In postmenopausal women, a trial of vaginal estrogen cream for one month prior to repeating the PAP smear should be considered because estrogen deficiency can cause mild cellular abnormalities that revert to normal in 90 percent of women after estrogen treatment. Women who are HPV positive should undergo colposcopy because they are at high risk for persistently abnormal PAP smears. The PAP smears of HPV negative women are more likely to spontaneously revert to normal, so these women may be followed with repeat PAP smears. Fifty to 90 percent of these smears will revert back to normal within 2 to 10 years without therapy. Determining the size and location of the lesion is helpful in deciding whether to treat the lesion or follow it with serial colposcopies.
Large lesions are less likely to spontaneously resolve.
Observing the extent and severity of the lesion is useful for establishing a baseline in women who are not treated and followed with colposcopy. All women with this finding on PAP smear should be referred for colposcopy and biopsy to confirm the diagnosis. Confirmed HSIL should be treated because approximately 20 percent of untreated patients will develop invasive cancer. If colposcopy does not confirm HSIL, then close follow-up and further testing is warranted to determine whether colposcopy has missed the lesion. All women with this diagnosis require colposcopy, biopsy of the endocervical canal, and possibly endometrial biopsy.