What are the current guidelines for cervical cancer screening, including start age, screening intervals, high‑risk group recommendations, and management of abnormal results?

Cervical Cancer Screening Guidelines

Start Age and Initial Screening Strategy

Begin cervical cancer screening at age 25 years with primary HPV testing every 5 years as the preferred strategy. 1 This represents the most recent American Cancer Society (ACS) 2020 guideline update, which moved the start age from 21 to 25 years based on the extremely low burden of cervical cancer in women aged 20-24 (only 0.8% of all cases and 0.5% of deaths). 1

However, if your institution has not yet transitioned to primary HPV testing, the USPSTF 2018 guidelines remain valid: begin screening at age 21 with cytology alone every 3 years until age 29. 1, 2

Key distinction by guideline:

• ACS 2020 (most recent): Start at age 25 with primary HPV testing 1
• USPSTF 2018: Start at age 21 with cytology alone 1, 2

Screening Intervals by Age Group

Ages 21-29 Years (if following USPSTF/older guidelines)

• Cytology alone every 3 years 1, 2
• Do NOT use HPV testing (neither primary HPV nor cotesting) in women under age 30, as HPV infections are extremely common and transient in this age group 3
• Never screen annually - annual screening provides minimal additional benefit while substantially increasing harms from false positives and unnecessary procedures 4

Ages 25-29 Years (if following ACS 2020)

• Primary HPV testing every 5 years (preferred) 1, 4
• Acceptable alternatives: Cotesting every 5 years OR cytology alone every 3 years 1, 4

Ages 30-65 Years

Three equally acceptable options exist: 1, 3, 2

1. Primary HPV testing alone every 5 years (preferred by ACS 2020) 1, 4
2. Cotesting (HPV + cytology) every 5 years 1, 3
3. Cytology alone every 3 years (acceptable but less preferred) 1, 3

Important caveat: The ACS explicitly states that cotesting and cytology-alone options will not be included in future guidelines as the U.S. transitions to primary HPV testing, which has superior performance especially in vaccinated populations. 1, 4

When to Stop Screening

Age 65+ Years

Discontinue screening if ALL of the following criteria are met: 1, 3, 2

• Adequate prior screening: Either 3 consecutive negative cytology tests OR 2 consecutive negative cotests within the past 10 years 1, 3
• Most recent test within the past 5 years 1
• No history of high-grade squamous intraepithelial lesion (HSIL), adenocarcinoma in situ, or cervical cancer 1

Do NOT stop screening if: The woman has a history of CIN 2/3, cervical cancer, HIV infection, immunosuppression, or in utero diethylstilbestrol (DES) exposure - these women require continued individualized surveillance. 1, 3

Special Populations Requiring Modified Screening

Post-Hysterectomy

Discontinue all screening if: 1, 4, 3, 2

• Total hysterectomy with cervix removal was performed
• No history of CIN 2/3 or more severe diagnosis in the past 25 years 4
• No history of cervical cancer ever 4

Continue screening if: Subtotal hysterectomy (cervix retained) or history of high-grade precancerous lesions or cervical cancer. 1

High-Risk Groups Requiring More Intensive Surveillance

The following populations need individualized, more frequent screening (often annually): 1, 3

• HIV-positive women 1, 3
• Immunocompromised women (organ transplant recipients, chronic corticosteroid use, chemotherapy) 1, 3
• History of in utero DES exposure 1, 3
• Previous treatment for CIN 2/3 or cervical cancer 1, 3

HPV-Vaccinated Women

Follow the same age-specific screening recommendations as unvaccinated women. 4, 3 Vaccination does not eliminate screening need because vaccines do not cover all oncogenic HPV types. 4, 3

Women Under Age 21

Do NOT screen, regardless of sexual history or age at first intercourse. 1, 3, 2 Screening before age 21 causes more harm than benefit due to unnecessary treatment of lesions that would naturally regress. 3

Management of Abnormal Results

Immediate Colposcopy Required

The following results mandate immediate colposcopy: 1

• Squamous cell carcinoma (SCC) - 84% risk of HSIL/cancer 1
• HSIL (with or without HPV positivity) - 49-71% risk 1
• Atypical squamous cells-cannot exclude HSIL (ASC-H) - 12-45% risk 1
• Atypical glandular cells (AGC) - 2-45% risk 1, 4
• HPV-positive LSIL - 19% risk 1
• HPV-positive ASC-US - 18% risk 1

Repeat Testing in 6-12 Months

• HPV-positive with negative cytology - 10% risk of HSIL/cancer 1
• ASC-US (without HPV testing or HPV-negative) - 1-7% risk 1

Repeat Testing in 3 Years

• HPV-negative with ASC-US - 1.1% risk 1
• Negative cytology alone - 0.68% risk 1

Repeat Testing in 5 Years

• HPV-negative with negative cytology (cotest negative) - 0.27% risk, the lowest risk category 1

Special Management for Young Women (Ages 21-24)

Conservative management is critical in this age group due to high regression rates: 1

• For ASC-US: Repeat cytology is preferred; reflex HPV testing is acceptable but only for ASC-US 1
• For HSIL: Colposcopy is recommended but immediate treatment is NOT recommended 1
• For CIN 1: Do NOT treat unless persistent for 2 years 1
• For CIN 2: Observation is recommended 1
• For CIN 3: Treat with diagnostic excisional procedure, but hysterectomy is NOT primary treatment 1

Common Pitfalls to Avoid

Never screen more frequently than recommended intervals. Annual screening is not recommended for any age group and substantially increases harms without meaningful benefit. 4

Do not use HPV testing in women under age 30 (except for ASC-US triage in ages 21-24). 3 HPV infections are extremely common and usually transient in younger women, leading to unnecessary anxiety and procedures.

Do not continue screening women over 65 with adequate prior negative screening. This provides no benefit and only increases harms. 1, 2

Do not screen women under age 21, regardless of sexual history. The cervical cancer burden is negligible (1-2 cases per million), and screening causes more harm than benefit. 1

Recognize that recent sexual intercourse does NOT require postponement of Pap testing. The CDC explicitly states no waiting period is needed after sexual activity. 5 However, postpone conventional cytology if the woman is actively menstruating. 5

For pregnant women with LSIL: Colposcopy is preferred, but deferring until 6 weeks postpartum is acceptable. 1 Do NOT treat CIN 1 during pregnancy. 1