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Above-average risk | HIV/immunocompromise, hx CIN2 or more severe dz, or in utero DES
HIV/immunocompromise, no in utero DES exposure If HIV(+), increased screening recommended w/ no upper age limit; visually inspect genitalia + anal canal at time of screenings for warts, intraepithelial neoplasia, invasive CA.1 - Screen w/ cytology at time of HIV dx, then annually; don’t hrHPV test; after 3 NL annual Paps, screen q3y.1,2
- Start Paps no later than 21 yo. Invasive cervical cancer (ICC) incidence is exceedingly low among pts <25 yo w/ HIV, but beginning screening at 21 yo provides 3- to 5-yr window before age 25, when ICC risk in pts w/ HIV exceeds that of the general population.1
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx; transgender women w/ neovagina don’t require Pap.3,4
- If hx cervical CA, continue annual cervical/vaginal cytology.5
- If s/p hysterectomy for CIN2 or worse dz: vaginal cuff Pap annually, per CDC/NIH/IDSA;1 ACOG6 recommends continued cytologic surveillance.
- If s/p hysterectomy w/ cervix removal for benign dz or gender affirmation: vaginal CA screening not recommended.1,3
If non-HIV immunocompromise (e.g., organ txp, chronic steroids): Reasonable to extrapolate recs for HIV(+) pts (e.g., annual screening starting at 21 yo), per ACOG;6 individualize frequency based on health care team, per ACS.7
Footnotes 1 CDC/NIH/IDSA 2023. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Clinicalinfo.HIV.gov. Updated September 25, 2023.
Accessed November 1, 2023
2 ACOG 2016. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Practice Bulletin No. 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus. Obstet Gynecol. 2016 Oct;128(4):e89-e110. PubMed® abstract
3 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
4 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
5 NCCN 2023. National Comprehensive Cancer Network. Cervical Cancer (Version 1.2024). September 20, 2023. Accessed November 2, 2023
6 ACOG 2016. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016 Oct;128(4):e111-e130. PubMed® abstract
7 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
If HIV(+), increased screening recommended w/ no upper age limit; visually inspect genitalia + anal canal at time of screenings for warts, intraepithelial neoplasia, invasive CA.1 - Screen w/ Pap alone or co-tests (Pap + hrHPV); after 3 NL annual Paps only or after 1 NL co-test, screen q3y1,2 (annually if hx cervical CA, per NCCN3); continue throughout lifetime, no upper age limit.1
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx; transgender women w/ neovagina don’t require Pap.4,5
- If s/p hysterectomy for CIN2 or worse dz: vaginal cuff Pap annually, per CDC/NIH/IDSA;1 ACOG6 recommends continued cytologic surveillance.
- If s/p hysterectomy w/ cervix removal for benign dz or gender affirmation: vaginal CA screening not recommended.1,4
If non-HIV immunocompromise (e.g., organ txp, chronic steroids): Reasonable to extrapolate recs for HIV(+) pts, per ACOG;6 individualize frequency based on health care team, per ACS.7
Footnotes 1 CDC/NIH/IDSA 2023. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Clinicalinfo.HIV.gov. Updated September 25, 2023.
Accessed November 1, 2023
2 ACOG 2016. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Practice Bulletin No. 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus. Obstet Gynecol. 2016 Oct;128(4):e89-e110. PubMed® abstract
3 NCCN 2023. National Comprehensive Cancer Network. Cervical Cancer (Version 1.2024). September 20, 2023. Accessed November 2, 2023
4 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
5 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
6 ACOG 2016. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016 Oct;128(4):e111-e130. PubMed® abstract
7 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
No HIV/immunocompromise, no in utero DES exposure If hx CIN2, CIN3, or AIS, continue w/ hrHPV or co-testing (hrHPV + Pap) q3y for ≥25y.1 - Continued surveillance >25y is acceptable as long as pt’s life expectancy and ability to be screened aren’t compromised by serious health issues.1
- Pap alone (q1y) acceptable if hrHPV or co-testing isn’t feasible.1
- If hx cervical CA: annual cervical/vaginal cytology for detection of lower genital tract neoplasia.2
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx.3,4
- If s/p hysterectomy, w/ or w/o cervix removal: If hysterectomy performed for tx, pt should have 3 consecutive annual HPV-based tests before entering long-term surveillance (HPV-based test q3y x25y). Screening generally not recommended s/p hysterectomy if no CIN2+ dx in past 25y or pt has completed 25-yr surveillance period.1
Footnotes 1 ASCCP 2020. Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020 Apr;24(2):102-131. Full-text PDF at PubMed® Central
2 NCCN 2023. National Comprehensive Cancer Network. Cervical Cancer (Version 1.2024). September 20, 2023. Accessed November 2, 2023
3 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
4 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
Specialized testing may be an option, but isn’t required, if DES exposure in utero (1938-1971). - Organizations have generally advised annual pelvic exam + Pap test, w/ colpo to f/u on abnormal findings. However, now that those exposed to DES in utero are older, relative benefits and harms of this approach are unclear.1
- If hx CIN2, CIN3, or AIS: Continue w/ hrHPV or co-testing (hrHPV + Pap) q3y for ≥25y.2
◦ Continued surveillance >25y is acceptable as long as pt’s life expectancy and ability to be screened aren’t compromised by serious health issues.2
◦ Pap alone (q1y) acceptable if hrHPV or co-testing isn’t feasible.2 - Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx.3,4
- If HIV(+), visually inspect genitalia + anal canal at time of screenings for warts, intraepithelial neoplasia, invasive CA.5
◦ Age <30 yo: Screen w/ cytology at time of HIV dx, then annually; don’t hrHPV test; after 3 NL annual Paps, screen q3y.5,6
◦ Age ≥30 yo: Screen w/ Pap alone or co-tests (Pap + hrHPV); after 3 NL annual Paps only or after 1 NL co-test, screen q3y.5,6 - DES-associated vaginal/cervix CA usually occurs in late teens/early 20s, but upper age limit unknown.7
Footnotes 1 NCI 2021. Diethylstilbestrol (DES) Exposure and Cancer. National Cancer Institute. Reviewed December 20, 2021. Accessed November 3, 2023
2 ASCCP 2020. Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020 Apr;24(2):102-131. Full-text PDF at PubMed® Central
3 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
4 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
5 CDC/NIH/IDSA 2023. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Clinicalinfo.HIV.gov. Updated September 25, 2023.
Accessed November 1, 2023
6 ACOG 2016. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Practice Bulletin No. 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus. Obstet Gynecol. 2016 Oct;128(4):e89-e110. PubMed® abstract
7 ACS 2015. DES Exposure: Questions and Answers. American Cancer Society. Revised June 10, 2015. Accessed November 3, 2023
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Average risk | No HIV/immunocompromise, no hx CIN2 or more severe dz, no in utero DES, no hx hysterectomy w/ cervix removal
Don’t screen, regardless of sexual hx/risk factors.1-6 - In pts <21 yo w/ cervix, such screening would lead to more harm than benefit; slow dz progression and high likelihood of regression in this age group.6
- Tx of CIN2 or CIN3 in pts <21 yo may also increase risk for adverse pregnancy outcomes.6
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
3 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
4 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
5 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
6 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
Screen w/ cytology alone q3y; don’t screen hrHPV. - Pap alone q3y recommended.1-3
- Don’t screen until 25 yo, per ACS.4
- Don’t screen hrHPV (alone or w/ Pap) in pts <30 yo.1-3
- HPV vax status doesn’t affect recommendations.4
- ACOG5 recommends pelvic exam as indicated by medical hx or sx.
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx; transgender women w/ neovagina don’t require Pap.6,7
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
3 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
4 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
5 ACOG 2018. ACOG Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018 Oct;132(4):e181-e186. Full-text article
6 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
7 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
Screen w/ cytology alone q3y; don’t screen hrHPV, per most groups (although ACS recommends primary high-risk HPV for pts ≥25 yo). - Pap alone q3y recommended by ACOG,1 ACP,2 USPSTF.3
- Don’t screen hrHPV (alone or w/ Pap) in pts <30 yo, per ACP,2 USPSTF;3 however, ACOG says primary hrHPV testing q5y can be considered in average-risk pts 25-29 yo,1 and ACS4 prefers primary hrHPV screening q5y for pts ≥25 yo, w/ alternatives: co-test (Pap + hrHPV) q5y or cytology q3y.
- HPV vax status doesn’t affect recommendations.4
- ACOG5 recommends pelvic exam as indicated by medical hx or sx.
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx; transgender women w/ neovagina don’t require Pap.6,7
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
3 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
4 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
5 ACOG 2018. ACOG Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018 Oct;132(4):e181-e186. Full-text article
6 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
7 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
Primary HPV test q5y or co-test (Pap + HPV) q5y or Pap alone q3y. - Co-test (Pap + hrHPV) q5y preferred by ACOG; primary hrHPV testing q5y or Pap alone q3y also acceptable, should be discussed w/ pt.1
- ACS recommends primary hrHPV test q5y; Pap alone q3y or co-test q5y if primary HPV test not available.2
- USPSTF3 recommends hrHPV testing alone q5y, Pap alone q3y, or co-testing q5y.
◦ Pt should discuss best testing strategy w/ clinician.
◦ Ensure pts receive adequate screening, appropriate eval of abnormal results, and indicated tx, regardless of screening strategy.
◦ Evidence from RCTs and other studies suggests that screening w/ cytology alone is slightly less sensitive for detecting CIN2 and CIN3 vs. screening w/ hrHPV testing alone, and has a lower false-positive rate and rate of additional testing. However, screening w/ hrHPV testing alone or in combo w/ cytology results in more diagnostic colpos for each case detected. - ACP4 recommends either Pap q3y or co-test q5y.
- HPV vax status doesn’t affect recommendations.2
- ACOG5 recommends pelvic exam as indicated by medical hx or sx.
- Screen transgender men w/ cervix according to same guidelines, regardless of hormone tx; transgender women w/ neovagina don’t require Pap.6,7
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
3 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
4 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
5 ACOG 2018. ACOG Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018 Oct;132(4):e181-e186. Full-text article
6 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
7 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
Stop if prior screening adequate; continue if prior screening inadequate. - Stop screens if pt had regular (-) screens over previous 10y,1-3 w/o CIN2 or worse in past 25y.4
- Adequate prior (-) screens = 3 consecutive (-) cytology or 2 consecutive (-) co-tests1-3 or 2 consecutive (-) hrHPV tests1 in previous 10y,1-3 w/ most recent test w/in recommended screening interval1 or past 5y.2,3
- ACOG5 recommends pelvic exam as indicated by medical hx or sx.
- Once screening ceases, don’t restart.3,4
- Use same guidance for transgender men w/ cervix, regardless of hormone tx.6,7
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
3 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
4 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
5 ACOG 2018. ACOG Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018 Oct;132(4):e181-e186. Full-text article
6 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
7 UCSF 2016. Hsiao KT. Screening for cervical cancer in transgender men. UCSF Transgender Care. June 17, 2016. Accessed May 4, 2021
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Below-average risk | s/p hysterectomy w/ cervix removal, w/ no hx CIN2 or more severe dz, no HIV/immunocompromise, no in utero DES
Don’t screen if s/p hysterectomy w/ cervix removal, unless hx CIN2 or worse, immunocompromise, or in utero DES. - Don’t screen unless: hx high-grade precancerous lesion (CIN2 or worse) or cervical CA, per ACOG,1,2 USPSTF;3 CIN2 or worse in past 25y, or cervical CA or serious precancer ever, per ACS.4 USPSTF recommends confirming cervix removal via surgical records or direct exam.3
- ACP also recommends not screening.5
- Once stopped, don’t restart screening, even if new sexual partner.1,3,4,6
Footnotes 1 ACOG 2021. Updated Cervical Cancer Screening Guidelines: Practice Advisory. The American College of Obstetricians and Gynecologists. April 2021. Accessed November 1, 2023
2 ACOG 2021. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88. Full-text article
3 USPSTF 2018. Final Recommendation Statement. Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 21, 2018. Accessed August 18, 2020
4 ACS 2021. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. Updated April 22, 2021. Accessed November 2, 2023
5 ACP 2015. Sawaya GF, et al. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Jun 16;162(12):851-9. Full-text article
6 ACOG 2016. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol. 2016 Oct;128(4):e111-e130. PubMed® abstract
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