Cervical Cancer Screening: Age to Start
Cervical cancer screening should begin at age 25 years for average-risk individuals with a cervix, regardless of sexual history or HPV vaccination status. 1
Current Guideline Recommendation
The American Cancer Society (ACS) updated its guidelines in 2020 to recommend starting cervical cancer screening at age 25 years, moving away from the previous age 21 recommendation that had been standard since 2010. 1
This represents the most recent evidence-based guideline from a major professional organization and reflects updated understanding of the disease burden and benefit-to-harm balance in younger age groups. 1
Rationale for Starting at Age 25
The decision to defer screening until age 25 is based on several key factors:
The burden of cervical cancer in women aged 20-24 years is extremely low, with only 0.8% of all new cervical cancer cases diagnosed in this age group and only 0.5% of cervical cancer deaths attributable to diagnoses in this age range. 1
High incidence of transient HPV infections in younger women that typically resolve spontaneously without intervention, leading to unnecessary procedures and anxiety. 1
Risk of adverse obstetric outcomes from treatment of precancerous lesions that would likely regress on their own, including preterm delivery and low birth weight. 1
Decision analysis demonstrates a favorable benefit-to-harm balance for beginning screening at age 25 years compared to earlier ages. 1
Alternative Acceptable Starting Age
It is important to note that the U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) still recommend starting screening at age 21 years. 1, 2
The USPSTF 2018 guidelines recommend screening begin at age 21 with cytology every 3 years for women aged 21-29 years. 2
This creates a divergence in current guidelines, with ACS recommending age 25 and USPSTF/ACOG recommending age 21. 1, 2
Screening Method at Initiation
For women aged 25-29 years:
Primary HPV testing every 5 years is the preferred screening strategy according to the 2020 ACS guidelines. 1
Cytology alone every 3 years or cotesting (HPV + cytology) every 5 years are acceptable alternatives as the healthcare system transitions to primary HPV testing. 1
Critical Exclusions from These Guidelines
These recommendations apply only to average-risk individuals and do NOT apply to: 1
- Women with a history of cervical cancer 1
- Women exposed in utero to diethylstilbestrol (DES) 1
- Immunocompromised individuals (HIV-positive, organ transplant recipients, chronic corticosteroid use) 1
- Women with a history of high-grade precancerous lesions (CIN2+) 1
These high-risk populations require earlier and more intensive screening protocols. 1
Common Pitfalls to Avoid
Never screen women younger than age 21 years, regardless of sexual activity history. This is a firm recommendation across all major guidelines. 1, 2
Do not screen more frequently than recommended intervals, as annual screening provides no additional benefit and increases harms. 1
HPV vaccination status does not change screening recommendations—vaccinated women follow the same screening schedule as unvaccinated women. 1
Practical Implementation Considerations
Given the divergence between ACS (age 25) and USPSTF/ACOG (age 21) guidelines:
In clinical practice, starting at age 21 remains defensible and aligns with USPSTF Grade A recommendations. 2
Starting at age 25 is supported by the most recent (2020) evidence-based analysis from ACS showing minimal disease burden in the 20-24 age group. 1
The choice between age 21 and 25 should consider individual patient factors, shared decision-making, and institutional protocols, though the trend is clearly moving toward age 25 as the evidence-based starting point. 1