Cervical Cancer Screening Guidelines
Primary Recommendation
Begin cervical cancer screening at age 21 years regardless of sexual activity history, screen every 3 years with Pap test alone for women aged 21-29, and transition to either Pap plus HPV co-testing every 5 years (preferred) or Pap alone every 3 years for women aged 30-65. 1, 2
Age-Specific Screening Algorithm
Women Under Age 21
- Do not screen, regardless of sexual activity status, including women who are sexually active 1, 2
- Cervical cancer incidence is extremely low in this age group, making screening ineffective and potentially harmful 1
Women Aged 21-29 Years
- Begin screening at age 21 1, 2
- Screen every 3 years with Pap test alone 3, 2
- Do NOT use HPV testing in this age group for routine screening or management of abnormal results 2
- After initial normal result, continue screening every 3 years 2
Women Aged 30-65 Years
- Preferred approach: Pap test plus HPV co-testing every 5 years 3, 2
- Acceptable alternative: Pap test alone every 3 years 3, 2
- The 5-year interval with co-testing is supported by increased sensitivity of the combined approach 2
Women Over Age 65
- Discontinue screening if adequate prior screening with normal results has been documented 3, 1, 2
- Adequate screening is defined as 3 consecutive negative Pap tests or 2 consecutive negative co-tests within the last 10 years, with the most recent test occurring within the past 5 years 4
- Once screening is discontinued, do not resume for any reason, even if the woman reports a new sexual partner 4
Special Populations Requiring Modified Screening
Post-Hysterectomy
- Discontinue screening if the cervix was removed and there is no history of high-grade precancerous lesions or cervical cancer 1, 2, 4
- Continue screening if hysterectomy was performed for cervical cancer or its precursors 2
High-Risk Women
Women with the following conditions may require more frequent screening beyond standard guidelines:
- History of cervical cancer, CIN2, CIN3, or adenocarcinoma in situ (continue screening for at least 20 years, even past age 65) 4
- HIV infection or immunocompromised status 1, 2
- History of persistent high-risk HPV types 2
- Multiple sex partners 4
- Current smoking 4
Never Previously Screened
- Perform at least two negative tests one year apart, regardless of age 2, 4
- Women who have never been screened have 3-4 times the incidence of disease compared to those with at least one prior normal Pap smear 4
Critical Pitfalls to Avoid
Over-Screening
- Annual Pap testing is NOT recommended for average-risk women 2
- The 3-year screening interval for Pap tests is supported by strong evidence showing that screening every 1-2 years improves effectiveness by less than 5% compared to every 3 years 2
- Over-screening increases costs and potential harms without significantly improving cancer detection 2
Inappropriate HPV Testing
- Never use HPV testing in women under age 30 for routine screening 2
- HPV testing is only appropriate for women aged 30-65 as part of co-testing 3, 2
Premature Discontinuation
- Do not stop screening before age 65 in women without adequate prior negative screening 2, 4
- Ensure documentation of 3 consecutive negative tests within the past 10 years before discontinuing 4
Screening After Adequate Prior Testing
- Do not continue screening past age 65 in well-screened women, as the absolute benefit is very small and comes at the cost of unnecessary colposcopies 4
- In well-screened women older than 65, CIN2+ prevalence is low and cervical cancer is rare 4
Documentation Requirements
- Provide written documentation to patients stating whether a Pap test was obtained during their visit 2
- Self-reports of Pap test completion are often inaccurate and require clinical record verification 2
- If documentation of recent screening cannot be obtained for women over 65, perform screening tests until criteria for cessation are met 4
Evidence Quality Notes
The most recent and comprehensive guidelines come from the American College of Obstetricians and Gynecologists, American Cancer Society, and U.S. Preventive Services Task Force, all of which align on the core recommendations presented above 3, 1, 2. The 2019 American Cancer Society guidelines represent the most current major society recommendations 3. Modeling studies demonstrate that continued screening of previously well-screened women over 65 reduces cervical cancer mortality by only 0.18% at age 65 and 0.06% at age 74, supporting cessation guidelines 4.