What are the guidelines for cervical cancer screening?

Cervical Cancer Screening Guidelines

The American Cancer Society recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary HPV testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, cotesting (HPV+cytology) every 5 years or cytology alone every 3 years are acceptable alternatives. 1

Age-Based Screening Recommendations

Under Age 21

• No screening recommended regardless of sexual activity, pregnancy status, or other risk factors 2

Ages 21-24

• According to the 2020 ACS guidelines, screening is not recommended to begin until age 25 1
• More conservative management is recommended for this age group if abnormalities are found, as precancerous lesions often regress 1

Ages 25-29

• Primary HPV testing every 5 years (preferred) 1
• If primary HPV testing unavailable: cytology (Pap test) alone every 3 years 1
• Cotesting is not recommended for screening in this age group, though it may be used for management of abnormal results 1

Ages 30-65

• Primary HPV testing every 5 years (preferred) 1
• If primary HPV testing unavailable: cotesting (HPV+cytology) every 5 years or cytology alone every 3 years 1

Over Age 65

• Discontinue screening if:
  • No history of cervical intraepithelial neoplasia grade 2 (CIN 2) or more severe disease within past 25 years
  • Documented adequate negative prior screening in the prior 10 years 1

Special Populations

After Hysterectomy

• No screening needed for women who have had a total hysterectomy (with removal of the cervix) for benign disease 1
• Continue screening for women who have had:
  • Subtotal hysterectomy (cervix remains) 2
  • History of CIN 2/3 until three consecutive negative cytology tests within a 10-year period 1

High-Risk Women

• Women with history of cervical cancer, in utero DES exposure, or immunocompromised status (including HIV positive):
  • Should continue screening beyond age 65 as long as they are in reasonably good health 1, 2
  • Should be screened more frequently (annually after age 30) 1, 2

Evolution of Screening Guidelines

The 2020 ACS guidelines represent significant changes from previous recommendations:

1. Preferred screening strategy is now primary HPV testing every 5 years
2. Recommended age to start screening increased from 21 to 25 years
3. Primary HPV testing is recommended starting at age 25 rather than 30
4. Cotesting and cytology alone are considered transitional options until primary HPV testing is universally available 1

These changes reflect growing evidence that HPV-based screening provides 60-70% greater protection against invasive cervical cancer compared to cytology-based screening 2.

Implementation Challenges

Despite guideline recommendations for extended screening intervals:

• Many physicians continue to recommend more frequent screening than guidelines suggest 3
• The majority of American women report being screened more frequently than recommended 4
• Approximately 55% of women undergo annual Pap testing despite guidelines recommending longer intervals 4
• Screening rates have been declining over time, with about 81.1% of eligible women reporting having a Pap test within 3 years 5

Clinical Pearls and Pitfalls

• HPV vaccination status does not change screening recommendations 2
• Pregnancy or recent childbirth is not an indication to perform cervical cancer screening earlier than recommended by age-based guidelines 2
• CIN 1 should not be treated in any age group unless persistent for 2 years 1
• Approximately 50% of cervical cancers occur in women who have never been screened or who have not been screened in the past 5 years, emphasizing the importance of regular screening 2
• Women with abnormal results should be managed according to the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines 1

Cervical cancer screening has dramatically reduced cervical cancer incidence and mortality by over 70% in the United States, highlighting the effectiveness of screening programs 2.