An abnormal Pap smear is one of the most under-explained results in Indian women’s healthcare. The report arrives with words like ASCUS, LSIL, HSIL, or CIN, and the recipient is rarely told what they mean in plain language or what the actual risk is. The result is anxiety on one side and inaction on the other, both of which are avoidable with five minutes of context.
This article is the checklist a gynaecologist works through after an abnormal Pap result, written so you can follow along with what’s happening to your case.
The vocabulary you’ll see on the report
Pap smear results in India are typically reported in the Bethesda system. The terms you’ll see, ranked from least to most concerning:
- NILM, Negative for Intraepithelial Lesion or Malignancy. The result is normal.
- ASCUS, Atypical Squamous Cells of Undetermined Significance. The cells look slightly abnormal but don’t clearly indicate a pre-cancer. This is a “grey zone” result.
- ASC-H, Atypical Squamous Cells, cannot rule out a high-grade lesion. More concerning than ASCUS.
- LSIL, Low-grade Squamous Intraepithelial Lesion. Mild abnormality, usually corresponds to CIN 1 on biopsy. Often clears on its own.
- HSIL, High-grade Squamous Intraepithelial Lesion. Moderate to severe abnormality, corresponds to CIN 2 or CIN 3 on biopsy. Pre-cancer that needs treatment.
- AGC, Atypical Glandular Cells. Refers to cells from the inner cervical canal or uterus rather than the outer cervix. Always needs further work-up.
- Carcinoma, invasive cancer is present.
On biopsy, “CIN” stands for Cervical Intraepithelial Neoplasia: CIN 1 (mild), CIN 2 (moderate), CIN 3 (severe). CIN 2 and CIN 3 are considered pre-cancers requiring treatment.
Step 1: HPV testing
Most abnormal Pap results, particularly ASCUS, LSIL, and AGC, are followed by an HPV test (sometimes “reflex HPV” testing, done on the same Pap sample). This identifies whether high-risk HPV strains are driving the abnormality.
The result splits the next step:
- HPV negative with ASCUS or LSIL → repeat Pap in 1 year (low risk of progression)
- HPV positive with any abnormal Pap → colposcopy
If your initial Pap was abnormal and HPV testing was not done, ask for it. It substantially changes the management pathway.
Step 2: Colposcopy
Colposcopy is a magnified visual examination of the cervix, performed in the outpatient setting. It takes about 15 minutes and uses dilute acetic acid (vinegar) and an iodine solution to highlight areas where abnormal cells are present.
If suspicious areas are seen, the colposcopist takes a biopsy, a small sample of tissue for pathology. The biopsy result is what determines whether treatment is needed.
There is some discomfort but not significant pain. No anaesthesia is required for the procedure itself.
Step 3: Pathology and decision
The colposcopy biopsy gives a definitive answer:
- No dysplasia or CIN 1 → observation with repeat Pap and HPV testing in 12 months. CIN 1 has a high spontaneous regression rate.
- CIN 2 → in younger women trying to preserve fertility, observation is reasonable; in others, treatment is offered.
- CIN 3 or carcinoma in situ → treatment is needed.
- Invasive carcinoma → referral to a gynaecological oncologist and staging work-up.
This is the point at which the right specialist matters. For CIN 2/3 management, precancerous cervical lesion treatment by a specialist trained in cervical pathology produces materially better outcomes than treatment by a general practitioner.
Step 4: Treatment options for high-grade lesions
For CIN 2/3, the two standard treatments are:
LEEP (Loop Electrosurgical Excision Procedure), a thin wire loop with a small electric current excises the affected area. Done in the outpatient setting with local anaesthesia. Takes about 20 minutes. Recovery is straightforward; mild spotting for a few weeks.
Cold knife conisation, a cone-shaped section of cervix is removed surgically under anaesthesia. Reserved for cases where LEEP is inadequate (e.g., extension into the endocervical canal, glandular pathology).
Both procedures preserve the uterus and most of the cervix, and both are compatible with future pregnancy. Cervical cerclage may be advised in subsequent pregnancies after a deep cone or repeat LEEP.
Step 5: Follow-up
After treatment for CIN 2/3, follow-up testing at 6 and 12 months is standard, then annually for several years. HPV testing during follow-up has become as important as Pap smear because it predicts recurrence risk.
When to escalate to a gynaecological oncologist
- Any biopsy result showing invasive cervical cancer
- AGC (atypical glandular cells) on Pap smear
- Persistent or recurrent CIN 2/3 after one round of treatment
- CIN 2/3 with deep extension into the cervical canal
- Adenocarcinoma in situ (AIS) on biopsy
- Any abnormal Pap result in a postmenopausal woman with concerning imaging
In these scenarios, treatment requires either more complex surgery or fertility-preserving cancer surgery, both of which are sub-speciality skills.
What you can ask for at every visit
A few questions that produce more useful answers:
- “What exactly does my Pap result say in Bethesda terminology?”
- “Was HPV testing done? What was the result?”
- “What is the next step based on this result, and why?”
- “If I have CIN, what’s the chance it will resolve on its own versus need treatment?”
- “If treatment is needed, what does it actually involve and what’s the recovery?”
You are entitled to all five answers. A good clinician will provide them without being asked.
The bottom line
An abnormal Pap smear is rarely an emergency. It is almost always a process, observe, retest, colposcopy, biopsy, treatment, follow-up, that is designed to catch pre-cancer years before it becomes cancer. The system works when it’s followed. The failures happen when patients drop out between steps because they don’t understand what each step is for.
If you are mid-process, the right next step is the one your gynaecologist has scheduled. Don’t skip it.
About the author
This article was reviewed by Dr. Nishtha Tripathi Patel (MBBS, DGO, DNB, Fellowship in Gynaecological Oncology, ESGO-certified), an ESGO-certified gynaecological oncosurgeon in Ahmedabad specialising in colposcopy, treatment of cervical pre-cancer, and surgery for cervical cancer. Reach her practice at +91 76988 00333.
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