Atypical Squamous Cells of Undetermined Significance

Aka: Atypical Squamous Cells of Undetermined Significance, Pap Smear Atypia, Cervical Cytology Atypia, ASCUS, ASC-US, ASC-H

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II. Background: ASCUS Pap (Now ASC-US or ASC-H)

  1. ASCUS Pap now divided into 2 categories
    1. Atypical Squamous Cells, Cannot exclude HSIL (ASC-H)
      1. Higher risk - requires Colposcopy
      2. Accounts for 10% of ASCUS cases
    2. Atypical Squamous Cells undetermined signif. (ASC-US)
      1. Can be managed below (as per prior ASCUS guideline)
      2. Accounts for 90% of ASCUS cases
  2. ASCUS Pap should be followed closely
    1. ASCUS most common abnormality before HGSIL or Cervical Cancer
    2. Kinney (1998) Obstet Gynecol 91:973-6 [PubMed]

III. Management: 2019 Guidelines

  1. Colposcopy indications
    1. HPV Positive ASC-US Pap Smear
    2. ASC-H Pap Smear
  2. HPV Positive ASC-US Pap Smear
    1. Colposcopy biopsy <CIN 2: One year follow-up
    2. Year 1 follow-up HPV Positive ASC-US Pap Smear: One year follow-up
    3. Year 2 follow-up
      1. HPV Negative and No CIN: Three year follow-up
      2. HPV Positive ASC-US Pap Smear: Colposcopy

IV. Management: Age 21 to 24 years old with ASC-US or ASC-H Cervical Cytology (2014 Guidelines)

  1. Colposcopy for all ASC-H (cannot exclude HSIL)
    1. See HSIL for protocol
  2. ASC-US
    1. See Low Grade Squamous Intraepithelial Lesion (LSIL)
    2. Treated the same as LSIL in ages 21-24 years old

V. Management: Age over 25 years old and initial ASC-US Cervical Cytology (2014 Guidelines)

  1. Colposcopy for all ASC-H (cannot exclude HSIL)
    1. No CIN 2 or 3
      1. See CIN 1
    2. CIN 2, 3
      1. See CIN 2 or CIN 3
  2. Options for ASC-US
    1. Option 1: Send liquid pap on for HPV DNA Test (preferred)
      1. HPV negative (or positive for low risk type)
        1. Repeat cytology and HPV in 3 years (co-testing)
      2. HPV posiitve for high risk type
        1. Colposcopy
    2. Option 2: Repeat Cytology in 1 year
      1. Abnormal (AS-CUS or worse)
        1. Colposcopy
      2. Normal
        1. Repeat cytology in 3 years
  3. Special Circumstances
    1. Pregnancy
      1. Manage the same as non-pregnant patients (but no ECC and avoid biopsies if possible)
    2. Post-Menopausal
      1. Option 1: Colposcopy
      2. Option 2: HPV DNA Testing
      3. Option 3: Trial of intravaginal Estrogen
        1. Use if signs of atrophy and no contraindication
        2. Repeat Pap Smear one week after Estrogen done
          1. Normal: Pap Smear in 4-6 months, then yearly
          2. ASCUS or CIN: Colposcopy

VI. Management: Colposcopy evaluation of ASCUS

  1. See Colposcopy Protocol

VII. Resources

  1. (2014) ASCCP Guidelines
    1. http://www.asccp.org/Guidelines-2/Management-Guidelines-2
  2. (2019) ASCCP Guidelines
    1. https://www.asccp.org/management-guidelines

VIII. References

  1. Apgar (2009) Am Fam Physician 80(2): 147-55 [PubMed]
  2. Apgar (1999) Am Fam Physician 59(10):2794-800 [PubMed]
  3. Apgar (2004) Am Fam Physician 70:1905-16 [PubMed]
  4. Brotzman (1996) Am Fam Physician 53(4):1154-62 [PubMed]
  5. Stack (1997) Postgrad Med 101(4):207-4 [PubMed]
  6. Wright (2002) J Low Genit Tract Dis 6:127-43 [PubMed]

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