Step 2 CK · Obstetrics & Gynecology

Cervical Dysplasia & Cervical Cancer Management

Name: Cervical Dysplasia & Cervical Cancer Management
Creator: Veli Bakalov, MD

From an abnormal Pap to colposcopy, excision, or chemoradiation

Obstetrics & Gynecology·Gynecologic Oncology·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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ASCCP management is risk-based: an immediate CIN3+ risk of 4% or more means colposcopy, and a risk of 60% or more makes expedited treatment preferred.
HPV-negative ASC-US returns to screening (HPV-based testing in 3 years); HPV-positive ASC-US or LSIL goes to colposcopy.
Ages 21–24 with ASC-US or LSIL get repeat cytology in 1 year, not colposcopy; no expedited LEEP under 25.
HPV 16 or 18 positivity requires colposcopy even with normal cytology; ASC-H always gets colposcopy.
HSIL in a nonpregnant patient 25 or older can go straight to LEEP (see-and-treat) or to colposcopy.
AGC requires colposcopy with endocervical curettage plus endometrial biopsy at age 35 or older or with endometrial risk factors.
CIN 1 is observed; CIN 2/3 is excised by LEEP or cold-knife cone, which raises later preterm birth risk, followed by HPV-based surveillance for 25 years.
In pregnancy, colposcopy and biopsy are safe but endocervical curettage is contraindicated; treatment of CIN is deferred until postpartum unless invasion is suspected.
A visible cervical lesion is biopsied directly; stage IA–IB2 cancer gets radical hysterectomy or trachelectomy, IB3–IVA gets cisplatin chemoradiation (plus pembrolizumab for stage III to IVA), and uremia from ureteral obstruction is the classic cause of death.

HPV and the risk-based framework

Natural history. Human papillomavirus infects the transformation zone, where columnar epithelium undergoes squamous metaplasia. About 90% of infections clear within 2 years; persistent high-risk HPV—type 16 (most squamous cancers) and type 18 (most adenocarcinomas)—drives cervical intraepithelial neoplasia (CIN). Viral E6 degrades p53 and E7 inactivates Rb. Smoking and immunosuppression promote persistence, and progression from CIN 3 to invasion usually takes years, which is why screening works.

Risk-based management. The 2019 ASCCP guidelines no longer map each result to a fixed step. Instead, the current cytology and HPV results are combined with prior history to estimate the immediate risk of CIN 3 or worse (CIN3+), and that risk selects the action.

≥4%immediate CIN3+ risk → colposcopy

25–60%expedited treatment acceptable

≥60%expedited treatment preferred (e.g., HSIL with HPV 16)

Below the 4% threshold, patients return for HPV-based testing in 1, 3, or 5 years depending on the estimated 5-year risk.

Managing abnormal cytology and HPV results

Common results and next steps (age ≥25, not pregnant)

Result	Next step	Comment
ASC-US, HPV-negative	Repeat HPV-based testing in 3 years	Very low risk; back to screening
NILM, HPV-positive (not 16/18)	Repeat HPV-based testing in 1 year	Most infections clear
NILM, HPV 16 or 18	Colposcopy	Genotype risk alone crosses 4%
ASC-US HPV-positive, or LSIL	Colposcopy	1-year follow-up acceptable only after a documented negative HPV screen within 5 years
ASC-H	Colposcopy	Regardless of HPV result
HSIL	Colposcopy or expedited LEEP	Expedited excision preferred if HPV 16-positive
AGC	Colposcopy + endocervical curettage ± endometrial biopsy	Endometrial biopsy if ≥35 or at risk (abnormal bleeding, obesity, anovulation)

Atypical endometrial cells: endometrial and endocervical sampling first. For AGC, repeat cytology or HPV testing alone is unacceptable.

Ages 21–24. HPV clearance is high and CIN 3 is rare, so ASC-US and LSIL are followed with repeat cytology in 1 year (reflex HPV testing is acceptable for ASC-US). Colposcopy is reserved for ASC-H, HSIL, or an abnormality that persists at 2 years, and expedited excision is not used.

Colposcopy. The cervix is magnified after applying acetic acid, which turns dysplastic epithelium acetowhite. Punctation, mosaicism, and especially atypical vessels (a sign of invasion) guide directed biopsies; Lugol iodine leaves glycogen-poor dysplastic areas unstained. Endocervical curettage samples the canal when the transformation zone is not fully visible.

Treating CIN and follow-up

CIN 1 (histologic LSIL). Usually a transient productive infection that regresses. Repeat HPV-based testing in 1 year; treatment is reserved for CIN 1 persisting 2 years or more.

CIN 2/3 (histologic HSIL). Treat by excising the transformation zone with a loop electrosurgical excision procedure (LEEP, done in the office) or a cold-knife cone, which provides a specimen with margins. Ablation (cryotherapy or laser) is acceptable only when the lesion and entire transformation zone are visible and the endocervical sample is negative. CIN 2 in patients younger than 25 may be observed with colposcopy and cytology every 6 months; patients 25 or older worried about future pregnancy may be observed with colposcopy and HPV-based testing every 6 months. Hysterectomy is not acceptable as primary therapy.

Adenocarcinoma in situ. Diagnostic excision, preferably a cold-knife cone to preserve margin interpretation; because AIS can be multifocal with skip lesions, hysterectomy is recommended once childbearing is complete.

Excision increases the risk of cervical insufficiency, preterm premature rupture of membranes, and preterm birth in later pregnancies—more so with deeper cones—and can cause cervical stenosis.

6 months after treatmentHPV-based test (also the preferred step for positive margins)
Then yearlyuntil three consecutive negative HPV-based tests
Then every 3 yearsfor at least 25 years
Past age 65continue surveillance while the patient is in reasonable health

Pregnancy and immunosuppression

Pregnancy. The goal of colposcopy in pregnancy is to exclude invasive cancer. Colposcopy and biopsy of suspicious areas are safe; endocervical curettage and endometrial sampling are contraindicated. Treatment of CIN 2/3 is deferred until at least 4 weeks postpartum, with repeat evaluation during pregnancy as needed; a diagnostic excision is performed only when invasion is suspected. Dysplasia does not change the route of delivery.

HIV and other immunosuppression. Screening starts within 1 year of sexual debut (and no later than 21), with cytology yearly and then every 3 years after three normal results; from 30, cotesting every 3 years is an option. Screening continues for life rather than stopping at 65. Invasive cervical cancer is an AIDS-defining illness.

Invasive cervical cancer

Presentation. Most cancers occur in women who were never or rarely screened. Symptoms include postcoital or intermenstrual bleeding and watery, bloody, or foul discharge; advanced disease causes pelvic or sciatic pain, leg edema, hydronephrosis, and fistulas. A visible or palpable lesion must be biopsied directly—cytology can be falsely negative because of blood and necrosis.

Staging. FIGO staging combines examination with imaging (MRI, CT, PET-CT) and pathology. Hydronephrosis or a nonfunctioning kidney places the tumor in stage IIIB regardless of size.

Stage-based treatment of cervical cancer

Stage	Extent	Treatment
IA1	Microscopic, invasion <3 mm	Cone (fertility-sparing) or simple hysterectomy
IA2–IB2	Confined to cervix, ≤4 cm	Open radical hysterectomy with pelvic node assessment; radical trachelectomy for fertility in small tumors
IB3–IVA	>4 cm, parametrium, vagina, sidewall, nodes, bladder or rectum	Cisplatin-based chemoradiation (external beam + brachytherapy); add pembrolizumab for FIGO 2014 stage III to IVA (KEYNOTE-A18)
IVB	Distant metastases	Platinum-based chemotherapy with bevacizumab ± immunotherapy; palliation

Minimally invasive radical hysterectomy had worse survival than open surgery in the LACC trial.

Cause of death. Lateral spread through the parametria to the pelvic sidewall obstructs the ureters; bilateral obstruction with renal failure and uremia is the classic cause of death.

Prevention. The 9-valent HPV vaccine is given routinely at 11–12 years (from age 9) with catch-up through 26; vaccinated women still follow standard screening.