Recommended Pap Smear and HPV Screening Timeline
The recommended cervical cancer screening timeline begins at age 25 (previously age 21), with screening every 3 years with cytology alone for ages 25-29, and for ages 30-65, screening every 5 years with HPV and cytology co-testing or every 3 years with cytology alone. 1
Initial Screening Age
- Begin cervical cancer screening at age 25, regardless of sexual history (per updated American Cancer Society 2020 guidelines) 1
- Previous guidelines recommended beginning at age 21 or within 3 years of sexual debut 2
Screening Intervals by Age Group
Ages 25-29
- Screen every 3 years with cytology (Pap test) alone 1
- HPV testing is NOT recommended for routine screening in this age group 1, 3
- HPV testing should only be used for triage of ASC-US (Atypical Squamous Cells of Undetermined Significance) results 2, 3
Ages 30-65
- Preferred approach: HPV and cytology co-testing every 5 years 1, 3
- Acceptable alternative: Cytology alone every 3 years 1
- Women negative on both HPV DNA testing and cytology should not be rescreened before 3 years 2
- Women negative by cytology but high-risk HPV DNA positive should have repeat HPV DNA testing along with cervical cytology at 6-12 months 2
Management of Abnormal Results
For ASC-US Results (Ages ≥21)
Three management options are available 2:
- Prompt colposcopy
- Repeat Pap tests at 6 and 12 months
- High-risk HPV DNA test
For Women with Positive HPV but Normal Cytology
Two options 3:
- 12-month follow-up with co-testing (Pap and HPV)
- Test for HPV16 or HPV16/18 genotypes
- If positive for HPV16 or HPV16/18: refer to colposcopy
- If negative for HPV16 or HPV16/18: 12-month follow-up with co-testing
When to Discontinue Screening
- Screening can be discontinued at age 65 if there have been at least 3 consecutive negative Pap tests or 2 consecutive negative co-tests within the past 10 years, with the most recent test occurring within the past 5 years 1
- Women who have had a total hysterectomy (with removal of the cervix) for benign reasons and no history of high-grade precancerous lesions should discontinue screening 1
Special Populations
Screening should be more frequent for:
- Women with HIV: Pap test twice in the first year after diagnosis, then annually if results are normal 1
- Women with immunocompromised status, in utero DES exposure, or previous cervical cancer/high-grade precancerous lesions 1
- Women with a history of cervical cancer or high-grade precancerous lesions should continue screening beyond age 65 1
HPV Vaccination Status
- Vaccinated women should follow the same screening guidelines as unvaccinated women 3
Common Pitfalls and Caveats
Overscreening: Despite guidelines recommending extended intervals with co-testing, many providers continue to recommend annual screening 4. This can lead to unnecessary procedures and patient anxiety.
Patient concerns about extended intervals: Many women express concern about extending screening intervals from 3 to 5 years 5. When explaining the interval change, emphasize that:
- HPV primary screening identifies those at lower risk
- HPV takes a long time to develop into cervical cancer
- The 5-year interval is evidence-based and safe
Underuse of co-testing: While co-testing has increased (from 10% in 2007 to 60.8% in 2016), there are still disparities in screening by race, ethnicity, and socioeconomic status 6.
Inappropriate HPV testing: HPV DNA testing should NOT be used for:
By following these evidence-based guidelines, providers can optimize the benefits of cervical cancer screening while minimizing unnecessary procedures and patient anxiety.