Lsil Triage

LSIL is a benign disease in young women. The higher rate of regression of LSIL in adolescents compared with adult women led to more reasonable guidelines (13). Conservative observation of LSIL by cytology rather than immediate referral to col-poscopy in adolescents and young women is now accepted. In the United States, it is recommended that a young woman with LSIL return in 6 months for repeat cytology. Any abnormality on repeat cytology leads to referral to colposcopy. However, in adolescents regression may take up to 36 months (40). Hence, close observation with repeat cytology every 6 months up to 2 years is reasonable. Appearance of HSIL on cytology at any follow-up visit should be referred to colposcopy. Alternatively, adolescents can return in a year for HPV testing (13). The evidence for this recommendation is sparse. The rational is that the increased sensitivity of HPV testing compared with cytology allows for longer intervals of follow-up. The presence of HPV at 1 year after a LSIL diagnosis is believed to reflect HPV persistence and hence, increased risk for HSIL development. However, in adolescents, the chances of the HPV infection reflecting persistent infection are low. It is far more likely that the HPV detected at 1-year follow-up reflects a new infection unrelated to the previous LSIL diagnosis. On the other hand, if the HPV test is negative, the LSIL has most likely regressed allowing the individual to be put back into standard screening.

Although, HPV testing is now being implemented in many countries for primary screening, the data clearly show that for primary screening in adolescents, HPV testing is not recommended. As mentioned previously, HPV detection in a woman more than 30 years of age who is in a monogamous relationship most likely reflects persistent infection. In contrast, detection of HPV in adolescents and young women most likely reflects an incident and transient infection.

In summary, although HPV is undoubtedly the cause of cervical cancer, HPV detection is not a specific sign of cervical cancer. In fact, in adolescents it is quite common with more than 50% acquiring HPV within 5 years after the onset of sexual intercourse. Although, HPV is a common infection, it is transient in most women. Persistence of

HPV is a key factor in the development of invasive cancer. However, natural history studies show that invasive cancers do not evolve within 3 years after exposure to HPV even with HPV persistence. Understanding the natural history of HPV in adolescents sheds light on the high rate of HPV infection reported in this age group. However, the association between age of first intercourse and invasive cancer cannot be ignored. Accordingly, although screening shortly after initiating intercourse is not necessary, adolescents who initiate sexual activity are vulnerable to HPV infection. Nonetheless, persistence is an important risk factor and development of invasive cancer usually takes decades. Recommendations for screening should assess risk based on behavior not simply on chronological age.

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