High Grade Squamous Intraepithelial Lesion

Delay LEEP until after pregnancy
1. Low risk of progression in pregnancy
2. Lesions often regress in Postpartum Period
3. Yost (1999) Obstet Gynecol 93:359-62 [PubMed]
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

Option 1: Colposcopy
1. CIN 2, 3
  1. See CIN 2 or CIN 3 protocol as below
2. No CIN 2 or 3: Observe with Colposcopy and repeat cytology every 6 months for 2 years
  1. HSIL cytology or high grade colpo for 1 year
    1. Biopsy and treat as CIN 2,3 if positive biopsy
  2. HSIL cytology without CIN 2,3 on colpo for 2 years
    1. Diagnostic excisional procedure when not pregnant
  3. Cytology negative x2 AND colpo without high grade colpo changes
    1. Return to routine screening
Option 2: Immediate Loop electrosurgical excision
1. Contraindicated in pregnancy or as initial management in age under 25 years old

Step 1a: Initial management of women over age 25 years based on Colposcopy results
1. Inadequate Colposcopy or Recurrent CIN 2, 3 or ECC with CIN 2, 3
  1. Diagnostic Excisional Procedure
2. Adequate Colposcopy
  1. Excision or ablation of transformation zone
Step 1b: Initial management of women under age 25 years based on Colposcopy results
1. Option 1: Treat using protocol as in 1a (see above)
  1. CIN 3 on Colposcopy
  2. Inadequate Colposcopy
  3. Per patient preference
2. Option 2: Observation with Colposcopy and cytology every 6 months for 12 months
  1. Cytology and Colposcopy negative at 6 and 12 months
    1. HPV and Cervical Cytology co-testing negative at 1 year
      1. Space co-testing to every 3 years
    2. HPV or Cervical Cytology co-testing positive at any time
      1. Repeat Colposcopy and biopsy
  2. Colposcopy positive for CIN 3 or persistent CIN 2 for 24 months
    1. Treat using protocol as in 1a (see above)
Step 2: Excisional procedure with positive CIN 2,3 margins (or on post-procedure ECC)
1. Option 1: Repeat Cytology and ECC in 4 to 6 months (preferred)
2. Option 2: Repeat diagnostic excisional procedure
3. Option 3: Hysterectomy
Step 3: Repeat HPV and Cervical Cytology (co-testing) at 12 and 24 months
1. Repeat Colposcopy if either HPV or cytology is abnormal at either 12 or 24 months
2. Repeat HPV and cytology co-testing in 3 years if all tests are negative at 12 and 24 months
  1. If negative repeat testing may return to routine screening