2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia
Canadian colposcopy guideline group · 2023 · Canada
Source and licence
- Authors
- Karla Willows, Amanda Selk, Marie-Hélène Auclair et al.
- Title
- 2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia
- Journal
- Current Oncology, 2023
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC10297713
Licence statement of the original publication
Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
3.1. The Lower Anogenital Squamous Terminology (LAST) for HPV-Related Lesions of the Cervix
- Recommendations• Histopathology should be reported using the two-tiered terminology described by the LAST Project: LSIL for CIN1 and HSIL for CIN2/CIN3 (conditional, moderate). • p16 immunohistochemistry may be used to upgrade CIN2 to CIN3. P16 should not be used to upgrade morphologically appearing CIN1strong, high
3.2. Risk-Based Entry to Colposcopy
- Recommendations• People with a positive HPV screening test should undergo HPV genotyping and reflex cytology before referral to colposcopy (strong, high). • People with HPV 16/18 should be referred to colposcopy (strong, high). • People with HPV ‘other’ ASCUS or LSIL should have HPV testing repeated at 12 and 24 months, only referred to colposcopy if they meet other criteria or have persistent HPV “other” at 24 months (conditional, moderate). • People with HPV-positive HSIL, ASC-H, AGC, AIS or cytology suspicious for invasive cancer should be referred directly to colposcopy, regardless of HPV genotype (strong, high). • People with immunocompromise with any HR HPV should be referred to colposcopyconditional, low
3.3. The Initial Colposcopic Exam and Documentation
- Recommendations• The transformation zone should be assessed, and the type should be documented (strong, high). • International Federation of Cervical Pathology and Colposcopy (IFCPC) terminology is recommended for documenting colposcopic findings (strong, high). • Targeted biopsies of lesions are recommended. In the setting of HSIL, or positive HPV16/18, where colposcopic impression is normal, any area of acetowhitening, metaplasia or uncertainty should be biopsied (strong, high). • Endocervical curettage and endometrial biopsies are contraindicated in pregnancy (strong, high). • Endocervical curettage is recommended with: (i) a type 3 transformation zone, (ii) HSIL/ASC-H cytology when no lesion is identified, (iii) AGC/AIS cytology, (iv) when excisional treatment has positive margins and (v) in people over age 45 with HPV 16 (conditional, moderate). • Endometrial sampling is recommended in those 35 years and older for all categories of AGC/AIS or atypical endometrial cells on cytology. Endometrial sampling is also indicated in those under 35 with increased risks of endometrial cancer (obesity, chronic anovulation or abnormal uterine bleeding) or atypical endometrial cells on cytology in those of any age (strong, moderate). • For pain management for routine exam and cervical biopsies, thorough pre-procedure counseling and non-pharmacologic methods are recommended. Oral analgesics may be considered. Topical and injected analgesics are not recommended for routine exam and biopsies of the cervixstrong, low
3.4. Low-Grade Referral Pathway (Figure 2)
- Recommendations• After initial colposcopy assessment, those with normal or LSIL histology can be discharged from colposcopy (strong, moderate). • Where HSIL is identified on histology, excisional procedure is recommendedstrong, high
3.5. High-Grade Referral Pathway (Figure 3)
- Recommendations• People with evidence of histologic HSIL should undergo an excisional procedure (strong, high). • In cases where no lesion is identified following referral for HPV-positive cytologic ASC-H/HSIL, review by an experienced cytopathologist should be considered (conditional, moderate). • In cases where no cervical lesion is identified following referral for HPV-positive cytologic ASC-H/HSIL, VAIN must be ruled out by colposcopy (conditional, low). • In cases of discordance, where no histologic HSIL is confirmed, management depends on transformation zone type and referral cytology (conditional, moderate). • For a type 3 transformation zone, excisional procedure is recommended (conditional, moderate). • For a type 1 or 2 transformation zone, the preferred management for ASC-H referral cytology is surveillance. For HSIL referral cytology, excisional procedure can be considered (conditional, moderate). • If surveillance without treatment is undertaken, people should remain in colposcopy at 6-month intervals with HPV testing at annual intervals until HPV is negative on two consecutive tests and histology remains normal or LSIL (conditional, moderate). • If HPV remains positive despite negative colposcopy, people should remain in colposcopy for surveillance at 12-month intervals until they meet the above criteria for discharge (conditional, moderate). • If, during surveillance, there is evidence of cytologic or histologic HSIL, excisional procedure is recommendedstrong, high
3.6. Conservative Management of CIN2 in People <30 Years Old Where Fertility Is a Concern (Figure 4)
- Recommendations• In people under the age of 30, where childbearing considerations outweigh the risk of pre-invasive or invasive disease, and where a pathologic distinction between CIN2 and CIN3 can be reliably made, a conservative approach may be undertaken (conditional, moderate). • In these cases, review by an expert cytopathologist should rule out CIN3 (conditional, high). • Findings of CIN2 in a young person with a type 3 transformation zone or CIN2 identified on endocervical curettage should undergo excisional procedure (conditional, moderate). • Findings of CIN2 in a young person with a type 1 or 2 transformation zone may be managed conservatively for childbearing considerations; surveillance should include colposcopy at 6-month intervals and HPV testing at annual intervals for 3 years to allow these young people to resolve their HPV infections (conditional, moderate). • If CIN2 persists, continue colposcopy at 6-month intervals with HPV testing annually. People under 30 with persistent CIN2 > 36 months or CIN3 at any colposcopy visit should have an excisional procedure (conditional, low). • People under the age of 30 with initial CIN2 who are managed conservatively can be discharged from colposcopy once histology is normal or LSIL and HPV is negative on two consecutive annual follow-up visits (conditional, moderate). • People under the age of 30 with initial CIN2 who remain HPV-positive at annual follow-up should remain in colposcopy with HPV tests at annual intervalsconditional, moderate
3.7. Treatment for HSIL Histology
- Recommendations• Recommended treatment for histological HSIL is an excision procedure with a LEEP (strong, high). • An ablative procedure with carbon dioxide laser is acceptable when used by trained and experienced colposcopists when specific criteria are met (conditional, low). • Cryotherapy for HSIL is not recommended (strong, high). • Treatment should be performed in the clinic setting with local anesthesia plus a vasopressor to the cervixconditional, moderate
3.8. Post-Treatment Pathway (Figure 5)
- Recommendations• All people undergoing an excisional procedure in colposcopy should have an HPV test of cure and cytology at 6 months post treatment, as well as colposcopic assessment and endocervical curettage if endocervical margin is positive on excision specimen (strong, high). • People who are HPV-negative with normal, ASCUS or LSIL cytology and histology after treatment can be discharged from colposcopy (strong, moderate). • People who remain persistently HPV-positive with cytology and/or histology that is normal, ASCUS or LSIL, regardless of genotype, should remain in colposcopy at 12-month intervals until HPV is negative (conditional, low). • After discharge from colposcopy, people treated for HSIL should have 12-month HPV-based screening with their primary care provider. If HPV-negative, they can resume HPV-based screening at 3-year intervals indefinitelyconditional, low
3.9. Glandular Pathway (Figure 6)
- Recommendations• All people with HPV-positive AGC or AIS cytology should be referred directly to colposcopy, regardless of HPV genotype (strong, high). • At time of initial colposcopic assessment, all people with HPV-positive AGC or AIS should have endocervical curettage (strong, high). • Endometrial biopsy is recommended for all people >35 years old AND/OR risk factors for endometrial cancer AND/OR atypical endometrial cells on cytology (strong, moderate). • People referred with AGC-NOS cytology, in the absence of endometrial pathology and histologic HSIL or AIS, may be managed conservatively with colposcopy, cytology and HPV testing at annual intervals. If all negative on two consecutive visits, they can be discharged from colposcopy to HPV-based screening at 5-year intervals (conditional, low). • All people AGC-N or AIS should undergo excisional procedure regardless of HPV status (strong, high). • Following the excisional procedure for AIS/AGC-N, if margins are positive, consider re-excision (strong, high). • Following excisional procedure for AIS/AGC-N, in the absence of cancer, surveillance with 6-monthly colposcopy, ECC and HPV testing is recommended; if surveillance is negative ×3 years in colposcopy (HPV-negative, ≤HSIL/AIS), people can be discharged to HPV-based screening at 3-year intervals. If HPV is persistently positive or histology shows HSIL or persistent glandular abnormalities, people should stay in colposcopy and be managed per algorithms (conditional, moderate). • Hysterectomy can be considered when post-treatment margins/ECC are persistently positive for AIS and/or fertility is not desiredconditional, moderate
3.10. Post-Discharge Follow-Up for People with Squamous Lesions Not Treated in Colposcopy (Figure 7)
- Recommendations• All people discharged from colposcopy should have HPV-based screening at 12 months with their primary care provider (conditional, very low). • Subsequent management depends on referral cytology and HPV status. • People referred with low-grade cytology who are HPV-negative on 12-month screening with their primary care provider may transition to routine HPV-based screening at 5-year intervals (conditional, moderate). • People referred with low-grade cytology who are HPV-positive (regardless of genotype) at 12-month screening with their primary care provider should be re-referred to colposcopy for the usual indications (conditional, moderate). • People referred with high-grade cytology (untreated) should have two negative annual HPV tests in colposcopy with colposcopic findings that are normal or LSIL before they can be discharged to 12-month HPV-based screening with their primary care provider (conditional, low). If HPV remains negative at 12-month post-colposcopy screening, they may transition to HPV-based screening at 3-year intervals indefinitely. If HPV is positive at 12-month post-colposcopy screening, they should be re-referred to colposcopy for the usual indicationsconditional, high
3.11.1. People under the Age of 25
- Recommendations• Those under 25 should not have screening with HPV testing or cytology (strong, high). • If screening occurs and high-grade cytologic abnormalities are identified, indications for colposcopy remain the same, regardless of age (conditional, low). • When a CIN2 lesion is confirmed, and CIN3 is ruled out, conservative management may be undertaken when childbearing considerations outweigh the risk of invasive diseasestrong, moderate
3.11.3. Immunocompromised People
- Recommendations• Colposcopy is recommended for all immunocompromised people who are HPV-positive, regardless of HPV genotypeconditional, low
3.11.4. Menopausal People
- Recommendations• Menopausal people have higher rates of cervix cancer and unsatisfactory colposcopy. Consider ECC and larger excisions when indicated (conditional, moderate). • Consider pre-treatment with vaginal estrogen for 6 weeks prior to colposcopy to increase the rates of a satisfactory exam in postmenopausal peopleconditional, low
3.12. Equity in Colposcopy
- Recommendations• Colposcopy providers should be aware of the barriers to access cervical cancer screening and colposcopy, including geographical, socioeconomic, cultural, physical, psychological, provider-related and system-related barriers (strong, low). • Colposcopy providers are encouraged to seek additional training in cultural safety and trauma-informed care (strong, low). • Every effort should be made to facilitate access to care for individuals from historically underserved populations, including people with mobility restrictions, obesity, members of the transgender community, immigrants, Indigenous peoples, people from rural communities and those with mental health disordersstrong, low
Abstract
This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.
Contents of the original publication
The section headings of the original.
- 1. Introduction
- 2. Methods
- 3. Results
- 3.1. The Lower Anogenital Squamous Terminology (LAST) for HPV-Related Lesions of the Cervix
- 3.2. Risk-Based Entry to Colposcopy
- 3.3. The Initial Colposcopic Exam and Documentation
- 3.4. Low-Grade Referral Pathway (Figure 2)
- 3.5. High-Grade Referral Pathway (Figure 3)
- 3.6. Conservative Management of CIN2 in People <30 Years Old Where Fertility Is a Concern (Figure 4)
- 3.7. Treatment for HSIL Histology
- 3.8. Post-Treatment Pathway (Figure 5)
- 3.9. Glandular Pathway (Figure 6)
- 3.10. Post-Discharge Follow-Up for People with Squamous Lesions Not Treated in Colposcopy (Figure 7)
- 3.11. Special Populations
- 3.12. Equity in Colposcopy
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