Abnormal Pap or Positive HPV? What the Results Really Mean

Most women don't think about their cervix until they have to get a Pap smear. As if the pelvic exam wasn’t stressful enough, getting the news that you had abnormal Pap or positive HPV results, especially when accompanied by words like “cervical dysplasia,” “biopsy,” or “pre-cancerous,”  can spin you out with worry. I get it. We’re not given much intel on what all those test results and terms really mean. On top of it, HPV vaccine marketing has put the fear of cervical cancer out there in a big way – so hearing you have HPV can make you panic.

Today I break it all down for you, explaining the most common abnormal results that show up on these tests, what they mean, and what next steps are recommended for you, at your specific age. Hopefully it will put these results into perspective, and help you breathe a little more easily.

Positive Results: Don’t Jump to the Worst Conclusion!

If your Pap test results came back positive, it doesn’t mean you have cervical cancer. More likely it means:

1. You had a false positive (that means you’re fine, and the results are wrong), or
2. Your health-care provider (HCP) found a possibly significant change in the cells on or just inside of your cervix.

Repeat. It doesn’t mean you have cervical cancer. In fact, you probably don’t. Most often the changes are due to the presence of a high-risk strain of HPV (hrHPV), so often testing for HPV will be part of the next level of testing, and depending on the degree of changes, a colposcopy. The results are a heads up. Even with the most significant changes seen on Pap (HSIL which is described below), only 2% of women who receive that result already have cervical cancer.

Wait, a Colposcopy? What's That?

Colposcopy, or as we call it shorthand in gynecology, a ‘colpo,’ is a closer examination of your cervix using a special microscope-like device. It’s very similar to getting a pap, though given that you’re getting it because of concerning results, your anxiety is likely to be higher.

During this exam, your health care provider can look for areas of concern, apply acetic acid (vinegar) to the cervix and look for specific changes that this causes on (or slightly inside) the cervix if there are areas of cellular change. If necessary, your provider can also take a small tissue sample (or several) called a biopsy. It is momentarily uncomfortable but when necessary, can provide important results to guide the next follow-up testing steps, or treatment, if needed.

Let’s Talk Results

My HPV Came Back Positive, What Does This Mean?

Human Papilloma Virus (HPV) is a contagious (and sexually transmitted) organism, and is the key culprit in causing cervical cancer. Read more about this in the my article Everything You Need to Know About the Pap Test, HPV, and Pelvic Exams here.

It’s spread mainly by direct skin-to-skin contact during vaginal, oral, or anal sex and it can be spread even when an infected person has no visible signs or symptoms. You can contract HPV even if you have only one sexual partner, but it’s more likely if you’ve had quite a few. There are over 100 types of HPV, but only about a dozen are associated with cervical cancer. It’s also associated with anal and throat cancer, also from sexual contact.

The HPV test looks for the high risk strains of (HPV) – though it only detects some, not all of them.

If you’re 29 and under, you won’t have this test done unless your Pap comes back abnormal. If you’re over 29, it might be part of your cervical cancer screening, depending on whether you choose Pap alone, co-testing, or HPV alone, which I explain in this article.

If your HPV results come back positive, don’t panic. Only a  very small number of women who are infected with HPV will go on to develop any cancer related to this virus. Further, HPV infection usually clears up without any intervention within a few months after acquisition, and about 90% clear within 2 years. It takes 15 to 20 years for cervical cancer to develop in women with normally functioning immune systems (and 5 to 10 years if there’s immunocompromise). The peak age for picking up an HPV infection is in the early 20s, yet it’s not likely to show up as serious cervical changes (i.e., HSIL, explained below) until around age 30, with the highest cancer risk at ages 45 to 60.

Because cervical cancer doesn’t cause symptoms until it’s advanced, testing is the best strategy for detecting and if necessary, treating early cervical changes. Keep in mind, it is very low risk, and the vaccination, which also has risks, doesn’t protect against all forms of HPV, including high-risk strains you were exposed to prior to getting vaccinated, so even if you had Gardasil or another HPV vaccine, you still need testing.

Another advantage of testing is that knowing you have cervical changes or HPV can alert you to the need for nourishing your vaginal microbiome, and boosting your overall immunity. I share proven strategies for clearing HPV and reversing mild cervical dysplasia (cellular changes) in a forthcoming article.

HPV Results

If you’re 21-29 years old:

• HPV testing is only done if your Pap shows abnormal cells, so see below for that.

If you’re 30 or over, with positive HPV and a normal Pap, HPV will still most commonly clear on its own within a year. The recommendation is to simply follow these steps:

• Repeat co-testing with both the Pap and HV in 1 year.
• If at that time, the testing is normal, as it will be in most women, repeat co-testing in 3 years. If, however, retesting at 1 year comes back abnormal again, then you go onto having a colposcopy.
• Feel like you just can’t wait a year to retest? Studies show that it’s very unlikely for cervical cancer to be missed by waiting, or even if it were present, because it is usually very slowly progressing, for waiting that year to have been a problem. But another option is to get HPV DNA typing done, and if this shows that you have a high risk strain of HPV you can reasonably go ahead with a colposcopy at that time.

Just the presence of HPV, in the absence of an abnormal pap, should not lead to colposcopy, unless you are high-risk HPV positive.

Some women have persistently positive HPV results, even over many years, and this can increase cervical cancer risk, so it’s important to also have Pap smears if this is the case for you. Persistent HPV infection is the most important risk factor for cervical cancer precursors and cervical cancer. The longer high-risk HPV infection is present, the greater the risk of high-grade squamous intraepithelial lesions (HSIL), which is a great reason to support a healthy general and cervical immune system with cancer preventative strategies that have been shown to clear HPV and reverse cervical changes.

What if you have abnormal Pap results? Let’s explore that together.

Abnormal Pap Results…and I’m Freaking!

Of course, your first thought when you get abnormal Pap results is that you’re headed for cervical cancer. You can hit-the-brakes on that runaway worry train. That’s rarely the case, especially with mild cervical changes. Your body knows how to heal – and given the right support, you can help your body along.

The next section reviews the 3 main Pap results and what they mean. This is based on what’s called the Bethesda System, which is the standard system used to categorize test results based on the level of risk of those cells turning into cervical cancer, and has a high rate of accuracy.

ASCUS: Atypical Squamous Cells of Undetermined Significance

This is the most common abnormal finding and means that your Pap shows some irregularity in your squamous cells, specific cells on the surface of the cervix, but that these cells do not have characteristics of squamous intraepithelial lesion (SIL) – possibly precancerous cervical changes. The risk of cervical cancer in women with ASCUS is extremely low, likely because up to two-thirds of the time it is not associated with high-risk HPV infection. If you do get this result, there are age related options:

If you’re between 21 and 24, these are the recommended next steps for either ASCUS or LSIL (described in the next section):

• If you haven’t done one, now’s the time to get an HPV test.
• If your HPV test is negative, you just do a regular testing schedule; if you’re HPV positive, you repeat a Pap in 12 months.
• If your HPV test is positive, you go onto colposcopy; if it’s negative you repeat a Pap again in 12 months, and if negative again, you resume your regular testing schedule.

If you’re between 25 and 65 (and not pregnant – discuss Paps with your midwife or OB if you are), these are two options for next steps:

• HPV testing is the preferred next step if you haven’t already had it. If it’s positive, a colposcopy is recommended. If the HPV test is negative, no colpo is needed, and you simply co-test for Pap +HPV in 3 years.
• Alternatively, you can repeat the Pap in 1 year. If negative, go back to normal screening; if ASCUS is present, or cell changes have worsened, then do colposcopy.

LSIL: Low-grade squamous intraepithelial lesion

This means that there are some potentially precancerous cells present, but that your cervical changes are mild and have a low likelihood of progressing onto cervical cancer. While your cells are most likely to revert to normal on their own, this is one of the times when colposcopy is recommended for some extra evaluation. However, for women 24 and under, LGSIL almost never turns out to be precancerous and often goes away on its own, so experts recommend that if you’re in this age range, you can simply wait and have another Pap in one year.

If you’re between 21 and 24, follow the steps as above for ASCUS for this age-range.

If you’ve 25 or over, if you come back LSIL positive, here are the next steps:

• If you’re LSIL positive with a negative HPV test, you repeat cotesting in 1 year; if both tests are normal at that time, you repeat both in 3 years.
• If you’re LSIL positive and HPV positive, or don’t have HPV results, you go onto colposcopy.

HSIL: High-grade squamous intraepithelial lesion

This is a more concerning result that suggests more serious changes in your cervical cells and so requires colposcopy and biopsy. It doesn’t mean you have cervical cancer, just that you’re higher risk for this type of abnormal cell becoming cervical cancer (only 2 percent of women with these changes have cancer already, but up to 20 percent of women with these lesions will progress to cancer if left untreated).

Remember, though, that as scary as all of this is, even serious abnormalities can almost always be successfully treated.

Don’t Put Your Cervix on the Back Burner

While it’s so easy to put yourself on the back-burner and not get testing, remember, it’s important to get tested properly. That said, there are risks to getting too many screening tests. Most HPV positive results and many of the abnormalities found on the Pap test will clear on their own. Too much testing can lead to unnecessary additional tests and treatments, including those that can cause cervical damage affecting future pregnancies and births.

If your testing is normal, it’s just once every 3 to 5 years – you’ve got that. And if you have any questionable results, all the more important to keep up with regular testing.