Cervical Cancer Screening Guidelines
Primary Screening Recommendations by Age
For women aged 21-29 years, screen with cervical cytology (Pap test) alone every 3 years. 1, 2, 3 Do not perform HPV testing in this age group for routine screening, as HPV infection is extremely common and typically transient in young women, leading to unnecessary interventions without improving cancer detection. 1, 2
For women aged 30-65 years, the preferred strategy is co-testing (Pap test plus HPV DNA test) every 5 years. 1, 4, 2, 3 Alternatively, cervical cytology alone every 3 years is acceptable if co-testing is not available or not preferred. 1, 3 Co-testing provides superior sensitivity (96-100% for detecting CIN 2/3 and cancer) and allows for longer, safer screening intervals. 5
Key Age-Based Rules:
- Do not screen women younger than 21 years, regardless of sexual activity history or HPV vaccination status. 1, 2, 3
- Annual screening is not recommended for any age group. 1
- HPV vaccination does not change screening recommendations—vaccinated women follow the same guidelines as unvaccinated women. 1, 2
When to Stop Screening
Women aged 65 years and older can discontinue screening only if ALL of the following criteria are met: 4, 3
- Three consecutive negative Pap tests OR two consecutive negative co-tests within the past 10 years
- Most recent test performed within the past 5 years
- No history of CIN 2 or higher-grade lesions within the past 20 years 4
Critical Pitfall to Avoid:
Do not rely on patient self-report of "adequate prior screening." Many women incorrectly believe they had a Pap test when only a pelvic examination was performed. 4 Always verify documented results before discontinuing screening.
Special Populations Requiring Extended Surveillance
Women with a history of abnormal Pap results require continued screening for at least 20 years after treatment, even if this extends well past age 65. 4 This "20-year rule" applies specifically to women with CIN 2/3 or higher-grade lesions. 4
Women who are immunocompromised (HIV-positive, organ transplant recipients, chronic corticosteroid use) should be screened more frequently and should not stop screening at age 65. 1 These patients require ongoing surveillance for as long as they are in reasonably good health. 1
Women with in utero DES exposure or history of cervical cancer should continue screening indefinitely, regardless of age. 1
Post-Hysterectomy Guidelines
Screening is not indicated for women who have had a total hysterectomy with removal of the cervix for benign indications. 1, 3 However, women with a history of CIN 2/3 or cervical cancer must continue screening for at least 20 years after hysterectomy, even if the cervix was removed. 1, 4
Management of Abnormal Results
When abnormalities are detected, the guiding principle is similar management for similar risks. 1 The hierarchy of abnormalities from lowest to highest cancer risk is: 1
- ASC-US (atypical squamous cells of undetermined significance)
- LSIL (low-grade squamous intraepithelial lesion)
- ASC-H (atypical squamous cells, cannot rule out high-grade)
- HSIL (high-grade squamous intraepithelial lesion)
- Invasive carcinoma
For women aged 21 and older with ASC-US, use HPV testing for triage. 2, 5 HPV-positive ASC-US, ASC-H, LSIL, or HSIL require colposcopy with directed biopsies. 1, 4
Women with HPV-negative ASC-US cannot exit screening at age 65 with just this result—they should be retested in 3 years and require documented negative results before discontinuing screening. 4
Testing Methodology
Both liquid-based cytology and conventional Pap smears are acceptable, with similar performance characteristics. 1 Liquid-based cytology offers the advantage of allowing HPV testing from the same sample (co-testing or reflex testing). 1
HPV testing should never be used as a stand-alone screening test—it must be combined with cytology for primary screening in women aged 30-65 years. 1