What is the recommended HPV screening strategy for average-risk women aged 30–65 with an intact cervix?

HPV Screening for Women Aged 30-65

For average-risk women aged 30-65 years with an intact cervix, the preferred screening strategy is primary HPV testing every 5 years, with co-testing (HPV plus cytology) every 5 years as an acceptable alternative, or cytology alone every 3 years if HPV testing is unavailable. 1

Recommended Screening Options

The current guidelines offer three acceptable approaches for this age group, with a clear hierarchy:

Primary HPV Testing (Preferred)

• Primary HPV testing alone every 5 years is now the preferred strategy according to the American Cancer Society 1, 2
• This approach maximizes sensitivity for detecting high-grade cervical lesions while allowing safe extension of screening intervals 3, 4
• HPV testing demonstrates 88-91% sensitivity for detecting CIN 3 or higher, compared to only 61% for cytology alone 4
• The American Cancer Society explicitly states that co-testing and cytology-alone options will be phased out as the transition to primary HPV testing is completed 1

Co-testing (Acceptable Alternative)

• HPV testing combined with cytology every 5 years remains an acceptable option 5, 6
• Co-testing provides the highest sensitivity and allows for the extended 5-year interval 6
• Women with negative co-testing results have an extremely low cumulative 5-year risk (0.34%) of developing CIN 2 or higher 5
• However, co-testing increases false-positive rates and unnecessary colposcopies without sufficient incremental benefit compared to primary HPV testing alone 1

Cytology Alone (Acceptable if HPV Testing Unavailable)

• Cytology alone every 3 years is acceptable when HPV testing is not available 5, 1, 6
• This requires more frequent screening due to lower sensitivity 4

Critical Implementation Points

Why HPV Testing is Appropriate at Age 30+

• HPV testing should not be used in women under 30 years due to the high prevalence (21%) of transient HPV infections in younger women 5, 7
• By age 30, persistent HPV infections are more likely to represent clinically significant disease 7
• All major guidelines agree that HPV testing (alone or as co-testing) should not be performed before age 30 5

Screening Intervals Matter

• Annual screening is never recommended at any age with any method 5
• More frequent screening provides minimal additional benefit but substantially increases harms including false-positives, unnecessary colposcopies, overtreatment, and adverse obstetric outcomes 1
• The average time for high-grade precancerous lesions to progress to invasive cancer is approximately 10 years, allowing ample time for detection with appropriate intervals 5

When to Stop Screening

Discontinue screening at age 65 if adequate prior negative screening has been documented 5, 1:

• Either: 3 consecutive negative cytology results within the past 10 years, with the most recent within 5 years
• Or: 2 consecutive negative co-tests within the past 10 years, with the most recent within 5 years 5
• And: No history of CIN 2 or more severe disease in the preceding 25 years 1
• Once screening stops after age 65, do not resume for any reason, including new sexual partners 1

Updated Exit Criteria (2026)

The American Cancer Society recently amended exit criteria due to high cervical cancer rates in women over 65 and poor implementation of prior criteria. The revised recommendation requires:

• Negative primary HPV tests (preferred) or negative co-testing at both ages 60 and 65 years 8
• The last HPV test must be at age 65 years or older 8
• If using self-collected vaginal specimens for HPV testing, follow the 3-year testing interval 8

Populations Requiring Modified Screening

These recommendations apply only to average-risk women. The following groups require different approaches 5, 1:

• HIV-positive or immunocompromised women: Annual screening regardless of age 1
• History of CIN 2, CIN 3, or adenocarcinoma in situ: Continue screening for 20-25 years after treatment, even beyond age 65 5, 1
• In-utero DES exposure: Continued surveillance per standard guidelines 5, 1
• History of cervical cancer: Indefinite screening 1
• Total hysterectomy with cervix removed (and no history of CIN 2+ or cancer in past 25 years): No screening required 5, 1
• Subtotal hysterectomy with cervix retained: Follow standard age-based screening 5, 1

Common Pitfalls to Avoid

HPV Vaccination Does Not Change Screening

• Screening recommendations are identical for vaccinated and unvaccinated women because vaccines do not cover all oncogenic HPV types 5, 1
• Never reduce screening frequency or stop screening early based on vaccination status 5

Documentation is Essential

• Never discontinue screening without verifying adequate prior negative screening through medical records review—verbal patient report is insufficient 1
• All women should receive written documentation of whether screening was performed 1

Addressing Disparities

• Longer screening intervals may differentially affect adherence among racial/ethnic minorities and persons with limited healthcare access 1
• The cervical cancer burden remains higher in racial/ethnic minorities, rural populations, lower socioeconomic groups, and the uninsured due to differences in screening participation, follow-up rates, and access barriers 1
• Inadequate screening at younger ages is a major predictor of cervical cancer diagnosis at older ages and late-stage disease 1

Management of Abnormal Results

• All abnormal screening results should be managed according to the 2019-2020 ASCCP Risk-Based Management Guidelines 1
• Immediate colposcopy is indicated for high-grade squamous intraepithelial lesion (HSIL) 1
• Timely follow-up of abnormal results and treatment realizes the highest impact on cervical cancer incidence and mortality 5