Cervical Cancer Screening Guidelines
Primary Screening Recommendations by Age
For women aged 25-65 years, primary HPV testing alone every 5 years is now the preferred screening strategy, with cotesting every 5 years or cytology alone every 3 years as acceptable alternatives. 1
Women Under Age 21
- Do not screen women younger than 21 years, regardless of sexual history or other risk factors. 2, 3
- Screening before age 21 causes more harm than benefit by leading to unnecessary interventions for lesions that would naturally regress. 2, 3
Women Aged 21-29 Years
- Screen with cervical cytology alone every 3 years. 2, 3
- HPV testing (either alone or as cotesting) is not recommended for this age group. 3
- The rationale is that HPV infections are common and typically transient in younger women, leading to excessive false positives. 3
Women Aged 30-65 Years
The American Cancer Society 2020 guidelines represent a significant shift from previous recommendations:
- Preferred approach: Primary HPV testing alone every 5 years (using an FDA-approved HPV test). 1
- Acceptable alternatives:
Important note: The ACS explicitly states that cotesting and cytology alone will not be included in future guidelines as the U.S. transitions to primary HPV testing. 1 This reflects the superior performance of HPV testing in vaccinated populations, where cytology disproportionately identifies minor abnormalities from low-risk HPV types. 1
Women Over Age 65
- Discontinue screening if adequate negative prior screening is documented and the woman is not at high risk. 2, 4
Adequate prior screening is defined as: 1
- 2 consecutive negative primary HPV tests, OR
- 2 consecutive negative cotests, OR
- 3 consecutive negative cytology tests
All within the past 10 years, with the most recent test occurring within the past 3-5 years depending on the test used. 1
Critical caveat: Women over 65 without documentation of adequate prior screening should continue screening until cessation criteria are met. 1 This is important because cervical cancer incidence remains elevated in older women who were inadequately screened, with rates not declining until age ≥85 years. 5
Special Populations
Post-Hysterectomy
- Do not screen women who have had a hysterectomy with cervix removal and no history of CIN2 or more severe diagnosis in the past 25 years, or cervical cancer ever. 1, 2, 4
HPV-Vaccinated Women
- Follow the same age-specific screening recommendations as unvaccinated women. 1, 2, 3
- Vaccination does not eliminate screening need because vaccines do not cover all oncogenic HPV types. 3
Immunocompromised Women
- Standard recommendations do not apply to women with HIV or other immunocompromising conditions, who require more frequent screening, often annually. 3
Management of Abnormal Results
- Women with abnormal screening results should be managed according to the 2020 ASCCP Risk-Based Management Consensus Guidelines. 1
- Immediate colposcopy is indicated for: 2
- HSIL (high-grade squamous intraepithelial lesion)
- HPV-positive HSIL
- HPV-positive ASC-H (atypical squamous cells, cannot exclude HSIL)
- Atypical glandular cells (AGC)
Critical Pitfalls to Avoid
Over-Screening
- Never screen more frequently than the recommended intervals. 1
- Annual screening is not recommended for any age group as it provides minimal additional benefit while substantially increasing harms from false positives and unnecessary procedures. 2
Under-Screening
- Approximately 18.4% of women aged 61-65 years have not been recently screened, approaching the stopping age without adequate prior screening history. 5
- An estimated 14 million women aged 21-65 have not been screened within the past 3 years. 6
- Target high-risk groups for outreach: recent immigrants, uninsured women, and those without a usual source of healthcare have significantly lower screening rates. 6
Inappropriate Early Screening
- Screening women under 21 leads to unnecessary treatment of lesions that would regress spontaneously. 2