What are the current guidelines for cervical cancer screening with Pap smears, including age‑specific intervals, HPV co‑testing, hysterectomy considerations, special populations, and criteria for discontinuation?

Cervical Cancer Screening Guidelines

Begin cervical cancer screening at age 21 years regardless of sexual history, screen women aged 21-29 years with cytology alone every 3 years, and use cotesting every 5 years (preferred) or cytology alone every 3 years for women aged 30-65 years. 1

Age to Initiate Screening

• Start screening at age 21 years for all women, regardless of age of sexual initiation or other risk factors. 1, 2
• Do not screen women under age 21 years under any circumstances—cervical cancer incidence is only 1-2 cases per 1,000 females aged 15-19 years, and early screening leads to unnecessary anxiety, procedures, and increased risk of preterm birth from treatment of lesions that would spontaneously regress. 1

Screening Intervals by Age Group

Women Aged 21-29 Years

• Screen with cytology (Pap test) alone every 3 years. 1, 2
• HPV testing should not be used for primary screening in this age group, either as standalone testing or as cotesting with cytology. 1, 2
• Reflex HPV testing is acceptable for managing ASC-US results in women aged 25-29 years, but not for routine screening. 1

Women Aged 30-65 Years

• Preferred approach: Cotesting with both cytology and HPV testing every 5 years. 1, 2
• Acceptable alternative: Cytology alone every 3 years. 1, 2
• Primary hrHPV testing alone every 5 years is also an acceptable option per USPSTF. 2
• Both liquid-based cytology and conventional Pap smears are acceptable methods, though liquid-based cytology allows for reflex HPV testing from the same sample. 1

Discontinuing Screening

Women Over Age 65 Years

• Discontinue screening after age 65 years if adequate prior negative screening has been documented: either 3 consecutive negative cytology tests OR 2 consecutive negative cotests within the past 10 years, with the most recent test within the last 5 years. 1, 3, 2
• An HPV-negative ASC-US result counts as negative for meeting exit criteria. 1, 3
• Once screening is discontinued, it should not resume for any reason, including a new sexual partner. 1, 3

Critical Exceptions—Continue Screening Beyond Age 65

• Women with a history of CIN2, CIN3, adenocarcinoma in situ, or cervical cancer must continue routine screening for at least 20-25 years after treatment, even if this extends screening past age 65 years. 1, 3
• Women with inadequate prior screening history should continue screening until cessation criteria are met. 3

Post-Hysterectomy Considerations

• Discontinue screening in women who have undergone total hysterectomy with removal of the cervix for benign indications and have no history of CIN2 or higher-grade lesions. 1, 3, 2
• Women with subtotal (supracervical) hysterectomy who retain their cervix should continue screening following standard age-based recommendations. 1, 3

Special Populations Requiring Modified Screening

These standard guidelines do not apply to higher-risk women who require more intensive surveillance: 1, 3

• Women who are HIV-positive or otherwise immunocompromised (organ transplant recipients, chronic corticosteroid use, chemotherapy)
• Women with in utero diethylstilbestrol exposure
• Women with a personal history of cervical cancer
• Pregnant women require conservative management with colposcopy deferred until 6 weeks postpartum when possible 1

Management Principles for Abnormal Results

• Conservative management is now recommended for young women aged 21-24 years to avoid overtreatment of lesions likely to regress spontaneously. 1
• For women aged 21-24 years with HSIL, colposcopy is recommended but immediate treatment is not; observation is preferred for CIN2 in this age group. 1
• CIN1 should not be treated in any age group unless persistent for 2 years. 1
• The guiding principle for managing abnormal results is "similar management for similar risks" regardless of the specific test combination that identified the abnormality. 1

HPV Vaccination Status

• Screening recommendations do not change based on HPV vaccination status—vaccinated women should follow the same screening guidelines as unvaccinated women. 1
• HPV vaccines cover approximately 70% of cervical cancers (primarily HPV 16 and 18), but not all high-risk HPV types. 1

Common Pitfalls to Avoid

• Annual screening is not recommended for any age group—this represents overscreening that increases harms without meaningful benefit. 1
• Do not use HPV testing as a standalone screening test in women under age 30 years due to high prevalence of transient infections that will clear spontaneously. 1
• Do not perform screening during pregnancy unless high-grade neoplasia or invasive cancer is suspected; defer routine screening until postpartum. 1
• Single-sample FOBT collected during digital rectal examination is not an adequate screening method (this applies to colorectal screening, not cervical). 1