The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The following recommendations are based on good and consistent scientific evidence (Level A):
- Annual cervical cytology screening should begin approximately 3 years after initiation of sexual intercourse, but no later than age 21 years.
- Women younger than 30 years should undergo annual cervical cytology screening.
- Women aged 30 years and older who have had three consecutive negative cervical cytology screening test results and who have no history of cervical intraepithelial neoplasia (CIN) grade 2 or CIN 3, are not immunocompromised and are not HIV infected, and were not exposed to diethylstilbestrol in utero may extend the interval between cervical cytology examinations to every 2 to 3 years.
- Evidence-based data indicate both liquid-based and conventional methods of cervical cytology are acceptable for screening.
- Women who have undergone hysterectomy with removal of the cervix for benign indications and who have no prior history of CIN 2 or CIN 3 or worse may discontinue routine cytology testing.
The following recommendations are based on limited and inconsistent scientific evidence (Level B):
- Women previously treated for CIN 2 or CIN 3 who have completed their posttreatment follow-up should be monitored annually until at least three consecutive negative cytology screening results are documented.
- The use of a combination of cervical cytology and human papillomavirus (HPV) deoxyribonucleic acid (DNA) screening is appropriate for women aged 30 years and older. If this combination is used, women who receive negative results on both tests should be rescreened no more frequently than every 3 years.
- Women who have undergone hysterectomy with removal of the cervix and have a history of CIN 2 or CIN 3 should continue to be screened annually until three consecutive negative vaginal cytology test results are achieved.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Physicians should consider individualization in determining the time to begin screening, the interval between cervical cytology examinations, the age at which cervical cytology testing is no longer needed, and the testing methodology to be used. In addition to considering risk factors for cervical cancer, the provider ideally should be able to determine the patient's past screening history and reliably monitor the patient in the future.
- Evidence is inconclusive to establish an upper age limit for cervical cancer screening. If screening is discontinued, risk factors should be assessed during the annual examination to determine if reinitiating screening is appropriate.
- Yearly testing using cytology alone remains an acceptable screening plan.
- Regardless of the frequency of cervical cytology screening, women should be counseled that annual examinations, including pelvic examination, are still recommended.
Definitions:
Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendations
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
