High Grade Squamous Intraepitheliel Lesion Treatment

In most cases, cervical cancer is a slow-progressing disease that often takes years to develop. Before any cancer develops, the cervix (the narrow neck of a woman's uterus) undergoes abnormal changes called cervical dysplasia. When caught at an early stage, cervical cancer is easier to treat and the survival rates are highest. This is why women undergo regular Pap Smear exams to screen for any abnormal changes to the cervix.

An abnormal result means that some of the cells in the cervix look different from normal cells. There are many types of Pap abnormalities:

Although untreated cervical dysplasia may lead to cervical cancer in some cases, having cervical dysplasia does not mean that a person has cancer or will ever develop the disease. It is commonly treated first with monitoring to see if it persists, and then with outpatient procedures in the doctor's office.

Pap smear medical test
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What an HGSIL Pap Smear Result Means

An HGSIL Pap smear result indicates that more defined changes in the size and shape of cervical cells have been detected, which—as mentioned above—indicates moderate-to-severe cervical dysplasia.

HPV testing is most often done along with a Pap smear, and if it was not done, should be performed on the sample. This testing looks for the high-risk forms of HPV that can lead to cervical cancer, including HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68, with HPV 16 and 18 most commonly found. The vast majority of cervical cancers are caused by these HPV infections.

Further Testing (or Expedited Treatment) is Needed

Pap smear screening results, such as HGSIL are incomplete as far making a diagnosis and planning treatment (they represent only a sampling of cells). A biopsy result obtained during a colposcopy, in contrast, allows a pathologist to see the actual changes in cells and their relation to each other within the tissue. This is needed to confirm whether precancerous changes or cancer is present or not. HSIL on a screening Pap smear usually corresponds to cervical intraepithelial neoplasia grade 2 (CIN2) or cervical intraepithelial neoplasia grade 3 (CIN3) on a biopsy.

An HGSIL Pap smear result cannot confirm whether precancerous changes or cancerous changes are present or not, and further testing is needed.

Confirming an HGSIL Result

If Pap smear results come back as HGSIL, your doctor may recommend a colposcopy exam and biopsy, or instead may suggest expedited treatment (immediate treatment with a colposcopy biopsy). This is true whether or not an HPV test is positive or negative.

A colposcopy exam is an in-office procedure that allows a doctor to visually examine the cervix with a lighted instrument called a colposcope. During the exam, the colposcope remains outside of the vagina. It acts like a microscope, allowing an in-depth view of the cervix. During the colposcopy, the doctor may also do a cervical biopsy, a procedure that removes small pieces of cervical tissue. The tissue samples are then sent to a lab for further examination. Think of a colposcopy as a more in-depth Pap smear.

Cervical biopsies may be returned as CIN2, CIN3, or sometimes, adenocarcinoma in situ (AIS).

Treatment

When choosing the best treatment for a HBSIL Pap smear result, physicians look a the risk of CIN3 being present. To do so they look at your current tests, your history of cervical cancer screening, your past medical history, your age, whether you plan to become pregnant in the future or are pregnant at the current time.

Colposcopic Biopsy vs. Expedited Treatment

If the risk of CIN3 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 CIN3 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 HGSIL along with an HPV test that is positive for HPV16. 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 doctor will help you understand whether you need to have an immediate colposcopy or if you can wait until you are postpartum (at least 4 weeks). If you had biopsies showing CIN2 or CIN3, she 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 higher chance of regression (the chance of cervical changes going away on their own), and any treatment is more likely to impact future pregnancies. That said, biopsies that are returned as CIN3 should always be treated as they are considered direct precursors to cancer.

Excisional (Removal) vs. Ablative Treatments

Treatments can be broken down into those that are excisional (remove tissue) such as a cone biopsy or LEEP and those that are ablative (destroy tissue), such as cryotherapy. Depending on your situation, one of these approaches may be preferred.

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), and 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.

Treatment Methods

There are advantages and disadvantages of all methods used to treat a HSIL Pap, and your doctor 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).

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

Possible treatments for HGSIL include:

  • 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.
  • Conization: Also called a cone biopsy or cold knife ionization, conization removes a larger, cone-shaped sample of abnormal tissue.
  • Laser Therapy: Laser therapy can be used as an excision technique (laser cone biopsy) or ablative (laser ablation). During laser therapy, a tiny beam of light is used to either cut out or destroy abnormal cells.
  • Cryotherapy: Cryotherapy is a technique that's used to destroy abnormal tissue by freezing it. It is also called cryosurgery.
  • Thermal ablation: Thermal ablation is similar to cryotherapy, but used heat instead of cold to destroy tissue.

Follow-Up Care After Treatment

Following up after treatment for HGSIL is absolutely necessary. Cells can become abnormal, despite treatment, and may require further treatment.

Following up consists of regular Pap smears and colposcopy exams for an extended period of time. Your particular schedule of followup 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 for at least 25 years, it's recommended that after treatment and 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.

A Word From Verywell

It can certainly be very frightening to be told you have an abnormal Pap smear, especially one that shows high-grade changes. While we discussed general approaches to Pap HSIL Pap smears, there are many considerations that we did not address, and it's important to have a detailed conversation with your doctor. Make sure to ask any questions you have (it helps to bring a partner with you who can help make sure they are answered), and ask again if you have any concerns.

If you are feeling very anxious, it may be helpful to keep in mind that cervical cancer is one of the more easily prevented cancers. It may be frustrated having to undergo treatments and continue followup for what seems like forever, but there is much to be gained. According to the CDC, 97% of cervical cancers could be prevented with regular screening and treatment of abnormalities that arise.

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Article Sources
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  2. American Cancer Society. Survival Rates for Cervical Cancer. Updated February 5, 2019.

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  4. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer PrecursorsJ Low Genit Tract Dis. 2020;24(2):102-131. doi:10.1097/LGT.0000000000000525

  5. Centers for Disease Control and Prevention. Cervical Cancer is Preventable. Updated 01/06/20.