The next step after an abnormal Pap smear depends on what type of abnormality was found. In most cases, it’s either an HPV test, a repeat screening in one to three years, or a closer examination of your cervix called a colposcopy. The result on your Pap report tells your doctor which path to take, so understanding what your specific result means is the key to knowing what comes next.
What Your Pap Result Actually Means
An “abnormal” Pap smear isn’t a single diagnosis. Labs classify cervical cell changes on a spectrum, and where your result falls determines how urgently it needs follow-up.
ASC-US is the mildest and most common abnormal result. It stands for “atypical squamous cells of undetermined significance,” which essentially means some cells looked slightly unusual but not clearly problematic. This is often caused by temporary irritation, infection, or a low-risk HPV strain that your body will clear on its own.
LSIL (low-grade squamous intraepithelial lesion) indicates mild cell changes, typically associated with an HPV infection. These changes correspond to the earliest stage of cervical dysplasia and frequently resolve without treatment.
HSIL (high-grade squamous intraepithelial lesion) signals more significant changes that include moderate to severe dysplasia. HSIL requires prompt evaluation because these cells have a higher chance of progressing to cervical cancer if left untreated.
ASC-H means atypical cells were found that your lab couldn’t confidently distinguish from HSIL. Because HSIL can’t be ruled out, this result is treated more seriously than ASC-US.
AGC (atypical glandular cells) involves a different cell type than squamous cell abnormalities. Glandular cells line the inner cervical canal and uterus, and abnormalities here always warrant further investigation.
The HPV Test: Your First Fork in the Road
If your result is ASC-US, the most common next step is a reflex HPV test. In many labs, this test is automatically run on the same sample that was collected during your Pap, so you may not need a second appointment. The HPV test checks specifically for high-risk strains of the virus that are linked to cervical cancer.
This single test effectively sorts ASC-US results into two very different categories. If you test negative for high-risk HPV, your risk of having a serious cervical lesion is essentially zero, and you can return to routine screening without any additional procedures. If you test positive for high-risk HPV, the two-year risk of developing severe precancerous changes or early cervical cancer is around 10%, which is high enough to justify a colposcopy.
When You’re Asked to Wait and Retest
Not every abnormal result leads to an immediate procedure. Based on your individual risk profile, your doctor may recommend returning for a repeat HPV test or a combined HPV/Pap cotest in one or three years. This approach is common for low-grade results, particularly in younger women whose immune systems frequently clear HPV infections and mild cell changes without any intervention.
Current guidelines from the National Cancer Institute emphasize detecting and treating severe changes that could become cancer while minimizing unnecessary testing and treatment for low-grade abnormalities that are likely to resolve. If your doctor recommends waiting, it’s not because the result is being ignored. It’s because overtreating mild changes carries its own risks, including unnecessary procedures on the cervix that can affect future pregnancies.
What Happens During a Colposcopy
A colposcopy is the standard next step for HSIL, ASC-H, AGC, and any ASC-US result paired with a positive high-risk HPV test. It’s a closer look at your cervix using a magnifying instrument, and it typically takes 15 to 20 minutes in your gynecologist’s office.
You’ll be positioned the same way as during a Pap smear, with a speculum holding the vaginal walls open. The colposcopist examines your vulva, vagina, and cervix first without any solutions, then applies a diluted acetic acid (essentially vinegar) to the cervix with a cotton swab. The acid sits for one to two minutes. Abnormal cells dehydrate and turn white when exposed to it, making them visible under magnification. Your doctor also uses colored light filters to identify blood vessel patterns that can signal dysplasia.
If white patches or other suspicious areas appear, your doctor takes small tissue samples called directed biopsies, using a punch forceps to remove tiny pieces from each abnormal-looking area. This is the part most women feel: a brief pinch or cramp for each sample. A clotting solution is applied to the biopsy sites afterward to stop any bleeding. The tissue samples go to a pathology lab, and results typically come back within one to two weeks.
Recovery After Colposcopy and Biopsy
You can return to work and normal activities right away after a colposcopy. If biopsies were taken, you may have light spotting or a dark discharge for a few days from the clotting solution. Your doctor will likely recommend waiting a day or two before having intercourse to avoid extra bleeding at the biopsy sites. Most women describe the discomfort as mild, similar to period cramps, and it usually passes within a few hours.
If Biopsy Results Confirm Precancerous Cells
Biopsy results from a colposcopy fall on the same spectrum as Pap results but are more definitive because actual tissue was examined. Low-grade changes (CIN 1) are often monitored with repeat testing rather than treated, since most cases resolve on their own. High-grade changes (CIN 2 or CIN 3) typically require a procedure to remove the abnormal tissue before it has a chance to progress.
The two most common removal procedures are a LEEP (loop electrosurgical excision procedure), which uses a thin heated wire loop to cut away abnormal tissue, and a cold knife cone biopsy, which removes a cone-shaped piece of the cervix with a scalpel under anesthesia. Both procedures are effective. In studies comparing the two, recurrence rates were around 7% after LEEP and about 6% after a cone biopsy, a difference that isn’t statistically significant. Residual disease rates were also comparable at roughly 9 to 11% for both approaches.
The choice between them depends on the location and type of abnormality. LEEP is more commonly used because it can be done in an office setting with local anesthesia, while a cone biopsy is typically reserved for cases where the abnormal cells extend into the cervical canal or involve glandular cells. For women who plan to have children, both procedures preserve fertility, though your doctor will discuss which option best balances thorough removal with preserving cervical tissue.
The Bigger Picture: What Abnormal Doesn’t Mean
An abnormal Pap smear does not mean you have cervical cancer. The vast majority of abnormal results reflect minor cell changes driven by HPV infections that your immune system will handle on its own. Even high-grade results, which do need treatment, are precancerous, meaning they’re caught at a stage where a straightforward outpatient procedure can remove them completely. The entire purpose of Pap screening is to find these changes years before they would ever become cancer, and that system works. Following through with whatever next step your result calls for is the most important thing you can do.