Management of women with low grade cytology: how reassuring is a normal colposcopy examination? ME Cruickshank, a SC Cotton, a L Sharp, b L Smart, c LG Walker, d J Little, e on behalf of the TOMBOLA Group* a Obstetrics & Gynaecology, University of Aberdeen, Aberdeen, UK b National Cancer Registry Ireland, Cork, Ireland c Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK d University of Hull, Kingston upon Hull, UK e Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada Correspondence: Prof ME Cruickshank, Division of Medical and Dental Education, University of Aberdeen, Suttie Building, Aberdeen AB25 7ZD, UK. Email m.e.cruickshank@abdn.ac.uk Accepted 1 April 2014. Published Online 20 June 2014. Objectives To determine the rate of cervical intraepithelial neoplasia grade 2 (CIN2+) in women with low grade cervical cytology and a normal colposcopy examination over 3 years of follow-up. Design Cohort study within a randomised controlled trial. Setting NHS Cervical Screening Programmes in Grampian, Tayside and Nottingham. Population Eight hundred and eighty-four women aged 20–59 years with borderline nuclear abnormalities (BNA) or mild dyskaryosis with a normal and adequate colposcopy examination. Methods Samples at baseline were tested for 14 high-risk (Hr) types using GP5+6+ methodology and for HPV 16 and 18 using type-specific primers. Women were followed up post-colposcopy by cervical cytology at 6-month intervals in primary care. After 3 years, women were invited for an exit colposcopy examination and underwent LLETZ if any colposcopic abnormality was identified. Main outcome measures Absolute and relative risks of CIN2+ during follow-up and/or at exit colposcopy. Results The median age was 36 years. The absolute risk of developing CIN2+ within 3 years was 1.86 per 100 woman years and for CIN3+, 0.64 per 100 woman years. One microinvasive cancer was identified. The relative risk (RR) was highest for women with initial mild dyskaryosis who were HrHPV-positive (RR 5.86, 95% confidence interval 2.53–13.56) compared with women with BNA who were HrHPV-negative. Conclusion For women with low grade cervical cytology, the risk of a high grade CIN within 3 years of a normal colposcopy examination is low. Women can be reassured that, even with a positive HPV test, the risk of developing CIN2 or worse is sufficiently low to return to the routine 3-year recall. Keywords Cervical intraepithelial neoplasia grade 2, colposcopy, human papillomavirus, low grade abnormalities. Linked article This article is commented on by Massad LS. To view this mini commentary visit http://dx.doi.org/10.1111/1471- 0528.12988. Please cite this paper as: Cruickshank ME, Cotton SC, Sharp L, Smart L, Walker LG, Little J, on behalf of the TOMBOLA Group. Management of women with low grade cytology: how reassuring is a normal colposcopy examination? BJOG 2014; DOI: 10.1111/1471-0528.12932. Introduction The most common cervical cytological abnormalities are borderline nuclear abnormalities (BNA) and mild dyskary- osis (considered clinically equivalent to ASCUS and LSIL in the Bethesda reporting system), especially in younger age groups. Women with low grade abnormalities are often referred for colposcopy assessment based on either their cytology or as a result of HPV triage or co-testing. This policy has the advantage to women of earlier detection and treatment if CIN2 or higher grade cervical disease (CIN2+) is identified. However short-term after-effects are common following colposcopy and its associated interventions. 1 In addition, there are longer-term concerns regarding obstetric outcome if women are treated. 2 If high grade CIN or can- cer can be accurately excluded on the results of colposcopy *Group members are listed in Acknowledgements. 1 ª 2014 Royal College of Obstetricians and Gynaecologists DOI: 10.1111/1471-0528.12932 www.bjog.org