Cervical Cancer Screening Guidelines
When to Start Screening
All women should begin cervical cancer screening at age 21 years, regardless of sexual activity history or HPV vaccination status. 1, 2 Do not screen women younger than 21 years under any circumstances, as cervical cancer incidence is extremely low in this age group even among sexually active women. 1, 3
Screening Strategy by Age Group
Ages 21-29 Years
- Screen with Pap test alone every 3 years 1, 3
- Do not use HPV testing (alone or with Pap) in this age group, as HPV infection is extremely common and usually clears spontaneously 1, 4
- Annual screening is not recommended for any age group 1
Ages 30-65 Years
The preferred approach is co-testing (Pap test plus HPV DNA test) every 5 years. 1, 4, 3 This provides higher sensitivity than Pap testing alone and justifies the extended screening interval. 4
An acceptable alternative is Pap test alone every 3 years if co-testing is not available. 1, 3
When to Stop Screening
Women can discontinue screening at age 65 if they meet ALL of the following criteria: 1, 4, 3
- ≥3 consecutive negative Pap tests OR ≥2 consecutive negative co-tests within the last 10 years
- Most recent test occurred within the last 5 years
- No history of high-grade precancerous lesions (CIN 2 or 3) or cervical cancer
- Not otherwise at high risk for cervical cancer
Critical Exceptions Requiring Continued Screening Beyond Age 65
Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ must continue routine screening for at least 20 years after treatment, even if this extends screening past age 65. 5, 4 This is non-negotiable due to persistent elevated cancer risk.
Women with lower-grade abnormalities (ASC-US, LSIL, or CIN 1) must demonstrate adequate negative screening AFTER resolution of the abnormality before standard cessation criteria apply. 5
High-risk women (HIV-positive, immunocompromised, history of cervical cancer) should continue annual screening and not follow standard cessation guidelines. 4
When NOT to Screen
Do not screen women who have had a total hysterectomy with removal of the cervix unless they have a history of high-grade precancerous lesions or cervical cancer. 1, 4, 3 Screening provides no benefit in this population.
HPV Testing Guidelines
Appropriate Uses
- Triage of women aged ≥21 years with ASC-US cytology results 1
- Routine co-testing with Pap test in women aged ≥30 years 1
Inappropriate Uses (Never Use HPV Testing For)
- Women younger than 30 years for routine screening 1, 4
- Deciding whether to vaccinate for HPV 1
- STD screening 1
- Stand-alone primary screening without Pap test 1
Common Pitfalls to Avoid
Over-screening remains a significant problem, with only 19-31% of physicians recommending guideline-concordant intervals. 4, 6 Most continue to screen annually, which increases costs and potential harms without improving cancer detection. 4
Many women equate having a pelvic examination with having a Pap test when no sample was actually taken. 1 Provide written documentation stating whether a Pap test was obtained during the visit, as self-reports are often inaccurate. 1, 4
Physicians are less likely to extend screening intervals when using co-testing compared to Pap alone, despite guidelines supporting 5-year intervals with co-testing. 6 Only 19% of physicians recommend the next Pap test in 3 years after a normal co-test result. 6
Special Populations
Women with immunosuppression, history of multiple sexual partners, smoking, pessary use, or high-risk ethnicity (Vietnamese or Hispanic) may require continued screening beyond age 65 even with adequate negative screening history. 5
Pregnant women should follow the same screening recommendations as non-pregnant women. 1
Women who have received HPV vaccination should be screened using the same recommendations as unvaccinated women. 1