Abnormal Pap Tests for Women Less than Age 21

Beginning December 2009, the American College of Obstetrics and Gynecology (ACOG) recommends that women have their first Pap test at age 21. Prior to this date ACOG recommended women begin Pap tests at age 21 or three years after their first intercourse, whichever comes first. What do you do if your Pap test is abnormal?  A lot depends on your age. The younger you are when you have your first Pap test, the less worrisome an abnormal result.

How are the results of a Pap test reported?

A Pap test is reported as normal (negative) when all the cells are of a healthy size and shape. An abnormal (positive) test is reported if any cells of different sizes or shapes are found. An abnormal Pap test does not mean you have cancer. Special terminology is used to describe the degree of abnormal cells. Since 2001, the categories used are: Benign Cellular or Reactive Changes; ASC-US (atypical squamous cells of undetermined significance); ASC-H (atypical squamous cells, cannot exclude high-grade), low-grade SIL (squamous intraepithelial lesion – often referred to as mild dysplasia), high-grade SIL (often referred to as moderate or severe dysplasia) and AGC (atypical glandular cells).

What causes an abnormal Pap test?

Abnormal cervical cells or dysplasia is caused by the human papilloma virus (HPV). HPV is sexually transmitted. It has been discovered that approximately 60% of sexually active college students acquire HPV at some point during college. HPV can cause genital warts, but fewer than 5% of women who are infected with the HPV will actually develop genital warts. The HPV can penetrate the cells of the cervix even if a woman has never had genital warts. The virus causes abnormal cell development on the cervix or dysplasia. Recent studies show that HPV can spontaneously disappear with time. Dysplasia can also spontaneously resolve with time. Smoking has been associated with an increased risk of the progression of dysplasia to cervical carcinoma.

The abnormal cell changes found on the surface of the cervix (or dysplasia) occur in three stages, mild, moderate, and severe. By definition, mild dysplasia involves only 25% of the thickness of the cell layer overlying the cervix. Moderate dysplasia involves 50% of the cell layer. Severe dysplasia is diagnosed when almost the full thickness of the surface cell layer is involved.

Cancerous cells are the most severe of the abnormal cells found on Pap tests. Carcinoma in situ involves the full thickness of the surface cells of the cervix. Invasive cancer of the cervix means that the disease has progressed beyond the surface layer of cells. Cervical cancer is very rare in women under the age of 21.

Atypical Squamous Cells of Undetermined Significance (ASC-US)

A Pap test with an ASC-US result is mildly abnormal. For women over 20, Pap tests with these results are further analyzed for high risk HPV DNA and if positive, colposcopy is recommended. For women under 21, the HPV test is not necessary or helpful. The best follow-up is simply to repeat the Pap test in one year.

Low Grade Squamous Intraepithelial Lesion (LGSIL)

LGSIL Pap test results are slightly more abnormal than ASC-US results. LGSIL suggests you may have mild dysplasia on your cervix. In women under 21, this is not a serious finding; usually mild dysplasia goes away without treatment. For follow-up, a repeat Pap test is recommended at age 21.

When would I need colposcopy?

A colposcope is very similar to a microscope and allows doctors to examine the external genital area (vulva), vagina, and cervix with magnification, so that abnormal cells may be more easily identified. If you are under 21 and had a Pap test under the old guidelines and your Pap test shows ASC-H (atypical squamous cells cannot rule out a high grade lesion), AGC (atypical glandular cells), or HGSIL (a high grade squamous intraepithelial lesion), you should also proceed directly to colposcopy without waiting.

If you are under 21 and your Pap test repeatedly shows ASCUS or LGSIL over 2 years, it is time to schedule a colposcopy. And at any age if your Pap test shows ASC-H (atypical squamous cells cannot rule out a high grade lesion), AGC (atypical glandular cells), or HGSIL (a high grade squamous intraepithelial lesion), you should also proceed directly to colposcopy without waiting.

How can I help my body recover from this condition more quickly?

If you smoke cigarettes: stop! Smoking depresses the immune system, which is responsible for the healing process. Eating a healthy diet, limiting alcohol intake and getting 6-8 hours of sleep a night may also help boost the immune system. Consistent use of condoms lessens the risk of further exposure to the virus and protects the cervix from further irritation.

To schedule an appointment, call 333-2700 and select Women’s Health.

References

Wright, T.C., et al. 2006 Consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 197 (4): 340-345, 2007.
Wright, T.C., et al. 2006 Consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 197 (4): 346-355, 2007.
American College of Obstetrics and Gynecology (ACOG) Practice Bulletin, Number 109, December 2009 -- Cervical Cytology Screening (Replaces Practice Bulletin Number 45, August 2003, Committee Opinion Number 300, October 2004, and Committee Opinion Number 431, May 2009)