A phone call from your doctor after a Pap smear almost always means something in your results needs a conversation, but that something is far more likely to be a minor cell change or an infection than cancer. The most common reason for the call is a finding of mildly abnormal cells, often labeled ASC-US, which in most cases resolve on their own without treatment. Still, the call itself can feel alarming, and understanding what your doctor might be seeing on that lab report can take a lot of the fear out of the conversation.
Mildly Abnormal Cells Are the Most Frequent Trigger
The single most common abnormal Pap result is a category called “atypical squamous cells of undetermined significance,” or ASC-US. The name is a mouthful, but the meaning is straightforward: some cells looked a little off under the microscope, and the lab couldn’t tell whether the change was caused by something harmless (like irritation or a vaginal infection) or by an early HPV-related process. In a large study of over 40,000 women with ASC-US results, about 41% tested positive for high-risk HPV strains, with that rate being highest in younger women and dropping considerably after age 29.1PubMed. The prevalence of HR-HPV DNA in ASC-US Pap smears: A military population study That means the majority of women with ASC-US results either do not have a high-risk HPV infection at all, or the cell changes are too subtle to classify further.
When your doctor calls about an ASC-US result, the usual next step is reflex HPV testing, which is often run automatically on the same sample already collected. If that HPV test comes back negative, you’ll typically be told to return for a routine screening in a few years. If it comes back positive for a high-risk HPV type, your doctor will likely recommend a closer look with a procedure called colposcopy.
What the Different Categories Actually Mean
Pap smear results fall along a spectrum defined by the Bethesda System, which pathologists worldwide use to classify cervical cell changes. The categories range from completely normal to clearly abnormal, and each one carries a different level of concern.2PubMed Central. Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System
- ASC-US: The mildest squamous cell abnormality, as described above. Most of the time it resolves without intervention.
- LSIL: Low-grade squamous intraepithelial lesion. This typically reflects an active HPV infection that is causing visible but mild cell changes. In most women, especially younger ones, the immune system clears the virus and the cells return to normal. Research on adolescents and young adults shows that the vast majority of HPV infections are transient, with over half to four-fifths of newly sexually active young women acquiring HPV within two to three years and then clearing it.3PubMed Central. HPV infections in adolescents High-grade dysplasia or worse is found on follow-up biopsy in roughly 8% of LSIL cases.4PubMed Central. Low-grade squamous intraepithelial lesion, cannot exclude high-grade: TBS says “Don’t Use It!” should I really stop it?
- ASC-H: Atypical squamous cells where a high-grade lesion can’t be excluded. This is a step up in concern. About half of women with ASC-H results have a high-grade lesion confirmed on biopsy.5Turkish Journal of Pathology. LSIL/ASC-H (LSIL-H) in Cervicovaginal Smear: Histopathological Outcomes and Clinical Significance
- HSIL: High-grade squamous intraepithelial lesion. This means the pathologist saw cells with changes that are more clearly precancerous. About two-thirds or more of HSIL results correspond to a confirmed high-grade lesion on biopsy, and these almost always require treatment.4PubMed Central. Low-grade squamous intraepithelial lesion, cannot exclude high-grade: TBS says “Don’t Use It!” should I really stop it?
- AGC (atypical glandular cells): This category is less common but taken seriously because it involves a different cell type and carries a wider range of possible underlying conditions, from benign polyps to endometrial or cervical cancer.
The takeaway from this spectrum is that the vast majority of abnormal Pap results land on the mild end. Your doctor’s call is most likely about a result in the ASC-US or LSIL range, where the odds strongly favor a benign outcome.
When the Result Points to Glandular Cell Changes
Atypical glandular cells on a Pap smear get handled differently from squamous cell findings, and your doctor’s tone on the phone might reflect that. Glandular cell abnormalities are rarer, but the workup is more thorough because the range of possible diagnoses is broader. A large review of AGC results found that about 71% corresponded to benign findings such as reactive changes, polyps, or normal tissue. However, roughly 11% had high-grade squamous lesions, about 3% had adenocarcinoma in situ, and about 5% had an actual malignancy, most commonly endometrial adenocarcinoma.6Obstetrics & Gynecology. Clinical Significance of Atypical Glandular Cells on Cervical Cytology
A more recent ten-year study at a colposcopy referral center found similar patterns: about 61% of women with atypical glandular cells had negative results on further evaluation, around 19% had benign conditions like cervical or endometrial polyps, about 12% had precancerous cervical lesions, and roughly 11% were diagnosed with invasive disease.7PubMed Central. Clinical significance of atypical glandular cells on cytology: 10 years’ experience of a colposcopic referral center Because the stakes can be higher, a doctor who calls about an AGC finding will often recommend colposcopy along with additional sampling, and sometimes an endometrial biopsy, especially for women with risk factors for uterine cancer.
Infections and Inflammation Can Also Prompt a Call
Not every callback is about precancerous cells. Pap smears can pick up signs of infection or chronic irritation in the cervix and vagina. The pathologist might note bacterial vaginosis, yeast, trichomoniasis, or nonspecific inflammation. Cervicitis from IUD use, chemical irritants, hormonal shifts, or chronic infection can all change how cells look on a slide, sometimes enough to mimic HPV-related changes.8PubMed Central. The Pap smear in inflammation and repair Your doctor might call simply to prescribe an antibiotic or antifungal, or to recommend a repeat Pap after the infection clears.
Bacterial vaginosis is worth mentioning specifically. While a Pap smear isn’t a great screening tool for BV on its own (it misses many cases), when BV does show up on a Pap it tends to be a real finding.9PubMed. Bacterial vaginosis: comparison of Pap smear and microbiological test results And there’s evidence that BV in the presence of a high-risk HPV infection is associated with a higher likelihood that the HPV will persist and that cervical cell changes will progress rather than resolve.10PubMed Central. Bacterial vaginosis in microscopic examination of Pap smears in patients with high-risk HPV is associated with viral persistence and cytological progression in a longitudinal study So treating BV isn’t just about symptom relief; it may also matter for the cervical health picture.
An Unsatisfactory Sample
Sometimes the reason for the call has nothing to do with abnormal cells at all. The lab may have deemed the sample “unsatisfactory,” meaning there weren’t enough cells on the slide, or blood, mucus, or inflammation obscured them too much for a reliable reading. In a review of more than 51,000 Pap tests, about 2.3% came back unsatisfactory.11PubMed Central. Retrospective analysis of clinician and patient factors associated with unsatisfactory Pap tests Unsatisfactory rates were higher in women over 50 and in certain demographic groups. If this is why your doctor calls, the request is simple: come back and repeat the test. An unsatisfactory result isn’t bad news; it’s no news.
What Happens After an Abnormal Result
Your doctor’s recommended next step depends on which category your result falls into and what your HPV status is. Current guidelines in the United States have moved away from a one-size-fits-all flowchart and toward a risk-based approach, where the decision about whether to watch and wait, repeat the test, or proceed to colposcopy depends on your overall risk of having or developing a precancerous lesion.12PubMed Central. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors That risk is calculated from your current test results, your past screening history, your age, and other factors.
Colposcopy is the most common follow-up procedure for higher-risk results. It involves looking at the cervix through a magnifying instrument and, if anything looks abnormal, taking a small biopsy. It’s the main tool used to evaluate women whose screening tests suggest increased risk of cervical neoplasia, including those with abnormal Pap results, positive HPV tests, or symptoms like unexplained bleeding or discharge.13Journal of Lower Genital Tract Disease. ASCCP Colposcopy Standards: Role of Colposcopy, Benefits, Potential Harms, and Terminology for Colposcopic Practice If the biopsy confirms a high-grade precancerous lesion, treatment typically involves removing the affected tissue. One of the most common methods is a loop electrosurgical excision procedure (LEEP), which uses a thin wire loop to cut away the abnormal area. LEEP is considered safe with low recurrence rates and clears the cervical HPV infection in the majority of cases.14PubMed. Assessment of cervical intraepithelial neoplasia (CIN) with colposcopic biopsy and efficacy of loop electrosurgical excision procedure (LEEP) Cryotherapy (freezing the tissue) is another option, though a randomized trial in women with HIV found that LEEP was significantly more effective, with recurrence of high-grade lesions running about 19% after LEEP versus 30% after cryotherapy over two years.15JAMA. Effect of Cryotherapy vs Loop Electrosurgical Excision Procedure on Cervical Disease Recurrence Among Women With HIV and High-Grade Cervical Lesions in Kenya
The Emotional Side of the Phone Call
Even when the medical picture is reassuring, the emotional impact of getting that call can be intense. In a German survey of women who had undergone cervical cancer screening, nearly 70% reported being afraid of developing cancer. Among women who had received abnormal findings, almost half did not clearly understand what stage their result fell into, and roughly 30% showed signs consistent with post-traumatic stress.16PubMed Central. Psychological distress in cervical cancer screening: results from a German online survey A separate European study found that anxiety, panic, and stress were frequent reactions to abnormal results, and that even after a reassuring conversation with their doctor, about half of women remained worried.17PubMed Central. Psychological impact, support and information needs for women with an abnormal Pap smear: comparative results of a questionnaire in three European countries
Part of the problem is how results get communicated. A UK audit found wide variation in how general practices delivered abnormal smear results. Some used phone calls, others letters. The amount of information included varied enormously, and the communication was typically handled by a practice nurse rather than the doctor who ordered the test.18PubMed. Communicating mild and borderline abnormal cervical smear results: how and what are women told? If you feel confused or frightened after a call, you are not unusual. Ask your provider to explain your specific result category, what the recommended next step is, and what the likely range of outcomes looks like. The overwhelming majority of abnormal Pap results do not lead to a cancer diagnosis.
Why Postmenopausal Women Get More Ambiguous Results
If you’re past menopause and get a callback, there’s an added wrinkle: low estrogen levels change the way cervical cells look under a microscope, and those changes can be mistaken for abnormalities. Atrophic cells, which are a normal consequence of the postmenopausal hormonal state, are one of the most commonly misread findings in cervical cytology. The most frequent error is interpreting an atrophic smear as ASC-US when the cells are actually benign.19PubMed Central. Cervical Cancer Screening in Postmenopausal Women: Is It Time to Move Toward Primary High-Risk Human Papillomavirus Screening? In a study of HPV-positive postmenopausal women who went on to colposcopy, about 28% turned out to have biopsy-confirmed lesions, meaning the majority did not.20PubMed Central. HPV Reflex Testing in Menopausal Women If you’re postmenopausal and receive an ASC-US result, your provider might suggest a short course of vaginal estrogen cream before repeating the Pap, since restoring some estrogen to the tissue often resolves the ambiguity.
Abnormal Results During Pregnancy
Getting a Pap smear callback while pregnant adds a layer of worry, but the management approach is deliberately cautious. Colposcopy during pregnancy is considered safe, but endocervical curettage (a more invasive sampling technique) is off the table because of the risk to the pregnancy. For most diagnoses, more aggressive intervention is delayed until after delivery.21Clinical Obstetrics and Gynecology. Evaluation and Management of Abnormal Cervical Cytology During Pregnancy The vast majority of pregnant women with abnormal Pap results can safely be monitored without treatment during the pregnancy, with a full reassessment planned for the postpartum period.
How Screening Is Shifting
The landscape of cervical cancer screening is changing in ways that affect how and why you might hear from your doctor. There is a growing emphasis on primary HPV testing rather than the traditional Pap smear alone. Modeling research suggests that HPV testing as the primary screen misses fewer precancerous cases per 1,000 women than Pap-based screening on its own, though it sends slightly more women to colposcopy who turn out to be fine.22medRxiv. Challenges of false positive and negative results in cervical cancer screening The Pap smear, for its part, still excels at picking up high-grade lesions with strong sensitivity and specificity.23PubMed Central. Comparison of papanicolaou smear and human papillomavirus HPV test as cervical screening tools can we rely on HPV test alone as a screening method An 11-year retrospective experience at a single institution
Another development is the option of self-collected vaginal HPV tests. The American Cancer Society now considers self-collected vaginal specimens acceptable for primary HPV screening in average-risk women aged 25 to 65, though clinician-collected cervical samples remain preferred. If the self-collected test is negative, repeat screening is recommended in three years rather than the five-year interval used for clinician-collected negative HPV results.24PubMed Central. Self-collected vaginal specimens for human papillomavirus testing and guidance on screening exit: An update to the American Cancer Society cervical cancer screening guideline The hope is that self-collection will expand access for women who currently skip screening due to barriers like lack of transportation, discomfort with pelvic exams, or limited clinic access.25PubMed Central. Self-Collected Vaginal Specimens for HPV Testing: Recommendations From the Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee
HPV Vaccination and What It Means for Your Results
If you were vaccinated against HPV, your overall risk of an abnormal Pap result is lower, though not zero. Population-level data from Australia showed that vaccinated women had significantly lower rates of both high-grade cervical abnormalities and high-grade cytology findings compared with unvaccinated women, with roughly a 25% reduction in high-grade abnormalities and a similar reduction in low-grade cytological findings.26PubMed Central. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study Victoria, Australia, where uptake was high, recorded a measurable drop in high-grade abnormalities in girls under 18 after the vaccination program launched.27The Lancet. Reduction in high-grade cervical abnormalities in Victoria, Australia following human papillomavirus (HPV) vaccination ordinances Modeling for the United States predicted that as vaccine coverage rises and vaccinated cohorts age into their twenties and beyond, the proportion of abnormal Pap results could decline by over 20% in the higher-coverage scenario within 25 years of the program’s start.28PubMed Central. Modeling the impact of quadrivalent HPV vaccination on the incidence of Pap test abnormalities in the United States
The vaccines don’t cover every HPV strain linked to cervical cancer, though, and they don’t help with infections acquired before vaccination. So even vaccinated women still need regular screening, and some will still get that phone call. The difference is that over time, the calls should become less frequent at the population level, and the underlying findings less likely to represent a serious problem.