What are the recommended HPV vaccination schedules and cervical cancer screening guidelines for adults?

HPV Vaccination and Cervical Cancer Screening Recommendations

All children should receive HPV vaccination at ages 11-12 years (can start at age 9), with a 2-dose schedule for those starting before age 15, and cervical cancer screening should begin at age 25 years with primary HPV testing every 5 years as the preferred strategy. 1

HPV Vaccination Schedule

Routine Vaccination (Ages 9-14)

• Start at ages 11-12 years (can begin as early as age 9) 2, 3
• 2-dose schedule: Second dose given 6-12 months after the first dose 2
• This applies to all children regardless of sex

Catch-Up Vaccination (Ages 15-26)

• 3-dose schedule required for those initiating vaccination at age 15 or older 2
• Catch-up vaccination recommended through age 26 for anyone not adequately vaccinated 4
• For adults ages 22-26 who are unvaccinated, providers should inform them that vaccination may not be effective in lowering cancer risk due to likely prior HPV exposure 2, 3

Adults Ages 27-45

• Shared clinical decision-making recommended 4
• Public health benefit is minimal in this age range because most sexually active adults have already been exposed to HPV 4
• Persons in long-term, mutually monogamous relationships are unlikely to acquire new HPV infections and would not benefit 4
• Those with new sexual partners may still benefit from vaccination 4

Critical caveat: HPV vaccination does NOT eliminate the need for cervical cancer screening—all women must continue screening regardless of vaccination status 1

Cervical Cancer Screening Guidelines

Ages 21-24: No Screening

• Do not screen women under age 25, regardless of sexual history or vaccination status 1
• This represents a change from older guidelines that recommended starting at age 21 5

Ages 25-65: Active Screening

Preferred strategy 1:

• Primary HPV testing every 5 years starting at age 25
• Must use FDA-approved HPV test for primary screening

Acceptable alternatives 1:

• Cotesting (HPV + cytology) every 5 years
• Cytology alone every 3 years

Important note: The 2020 ACS guideline explicitly states that cotesting and cytology alone will not be included in future guidelines as the U.S. transitions to primary HPV testing 1

The USPSTF 2019 guidelines differ slightly, recommending 6:

• Ages 21-29: Cytology alone every 3 years
• Ages 30-65: Either cytology every 3 years, primary HPV testing every 5 years, or cotesting every 5 years

Age 65+: Discontinue Screening

Stop screening if adequate prior negative screening 1:

• 2 consecutive negative primary HPV tests, OR
• 2 consecutive negative cotests, OR
• 3 consecutive negative cytology tests
• All within the past 10 years, with the most recent test within the past 3-5 years (depending on test used)

Continue screening beyond age 65 if 1:

• No documentation of adequate prior screening
• History of CIN2 or worse in the past 25 years
• History of cervical cancer ever

Special Populations

After hysterectomy 1:

• No screening needed if cervix removed AND no history of CIN2+ or cervical cancer
• Continue screening if history of CIN2+ in past 25 years or cervical cancer ever

Immunocompromised patients (HIV+, organ transplant, chronic steroids) 7:

• Screen twice in first year after diagnosis
• Then annually thereafter
• No upper age limit for stopping screening

History of DES exposure in utero 5:

• Continue screening for life with no upper age limit

Key Implementation Points

Common Pitfalls to Avoid

1. Don't screen too early: Starting before age 25 (or 21 per USPSTF) leads to overdetection of transient HPV infections that would clear spontaneously 1

2. Don't screen annually: No screening strategy recommends annual testing for any age group—this causes unnecessary harms 8, 1

3. Don't use HPV testing alone in women under 25: HPV prevalence is very high in this age group with most infections clearing spontaneously 5

4. Don't stop screening in vaccinated women: Vaccines don't cover all high-risk HPV types, and many women were infected before vaccination 1

5. Don't forget to document screening history: Adequate documentation is essential for determining when to stop screening at age 65 1

Divergence in Guidelines

The main difference between ACS 2020 and USPSTF 2019 guidelines is the starting age (25 vs. 21 years) and the preferred test for ages 25-29 (primary HPV vs. cytology alone). The ACS guideline is more recent (2020 vs. 2019) and represents the most current evidence-based approach, particularly regarding the shift to primary HPV testing and later screening initiation 1.

Both guidelines agree on screening intervals for ages 30-65, discontinuation criteria at age 65, and the importance of continued screening regardless of vaccination status.