What are the guidelines for Pap (Papanicolau) testing and Human Papillomavirus (HPV) screening?

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

Screening Strategy by Age

Ages 21-29 Years

• Screen with Pap test alone every 3 years 1, 2, 3
• HPV testing should NOT be used for primary screening in this age group 3
• HPV testing may only be used for triage of ASC-US results, not for routine screening 1, 3
• The rationale: HPV prevalence is substantially higher in younger women, leading to excessive false-positives and unnecessary colposcopies without improving cancer prevention 3

Ages 30-65 Years

• Co-testing (Pap test plus HPV DNA test) every 5 years is the preferred approach 1, 2, 3
• Acceptable alternative: Pap test alone every 3 years 1
• Another acceptable alternative: Primary HPV testing alone every 5 years 3
• Co-testing maximizes cancer prevention while reducing false-positives compared to younger age groups 3

When to Stop Screening

Women can discontinue screening at age 65 if they meet ALL of the following criteria: 1, 2, 4

1. Three consecutive negative Pap tests OR two consecutive negative co-tests within the last 10 years 1, 4
2. Most recent test occurred within the past 5 years 4
3. No history of CIN2+ (high-grade precancerous lesions) or cervical cancer 4

Once screening is discontinued, it should not resume for any reason, even if a woman reports having a new sexual partner 4

Critical Exceptions to Stopping at Age 65

Continue screening beyond age 65 in these situations: 4

• History of CIN2, CIN3, or adenocarcinoma in situ: Continue routine screening for at least 20 years after treatment, even if this extends past age 65 4
• HIV infection or immunosuppression 4
• Multiple sexual partners 4
• Inadequate documentation of prior screening 4
• Never been screened or under-screened: Perform at least 2 negative tests 1 year apart, regardless of age 4

Special Populations

Post-Hysterectomy

• Women who have had a total hysterectomy (cervix removed) for benign reasons should stop all cervical cancer screening 1, 4
• Exception: Continue screening if hysterectomy was performed for cervical cancer or its precursors 4

HPV-Vaccinated Women

• Screen using the same recommendations as unvaccinated women 1, 2
• HPV vaccination status does not change screening intervals or methods 2

Pregnant Women

• Follow the same screening recommendations as non-pregnant women 2

Management of Abnormal Results

ASC-US (Atypical Squamous Cells of Undetermined Significance)

For women ≥21 years with ASC-US, three management options exist: 1

1. HPV triage testing (preferred): Refer to colposcopy if HPV-positive 1
2. Repeat Pap tests at 6 and 12 months until two consecutive negative results 1
3. Prompt colposcopy if concerns about adherence or other clinical indications 1

• Do NOT use HPV 16/18 genotyping for ASC-US triage, as results do not alter management 1

ASC-H, LSIL, or HSIL

• Refer to colposcopy for evaluation 1
• Exception: For women <21 years with ASC-US or LSIL, repeat Pap testing at 12 and 24 months is recommended instead of colposcopy due to high spontaneous clearance rates 1

HPV-Negative ASC-US in Women ≥65 Years

• Not sufficiently reassuring to stop screening at age 65 1
• Retest in 3 years and continue surveillance until achieving 2 consecutive negative co-tests or 3 consecutive negative Pap tests 1
• Cancer risk is disproportionately high despite low dysplasia risk 1

Common Pitfalls to Avoid

• Do not screen women <21 years, regardless of sexual activity 1, 5
• Do not use HPV testing alone or with Pap testing in women <30 years for primary screening 1, 3
• Do not screen annually when 3-year or 5-year intervals are appropriate 5
• Do not use HPV DNA testing to decide whether to vaccinate for HPV 1
• Do not continue screening past age 65 in adequately screened women without high-risk factors, as the benefit-to-harm ratio becomes unfavorable 4

Evidence Quality Note

The 2019 American Cancer Society guidelines represent the most current consensus recommendations 1, with strong support from multiple organizations including ACOG and USPSTF 2, 3, 4. Primary HPV testing shows 51% higher detection of high-grade lesions at enrollment and 42-47% reduction in subsequent detection compared to cytology alone, but the benefit-to-harm ratio only becomes favorable at age 30 and above 3.