In a patient with HSIL on Pap smear, what is the most appropriate next diagnostic step?

• A. HPV DNA testing
• B. Pelvic ultrasound
• C. Repeat Pap smear in 4-6 months
• D. Colposcopy with endocervical curettage

Answer: (D)

High-grade cytology signals a high risk of a significant cervical lesion, so the next move is to obtain histologic confirmation and assess the cervix directly. Colposcopy allows a magnified view of the cervical epithelium to identify areas that look abnormal and to guide targeted biopsies, which is essential to determine whether CIN2/3 or even invasion is present. Including endocervical curettage samples the endocervical canal, improving detection of disease that may extend into the canal and might be missed on surface sampling. HPV testing wouldn’t change the immediate need for tissue diagnosis because HSIL already indicates high-risk HPV and warrants visualization and biopsy. Repeating a Pap smear later or using ultrasound wouldn’t provide the necessary diagnostic information about cervical intraepithelial neoplasia. Thus, colposcopy with endocervical curettage is the most appropriate next step.