An abnormal Pap smear or a positive HPV test usually does not mean cancer; most people with such a result have an HPV infection or early changes that only need follow-up [1]. The next step depends on your risk: for a positive HPV test with a normal Pap smear, usually a repeat test after a year (unless it is HPV 16 or 18); for ASCUS or LSIL with a positive HPV test, usually colposcopy; and for ASC-H or HSIL, colposcopy and sometimes treatment straight away [2]. If precancer (CIN 2 or 3) is found, it is removed with a simple outpatient procedure such as LEEP, which prevents cancer [1, 7].
Key points
- Most abnormal results are not cancer: most are HPV infections or early changes that only need follow-up [1].
- The next step is based on risk: your current result, the HPV type and your earlier results are considered together [2].
- Normal Pap smear and positive HPV test: usually a repeat test after a year; if it is HPV 16 or 18, colposcopy [2, 3].
- Many CIN 2 lesions go away on their own, especially in women under 30 [4]; CIN 3 is always treated [2].
- Treating precancer is simple and effective [7], but it may raise the chance of preterm birth; so talk to your doctor about future pregnancies before treatment [2, 5].
My Pap smear result is abnormal or suspicious: should I be worried?
It is natural to worry after such a result, but most people who get an abnormal result do not have cancer [1]. Two tests can come back abnormal:
- An abnormal Pap smear means some cells of the cervix do not look completely normal; most of these changes are caused by HPV and many go away on their own [1].
- A positive HPV test means a high-risk type of the virus was found; the body clears most of these infections by itself [7].
Rather than looking at a single result, doctors now assess risk: your current result, the HPV type, your earlier test results and any earlier treatment are considered together [1, 2]. That is why two people with the same result may get different plans. Read about the virus itself: What is HPV? and about the tests: Pap smear and HPV test: who needs them and how often?
What the terms on a Pap smear report mean: ASCUS, LSIL, HSIL and others
| Term on the report | What it means | Usual next step |
|---|---|---|
| NILM (negative or normal) | No abnormal cells were seen [8] | If the HPV test is also negative, the next test on the usual schedule [2] |
| ASCUS (ASC-US) | The most common abnormal result; some cells do not look completely normal, but it is not clear whether HPV is the cause [1] | HPV negative: repeat test in 3 years; HPV positive: usually colposcopy [2] |
| LSIL | Mild changes, usually caused by an HPV infection [1] | HPV positive: usually colposcopy; HPV negative: repeat test in a year [2] |
| ASC-H | Cells that may be severe changes (HSIL), but this is not certain [1] | Colposcopy, whatever the HPV test result [2] |
| HSIL | Moderate or severe changes that could become cancer in the future if not treated [1] | Colposcopy; or sometimes treatment straight away without a biopsy first [2] |
| AGC | Some glandular cells do not look normal; sometimes a sign of a problem higher up, inside the womb [1] | Colposcopy and a sample from inside the cervical canal; from age 35 (or earlier if you are at risk) a sample from inside the womb as well [2] |
| AIS | An advanced change in the glandular tissue of the cervix that counts as precancer [1] | Assessed like AGC; treated by removing the tissue [2] |
These names come from the Bethesda System for reporting Pap smears [8]. The plan is different for women under 25, pregnant women and those who have had an abnormal result or treatment before [2].
Normal Pap smear but positive HPV test: what does it mean?
It means a high-risk type of HPV was found in the cervix, but the cells have not yet changed in a way that can be seen. This result is common, and in most women the HPV test turns negative over time, because the body clears most infections by itself [7]. The next step depends on the type of virus:
- HPV 16 or 18: colposcopy is recommended, even if the Pap smear is normal, because these two types carry the highest risk [2, 3].
- Other high-risk types (such as 31, 33, 35, 45, 52 and 58): if the Pap smear is normal, the test is usually repeated after a year [2]. If the laboratory has reported the exact type of virus, your doctor may tailor the plan to it [3].
- Only HPV 56, 59 or 66: the risk is lower, and the HPV test is repeated after a year [3].
If the HPV test is still positive a year later, colposcopy is usually done [2]. In the programmes the World Health Organization recommends, a woman who tests HPV positive is either treated directly or first has a further test (such as identifying the virus type, colposcopy or a Pap smear); if the further test is normal, the HPV test is repeated two years later [6].
If you are worried about where the virus came from, or whether your partner should be tested, read: What is HPV?
What is colposcopy and does it hurt?
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A close look at the cervix
As with a Pap smear, the doctor gently opens the vagina with a speculum. A weak vinegar solution is then applied to the cervix to show abnormal areas more clearly, and the doctor looks at the cervix closely with an instrument that has a bright light and a magnifying lens (a colposcope). The instrument stays outside the body [1].
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Afterwards
You may have some bleeding or discharge, and some people have pain that feels like period cramps [1].
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The result
The biopsy result is reported as CIN 1, 2 or 3 (or as low-grade or high-grade lesions in the tissue); the next section explains what these mean [2].
What do CIN 1, CIN 2 and CIN 3 mean?
| Result | What it means | What is usually done |
|---|---|---|
| CIN 1 (low-grade lesion in the tissue) | Mild changes; usually go away on their own [1] | No treatment needed; follow-up with a test a year later [1, 2] |
| CIN 2 (high-grade lesion in the tissue) | Moderate changes; sometimes go away on their own [1] | Usually treated; in women under 25 close follow-up is preferred, and it is also acceptable for women worried about future pregnancies (an examination and tests every 6 months) [2] |
| CIN 3 (high-grade lesion in the tissue) | Severe changes; not yet cancer, but may become cancer if not treated [1] | Always treated, except in pregnancy, when treatment waits until after the birth [1, 2] |
What happens to CIN 2 without treatment? In a review of 36 studies of more than 3,000 women with CIN 2 who were followed up without treatment, after 2 years about 5 in 10 women had recovered, about 3 stayed the same and about 2 got worse [4]. In women under 30, about 6 in 10 recovered and about 1 got worse [4]. That is why, for young women who can come regularly for follow-up, close monitoring instead of immediate treatment is a reasonable option [2, 4].
Treating precancer: LEEP, cone biopsy and other methods
Treating precancer is simple and effective and prevents cervical cancer [7]. The methods [1, 7]:
- LEEP (loop electrosurgical excision): the abnormal tissue is removed with a thin wire loop through which an electric current passes. It is usually done in a doctor's office under local anaesthetic and takes a few minutes [1].
- Cold knife cone biopsy: the tissue is removed with a scalpel, in hospital under general anaesthetic [1].
- Destroying the cells with cold or heat: abnormal cells are destroyed with a cold probe (cryotherapy) or a heated probe [1, 7].
- Laser: to remove or destroy abnormal tissue [1].
After treatment, the first HPV test is done about 6 months later (World Health Organization: 12 months later) [2, 6]. The test is then repeated every year until it has been negative three times in a row; after that every 3 years, for at least 25 years [2].
Does treatment affect pregnancy?
Most women treated for precancer go on to give birth at term [5]. But treatment can rarely weaken the cervix and may raise the chance of preterm birth or miscarriage [1]. In a review of 69 studies [5]:
- Preterm birth was nearly twice as common in treated women as in untreated women; even so, about 9 in 10 treated women did not have a preterm birth.
- The risk was higher with methods that remove tissue (such as LEEP and cone biopsy) than with methods that destroy the cells; the deeper the tissue removed, or if treatment was repeated, the higher the risk.
- Most of these studies were of low quality, and the results should be interpreted with caution.
If you want to become pregnant in the future, talk to your doctor before treatment; for CIN 2, follow-up is sometimes chosen instead of immediate treatment [2]. If you become pregnant after treatment, tell your doctor that you have had it.
When should I contact a doctor?
Some bleeding, discharge and pain like period cramps are normal after a biopsy or treatment [1]. But see a doctor soon if you have [6]:
- A fever, or a foul-smelling vaginal discharge
- Severe pain in the lower abdomen, worse than normal period pain
- Heavy bleeding, especially with clots
If heavy bleeding comes with dizziness, severe weakness or feeling faint, call your local emergency number straight away [6].
Above all, do not put off follow-up. Precancer gives years of opportunity for treatment, but only if the follow-up tests are done on time [7].
Frequently asked questions
My Pap smear shows ASCUS and my HPV test is positive: do I have to have a colposcopy?
Does CIN 3 mean I have cancer?
I am under 25 and my Pap smear shows LSIL: what should I do?
I am pregnant and my Pap smear is abnormal: what happens?
Assessment follows the same criteria as for women who are not pregnant, and colposcopy can be done in pregnancy [2]. But some procedures, such as taking a sample from inside the cervical canal, are not done in pregnancy, and treatment of CIN 2 or 3 usually waits until after the birth [2]. Your doctor will discuss the timing of each step with you [1].
After treatment, does HPV come back?
Risk-based management (for doctors)
For physicians
ASCCP 2019 thresholds. Immediate CIN3+ risk of 4% or more: colposcopy; expedited treatment (excision without biopsy) in non-pregnant patients aged 25 or older is preferred at an immediate risk of 60% or more and acceptable at 25 to 60%; immediate risk below 4%: return based on 5-year risk, at 1 year (0.55% or more), 3 years (0.15% to below 0.55%) or 5 years (below 0.15%) [2]. Immediate CIN3+ risks in the KPNC data: HPV+/NILM 2.1% (1-year repeat); HPV-/LSIL 1.1% (1 year); HPV-/ASC-US with a 5-year risk of 0.40% (3 years); HPV+/ASC-US 4.2% (colposcopy); HPV+/ASC-H 26% (HPV-/ASC-H 3.4% but cancer risk 0.69%; colposcopy regardless of HPV); HPV+/HSIL 49% (CIN2+ 77%); HPV16-positive HSIL 60% (expedited treatment preferred, as for HPV-positive HSIL in never or rarely screened patients) [2]. HPV16/18 positive even with negative cytology: colposcopy. After a negative HPV test or co-test within about the past 5 years, new HPV+ ASC-US/LSIL: 1-year surveillance instead of colposcopy [2].
Extended genotyping (Enduring Guidelines 2025, Onclarity assay). HPV16 and 18: colposcopy; 45, 33/58, 31, 52, 35/39/68 or 51 without 16/18: triage with cytology or dual stain; only 56/59/66 on primary HPV screening: repeat HPV in 1 year; on co-testing with 56/59/66: NILM, ASC-US and LSIL 1-year return, ASC-H, AGC, HSIL or carcinoma colposcopy. With prior high-grade cytology or histology, or during follow-up after treatment of CIN2+, manage by the 2019 guideline [3].
AGC/AIS. Colposcopy and endocervical sampling regardless of HPV (except in pregnancy); endometrial sampling at 35 or older and below 35 when at risk (abnormal uterine bleeding, chronic anovulation, obesity); AIS: excision [2].
Histology and treatment. CIN1: observation preferred; treatment acceptable for CIN1 persisting 2 years or more. CIN3: always treat (except in pregnancy). CIN2: treat; observation with colposcopy and HPV testing every 6 months acceptable when future pregnancy is a concern; under 25, observation preferred. Excision is preferred over ablation (in the USA); non-surgical treatments (topical agents, therapeutic vaccines) are unacceptable outside trials, and hysterectomy as primary treatment of HSIL is unacceptable. Under 25 with LSIL or HPV+ ASC-US: cytology at 1 and 2 years. Pregnancy: same thresholds; ECC, endometrial biopsy and treatment without biopsy are unacceptable; treatment of CIN2/3 is not recommended; postpartum colposcopy no earlier than 4 weeks after delivery. After treatment of HSIL: HPV-based test at 6 months, then annually until 3 consecutive negative tests, then every 3 years for at least 25 years, even beyond age 65 [2]. WHO 2021: HPV positive with negative triage, repeat HPV at 24 months; after treatment of CIN2/3 or AIS, HPV test at 12 months [6].
Natural history of CIN2 (Tainio, BMJ 2018; 36 studies, 3160 women). At 24 months: regression 50% (43 to 57), persistence 32% (23 to 42), progression 18% (11 to 27); under 30 (1069 women): 60%, 23% and 11%; non-adherence to follow-up about 10% [4].
Obstetric outcomes (Kyrgiou, Cochrane 2017; 69 studies). Preterm birth before 37 weeks 10.7% versus 5.4% (RR 1.75; 1.57 to 1.96); excision RR 1.87 and ablation RR 1.35; CKC RR 2.70, LLETZ RR 1.58; repeat treatment RR 3.78; cone depth 20 mm or more RR 4.91; low or very low quality evidence [5].
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References
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Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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