The diagnostic value of colposcopy in postmenopausal women: a retrospective study

Abstract

Background

Postmenopausal women undergo physiological changes in the vaginal and cervical transformation zones, which influence the accuracy of cervical cancer screening and colposcopy results. This study aims to evaluate the immediate risk of cervical intraepithelial neoplasia (CIN) in postmenopausal women who are positive non-16/18 high-risk human papillomavirus (HPV) and Thinprep Cytologic Test (TCT) results classified as either no intraepithelial lesion or malignancy (NILM) or atypical squamous cells of undetermined significance (ASC-US), examine the clinical implications of cervical cancer screening and colposcopy in this population and identify potential approaches to enhance current diagnostic protocols.

Methods

This study collected and analyzed clinical data from postmenopausal women who tested positive for either abnormal cytology or HPV between January 2023 to December 2024 at a single center hospital. The incidence of CIN was compared between the HPV16/18-positive group and the non-HPV16/18-positive group among patients with TCT results categorized as NILM or ASC-US. Additionally, a detailed analysis of the colposcopic results was performed for non-HPV16/18-positive women presenting with NILM or ASC-US on TCT.

Results

Among the 392 patients who were non-HPV16/18-positive and had TCT results indicating either NILM or ASC-US, there were 50 cases (12.76%) of CIN 1, 18 cases (4.59%) of CIN 2/3, and 1 case (0.26%) of cervical cancer. Of these patients, 312 had TCT results classified as NILM and 80 as ASC-US. Within these subgroups, 15 cases (4.81%) in the NILM group and 4 cases (5.00%) in the ASC-US group developed CIN 2 + lesions. The difference between the two groups was not statistically significant (p = 0.94). Among the 104 patients diagnosed with CIN 2 + lesions, 27 cases (25.96%) exhibited symptoms such as postmenopausal vaginal bleeding or abnormal discharge symptoms of varying degrees.

Conclusions

Vaginal bleeding and abnormal discharge in postmenopausal women warrant immediate evaluation. For postmenopausal patients who are HPV 16/18‑negative and have NILM or ASC‑US cytology, routine surveillance is appropriate. Adjunctive testing with E6/E7 mRNA assays or p16/Ki‑67 dual‑staining may be employed; any abnormal result should prompt diagnostic work‑up.

Background

Cervical cancer imposes a substantial global burden on women’s health, with its incidence displaying distinct age-related patterns amid the global aging trend [1, 2]. In China, the disease exhibits a typical “bimodal” age distribution: the first incidence peak occurs between 35 and 39 years, and the second between 60 and 64 years, with postmenopausal women accounting for 29.8% of all newly diagnosed cases [3, 4]. Notably, postmenopausal women are at an elevated risk of persistent high-risk human papillomavirus (HPV) infection due to immune dysfunction and vaginal microecological imbalance induced by estrogen depletion, with an HPV-positive rate of 17.20%—higher than the 13.55% reported in the general Chinese female population. Additionally, most Chinese women over 60 lack a history of HPV vaccination, which further enhances their susceptibility to the progression of cervical lesions [1, 4]. This unique epidemiological profile highlights the urgent need for targeted public health interventions to refine strategies for the prevention and management of cervical cancer in postmenopausal women.

The pathogenesis of cervical cancer is a complex multifactorial process involving host genetic susceptibility, persistent high-risk human HPV infection, sexual behavioral factors, and immune status [5, 6]. Early screening plays a pivotal role in detecting precancerous lesions, thereby effectively reducing the incidence and mortality of cervical cancer [7, 8]. Currently, the combined screening strategy of HPV DNA testing and ThinPrep Cytology Test (TCT, a type of liquid-based cytology) is recommended as the preferred approach in resource-sufficient regions and for special populations. This strategy achieves a sensitivity of up to 94.6%—more than 25% higher than either test alone—synergistically improving the detection of abnormal cervical cells and high-risk human HPV infections, and providing robust technical support for early diagnosis [9, 10].

Despite its advantages, the HPV-TCT combined screening strategy has inherent limitations. While it maximizes sensitivity, it simultaneously increases the risk of false-positive results and subsequent referrals for colposcopy. Colposcopy enables directed biopsy by providing magnified visualization of epithelial and vascular patterns. Both international and national guidelines mandate the standardized use of colposcopy for abnormal cytological findings or positive HPV results. Nevertheless, colposcopy also has notable limitations: it may miss endocervical lesions, its accuracy is operator-dependent, and distinguishing high-grade squamous intraepithelial lesions (HSIL) from early invasive cancer remains challenging. When the transformation zone is entirely intracanalicular, it cannot be visualized by acetic acid or iodine staining, which reduces sensitivity and increases the risk of misdiagnosis. High false-positive rates can lead to unnecessary colposcopies, thereby elevating the risk of unwarranted interventions, imposing financial burdens, and causing physical and psychological distress (e.g., vaginal bleeding, infection) associated with biopsy complications [11].

Postmenopausal women face unique challenges in cervical cancer screening due to estrogen-related physiological changes. Cervicovaginal atrophy, epithelial thinning, and inward migration of the squamocolumnar junction (occurring in 63–85% of cases) result in three key cytological limitations: reduced cellular yield due to cervical stenosis (a 30–50% decrease), a high prevalence of type III transformation zones (72.3%), and lower accuracy in detecting atypical squamous cells of undetermined significance (ASC-US; 67.4% vs. 82.6% in premenopausal women) [12–14]. These factors increase the false-negative rate, compromise screening reliability, and elevate the risk of cervical cancer—often leading to underdiagnosis and increased referrals for colposcopy [15].

A critical research gap further compounds this challenge: the clinical implications of non-HPV16/18-associated screening abnormalities in postmenopausal Chinese women remain inadequately explored. Most existing studies focus on the general female population or HPV16/18-positive cases, with few specifically addressing the clinical significance of initial screening abnormalities defined as HPV16/18 negativity combined with ASC-US on TCT in this subgroup. Given that non-HPV16/18 HPV subtypes also contribute to the development of cervical lesions¹, understanding their clinical significance in postmenopausal women is essential for formulating targeted screening strategies.

Therefore, establishing accurate screening and individualized management protocols for postmenopausal women with HPV16/18-negative ASC-US is clinically significant, as this will improve early cervical cancer detection and enable timely clinical intervention. Accordingly, this study systematically integrates and analyzes colposcopic imaging features and histopathological data of such patients to address three objectives: (1) clarify the risk characteristics of cervical intraepithelial neoplasia (CIN) grade 2 or higher (CIN2+) in this population; (2) elucidate the clinical implications of these screening abnormalities; (3) explore feasible strategies to optimize cervical cancer screening protocols and colposcopic biopsy indications.

Methods

This retrospective case study systematically collected clinical data from postmenopausal women who underwent colposcopy at Fenyang Hospital, Shanxi Province, between January 2023 and December 2024. Adopting stratified screening principles, the study included women who met all the following criteria: (1) absence of menses for 12 consecutive months since the end of the last menstrual period; or serum follicle stimulating hormone (FSH) ≥ 30 IU/L and estradiol (E2) ≤ 30 pg/mL; (2) tested positive for HPV or had abnormal TCT results; (3) underwent cervical biopsy under colposcopy at our hospital; and (4) had no prior history of cervical cancer vaccination.

It also evaluated colposcopic findings in the latter group. Exclusion criteria were: (1) prior total hysterectomy; (2) drug-induced or iatrogenic menopause; (3) no history of sexual activity (no vaginal intercourse or cervical surgery); (4) previous history of cervical cancer or precancerous lesions; (5) concurrent malignant tumors or sexually transmitted infections; and (6) missing key clinical data (e.g., unavailable pathological reports), poor-quality examinations (e.g., blurred colposcopic images, incomplete test reports), or duplicate medical records. The collected variables included age, clinical symptoms, HPV genotyping results, and TCT findings.

A systematic approach was employed for screening and stratification of cervical lesions. All participants underwent combined HPV and TCT screening. Sample collection was performed using disposable sterile instruments of the same brand and batch, and cytological classification strictly followed the 2014 Bethesda System criteria. Endocervical curettage was routinely performed to enhance the detection of occult lesions in the cervical transformation zone. HPV genotyping was conducted using a clinically validated assay capable of identifying 18 high-risk HPV genotypes (HPV 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, and 82) and three low-risk types (e.g., HPV 6, 11, and 81). HPV 16 and 18 were considered highest risk and analyzed separately; other high-risk types were grouped as “non-16/18 HPV.”

For cytological evaluation, a two-tier grouping system was established for TCT results, with explicit grouping criteria and rationale as follows: Group A: Comprising “no intraepithelial lesion or malignancy (NILM)” and “ASC-US”. This grouping was based on the similar low risk of high-grade cervical lesions (CIN2+) associated with these two categories. NILM indicates no cytological abnormalities, while ASC-US represents borderline cytological changes of uncertain clinical significance, most of which are benign (e.g., induced by inflammation or transient HPV infection) with a low progression risk to high-grade lesions (approximately 10%). Group B (non-NILM/ASC-US): Encompassing low-grade squamous intraepithelial lesion (LSIL), HSIL, atypical squamous cells cannot exclude HSIL (ASC-H), and atypical glandular cells (AGC). This grouping was justified by the significantly higher risk of CIN2/3 or invasive cancer associated with these cytological abnormalities. Based on these results, participants were divided into four groups: Group 1: HPV 16/18 with NILM/ASC-US; Group 2: HPV 16/18 with non-NILM/ASC-US; Group 3: non-16/18 HPV with NILM/ASC-US; Group 4: non-16/18 HPV with non-NILM/ASC-US.

In accordance with international cervical cancer screening consensus, colposcopy was performed for all cases. Targeted biopsies were obtained from suspicious lesions identified during colposcopy. All colposcopic examinations were performed by the same senior gynecologist to ensure consistency, and pathological slides were independently reviewed by two designated pathologists. For cases with no visible lesions under colposcopy, standardized four-quadrant biopsies were performed at the 3, 6, 9, and 12 o’clock positions of the cervix to reduce the risk of missed diagnosis. Histopathological diagnosis strictly adhered to the WHO classification system, which categorized lesions into four grades: chronic cervicitis, CIN1, CIN2/3, and invasive cervical cancer. CIN2+ (encompassing CIN2/3 and invasive cervical cancer) was defined as the clinical intervention threshold. A flowchart of the entire case screening and stratification process is presented in Fig. 1.

Fig. 1.

Flow chart of case screening

Statistical analyses were performed using GraphPad Prism 9.0 software. Continuous variables were expressed as mean ± standard deviation (mean ± SD). Categorical variables were compared between groups using the chi-square test. Multivariate logistic regression models were constructed to adjust for potential confounding factors, including age (continuous or stratified), presence of clinical symptoms (yes/no), parity (nulliparous vs. multiparous), and previous screening history (yes/no). Additionally, logistic regression analysis was conducted to assess the risk of CIN2 + lesions associated with key variables (e.g., HPV genotype, TCT grouping, and postmenopausal symptoms). Odds ratios (OR) with 95% confidence intervals (CI) were calculated to quantify risk associations. Statistical significance was defined as p < 0.05, with p < 0.01 indicating high statistical significance.

Results

A total of 761 patients were enrolled in this study, with their baseline characteristics summarized in Table 1. All participants underwent colposcopy and cervical biopsy. Among these patients, 9 patients tested negative for HPV. Of the HPV-positive cases, 292 (38.37%) were infected with HPV16 and/or HPV18 (including 155 with HPV16 alone, 31 with HPV18 alone, and 106 with co-infection; detailed in Table 1), while the remaining 460 cases were infected with non-HPV16/18 genotypes.

Table 1.

Clinical characteristics of the study participants(n = 761)

Characteristics	Number	Percentage (%)
Total
Age (years), mean (SD)	57.52(11.31)	-
HPV genotype
HPV 16/18	292	38.37
Non- HPV16/18	460	60.45
HPV (-)	9	1.18
TCT result
NILM	507	66.63
ASC-US	118	15.51
ASC-H	17	2.23
LSIL	73	9.59
HSIL	43	5.65
AGC	3	0.39
Pathological biopsy result
Chronic cervicitis	549	72.14
CIN 1	102	13.40
CIN 2/3	58	7.62
Invasive carcinoma	46	6.05
Other	6	0.79

HPV Human papillomavirus, TCTThinPrep cytologic test, CIN 1 Cervical intraepithelial neoplasia grade 1, CIN 2/3 Cervical intraepithelial neoplasia grade 2 and grade 3, CIN 2+ Conclude CIN 2/3 and invasive cancer, NILM No intraepithelial lesion or malignancy, ASC-US Atypical squamous cells of undetermined significance, LSIL Low-grade squamous intraepithelial lesion, HSIL High-grade squamous intraepithelial lesion, ASC-H Atypical squamous cells cannot exclude HSIL, AGC Atypical glandular cells

TCT results showed that 82.13% (n = 625) of cases had NILM or ASC-US findings, and 17.87% (n = 136) had ASC-H or higher-grade lesions. Histopathological analysis revealed chronic cervicitis as the most prevalent finding (72.14%), followed by CIN1 (13.40%), CIN2/3 (7.62%), invasive cancer (6.05%), and other lesions (0.79%). The prevalence of CIN2 + lesions was significantly higher in HPV16/18-positive patients (24.32%, 95% CI: 19.65%-29.58%) than in non-HPV16/18-positive patients (7.04%, 95% CI: 4.93%-9.83%) (p < 0.01; 95% CI: 0.228–0.463) (Table 2). Logistic regression analysis further confirmed that HPV16/18 positivity was a risk factor for CIN2 + lesions (OR = 4.23, 95% CI: 2.78–6.45, p < 0.01). Among the 104 patients diagnosed with CIN2+, 25.96% (n = 27; 95% CI: 18.32%-34.89%) reported symptoms of postmenopausal vaginal bleeding or abnormal vaginal discharge. The nine most prevalent HPV genotypes, in descending order, were HPV16 (21.90%), HPV52 (12.51%), HPV58 (9.75%), HPV53 (8.83%), HPV56 (6.07%), HPV18 (5.70%), HPV39 (5.06%), HPV51 (4.88%), and HPV33 (4.05%) (Fig. 2).

Table 2.

Pathological biopsy results between non-HPV16/18 and HPV16/18 group

Pathological biopsy results	HPV 16/18 (n = 292)	Non-HPV 16/18 (n = 469)
CIN 2+	71(24.32%)	33(7.04%)
Other	221(75.68%)	436(92.96%)

Fig. 2.

The proportion of different HPV types was ranked from high to low

Among 392 non-HPV16/18-positive patients with TCT results of NILM or ASC-US, pathological diagnosis showed that chronic cervicitis accounted for 81.63%, CIN2/3 lesions were detected in 4.59% (95% CI: 2.91%-7.68%), and invasive cancer was detected in 0.26% (1/392) (Table 3; Fig. 3). Notably, 31.58% (n = 6; 95% CI: 13.27%-57.12%) of the 19 CIN2 + cases in this subgroup reported varying degrees of vaginal symptoms, including postmenopausal vaginal bleeding or abnormal discharge. Subgroup analysis of TCT results revealed no statistically significant differences in the distribution of pathological findings between the NILM group (n = 312) and the ASC-US group (n = 80): chronic cervicitis was observed in 81.73% (255/312) and 81.25% (65/80) of cases, respectively (p = 0.85); CIN1 in 12.82% (40/312) and 12.50% (10/80), respectively (p = 0.65); and CIN2 + lesions in 4.81% (15/312) and 5.00% (4/80), respectively (p = 0.94) (Table 4; Fig. 4).

Table 3.

Pathological biopsy results comparing in group 3 or the other groups

Pathological biopsy results	Group 3 (n = 392)	Group 1 + Group 2 + Group 4 (n = 369)	p
Chronic cervicitis	320(81.63%)	229(62.06%)	<0.01
CIN 1	50(12.76%)	52(14.09%)	0.59
CIN 2/3	18(4.59%)	40(10.84%)	<0.01
Invasive carcinoma	1(0. 26%)	45(12.20%)	<0.01
Other	3(0.76%)	3(0.81%)	0.94

Group 1: HPV 16/18 with NILM/ASC-US; Group 2: HPV 16/18 with non-NILM/ASC-US; Group 3: non-16/18 HPV with NILM/ASC-US; Group 4: non-16/18 HPV with non-NILM/ASC-US

Data are presented as mean ± SD, p < 0.05 and p < 0.01 were considered statistically significant

Fig. 3.

In the 3 group and the other groups, the proportions (%) of chronic cervicitis, CIN 1, CIN 2/3 and invasive cancer were presented respectively

Table 4.

Comparison of case outcomes between NILM and ASC-US in Non-HPV16/18

Pathological biopsy results	Non-HPV16/18、 TCT: NILM (n = 312)	Non-HPV16/18、 TCT: ASC-US (n = 80)	p
Chronic cervicitis	255(81.73%)	65(81.25%)	0.85
CIN 1	40(12.82%)	10(12.50%)	0.65
CIN 2+	15(4.81%)	4(5.00%)	0.94
Other	2(0.64%)	1(1.25%)	0.49

Group 1: HPV 16/18 with NILM/ASC-US; Group 2: HPV 16/18 with non-NILM/ASC-US; Group 3: non-16/18 HPV with NILM/ASC-US; Group 4: non-16/18 HPV with non-NILM/ASC-US

CIN 2+: conclude CIN 2/3 and invasive cancer. Data are presented as mean ± SD, p < 0.05 and p < 0.01 were considered statistically significant

Fig. 4.

Compare the proportions of chronic cervicitis, CIN 1 and CIN 2 + in Non-HPV16/18 and TCT: NILM groups and Non-HPV16/18 and TCT: ASC-US groups

In HPV16/18-positive patients with TCT results of NILM or ASC-US (n = 233), chronic cervicitis was the most common pathological finding, followed by CIN1, CIN2/3, and invasive cancer; one case was categorized as other (CIN1–2 without immunohistochemical confirmation). Notably, in HPV16/18-positive patients with TCT results of higher (n = 59), invasive cancer and CIN2/3 were predominant, while chronic cervicitis and CIN1 were less common (one additional case of CIN1–2 without immunohistochemical confirmation) (Table 5).

Table 5.

Pathological biopsy results of different groups

Pathological biopsy results	Group 1 (n = 233)	Group 2 (n = 59)	Group 3 (n = 392)	Group 4 (n = 77)
Chronic cervicitis	169(72.53%)	17(28.81%)	320(81.63%)	43(55.84%)
CIN 1	29(12.45%)	4(6.78%)	50(12.76%)	19(24.68%)
CIN2/3	19(8.15%)	13(22.03%)	18(4.59%)	8(10.39%)
Invasive carcinoma	15(6.44%)	24(40.67%)	1(0. 26%)	6(7.79%)
Other	1(0.43%)	1(1.69%)	3(0.76%)	1(1.30%)

Group 1: HPV 16/18 with NILM/ASC-US; Group 2: HPV 16/18 with non-NILM/ASC-US; Group 3: non-16/18 HPV with NILM/ASC-US; Group 4: non-16/18 HPV with non-NILM/ASC-US

Among patients with TCT results showing abnormalities greater than ASC-US (Groups 2 and 4), the detection rate of CIN2 + lesions was significantly higher in HPV16/18-positive patients (Group 2: 62.71%, 37/59; 95% CI: 49.13%-74.98%) than in non-HPV16/18-positive patients (Group 4: 18.18%, 14/77; 95% CI: 10.35%-28.57%) (p < 0.01). Logistic regression analysis confirmed that the combination of HPV16/18 positivity and TCT abnormalities greater than ASC-US was an high-risk factor for CIN2 + lesions (OR = 7.85, 95% CI: 4.12–15.09, p < 0.01), enabling more accurate risk assessment than chi-square test alone.

Discussion

Cervical cancer, a prevalent female reproductive malignancy, is primarily driven by persistent high-risk HPV infection [16]. It progresses sequentially through CIN1 (mild), CIN2 (moderate), and CIN3 (severe dysplasia/carcinoma in situ) [17], with ~ 30% of untreated CIN3 progressing to invasive cancer [18]. Early cervical cancer is typically asymptomatic; ~90% of HPV infections resolve spontaneously within 2 years, while < 4% persist and may progress to cancer over 10–20 years, underscoring the critical role of regular screening [19, 20]. Postmenopausal hormonal changes induce cervical atrophy and alter genital anatomy, reinforcing the need for continued screening in this population [12]. Epidemiological data show HPV infection in 99.7% of cervical cancers, with HPV16/18 accounting for ~ 70% [21]. HPV genotyping of 761 postmenopausal women from a single Shanxi center revealed HPV16 in 21.9% of samples (significantly higher than other subtypes), confirming its dominant role in cervical carcinogenesis. Elevated HPV52/58 detection aligns with Asian HPV distribution profiles [22–24], which may inform localized screening strategies but are not generalizable to regions with divergent genotypes or demographics.

TCT is pivotal for detecting cervical lesions, with ASC-US—a Bethesda System “grey zone”—accounting for > 50% of abnormal findings and raising specificity concerns [25]. Further analysis of 392 non-HPV16/18 postmenopausal women with TCT: NILM or ASC-US showed most had chronic cervicitis, with few CIN1, CIN2/3, or rare invasive cancer. Consistent with prior reports, this indicates low cervical cancer risk in this subgroup. Nevertheless, CIN2 + lesions are clinically relevant due to malignant progression potential. Of 19 CIN2 + cases, 31.6% (6/19) had postmenopausal vaginal bleeding/discharge, all concentrated in CIN3 (5 cases) and invasive cancer (1 case). Notably, 25.96% of CIN2 + patients exhibited these symptoms, suggesting they are key indicators for high-grade lesions. These observations imply perimenopausal immune decline may facilitate persistent HPV infection, emphasizing timely colposcopy for symptomatic postmenopausal women.

Subgroup analysis of hpv16/18 negative postmenopausal women (NILM: n = 312; ASC-US: n = 80) showed no significant difference in pathological grade between the two groups (all p > 0.05), confirming that the risk of cervical lesions was similar in these two groups. This contrasts with earlier reports of higher CIN2 + rates (7.8%-15.2%) in ASC-US [26]. In our study, only 5% of ASC-US cases progressed to CIN2+, likely due to sampling factors (cervical atrophy reducing TCT accuracy and increasing false positives) and biological alterations. Estrogen decline slows cervical epithelial proliferation, constraining HPV replication (dependent on host cell division for carcinogenesis) [27, 28]. Additionally, perimenopausal immune senescence may be counterbalanced by reduced epithelial proliferation, forming a “proliferation-immunity balance” that prevents high-grade lesion progression in non-HPV16/18 infections [27].

Our data showed 4.85% of non-HPV16/18 postmenopausal women with NILM/ASC-US would have undetected CIN2 + without colposcopy, slightly exceeding the 2019 ASCCP 4% intervention threshold. Notably, the 5% CIN2 + rate in non-HPV16/18 ASC-US postmenopausal women was lower than the guideline-reported 7.8–15.2%. Given proximity to the threshold and balancing resource utilization with patient burden, we recommend 12-month repeat cytology/HPV testing per ASCCP’s flexible management for near-threshold patients [29, 30].

The risk of invasive cancer and the detection rate of CIN2/3 lesions were significantly higher in the HPV16/18-positive group than in the non-HPV16/18 group (p < 0.01, 95% CI: 3.04, 21.6), confirming HPV16/18 as a core risk factor for high-grade cervical lesions in postmenopausal women. In the subgroup of patients with TCT results more severe than ASC-US (i.e., LSIL, HSIL, ASC-H, and AGC), the rate of high-grade lesions increased with the severity of cytological abnormalities. Logistic regression analysis showed that HPV16/18 positivity combined with TCT results more severe than NILMASC-US increased the risk of CIN2 + lesions by 7.85-fold (95% CI: 4.12–15.09, p < 0.01), providing more precise risk stratification than chi-square test alone. This highlights the importance of HPV genotyping in cervical cancer risk assessment, as the co-occurrence of HPV16/18 infection and cytological abnormalities significantly elevates malignancy risk, warranting prioritized clinical follow-up. Additionally, the HPV16/18-positive group demonstrated a substantially higher risk of high-grade lesion development compared to the non-16/18 HR-HPV group. Logistic regression confirmed that HPV16/18 positivity is a risk factor for CIN2 + lesion development (OR = 4.23, 95% CI: 2.78–6.45, p < 0.01). This conclusion aligns with the core recommendations of the European Society of Gynaecological Oncology (ESGO) guidelines, which explicitly emphasize the critical role of HPV genotyping in cervical lesion risk stratification and specifically recommend prioritized colposcopy for HPV16/18-positive patients.

Recent advances—including multisite colposcopic biopsies, endocervical curettage, and combined HPV/TCT screening—have improved lesion detection in postmenopausal women, a population that otherwise faces diagnostic challenges due to estrogen-related cervical atrophy and a recessed squamocolumnar junction. Our findings showed that postmenopausal women positive for non-16/18 HPV with NILM or ASC-US cytology had a CIN2 + rate of 4.85%. This relatively low risk profile suggests that routine colposcopy for this group may yield only modest benefits while potentially increasing patient anxiety, exposure to invasive procedures, and healthcare costs. These findings underscore the value of developing precise, risk-stratified management approaches.

From a molecular perspective, HPV drives carcinogenesis through sustained expression of E6 and E7 oncoproteins: E6 mediates the degradation of the p53 tumor suppressor, while E7 inactivates the retinoblastoma protein (pRb), collectively leading to genomic instability [31, 32]. This mechanism provides the biological basis for emerging triage markers, such as E6/E7 mRNA, p16/Ki-67 dual staining, and DNA methylation assays. E6/E7 mRNA testing improves specificity from 62.3% to 88.6%, enabling better differentiation between transient and persistent HR-HPV infections [33, 34]. In postmenopausal women—for whom cytology is often less reliable—molecular triage (combining HPV genotyping with methylation testing or dual staining) has been shown to reduce unnecessary colposcopy referrals without compromising the detection of CIN2+. This is consistent with the framework of the European Federation of Colposcopy guidelines, which recommend triage using molecular markers (e.g., E6/E7 mRNA, methylation testing) for HPV-positive but TCT-negative patients to minimize unnecessary colposcopy. Notably, p16/Ki-67 dual staining is less affected by cervical atrophy in postmenopausal women (as it targets cellular proliferation markers independent of epithelial thickness), whereas E6/E7 mRNA testing requires caution due to potential sensitivity reduction caused by cervical secretion dilution. Methylation testing is particularly valuable for HPV-positive/TCT-negative cases, while p16/Ki-67 dual staining performs consistently across all age groups. Due to higher associated costs, widespread implementation of these molecular tests should be phased according to resource availability and validated in multicenter studies.

From a clinical management perspective, this study has two key implications for guideline practice. First, for postmenopausal women who are non-HPV16/18 with NILM/ASC-US cytology, conservative follow-up rather than immediate colposcopy is clinically justified, allowing for extended re-evaluation intervals for low- to intermediate-risk HPV subtypes. Second, HPV genotyping remains indispensable: HPV16/18-positive patients exhibit a CIN2 + risk of 24.32%, comparable to the 7.04% risk observed in HPV-negative women. This underscores the importance of genotype-based risk reclassification.

This study has several design limitations. First, its retrospective design relies on existing medical records, which may result in incomplete data, information bias, or selection bias. Second, as a single-center study, it is constrained by the homogeneity of patient characteristics (e.g., local demographics with high HPV52/58 prevalence, lifestyle factors, and average body mass index) and regional medical protocols (e.g., TCT operational standards)—factors that may not reflect the diversity of postmenopausal women in other regions (e.g., areas with low HPV52/58 prevalence). Finally, The study was conducted during and after the Covid-19 pandemic. The Covid-19 pandemic and the virus infection itself may have had an impact on the quality of medical care and the immune system, and thus on the chronicity of HPV infection. It is difficult to fully account for potential confounding factors, such as baseline health status and treatment adherence, which may influence results and limit the generalizability of the findings.

Conclusions

In conclusion, while cytology and colposcopy have long been central to cervical cancer screening in postmenopausal women, further improvements in detection technologies, protocols, and assessment systems are needed to enhance early lesion detection and diagnostic accuracy. Routine testing or E6/E7 mRNA, p16/Ki-67 dual staining and methylation testing are feasible triage options for postmenopausal women with NILM/ASC-US and non-HPV16/18 positive.

Abbreviations

HPV

Human papillomavirus

TCT

ThinPrep cytologic test

CIN

Cervical intraepithelial neoplasia

CIN 1

Cervical intraepithelial neoplasia grade 1

CIN 2/3

Cervical intraepithelial neoplasia grade 2 and grade 3

CIN 2+

Conclude CIN 2/3 and invasive cancer

NILM

No intraepithelial lesion or malignancy

ASC-US

Atypical squamous cells of undetermined significance

LSIL

Lw-grade squamous intraepithelial lesion

HSIL

High-grade squamous intraepithelial lesion

AGC

Atypical glandular cells

ASC-H

Atypical squamous cells cannot exclude HSIL

Authors’ contributions

Peili Li conceived the study and wrote the manuscript.Huiru Wang collected the study data and analyzed the data.

Funding

This work was supported by Science and Technology Innovation Plan of Shanxi Province (2022L672).

Data availability

The original research data in the article are available from the corresponding author.

Declarations

Ethics approval and consent to participate

This research was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Medical Ethics Committee of Fenyang Hospital, Shanxi Province. The informed consent of all participants was obtained before the study.

Consent for publication

Not Application.

Competing interests

The authors declare no competing interests.