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Patient education: Cervical cancer screening (Beyond the Basics)

Patient education: Cervical cancer screening (Beyond the Basics)
Authors:
Sarah Feldman, MD, MPH
Annekathryn Goodman, MD, MPH, MS
Jeffrey F Peipert, MD, PhD
Section Editors:
Joann G Elmore, MD, MPH
Barbara Goff, MD
Deputy Editors:
Alana Chakrabarti, MD
Jane Givens, MD, MSCE
Literature review current through: Nov 2022. | This topic last updated: Sep 15, 2022.

CERVICAL CANCER SCREENING OVERVIEW — The cervix is the bottom part of the uterus; it opens into the vagina (figure 1). Cervical cancer happens when normal cells in the cervix change into abnormal cells and grow out of control. There are two main types of cervical cancer, "squamous cell carcinoma" and "adenocarcinoma."

Screening tests can find cervical cancer and precancer in the early stages when it can be treated, and thus may reduce the number of people who develop cervical cancer as well as the number of deaths due to the disease.

There are several types of screening tests for cervical cancer:

The Papanicolaou or "Pap" test (sometimes called a "Pap smear")

A human papillomavirus or "HPV" test

A combination of both tests done together, known as "co-testing"

This article discusses the recommendations and process for cervical cancer screening. Information about follow-up after an abnormal Pap test is available separately. (See "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)" and "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)".)

CERVICAL CANCER RISK FACTORS — The most important risk factor for cervical cancer is infection with the human papillomavirus (HPV). There are over 100 different types of HPV; however, most types of HPV do not cause cancer. At least 80 percent of females are exposed to the HPV virus during their lifetime. Most of the time, the body's immune system gets rid of the virus before it does harm.

Researchers have labeled the different HPV types as being high or low risk for causing cervical cancer.

Low-risk HPV types – Two low-risk HPV types, 6 and 11, can cause genital warts. These are considered low-risk because they rarely cause cervical cancer. (See "Patient education: Genital warts in women (Beyond the Basics)".)

High-risk HPV types – High-risk HPV types may cause cervical cancer in some people. High-risk HPV types can cause other types of cancer, too.

Although most people who are infected with the high-risk HPV types do not develop cancer, those who test positive for high-risk HPV over time (typically two or more years) are at a higher risk of cervical cancer. Although approximately 14 high-risk HPV types have been identified, the highest-risk are HPV types 16 and 18; these two are responsible for most HPV-related cancers [1,2].

HPV is spread by direct genital skin-to-skin contact, including vaginal intercourse, oral sex, anal sex, and other types of sexual contact. It can be spread regardless of your or your partners' birth-assigned sex or gender identity. Since HPV is transmitted by sexual contact, having multiple sexual partners is associated with an increased risk for cervical cancer. Condoms provide only partial protection, since they do not cover all of the skin in the genital area. It is not possible to become infected with HPV by touching an object, such as a toilet seat.

Most people who are infected with HPV have no signs or symptoms. Most HPV infections are temporary and resolve within two years. When the virus persists beyond two years (in 10 to 20 percent of cases), there is a chance of developing cervical precancer or cancer. However, it usually takes many years for HPV infection to cause cervical cancer.

Things that increase the risk of cervical cancer include smoking and having a medical condition (or taking a medication) that weakens the immune system. If you smoke, you can lower your risk of cervical cancer (as well as other problems) by quitting. (See "Patient education: Quitting smoking (Beyond the Basics)".)

A vaccine to help prevent infection with some high-risk types of HPV is recommended for all children ages 11 to 12 years, but it can be given as early as age 9. "Catch-up" vaccination is recommended for all people up to 26 years of age who have not yet received it, but it can be given up to age 45. (See "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

CERVICAL CANCER SCREENING TESTS — Screening tests can be done at any time during your menstrual cycle. However, some providers may suggest scheduling your cervical cancer screening during a time when you do not expect to have your period.

Cervical cancer screening can be done using several different tests.

Pap test — The Pap test (sometimes called a "Pap smear") is a method of examining cells from the cervix. Another term for a Pap test is "cervical cytology."

For a Pap test, the provider will do a pelvic examination using a device called a speculum to open the vagina. Then they will use a small brush or spatula to collect cells from the cervix. This may be uncomfortable but usually is not painful. The cells are added to a container with preservative fluid or smeared on a glass slide for examination.

HPV test — Like a Pap test, the human papillomavirus (HPV) test is done during a pelvic examination, using a small brush to collect a sample from the cervix. HPV tests do not test for all different types of HPV. They only test for the strains of HPV that are associated with cervical cancer; a positive result indicates that one or more of these strains were found. Sometimes, the lab will specifically report if you have either of the two highest-risk HPV types, known as HPV 16 and HPV 18. This is called "genotyping."

It is important to remember that most people with a positive HPV result will not develop cancer.

Combination test ("co-testing") — This involves doing a Pap and HPV test at the same time.

WHO SHOULD BE SCREENED FOR CERVICAL CANCER AND WHEN? — Screening recommendations only apply to people with a cervix who have had all normal tests in the past, do not have any abnormal symptoms, and who have a normal immune system. People who have a compromised immune system follow different screening guidelines. People who have a history of abnormal results or have abnormal symptoms also do not follow the usual screening guidelines; in these situations, testing is called "surveillance" as opposed to screening.

Cervical cancer is very rare in younger people. In healthy people, screening before age 21 is not recommended regardless of sexual activity; there is a high risk of "false positive" results since many human papillomavirus (HPV) infections in this age group are only temporary and do not lead to cancer. In some cases, false-positive results could lead to unnecessary procedures which could cause problems with future pregnancies. There are special guidelines for people younger than age 21 who are immunocompromised (have a weaker than normal immune system) [3].

Age 21 to 29 — The exact age at which to begin cervical cancer screening and the preferred method to use is not completely clear, and recommendations from expert groups vary. The goal is to start screening at the point at which the benefits of screening are likely to outweigh the risks.

In the United States:

Most health care providers begin screening at age 21 with Pap testing every three years. This is based on recommendations from the United States Preventative Services Task Force (USPSTF). (See 'Pap test' above.)

Some providers begin screening at age 25 with HPV-only testing (ie, primary HPV testing) every five years, based on guidance from the American Cancer Society (ACS). However, the specific type of HPV testing needed for this screening is not always available, so this may not be an option. (See 'HPV test' above.)

Any person with a cervix within this age group should be screened, regardless of gender identity or sexual orientation. You should be screened even if you are not currently sexually active or if you have never had vaginal intercourse. HPV can be spread through other types of sexual contact even without intercourse. (See 'Cervical cancer risk factors' above.)

Even if you have received the HPV vaccine, you should still be screened for cervical cancer. (See "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

Age 30 to 65 — Experts recommend continuing with regular screening through age 65 for people with all normal results. This can be done with:

HPV-only testing (also called primary HPV testing) every five years (see 'HPV test' above)

Co-testing (both Pap and HPV testing) every five years (see 'Combination test ("co-testing")' above)

A Pap test every three years (see 'Pap test' above)

After age 65 — Most experts feel that many people can stop having cervical cancer screening after the age of 65, though it depends on their risk factors. Some clinicians, however, continue to offer screening through age 74 years for those who are healthy.

For example, you may need to continue having cervical cancer screening beyond the age of 65 if you have any of the following:

You have ever had an abnormal Pap test, an abnormal HPV test, or treatment for cancer or precancerous cells of the cervix, vagina, vulva, or anus.

You have not had adequate prior screening or have an unknown screening history.

You have HIV infection or another condition that suppresses the immune system.

You were exposed to diethylstilbestrol (DES) when you were in the womb – DES is a drug that was given to many people before 1981 to prevent pregnancy complications. Females who were exposed while in the womb have an increased risk of certain health problems, including cervical cancer.

If you are 65 or older and do not have any of the above risk factors, many experts in the United States feel that you can stop having cervical cancer screening if:

You have had all normal screening tests on a regular basis in the past, and

You have had at least three normal Pap tests in a row or two normal co-tests (combination Pap and HPV tests) over the past 10 years, with the most recent test within the past 5 years.

After hysterectomy — If you have had a hysterectomy (surgical removal of the uterus and sometimes the cervix), you do not need screening for cervical cancer, unless any of the following situations apply to you:

The hysterectomy did not remove your cervix (this is sometimes called a "subtotal" hysterectomy). If you are not sure if your cervix was removed during your hysterectomy, your health care provider can examine you to determine this.

Your hysterectomy was done because of cervical cancer or precancer ("dysplasia") or you have a history of an abnormal Pap or HPV test that requires screening beyond age 65.

You were exposed to DES during your mother's pregnancy.

SCREENING TEST RESULTS

Pap test — If a Pap test was done as part of your cervical cancer screening, the results from your Pap test will be available a few weeks after your visit. Pap test results may be reported as:

Negative – Pap tests that have no abnormal, precancerous, or cancerous cells are labeled as negative for intraepithelial lesion or malignancy.

Abnormal results – Cervical cells may appear abnormal for a variety of reasons. For example, you may have a cervical infection or you may have a precancerous area or even cervical cancer.

HPV test — If a human papillomavirus (HPV) test was done as part of your cervical cancer screening, the results will be available a few weeks after your visit. The results may be reported as:

Negative – There are no high-risk HPV strains present.

Positive – There are high-risk HPV strains present. Some labs will specify if the highest-risk HPV types (HPV 16 or HPV 18) are present. (See 'Cervical cancer risk factors' above.)

Follow-up testing — If your Pap or HPV test results are abnormal, you may need follow-up testing; the best strategy will depend on several individual factors.

Follow-up for abnormal Pap tests is discussed separately:

(See "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)".)

(See "Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)".)

(See "Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)".)

(See "Patient education: Colposcopy (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Cervical cancer (The Basics)
Patient education: Cancer screening (The Basics)
Patient education: Human papillomavirus (HPV) vaccine (The Basics)
Patient education: Human papillomavirus (HPV) (The Basics)
Patient education: Cervical cancer screening tests (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)
Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)
Patient education: Colposcopy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing
Cervical cytology: Evaluation of atypical and malignant glandular cells
Cervical cancer screening: Management of results
Screening for cervical cancer in resource-rich settings
Screening for cervical cancer in patients with HIV infection and other immunocompromised states

The following organizations also provide reliable health information.

National Library of Medicine

(medlineplus.gov/healthtopics.html)

American Society for Colposcopy and Cervical Pathology

(www.asccp.org/Default.aspx)

American Cancer Society

(www.cancer.org/)

Centers for Disease Control and Prevention

(www.cdc.gov)

American Sexual Health Association

(www.ashasexualhealth.org)

  1. Koshiol J, Lindsay L, Pimenta JM, et al. Persistent human papillomavirus infection and cervical neoplasia: a systematic review and meta-analysis. Am J Epidemiol 2008; 168:123.
  2. HPV and Cancer. National Cancer Institute. Available at: https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer#:~:text=High%2Drisk%20HPVs%20can%20cause,for%20most%20HPV%2Drelated%20cancers (Accessed on August 11, 2022).
  3. Moscicki AB, Flowers L, Huchko MJ, et al. Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection. J Low Genit Tract Dis 2019; 23:87.
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