Cervical Cancer in Adolescents: Screening, Evaluation,

and Management
ABSTRACT: Based on several recent studies, new guidelines for initiation of cervical cancer screening have
been developed. Evidence shows that screening before the age of 21 years does not change the rate of cervical
cancer in that age group or in older women. Cervical cancer, in general, is extremely rare in those younger than
21 years. Consequently, cervical cancer screening should begin at age 21 years. If cytology is performed before
age 21 years, it is important to recognize that the management of cervical cytologic abnormalities in adolescents
differs from that of the adult population. The publication of the American Society of Colposcopy and Cervical
Pathology 2006 consensus guidelines has led to major changes in the management of cervical disease in adoles-
cents, which emphasize minimal to no intervention. These guidelines advise against human papillomavirus testing
and recommend observation for the management of cervical intraepithelial neoplasia 1 in adolescents. In addition,
observation is preferred for the management of cervical intraepithelial neoplasia 2. The guidelines were estab-
lished to minimize the potential negative effect that screening can cause, unnecessary referrals for colposcopy,
and the negative effect that treatment can have on future pregnancy outcomes.
Committee on Adolescent Health Care
This document reflects emerging clinical and scientific advances as of the date issued and is
subject to change. The information should not be construed as dictating an exclusive course of
treatment or procedure to be followed.
Natural History of Human
Papillomavirus Infection
Human papillomavirus (HPV) is the most common sexu-
ally acquired infection in the world. Numerous natural
history studies (1, 2) have demonstrated that as many as
50% of sexually active young women in the United States
will have positive test results for HPV within 36 months
of the onset of sexual activity. Recurrent infections also
are common. Consequently, prevalence data indicate that
up to 57% of sexually active female adolescents in the
United States at any one point in time are infected with
HPV (3). In adolescent patients with an intact immune
system, 90% of cases of HPV infection will resolve within
24 months (4).
Cervical Cancer Screening
In the past, the American Cancer Society, the American
College of Obstetricians and Gynecologists, and the
American Society of Colposcopy and Cervical Pathology
(ASCCP) recommended the initiation of cervical cytol-
ogy screening in an adolescent based on time since
onset of vaginal intercourse. However, there was much
confusion and nonadherence to the guidelines. Con-
sequently, many adolescents were being screened inap-
propriately. In light of recent evidence that screening
in adolescents does not appear to change the rate of
cervical cancer in these groups (5), the American College
of Obstetricians and Gynecologists now recommends
that cervical cytology screening begin at age 21 years,
regardless of the age of onset of sexual activity. The few
rare cases of cervical cancer in this population do not
appear to have been preventable by screening.
With the new screening recommendations, cervical
cytology will not be obtained in most women younger
than 21 years. An adolescent with a history of normal
cytologic screening in the past should not be rescreened
until age 21 years. If an adolescent has had a Pap test
result of atypical squamous cells of undetermined signifi-
cance (ASC-US) or low-grade squamous intraepithelial
lesions (LSIL), or cervical intraepithelial neoplasia (CIN)
1 histology in the past, but has had two subsequent nor-
mal Pap test results, rescreening can be delayed until
age 21 years. For adolescents with high-grade squamous
intraepithelial lesions (HSIL); atypical squamous cells,
cannot exclude HSIL (ASC-H); or CIN 2 or more severe,
COMMITTEE OPINION
Number 463 August 2010
The American College of Obstetricians and Gynecologists
Womens Health Care Physicians
2 Committee Opinion No. 463
the current management guidelines detailed in this
Committee Opinion should be followed. Once regression
is established based on current criteria, rescreening can be
delayed until 21 years of age. Annual cytologic screening
also can be considered.
It is recommended that adolescents with human
immunodeficiency virus (HIV) have cervical cytology
screening twice in the first year after diagnosis and annu-
ally thereafter (6). Guidelines for treatment of cervical
cytologic abnormalities in individuals with HIV infection
can be obtained at http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5804a1.htm. Sexually active immunocom-
promised adolescents, including those who have received
an organ transplant or those with long-term steroid use,
should undergo screening after the onset of sexual activity
and not wait until 21 years of age. This screening should
include Pap tests at 6-month intervals during the first
year of screening and then annual Pap tests thereafter.
Human Papillomavirus Testing
Human papillomavirus testing is not recommended at
any time in adolescents. Because of the high prevalence of
HPV infection in adolescents, there is little utility in HPV
testing in this population. There are no clinical situations,
screening, triage, or follow-up that require HPV testing in
this population. If conducted, a positive test result should
not influence management. There is no role for HPV test-
ing in the patient before HPV vaccination.
Management of Cervical Cytologic
Abnormalities
Although nonadherence to screening guidelines can
occur, the low rates of progression of cervical cytologic
abnormalities and the slow rates at which progression
typically occurs if the abnormality does not regress, indi-
cate that conservative observational management should
be the mainstay of care in adolescents with abnormal
cytology results. The following guidelines are for man-
agement of cytologic and histologic abnormalities. These
guidelines also address the situation in which screening
or treatment or both took place before the release of the
new cervical cytology screening guidelines in 2009.
Atypical Squamous Cells of Undetermined
Significance, Low Grade Squamous
Intraepithelial Lesions, and Cervical
Intraepithelial Neoplasia 1
The ASCCP 2006 consensus guidelines for the man-
agement of ASC-US, LSIL, and CIN 1 in adolescents
recommend repeat cytology at 12-month intervals for a
period of 2 years (79). This recommendation is based
on natural history studies of ASC-US, LSIL, and CIN 1
that demonstrate a high rate of resolution of the disease
within 23 years (1, 10). Clinicians should perform col-
poscopy only for a cytologic diagnosis of HSIL at any visit
or after the persistence of ASC-US or LSIL for a period
of 2 years. The management of a patient with persistent
CIN 1 (greater than 24 months) should be individual-
ized. Strong consideration should be given to continued
monitoring of these adolescent patients because of the
frequency of newly acquired HPV infections.
Atypical Squamous Cells, Cannot Exclude High-
Grade Squamous Intraepithelial Lesions
Atypical squamous cells, cannot exclude HSIL represents
a small proportion of cervical cytology results. Multiple
studies have demonstrated that women who receive an
ASC-H diagnosis frequently have an ongoing HPV infec-
tion (approximately 80%), and are at an increased risk of
CIN 2,3 in a 2-year period (11). Because there are limited
data, ASC-H in adolescents is managed with colposcopic
evaluation. In women where no CIN 2,3 is identified his-
tologically, the subsequent management approach is cyto-
logic evaluation at 6-month intervals. If any abnor-
mality is found (greater than or equal to atypical
squamous cells), the patient should undergo a repeat col-
poscopy. When the patient has two consecutive normal
Pap test results, screening can be reinitiated at age 21 years.
High-Grade Squamous Intraepithelial Lesions
The adolescent with HSIL requires a colposcopic evalu-
ation with endocervical assessment. Use of the see and
treat loop electrosurgical excision procedure for patients
with HSIL who are younger than 21 years is considered
unacceptable. If on biopsy no CIN 2,3 is found, observa-
tion with colposcopy and cytology at 6-month intervals is
recommended for up to 2 years provided the result of the
endocervical sampling is negative. If HSIL or high-grade
colposcopic lesions persist at 1 year, repeat biopsy and
thorough examination of the vagina is recommended. A
diagnostic excisional procedure is recommended if HSIL
persists at 24 months as confirmed by either cytology or
colposcopy results and if the examination of the vagina
does not explain the abnormality. The rationale for less
intervention in adolescents is the high rate of resolution
of CIN 2 in this population and the increased relative risk
of preterm labor and premature rupture of membranes in
women after undergoing a loop electrosurgical excision
procedure (12, 13).
Atypical Glandular Cells
The prevalence of atypical glandular cells (AGC) in the
adolescent population is very low, and most of these
abnormalities will arise from the squamous component
of the cervix (14). Because this diagnosis is rare and can
have significant clinical implications, a physician with
expertise in managing cervical dysplasia should manage
cases of AGC in the adolescent. The adolescent with AGC
should undergo a colposcopy and endocervical sampling.
Endometrial sampling would not be used in most adoles-
cents unless they are morbidly obese, they have abnormal
uterine bleeding or oligomenorrhea, or there is a suspi-
cion of endometrial cancer.
Committee Opinion No. 463 3
Consent for the examination should be obtained from the
minor or parent or both, if needed. Colposcopy is likely
to generate a bill, which can compromise confidentiality.
This issue should be discussed with the adolescent and
parental involvement should be encouraged, even if
parental consent is not legally required.
Pregnancy and Screening for Sexually
Transmitted Infections
Having a non-HIV STI diagnosis is not an indication
for earlier cervical cancer screening. Because of high
rates of STIs in adolescents, screening and treatment
for Chlamydia trachomatis and Neisseria gonorrhoeae
before any cervical treatment, if appropriate, is strongly
recommended (19). Pregnancy in adolescents does not
alter screening guidelines. The management of cervical
cytologic abnormalities in pregnant women is discussed
in Practice Bulletin No. 99 (20).
References
1. Moscicki AB, Hills N, Shiboski S, Powell K, Jay N, Hanson E,
et al. Risks for incident human papillomavirus infection and
low-grade squamous intraepithelial lesion development in
young females. JAMA 2001;285:29953002.
2. Winer RL, Lee SK, Hughes JP, Adam DE, Kiviat NB,
Koutsky LA. Genital human papillomavirus infection: inci-
dence and risk factors in a cohort of female university
students [published erratum appears in Am J Epidemiol
2003;157:858]. Am J Epidemiol 2003;157:21826.
3. Moscicki AB, Ellenberg JH, Vermund SH, Holland CA,
Darragh T, Crowley-Nowick PA, et al. Prevalence of and
risks for cervical human papillomavirus infection and
squamous intraepithelial lesions in adolescent girls: impact
of infection with human immunodeficiency virus. Arch
Pediatr Adolesc Med 2000;154:12734.
4. Moscicki AB, Schiffman M, Kjaer S, Villa LL. Chapter 5:
Updating the natural history of HPV and anogenital cancer.
Vaccine 2006;24(Suppl 3):S3/4251.
5. Barnholtz-Sloan J, Patel N, Rollison D, Kortepeter K,
MacKinnon J, Giuliano A. Incidence trends of invasive
cervical cancer in the United States by combined race and
ethnicity. Cancer Causes Control 2009;20:112938.
6. Kaplan JE, Benson C, Holmes KH, Brooks JT, Pau A, Masur H.
Guidelines for prevention and treatment of opportu-
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recommendations from CDC, the National Institutes of
Health, and the HIV Medicine Association of the Infectious
Diseases Society of America. Centers for Disease Control
and Prevention (CDC); National Institutes of Health; HIV
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7. Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ,
Solomon D. 2006 Consensus Guidelines for the Management
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Cervical Intraepithelial Neoplasia 2,3
Cervical intraepithelial neoplasia 2 is a significant abnor-
mality that has classically required therapy. A variety of
studies, including the ASCUS-LSIL Triage Study trial,
have demonstrated that this lesion may have a significant
rate of resolution (up to 40%) in adults (15). This rate
of resolution is suspected to be higher in adolescents.
The management approach of CIN 2,3 in adolescents
and young women is observation with colposcopy and
cytology at 6-month intervals for up to 24 months or
treatment with either ablation or with excision of the
transformation zone, provided that the colposcopy result
is satisfactory (7, 9). When the colposcopy result is unsat-
isfactory, treatment is recommended. When CIN 2 is
specified on cervical biopsy, observation is preferred, but
treatment is acceptable. During the observation period,
if the colposcopic appearance of the lesions worsens, or
if the high-grade cytology or colposcopy result persists
for 1 year, a repeat biopsy is warranted. Treatment is
recommended for the patient with persistent CIN 2,3 as
confirmed by histology results for a 24-month period.
If CIN 1 is found, continued observation is an option.
In the ASCCP 2006 consensus guidelines, the definition
of young women was left deliberately vague, but among
the factors that should be taken into consideration in
applying this definition are the number of years since
first intercourse and the womans parity and desire for
future fertility.
Cervical intraepithelial neoplasia 3 is a significant
cervical abnormality. Cervical cancer is very rare in the
adolescent population and the natural history of CIN 3
in this population has not been examined. Therapy is
recommended for all women with CIN 3. Randomized
prospective clinical trials have demonstrated that cryo-
therapy, laser therapy, and the loop electrosurgical exci-
sion procedure are equally effective interventions for the
treatment of CIN 3 (16). In one of the largest follow-up
studies of women having undergone outpatient abla-
tive therapy of CIN, four cases of microinvasive cervical
cancer and five cases of frankly invasive cancer were
subsequently diagnosed among 3,738 adult women (17).
Because of these considerations, some authors have rec-
ommended that excision be used for the management of
biopsy-confirmed CIN 3, especially for large lesions that
are at increased risk of having microinvasive or occult
invasive carcinoma. The type of intervention should be
based on the geometry of the cervical lesion as well as
the clinical recommendations of the health care provider.
Consent
Minors undergoing a colposcopic examination may find
it helpful to have parental involvement for the proce-
dure. However, colposcopic examinations are considered
evaluation for sexually transmitted infections (STIs), and
minors generally are allowed to consent for diagnosis and
treatment of STIs. State laws should be addressed when
making a decision about obtaining parental consent (18).
4 Committee Opinion No. 463
16. Kyrgiou M, Tsoumpou I, Vrekoussis T, Martin-Hirsch P,
Arbyn M, Prendiville W, et al. The up-to-date evidence on
colposcopy practice and treatment of cervical intraepithe-
lial neoplasia: the Cochrane colposcopy & cervical cytopa-
thology collaborative group (C5 group) approach. Cancer
Treat Rev 2006;32:51623.
17. Pearson SE, Whittaker J, Ireland D, Monaghan JM. Inva-
sive cancer of the cervix after laser treatment. Br J Obstet
Gynaecol 1989;96:4868.
18. English A, Kenney KE. State minor consent laws: a sum-
mary. 2nd ed. Chapel Hill (NC): Center for Adolescent
Health and the Law; 2003.
19. Harel Z, Riggs S. On the need to screen for Chlamydia and
gonorrhea infections prior to colposcopy in adolescents. J
Adolesc Health 1997;21:8790.
20. Management of abnormal cervical cytology and histol-
ogy. ACOG Practice Bulletin No. 99. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2008;
112:141944.
8. American Society for Colposcopy and Cervical Pathology.
Management of women with atypical squamous cells of
undetermined significance (ASC-US). Hagerstown (MD):
ASCCP; 2007. Available at: http://www.asccp.org/pdfs/con-
sensus/algorithms_cyto_07.pdf. Retrieved April 13, 2010.
9. American Society for Colposcopy and Cervical Pathology.
Management of women with a histological diagnosis of
cervical intraepithelial neoplasia grade 1 (CIN 1) preceded
by ASC-US, ASC-H or LSIL cytology. Hagerstown (MD):
ASCCP; 2007. Available at: http://www.asccp.org/pdfs/con-
sensus/algorithms_hist_07.pdf. Retrieved April 13, 2010.
10. Moscicki AB, Shiboski S, Hills NK, Powell KJ, Jay N,
Hanson EN, et al. Regression of low-grade squamous
intra-epithelial lesions in young women. Lancet 2004;364:
167883.
11. Sherman ME, Castle PE, Solomon D. Cervical cytology of
atypical squamous cells-cannot exclude high-grade squa-
mous intraepithelial lesion (ASC-H): characteristics and
histologic outcomes. Cancer 2006;108:298305.
12. Sadler L, Saftlas A, Wang W, Exeter M, Whittaker J,
McCowan L. Treatment for cervical intraepithelial neopla-
sia and risk of preterm delivery. JAMA 2004;291:21006.
13. Nohr B, Tabor A, Frederiksen K, Kjaer SK. Loop electro-
surgical excision of the cervix and the subsequent risk of
preterm delivery. Acta Obstet Gynecol Scand 2007;86:
596603.
14. Raab SS. Can glandular lesions be diagnosed in pap smear
cytology? Diagn Cytopathol 2000;23:12733.
15. Walker JL, Wang SS, Schiffman M, Solomon D. Predicting
absolute risk of CIN3 during post-colposcopic follow-up:
results from the ASCUS-LSIL Triage Study (ALTS). ASCUS
LSIL Triage Study Group. Am J Obstet Gynecol 2006;195:
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ISSN 1074-861X
Cervical cancer in adolescents: screening, evaluation, and manage-
ment. Committee Opinion No. 463. American College of Obstetricians
and Gynecologists. Obstet Gynecol 2010;116:46972.