormality discharge or spotting

Refer for further

Manage result gynecologic Repeat cytology
per guidelines evaluation, possible In 6 months
colposcopy
 ALGORITHM 6: MANAGEMENT OF OTHER PAP FINDINGS - PART II

Benign appearing
Blood or
Atrophy Trichomonas Infection endometrial cells in a
obscuring inflammation
woman over 40 years

yes yes yes

Normal in postmenopausal Evaluate for symptoms, Note LMP. In the absence of

Review clinical history* women but result may show perform wet mount and/or risk factors for endometrial
ASC-US culture if available cancer, continue routine care
per guidelines.
yes
If negative If positive If evaluation
not possible If

In setting
of ASC-US, Antibiotic Increased
Cytology Cytology treatment Is risk of
perform
otherwise unsatisfactory high-risk HPV reasonable if endometrial
negative for evaluation testing trichomonas cancer, perform
yes yes If high-risk If unavailable detected on cytology endometrial biopsy
HPV positive

* Review clinical history- if significant positives on

cancer screening (e.g. abnormal bleeding,
Repeat liquid- May administer
based cytology in Repeat liquid- spotting, discharge, post coital staining) further
0.3mg conjugated evaluation is needed, including possible
12 months based cytology Colposcopy*** estrogen vaginally at
if patient does not in 3-6 months bedtime for 4 weeks
colposcopy, endocervical curretage or
meet high risk (if not contraindicated) endometrial biopsy
criteria** Repeat cytology one
week post treatment ** See Algorithim 4

result result *** Post-colposcopy follow-up per ASCCP

guidelines

If cytology Cytology negative, return to

If cytology result
after estrogen after estrogen is regular screening interval
reveals ASC-US or negative, repeat
greater, refer for cytology In 4-6
colposcopy* result Cytology ASC-US or greater,
months
refer for colposcopy***