Cervical Cancer Screening Recommendations for Average-Risk Women
For average-risk women, begin screening at age 21 with cytology alone every 3 years, transition to either cytology every 3 years or co-testing (cytology plus HPV) every 5 years at age 30, and discontinue screening at age 65 if adequately screened. 1
Age-Based Screening Algorithm
Women Under Age 21
- Do not screen women younger than 21 years, regardless of sexual activity or other risk factors 1, 2
- This prevents unnecessary procedures and overtreatment in a population where cervical cancer is extremely rare 3
Women Ages 21-29
- Screen every 3 years with cytology (Pap test) alone 1, 2
- Do not perform HPV testing in this age group, as HPV prevalence is high (21%) and most infections resolve spontaneously 1
- Do not screen more frequently than every 3 years, even if the patient requests it 1
Women Ages 30-65
You have two equally acceptable options 1, 2:
- Option 1: Continue cytology alone every 3 years
- Option 2: Co-testing (cytology plus HPV testing) every 5 years for women who prefer less frequent screening 1
The choice between these strategies should be based on patient preference for screening frequency, as both provide equivalent protection against cervical cancer mortality 2.
Women Over Age 65
- Stop screening if the patient has had adequate prior screening defined as: 1, 2
- 3 consecutive negative cytology results, OR
- 2 consecutive negative co-test results within the past 10 years
- With the most recent test performed within the past 5 years 1
Special Circumstances Requiring No Screening
Post-Hysterectomy
- Do not screen women who have had a hysterectomy with removal of the cervix for benign indications 1, 2
- Continue screening only if the hysterectomy was performed for high-grade precancerous lesions or cervical cancer 2
Critical Pitfalls to Avoid
Overscreening
- Never screen more frequently than every 3 years with cytology in any age group 1
- Annual screening increases harms (unnecessary procedures, anxiety, overtreatment) without improving mortality outcomes 1
- Despite guidelines, data show many women continue to be screened annually, representing poor guideline adherence 4, 5
Underscreening High-Risk Groups
- Women without insurance, recent immigrants, and those without a usual source of care have significantly lower screening rates 4
- Approximately 14 million eligible women aged 21-65 have not been screened within the recommended timeframe 4
Age-Related Errors
- Do not start screening before age 21, even in sexually active adolescents (unless immunocompromised) 1, 2
- Do not continue routine screening beyond age 65 in adequately screened women 1
Important Exclusions
These recommendations apply ONLY to average-risk women. The following populations require different screening protocols and are explicitly excluded from these guidelines 6:
- HIV-positive individuals: Require annual screening starting at age 21 or within 1 year of sexual debut, with lifelong screening regardless of age 7, 6
- Immunocompromised patients: Need more intensive surveillance 6
- Women with history of high-grade dysplasia or cervical cancer: Require individualized follow-up 6
Screening Method Considerations
- Primary HPV testing alone (without cytology) was FDA-approved in 2014, but major guideline organizations have not yet issued formal recommendations on this strategy 1
- When co-testing is performed in women aged 30-65, both tests must be negative to extend the screening interval to 5 years 1
- All screening methods (cytology alone, HPV alone, or co-testing) effectively detect high-grade precancerous lesions when used at appropriate intervals 2