Management of Normal Pap with Positive HPV 18/45

Rationale for Colposcopy

The Centers for Disease Control and Prevention recommends colposcopy for patients with normal Pap smear but positive HPV 18/45 due to the high association of HPV 18 with cervical cancer, particularly adenocarcinoma 1, 2
The American College of Obstetricians and Gynecologists suggests that because of the specific association of HPV 18 with adenocarcinoma, endocervical sampling is acceptable at the time of colposcopy 2
The 2021 CDC STI Treatment Guidelines specifically recommend colposcopy for HPV 18-positive results regardless of cytology findings, with a strength of evidence level of A 3

During colposcopy, the clinician should perform a thorough examination of the transformation zone, consider endocervical sampling due to HPV 18's association with adenocarcinoma, and take directed biopsies of any suspicious areas, as recommended by the American Society for Colposcopy and Cervical Pathology 2, 3, 4

If colposcopy is negative, HPV testing or cotesting at 12 months is recommended by the National Comprehensive Cancer Network, with HPV testing or cotesting preferred over cytology alone for follow-up 2, 3, 5
If colposcopy reveals CIN 1 or less, repeat HPV testing with or without concurrent Pap test in 1 year is recommended by the American College of Obstetricians and Gynecologists, with referral for colposcopy if positive again 3, 6
If colposcopy reveals CIN 2+ (moderate or severe dysplasia), treatment options include ablative or excisional procedures, with surveillance continuing for at least 25 years, as recommended by the American Society for Colposcopy and Cervical Pathology 1, 2, 6

Studies show that approximately 14% of women with HPV 18 infection develop CIN 3 or higher lesions, highlighting the importance of prompt colposcopy and follow-up, as reported by the Journal of the National Comprehensive Cancer Network 6

The Centers for Disease Control and Prevention advises against delaying colposcopy for HPV 18-positive results, recommending immediate colposcopy due to its high association with adenocarcinoma, with a strength of evidence level of A 2, 3
The American College of Obstetricians and Gynecologists emphasizes the importance of not overlooking endocervical sampling due to HPV 18's association with adenocarcinoma, which may develop higher in the endocervical canal 2