How Cervical Screening Guidelines Changed

Contents

1. The era of the yearly Pap test
2. Longer intervals and the arrival of cotesting
3. HPV testing moves to the front

Patients often want to know why the yearly Pap test gave way to a test every three or five years, a change that also reshaped how women come to colposcopy and the LEEP procedure, both part of Candace Cooley’s office based experience. The short answer is the virus. As researchers learned that nearly all cervical cancer begins with a persistent infection by high risk types of human papillomavirus,³ and that the path from infection to cancer usually takes a decade or more,⁷ screening could be done less often and aimed at the virus itself. The longer answer runs through three stages of advice.

The era of the yearly Pap test

For much of the twentieth century the yearly smear was the standard. CNN’s 2012 explainer by Otis Brawley recalls that in the 1930s cervical cancer killed more American women than breast or lung cancer, and that the death rate fell steeply over the following eight decades as screening and treatment improved.⁷ The story of the test itself is told in the entry on Papanicolaou and the Pap test.

By the early 2000s the advice was already loosening. American Family Physician’s summary of the 2003 ACOG guideline set screening to begin about three years after first intercourse and no later than 21, yearly until 30, and every two to three years after three consecutive normal results for women 30 and older.¹ The same guideline noted that incidence and deaths had fallen by almost half since the early 1970s, and that sampling and interpretation errors were associated with 30 percent of new cases each year.¹ HPV testing was then mainly a tiebreaker for borderline smears, read as atypical squamous cells of undetermined significance. The guideline also recorded a new option, recently approved by the Food and Drug Administration: a Pap test combined with an HPV test for women 30 and older, repeated no more often than every three years when both were negative.¹ Even then, the guideline kept more frequent screening for women with HIV, with weakened immune systems or with exposure to diethylstilbestrol before birth, and accepted both conventional and liquid based cytology.¹

Figure

What the 2012 guidance changed

	Earlier guidance	2012 guidance
When screening starts	Three years after first intercourse	Age 21, whatever the history
Ages 21 to 29	A Pap test every year, or every two years with liquid based cytology	A Pap test every three years, and not yearly
Age 30 and over	Every two to three years after three normal results	Pap and HPV cotesting preferred, every three to five years

Longer intervals and the arrival of cotesting

The decisive turn came in 2012, when the United States Preventive Services Task Force and a joint panel of the American Cancer Society and two professional societies published matching recommendations. As CNN summarized them, screening would start at 21 regardless of history, women from 21 to 29 would have a Pap test once in three years rather than yearly, and cotesting every three to five years became the preferred approach from 30.⁷ Screening could stop after 65 for women with a run of normal results. CBS News reported that the task force based the change on research showing that screening too often produced false alarms and unnecessary tests and procedures.¹⁰

The reasoning rested on how the virus behaves. Brawley explained that many young women acquire HPV and develop lesions that nearly always disappear on their own, while treating them early can harm the cervix, and that HPV can take more than a decade to progress to precancer or cancer.⁷ The 2013 summary of ACOG’s guideline made the same case in figures: annual screening has a very small effect on cancer prevention while leading to excessive procedures and treatment, and cervical cancer usually arises 15 to 25 years after infection. It also kept special rules for women with HIV and for those treated for higher grade disease, and stated that HPV vaccination does not change the schedule. For the common puzzle of a normal smear alongside an HPV test that comes back positive, it offered two paths: repeat cotesting in 12 months, or test at once for HPV types 16 and 18, with colposcopy if that test is positive.² Those two types, Brawley noted, cause about 70 percent of cervical cancers.⁷ When results are abnormal, the next step is often colposcopy.

Brawley also pointed to who was dying. A review of the women who died of the disease in 2009 found that most had never been screened, or had last been screened more than a decade before diagnosis.⁷ Less frequent testing for the screened, in other words, was never the main risk.

Figure

Keeping up with screening

of women aged 21 to 65 were up to date with cervical screening in 2023

75.8%

the national target for 2030

84.3%

HPV testing moves to the front

The next step put the HPV test first. CNN reported in 2018 that the task force now gave women from 30 to 65 three choices: an HPV test alone every five years, a Pap test at three year intervals, or both together every five years.⁸ In 2020 the American Cancer Society went further. ABC News described its call to begin at 25 rather than 21, with an HPV test every five years and no routine Pap test at all, citing the rarity of invasive cancer in the early twenties, the tendency of most infections at that age to clear within a year or two, and the effect of vaccination; not every gynecologist agreed that the Pap test should be dropped. The society estimated that starting HPV testing at 25 instead of 30 could prevent 13 percent more cervical cancers and 7 percent more deaths from the disease.⁹

Self collection is the newest change. HealthDay reported in late 2025 that the Food and Drug Administration had approved three self collected HPV tests since 2024, two for use in medical settings and one for home, and that the American Cancer Society now endorses self collection every three years after a negative result, alongside clinician collected testing every five.⁵ Writers in STAT noted that self collected and clinician collected samples show similar accuracy, and that half of all cervical cancers in the United States occur in women never or rarely screened.⁴ News 12 Westchester quoted a gynecologic oncologist describing the home test as approved for women 30 and older and as a way to reach women who avoid the pelvic examination.⁶ The details of that option belong to the entry on self collected HPV testing.

Coverage still lags behind the advice. In 2023, by the National Cancer Institute’s progress report, screening was current for 75.8 percent of eligible women between the ages of 21 and 65, short of a national target of 84.3 percent.³

Figure

The American Cancer Society update of 2025

1. 01
   StartScreening begins at age 25.
2. 02
   Clinician collected HPV testEvery five years when results are negative.
3. 03
   Self collected HPV testEvery three years when results are negative, using an approved method.
4. 04
   CotestingAn HPV test combined with a Pap test remains an option.
5. 05
   StopAt 65, only after at least 10 years of consistently negative results.

Guidelines also differ from one another, and the right schedule for one woman depends on her history and is settled with her own clinician. A few terms make any conversation about screening easier. Cytology is the Pap test, a look at cervical cells under the microscope. An HPV test detects the virus itself rather than examining cells. Cotesting means doing both at once, and primary HPV testing means the virus test alone. Self collection is a swab taken by the patient herself. ASC US is the borderline smear result that often triggers an HPV test, and CIN, graded 1 to 3, names the cell changes a biopsy can find.