Low Grade Squamous Intraepithelial Lesion

1. Precautions
   1. LEEP or other destructive measure is no longer recommended for LGSIL
   2. Refer if inadequate Colposcopy
      1. Adequate Colposcopy requires visualization of SCJ
      2. Colposcopy adequate if SCJ fully visualized and
         1. Lesion not identified and ECC completed or
         2. Lesion responsible for abnormal pap was found
   3. Consider trial of intravaginal Estrogen in post-menopausal women
      1. Use if signs of atrophy and no contraindication
      2. Repeat Cervical Cytology one week after Estrogen course completed
2. Evaluation: Age 21 to 24 years old with LSIL (or ASC-US)
   1. Option 1: Reflex HPV Testing (ASC-US Pap Smear only)
      1. HPV negative
         1. Return to routine screening
      2. HPV positive
         1. Go to option 2
   2. Option 2: Repeat Cervical Cytology in 12 months (preferred)
      1. Cytology ASC-H, AGC, HSIL
         1. Colposcopy
      2. Cytology Negative, ASC-US or LSIL
         1. Repeat cytology in 12 months
            1. Colposcopy if cytology ASC-US or worse
            2. Routine screening after 2 negative cytology results
3. Evaluation: Age over 25 years with LSIL
   1. LSIL and HPV negative (age >30 years old)
      1. Option 1: Repeat co-testing (cytology and HPV) in 1 year (preferred)
         1. Colposcopy if cytology ASC-US or worse, or HPV positive
         2. Repeat co-testing in 3 years if cytology and HPV negative
      2. Option 2: Colposcopy (see below)
   2. Colposcopy for LSIL with positive or unknown HPV (or negative and elects Colposcopy)
      1. Endocervical sampling
         1. Preferred in non-pregnant patients with no lesion identified or inadequate Colposcopy
         2. Optional with an adequate Colposcopy and lesion identified
      2. Interpretation
         1. No CIN 2 or 3
            1. See CIN 1 as below
         2. CIN 2 or 3
            1. See CIN 2 or CIN 3
4. Evaluation: LSIL in pregnancy
   1. Option 1: Delay Colposcopy until 6 weeks postpartum
   2. Option 2: Colposcopy (preferred)
      1. No CIN 2 or 3
         1. Postpartum follow-up
      2. CIN 2 or 3 (or suspected CIN 2/3 or cancer)
         1. See CIN 2 or CIN 3
5. Evaluation: CIN 1 on Colposcopy
   1. Prior Lesser abnormalities (ASC-US, LSIL, HPV 16, 18 or persistent HPV)
      1. Age under 25 and repeat cytology in 12 months positive for ASC-H or HSIL
         1. Colposcopy
      2. Age under 25 and repeat cytology in 12 months negative for ASC-H or HSIL
         1. Repeat cytology in 12 months
            1. Colposcopy if positive (ASC-US or worse)
            2. Routine screening if negative
      3. Age over 25 and HPV negative and Cervical Cytology negative at 12 months
         1. Repeat cytology (and HPV if age >30 years old) in 3 years
            1. Colposcopy if ASC-US or HPV positive
            2. Routine screening with Cervical Cytology (and HPV if age >30) if cytology negative
      4. Age over 25 and HPV positive or Cervical Cytology positive (ASC-US or worse)
         1. Colposcopy with No CIN
         2. Colposcopy with CIN 1 that persists at least 2 years
            1. Excision (esp. if colpo inadequate, ECC positive or prior treatment) OR
            2. Ablation
         3. Colposcopy with CIN 2, 3
            1. See CIN 2 or CIN 3
   2. Prior ASC-H or HSIL
      1. Age under 25 years old
         1. Manage as per HSIL protocol after a non-CIN 2, 3 Colposcopy
      2. Age 25 years old and older
         1. Option 1: Revise diagnosis and treat based on re-review of cytology, biopsy, Colposcopy
         2. Option 2: Diagnostic excisional procedure (if not pregnant or age <25 years old)
         3. Option 3: Repeat HPV and cytology in 12 and 24 months (only if adequate colpo with negative ECC)
            1. Diagnostic excisional procedure if HSIL on cytology
            2. Colposcopy if HPV positive or cytology positive for ASC-US, ASC-H, LSIL
            3. Repeat cytology (and HPV if age >30) in 3 years if HPV and Cervical Cytology negative
6. References
   1. (2014) ASCCP Guidelines
      1. http://www.asccp.org/Guidelines-2/Management-Guidelines-2
   2. Apgar (2009) Am Fam Physician 80(2): 147-55 [PubMed]
   3. Apgar (2004) Am Fam Physician 70:1905-16 [PubMed]
   4. Nyirjesy (1998) Obstet Gynecol 92:601-7 [PubMed]
   5. Wright (2002) J Low Genit Tract Dis 6:127-43 [PubMed]