Major Changes in ACOG Cervical Cytology Screening Recommendations

The American College of Obstetricians and Gynecologists (ACOG) recently recommended important changes in cervical cytology screening practices. Revisions to these guidelines, which are not intended to impose absolute protocols for screening and treatment, largely stem from a better understanding of the natural history of human papillomavirus (HPV) infections. HPV transmission is very common; however, more than three quarters of women — especially those who are in their early 20s or younger — clear their HPV infections within 8 to 24 months. Cervical cancer in young women is extremely rare (1–2 cases per million women who are 15–19 years of age). Evaluations such as colposcopy and excisional procedures often are stressful, especially to young women, in whom cervical abnormalities are most likely to resolve. Excisional procedures are associated with excess risk for cervical incompetence, which can lead to premature births.

Highlights of the revised ACOG guidelines are:

Cervical cancer screening should begin at age 21 regardless of age at onset of sexual activity.
Cervical cytology screening from age 21 to 29 is recommended every 2 years but should be more frequent in women who are HIV-positive, are immunosuppressed, were exposed in utero to diethylstilbestrol, or have been treated for cervical intraepithelial neoplasia (CIN) 2, 3 or cervical cancer.
Women age $≥$ 30 who have three consecutive negative screens and who do not fit the above criteria for more-frequent screening may be tested every 3 years. Co-testing with cervical cytology and high-risk HPV typing is also appropriate; if both tests are negative, rescreening in 3 years is warranted.
Cervical cancer screening is unnecessary in women who have undergone hysterectomies for benign disease and who have no histories of CIN.
Discontinuation of screening after age 65 or 70 is reasonable in women with $≥$ 3 negative consecutive tests and no cervical abnormalities during the previous decade.
Women with histories of CIN 2, 3 or cancer should undergo annual screening for 20 years after treatment.
HPV vaccination does not change these recommendations.

Comment: Although ACOG's new cervical screening recommendations are not linked in any way to the revised breast screening recommendations recently published by the U.S. Preventive Services Task Force, the temporal proximity of both new positions might fuel added controversy, especially in light of the ongoing debates about healthcare reform. If patients and clinicians alike agree with these new guidelines, will women access gynecologic care less often? The public must understand that annual gynecologic evaluation has other indications: For example, sexually active women who are $≤$ 24 should undergo annual chlamydia screening, and any woman with abnormal vaginal discharge, pain, or other such concerns should schedule a pelvic exam. We, as women's healthcare providers, face especially difficult decisions as we individualize the line between doing good and doing no harm.

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