Purpose of screening: The NHS cervical screening programme detects high-risk human papillomavirus (hrHPV) and cellular changes (dyskaryosis) that may lead to cervical cancer if untreated.

🔍 Background

Primary hrHPV testing is performed on all samples; cytology is only examined if hrHPV is detected.
Persistent hrHPV produces viral oncoproteins (E6, E7) → inactivation of tumour suppressors (p53, Rb).
This drives the pathway CIN1 → CIN2 → CIN3 → carcinoma in situ → invasive cancer.

📊 Types of Abnormal Results

HPV Negative → routine recall (3-yearly age 25–49, 5-yearly age 50–64).
HPV Positive, Cytology Negative → repeat test in 12 months; persistent positivity → colposcopy.
HPV Positive + Abnormal Cytology → direct referral to colposcopy.
- Borderline or low-grade dyskaryosis → often CIN1.
- High-grade dyskaryosis (moderate or severe) → usually CIN2/3.
- Suspicious of glandular neoplasia or invasion → urgent colposcopy.

🧬 Pathophysiology

HPV 16 and 18 integrate into host DNA. Viral oncoproteins disrupt normal cell-cycle control, leading to dysregulated proliferation. Without immune clearance, progressive CIN may evolve over years into invasive squamous carcinoma.

🩺 Management Principles

Colposcopy is used for visual assessment and directed biopsy.
CIN1 is often observed as many regress spontaneously.
CIN2/3 usually requires excision with LLETZ.
All treated women have a “test of cure” (HPV + cytology) at 6 months.

🇬🇧 UK Practical Context

Offered to women and people with a cervix aged 25–64.
25–49 years: every 3 years; 50–64 years: every 5 years.
HPV vaccination is expected to reduce future rates of abnormal smears and CIN.

✨ Key Learning Points

An abnormal smear is not cancer but signals increased risk.
Persistent hrHPV is the critical driver of progression.
Screening + vaccination together offer strong protection against cervical cancer.

Cases

Case 1 — Borderline Change with High-Risk HPV: A 28-year-old woman attends routine cervical screening. Her cytology shows borderline squamous changes, and reflex testing is positive for high-risk HPV. 💡 In the UK screening programme, borderline or mild dyskaryosis with high-risk HPV prompts referral for colposcopy. This approach helps detect and treat high-grade CIN early, preventing progression to cervical cancer. If HPV were negative, she would simply return to routine recall.
🧪 Case 2 — Low-Grade Dyskaryosis: A 34-year-old woman has her first abnormal smear showing low-grade dyskaryosis (possible CIN1). HPV testing is positive. 💡 Low-grade changes often reflect transient HPV infection, especially in younger women. Colposcopy is arranged to confirm the diagnosis. If CIN1 is confirmed, many cases regress spontaneously, so observation with repeat cytology/HPV testing is often appropriate unless persistence or progression occurs.
🧪 Case 3 — High-Grade Dyskaryosis: A 41-year-old woman presents with a smear showing high-grade dyskaryosis suggestive of CIN2/3. 💡 High-grade abnormalities indicate significant risk of progression to invasive cancer. Colposcopy with biopsy is performed, and if confirmed, treatment usually involves large loop excision of the transformation zone (LLETZ). Women require long-term surveillance following treatment, as recurrence risk is higher.

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Abnormal Cervical Smear Results