What are the guidelines for Human Papillomavirus (HPV) testing in females?

HPV Testing Guidelines for Females

For women aged 30-65 years, the preferred screening approach is cotesting with both HPV testing and cytology every 5 years, though cytology alone every 3 years remains acceptable; HPV testing should not be used in women under 30 years except as reflex testing for ASC-US results. 1

Screening by Age Group

Women Under 21 Years

• No screening should be performed regardless of age of sexual initiation or risk factors. 1, 2
• HPV testing is specifically not recommended in this age group due to extremely high infection rates that typically resolve spontaneously. 1, 3

Women Aged 21-29 Years

• Screen with cytology alone every 3 years. 1, 2
• HPV testing should NOT be used for primary screening in this age group, either as a stand-alone test or as cotesting with cytology. 1
• HPV testing may only be used as reflex testing when cytology shows atypical squamous cells of undetermined significance (ASC-US). 1
• The rationale for avoiding HPV testing in younger women is the extremely high prevalence of transient HPV infections that clear spontaneously without clinical significance. 1, 3

Women Aged 30-65 Years

• Preferred strategy: Cotesting with both HPV and cytology every 5 years. 1
• Acceptable alternative: Cytology alone every 3 years. 1, 2
• Primary HPV testing alone every 5 years is also acceptable per USPSTF 2018 guidelines. 2
• Women with HPV-negative ASC-US results should return for screening in 3 years rather than 5 years. 1
• The negative predictive value of combined negative HPV and cytology testing is exceptionally high, with cumulative 5-year risk of CIN2+ being only 0.34%. 1, 4

Women Over 65 Years

• Discontinue screening if adequate prior screening has been documented: 3 consecutive negative cytology tests OR 2 consecutive negative cotest results within the past 10 years, with the most recent test within 5 years. 1, 2
• HPV-negative ASC-US results count as negative for purposes of discontinuing screening. 1
• Once screening is discontinued, it should not resume for any reason, including new sexual partners. 1

Special Populations Requiring Different Approaches

Women with History of High-Grade Lesions

• After treatment for CIN2, CIN3, or adenocarcinoma in situ, continue routine screening for at least 20 years, even if this extends beyond age 65. 1, 5
• Initial post-treatment surveillance should include HPV testing or cotesting at 6,18, and 30 months. 5
• Long-term surveillance for at least 25 years is recommended. 5, 6

Immunocompromised Women

• These guidelines do NOT apply to women who are HIV-positive, immunocompromised by organ transplantation, chemotherapy, or chronic corticosteroid treatment. 1
• HIV-positive individuals should begin screening at age 21 or within 1 year of sexual debut, whichever comes first, with annual cytology. 3

Post-Hysterectomy

• Women who have had total hysterectomy with cervix removal should NOT be screened unless they have a history of CIN2 or more severe diagnosis. 1, 2
• Women with subtotal (supracervical) hysterectomy should continue screening per standard guidelines. 1

HPV Testing Technical Specifications

FDA-Approved Tests

• Current FDA-approved tests detect 13-14 high-risk HPV types (16,18,31,33,35,39,45,51,52,56,58,59,66,68). 1, 6, 3
• Type-specific tests can identify HPV 16 and 18 individually. 1, 6
• Tests are only FDA-cleared for cervical specimens collected during clinical examinations, not for self-testing. 6, 3

When HPV Testing Should NOT Be Used

• Never use for deciding whether to vaccinate against HPV. 1, 3
• Never use for routine STD screening. 1, 6, 3
• Never use as stand-alone test in women under 30 years. 1
• Never use for testing oral or anal specimens. 6, 3
• Never use for testing male partners or for genital warts. 3

Management Based on Results

Positive HPV with Normal Cytology (Age 30+)

• If HPV 16 or 18 positive: Immediate colposcopy due to high cancer risk. 5, 6
• If other high-risk HPV types positive: Repeat testing in 1 year. 5, 6
• The incidence of CIN2/3 is much lower with normal cytology/positive HPV compared to ASC-US/positive HPV. 1

HPV Vaccination Status

• Screening recommendations do NOT change based on HPV vaccination status. 1
• Vaccinated women should be screened identically to unvaccinated women. 1

Critical Pitfalls to Avoid

• Never screen women under 21 years - this leads to unnecessary procedures for lesions with high regression rates. 1, 2
• Never perform annual screening at any age - too-frequent screening increases false-positives without improving cancer detection given the 10-year average progression time from high-grade lesions to cancer. 1
• Never use HPV testing in women 21-29 years for primary screening - the high prevalence of transient infections causes excessive false-positives. 1
• Never delay colposcopy for high-grade abnormalities (HSIL, ASC-H) regardless of sexual activity status, as these carry significant risk of underlying high-grade disease. 5
• Never assume HPV infection indicates recent sexual activity or infidelity - the virus can remain dormant for many years before reactivation. 6, 3