High Grade Squamous Intraepithelial Lesion Treatment

An abnormal Pap smear result of high-grade squamous intraepithelial lesion (HSIL) means that cells of the cervix (the narrow neck of a woman's uterus) look somewhat to very abnormal when examined under a microscope.

Before cervical cancer forms, the cells of the cervix undergo abnormal changes called cervical dysplasia. Although untreated cervical dysplasia can lead to cervical cancer, having it does not mean that a person has cancer or will develop the disease.

Additional testing is typically needed for HSIL to confirm cervical dysplasia and to learn more about the severity of the abnormal cells. It may be treated first with monitoring to see if it persists or with an outpatient procedure in the healthcare provider's office.

According to the Centers for Disease Control and Prevention, up to 93% of cervical cancers are preventable with regular screening and treatment of abnormalities. This is why women undergo regular Pap smear exams to screen for any abnormal changes to the cervix.

This article will explore HSIL, what it is, how it is treated, and what follow-up care entails.

Treatment

When choosing the best treatment for a HSIL Pap smear result, healthcare providers look at the risk of CIN 3 being present. To do so, they look at your current tests, your history of cervical cancer screening, your past medical history, your age, and whether you plan to become pregnant in the future or are pregnant at the current time.

Expedited Treatment

If the risk of CIN 3 is not very high, waiting for the results of biopsies done during a colposcopy is often the first step.

In some cases, expedited treatment (treatment without doing biopsies) is recommended. This approach is recommended for non-pregnant women over the age of 25 when the risk of CIN 3 is considered to be 60% or more, and is an acceptable approach if the risk if between 25% and 60%.

Examples include women who have a Pap smear result that shows HSIL along with an HPV test that is positive for HPV 16. This is also the case in women who have a positive HPV test for any strain of HPV, and have not had recent cervical cancer screening.

Removing tissue in this case not only removes the abnormal tissue, but may reduce the possibility of cervical cancer in the future.

Treatment During Pregnancy

Some of the treatments used for HSIL cannot be used during pregnancy. Your healthcare provider will help you understand whether you need to have an immediate colposcopy or if you can wait until you are postpartum (at least four weeks). If you had biopsies showing CIN 2 or CIN 3, they may recommend holding off on treatment and simply testing (Pap or colposcopy) every 12 weeks, but this will vary depending on your particular risk factors.

Young Patients

Treatment choices need to be individualized in women under the age of 25. With younger women there is a higher chance of regression (cervical changes going away on their own), and any treatment is more likely to impact future pregnancies. That said, biopsies that are returned as CIN 3 should always be treated, as they are considered direct precursors to cancer.

Treatment Methods

There are advantages and disadvantages with all methods used to treat HSIL, and your healthcare provider will help you weigh the benefits (the chance that the procedure will be effective in removing abnormal tissue), against the risks (the chance of side effects related to the procedure).

Treatments can be broken down into those that are excisional (remove tissue) and those that are ablative (destroy tissue). Depending on your situation, one of these approaches may be preferred.

Ablation

Ablation treats the abnormal cells by using things like freezing, heat, or other measures to destroy the cells. There are different kinds of ablative treatments.

Cryotherapy

Cryotherapy is a technique that's used to destroy abnormal tissue by freezing it. It is also called cryosurgery.

CO2 Laser Ablation

This type of laser therapy uses a tiny beam of light to destroy abnormal cells.

Thermal Ablation

Thermal ablation is similar to cryotherapy, but uses heat instead of cold to destroy tissue.

Surgical Excision

Surgical excision removes the abnormal tissue in order to treat it. Excisional treatments are used more commonly in the United States and have the advantage of providing a piece of tissue that a pathologist can view under the microscope (to assess the margins, or how close any abnormal cells were to the edge of the sample), helping to predict the risk of recurrence. While associated with a lower risk of recurrence, excisional techniques also tend to have a higher risk of adverse effects.

In some situations, excisional treatment should always be done. This includes abnormal changes that extend into the cervical canal and more.

The primary risk with excision methods is of pregnancy complications, such as premature births, in the future. Since abnormal cervical changes alone may increase the risk of preterm births, your healthcare provider will help you understand the best option for you if you plan to become pregnant in the future.

Loop Electrosurgical Excision Procedure (LEEP)

During a LEEP, an electric current is sent through a wire loop. The wire loops act as a knife, removing abnormal cervical cells.

Laser Cone Biopsy

This type of laser therapy uses a tiny beam of light to cut out abnormal cells.

Cold Knife Cone

Also called a cone biopsy or cold knife ionization, conization removes a larger, cone-shaped sample of abnormal tissue.

Topical Therapy

Right now there are no topical therapies approved to treat HSIL, but there are some being studied.

Imiquimod Cream

One study found that 61 percent of participants receiving treatment with imiquimod cream applied to the cervix weekly had regression of their HSIL. There were a variety of adverse effects, like itching, vaginal ulcer, and pelvic pain. More studies are necessary to evaluate this treatment.

Cidofovir Cream

Cidofovir, an antiviral, is a treatment for vulvar and non-genital HPV lesions, as well as for viruses like herpes. Studies of the cidofovir gel being used in a variety of dosing schedules have shown effectiveness for treating HSIL, with regression of the disease. More studies need to be done.

5-Fluororouracil Cream

5-Flurorouracil (5-FU) is an antimetabolite that is also used as a chemotherapy drug. Topical 5-FU has been used to treat genital warts and vulvar/vaginal dysplasia. It cannot be used daily because of adverse effects, so it's been limited to biweekly dosing or diluting the strength of the topical solution. It has shown some effectiveness in treating HSIL, but more studies need to be done on the safety as well as the effectiveness of it.

Follow-Up Care After Treatment

Following up after treatment for HSIL is absolutely necessary. Cells can become abnormal again, despite treatment, and may require additional treatment.

Follow-up care consists of regular Pap smears and colposcopy exams for an extended period of time. Your particular schedule of follow up will depend on results of any biopsies you had and treatments you have chosen, but is usually at least annually for a few years.

Since the risk of abnormalities progressing to cancer lasts for at least 25 years, it's recommended that after treatment and the initial first years of followup, testing (either HPV or cotesting) should be continued for at least 25 years, or at least as long as life expectancy warrants testing and that testing does not compromise health.

Summary

HSIL requires treatment, and there are various treatments from which to choose, although in the US, excisional treatments are most common. Your healthcare provider will go over your treatment options, as well as what to expect with your course of treatment and follow-up. Treatment is necessary, because left untreated, HSIL is more likely to lead to precancer or cancer of the cervix.

A Word From Verywell

If you are feeling anxious after being told that you have an abnormal Pap smear, especially one that shows high-grade changes, keep in mind that cervical cancer is one of the more easily prevented cancers and it is a slow-progressing disease that often takes years to develop.

While it can be frustrating to undergo treatments and so many follow-up appointments, you are taking steps to prevent cervical cancer or to detect it at an early stage when treatment is more likely to be successful.

Cervical Cancer Healthcare Provider Discussion Guide

Get our printable guide for your next healthcare provider's appointment to help you ask the right questions.

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