Recent Guidelines for Pap Smear and Colposcopy
The most current cervical cancer screening guidelines recommend starting screening at age 25 years with primary HPV testing every 5 years as the preferred approach, though cytology alone every 3 years or cotesting every 5 years remain acceptable alternatives for women aged 30-65 years. 1
Screening Initiation and Age-Specific Recommendations
Ages 21-24 Years
- Do not screen women under age 21 years, regardless of sexual history or activity. 1
- For women aged 21-24 years, screening with cytology alone every 3 years is recommended if screening is initiated at age 21. 1
- However, the 2020 American Cancer Society guideline now recommends delaying screening initiation until age 25 years based on the very low cancer burden in younger women, high rates of HPV regression, and potential obstetric harms from treating transient lesions. 1
Ages 25-29 Years
- Primary HPV testing every 5 years is preferred. 1
- Cytology alone every 3 years remains acceptable. 1
- HPV testing should not be used for routine screening in women under age 30 in older guidelines, though the 2020 ACS guideline supports starting HPV-based screening at age 25. 1
Ages 30-65 Years
- Three acceptable screening strategies exist: 1
Screening Cessation (Age 65+)
- Women may discontinue screening after age 65 years if they meet adequate prior screening criteria: 1
- 3 consecutive negative cytology results OR
- 2 consecutive negative cotest results within the past 10 years, with the most recent test within 5 years 1
- Women with HPV-negative ASC-US results at age 65 should continue screening for 3 more years until achieving 2 consecutive negative cotests or 3 consecutive negative Pap tests. 1
Colposcopy Indications
Immediate Colposcopy Required
- ASC-US with positive HPV 16 or 18: Immediate colposcopy is indicated due to significantly elevated risk for CIN3+, particularly with HPV 18's association with adenocarcinoma. 1, 2
- Endocervical sampling is acceptable at colposcopy when HPV 18 is detected due to adenocarcinoma risk. 2
- ASC-US or worse cytology with any high-risk HPV type warrants colposcopy, though risk is lower with non-16/18 types. 1
HPV Genotyping Strategy
- For women aged 30-65 with negative cytology but positive HPV: Reflex HPV 16/18 genotyping should be performed. 1
- HPV 16/18 genotyping should NOT be used for ASC-US results because colposcopy is already indicated regardless of specific genotype. 1
Critical Screening Intervals and Common Pitfalls
Avoid Annual Screening
- Women at any age should NOT be screened annually by any method. 1
- Annual screening doubles lifetime colposcopies (approximately 2000 per 1000 women vs. 760 per 1000 with 3-year intervals) with minimal additional cancer detection benefit. 1
Post-Treatment Surveillance
- After treatment for CIN2/3, surveillance should continue for at least 25 years. 2
- Initial post-treatment testing includes HPV test or cotest at 6,18, and 30 months. 2
- HPV testing has 99-100% negative predictive value for remaining disease-free after treatment. 1
Special Populations Requiring Different Protocols
These standard guidelines do NOT apply to: 1
- Women with history of cervical cancer
- Women exposed to diethylstilbestrol in utero
- Immunocompromised women (HIV+, organ transplant, chronic corticosteroids, chemotherapy)
- Women who have had their cervix removed (unless history of high-grade lesions)
Key Differences Between Major Guidelines
The 2020 ACS guideline differs from the 2018 USPSTF recommendation primarily in: 1
- ACS strongly recommends starting at age 25 (vs. USPSTF age 21)
- ACS prefers primary HPV testing (vs. USPSTF considers all three strategies equivalent)
- Both agree on screening cessation criteria at age 65 1
The shift toward HPV-based screening reflects superior sensitivity and negative predictive value compared to cytology alone, with particular benefit for detecting adenocarcinoma precursors that cytology often misses. 1