ACOG: Cervical screening should begin at age 21

Committee Opinion #463. Obstetrics & Gynecology. 2010:116:469-472.

The American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care has issued a new committee opinion updating recommendations on cervical cancer screening that were originally released in November.

The updated guideline confirms the recommendation that cervical cancer screening in adolescents should not begin until age 21 years, regardless of the age of onset of sexual activity; however, it also discusses exceptions to this recommendation.

According to the opinion, published in Obstetrics & Gynecology, evidence from several recent studies indicates that cervical cancer screening before age 21 years does not change the rate of cervical cancer in that age group. Previous recommendations for cervical screening from ACOG and the American Society for Colposcopy and Cervical Pathology were based on time since onset of vaginal intercourse.

“The vast majority of adolescent girls should wait until they turn 21 before they have their first Pap test,” Cheryl B. Iglesia, MD, chair of the Committee on Gynecologic Practice, said in a press release.

Iglesia said even though most teen girls no longer need Pap screening, they should continue with annual visits to their gynecologist.

Exceptions

The committee listed certain exceptions to the screening recommendation. Adolescents who have HIV and others with weakened immune systems should begin routine cervical screening right away. According to the opinion, adolescents with weakened immune systems cannot fend off viral infections, such as human papillomavirus, as easily as those with healthy immune systems. Because of this, HIV-infected adolescent girls should have cervical screening twice in the first year after HIV diagnosis and once a year thereafter.

In addition, sexually active adolescents who have weakened immune systems from organ transplant or long-term steroid therapy should also be screening 6 months apart in the first year after they begin having sex and then continue with annual tests.

Any adolescent girl with a normal immune system who has one or more Pap test with normal results should not be screened again until age 21 years. Teens who have had a previous abnormal test followed by two normal tests can also wait until age 21 years to be rescreened.

Other recommendations

In addition, these guidelines recommend against HPV testing for adolescents.

“There’s no point in testing for HPV because it’s so common among teens, and 90% of HPV infections are naturally resolved by the immune system within 2 years,” Iglesia said. “Adolescents have been over-treated for something that typically resolves on its own. We know that unnecessary treatments compromise the cervix and increase a teen’s risk of having a preterm birth later in life.”

Finally, the opinion discussed the management of cervical intraepithelial neoplasia in adolescents.

Adolescents who have low- to high-grade dysplasia — with the exception of cervical intraepithelial neoplasia 3 (CIN 3) — generally should be managed by periodic observation. The guidelines recommend that rescreening be delayed until age 21 when the Pap test results show regression of the dysplasia, but annual screening is also an acceptable alternative. Although rare in adolescents, CIN 3 is considered a significant precancerous condition that does require treatment with cryotherapy, laser therapy or loop electrosurgical excision.

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