The October 2003 article, "The Clinical Significance of HPV" was excellent, and quite thorough, however I did want to make a comment. On page 16 under "treatment", I take issue with line six where you state that both LSIL and HSIL are more severely dysplastic lesions and both need immediate colposcopic referral. HSIL is in fact the only one that requires immediate attention.

I am a practicing nurse colposcopist and attended the ASCCP (American Society For Colposcopy and Cervical Pathology) Conference in Phoenix in 2001.

Many of the authors of Bethesda I and II were there, and the panel agreed that an acceptable algorithm for LSIL is a repeat pap smear in 4-6 months, and then colposcopy if it has not resolved. The patient, of course, also has the option of colposcopy at this point. HSIL and CIS are the severe lesions, which need timely colposcopy.

I bring up what may seem a small point because I see daily the high anxiety that occurs when I give the news of any abnormal Pap. Part of my professional role is to tell the truth and impress upon the client the importance of follow up without making it sound like an emergency. When I tell a patient that the LSIL or ASCUS rarely turns out to be serious I am telling them the truth (70% of ASCUSs and LSILs spontaneously resolve and only 15% have CIN 2 or 3 on BX. Only 0.25% and 0.44% of those BXs respectively go on to CA if left untreated).

First available appointments are reasonable if they choose colposcopy over repeat Paps.

If a patient has an HSIL, I explain the situation differently and impress upon them the importance of ASAP appointment. Often, patients hear that they must be seen immediately and the patient feels she either has cancer now or will get cancer tomorrow. In fact, most HSILs do not progress to cancer (only 1.65%), and the progression still takes a significant amount of time if it does progress. It becomes very tricky when someone receives that information, but then cannot get a colposcopy appointment the next day or even in the next month in some cases where resources are short.

There is a huge psychological overlay to consider when dealing with abnormal Paps including body image and sexual functioning. I have struggled for years to give just the right amount of information so a patient is concerned and follows up, and doesn't get stuck in fear and not follow up.

Thank you for your enlightening and informative article.

Maggie Kubovchik, CRNP