Guidelines & Advice

Cervical Screening Recommendations Summary

Also available as a handout: Guide to Cervical Screening

Screening Initiation and Eligibility

People are eligible for cervical screening in the Ontario Cervical Screening Program (OCSP) if they have a cervix, are age 25 and older, have ever been sexually active and are asymptomatic.¹ Eligible people include women, Two-Spirit people, transmasculine people, nonbinary people, pregnant people, post-menopausal people, people who have undergone a subtotal hysterectomy and retained their cervix, and people who have had the human papillomavirus (HPV) vaccine.

Routine screening is not recommended for people who have had their cervix removed as a result of a hysterectomy. For more information, refer to the OCSP’s Vaginal Vault Testing Guidance.

Cervical Screening Test

Providers may perform a cervical screening test (HPV test with reflex cytology) on anyone who is eligible for cervical screening through the OCSP.^2,3,4

Management of HPV-negative test results

People with HPV-negative test results can return to average risk screening in 5 years. People who are immunocompromised⁵ can return to screening in 3 years or stop screening if cessation criteria have been met.

Management of HPV-positive test results

The laboratory will automatically perform reflex cytology on cervical samples with HPV-positive test results. HPV type and reflex cytology test results are used in combination to determine next steps in the clinical pathway.

People with HPV-positive (types 16, 18/45) test results are categorized as elevated risk and referred to colposcopy, regardless of their reflex cytology test result.
People with HPV-positive (other high-risk types) and high-grade reflex cytology (ASC-H, LSIL-H, HSIL, AGC⁶, AIS, SCC⁷, ACC⁷, ACC-E⁷, PDC⁷) test results are categorized as elevated risk and referred to colposcopy.
People with HPV-positive (other high-risk types) and normal reflex cytology (NILM) or low-grade reflex cytology (ASCUS, LSIL) test results are categorized as moderate risk and advised to repeat a cervical screening test in 2 years.
- If the result of the subsequent test is HPV-negative, they can return to average risk screening in 5 years or if they are immunocompromised, they may return to screening in 3 years.
- If the result of the subsequent test is HPV-positive, they are referred to colposcopy, regardless of their reflex cytology test result.

ACC = adenocarcinoma; ACC-E = endocervical adenocarcinoma; AGC = atypical glandular cells;

AIS = adenocarcinoma in situ;

ASC-H = atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion;

ASCUS = atypical squamous cells of undetermined significance; HPV = human papillomavirus;

HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion;

LSIL-H = low-grade squamous intraepithelial lesion, cannot exclude HSIL;

NILM = negative for intraepithelial lesion or malignancy; PDC = poorly differentiated carcinoma; SCC = squamous cell carcinoma

Cervical Screening Cessation

Age	Test result	Clinical next step	Considerations and exceptions
65 to 69	Not screened	Continue screening	If someone did not have a cervical screening test from age 65 to 69, they should be screened until age 74.
65 to 69	HPV-negative	Stop screening	Someone can stop cervical screening if they have had 1 negative HPV test result from age 65 to 69, with the following exceptions: If they are immunocompromised,⁵ they should be screened until age 74. If they are age 65 to 69, have been discharged from colposcopy and have been advised to screen every 2 years because they have not yet met the criteria to return to routine cervical screening, they should continue to screen until age 74.
65 to 69	HPV-positive	Continue to follow cervical screening pathway and refer to colposcopy, if appropriate	Follow the cervical screening pathway until someone has a negative HPV test or until they are age 74, whichever occurs first.
70 to 74	HPV-positive, regardless of HPV type or reflex cytology	Refer to colposcopy	People ages 70 to 74 who have an HPV-positive test result require colposcopy to exclude a high-grade lesion and can safely stop screening if colposcopy is negative.
75 and older	Not applicable	Not applicable	The OCSP does not recommend cervical screening for people age 75 and older. People age 75 and older with any visible cervical abnormalities or abnormal symptoms must be investigated, regardless of age. Due to potential discomfort and atrophy, which causes visual inspection issues, using intravaginal estrogen therapy can be considered if there are no medical contraindications.

Care in colposcopy

In colposcopy, an examination of the cervix is used to rule out the presence of cervical pre-cancer or cancer. Regardless of HPV type or reflex cytology test result at referral, most people referred to colposcopy will not have high-grade histology detected in colposcopy. People without high-grade histology will not require treatment and can be discharged after 1 or 2 visits. People with high-grade histology will be treated and followed up over a number of visits at a colposcopy clinic (known as an episode of care).

Discharge from colposcopy to primary care

When someone is discharged from colposcopy after being assessed or treated, their likelihood of developing cervical pre-cancer and cancer is greatly reduced and they can return to cervical screening in primary care. At discharge from colposcopy, a colposcopist should recommend the next interval for cervical screening in primary care as part of the discharge summary.

Resuming Cervical Screening Post-discharge from Colposcopy

Also available as a handout: Guide to Resuming Cervical Screening Post-discharge from Colposcopy

Table 1: Post-discharge cervical screening recommendations for people not treated in colposcopy (i.e., HSIL or AIS histology not detected in colposcopy)
First post-discharge screening interval: Referral cytology from primary care	First post-discharge screening interval: HPV status at discharge from colposcopy	First post-discharge screening interval: Action	Second post-discharge screening interval: Screening result at first recall	Second post-discharge screening interval: Action
Normal (NILM) or low-grade (ASCUS or LSIL)	N/A (HPV test not repeated in colposcopy)	Screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years
Normal (NILM) or low-grade (ASCUS or LSIL)	N/A (HPV test not repeated in colposcopy)	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy
High-grade (ASC-H, LSIL-H, AGC, HSIL or AEC)	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years	N/A	N/A
High-grade (ASC-H, LSIL-H, AGC, HSIL or AEC)	HPV-positive⁸	Screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years
High-grade (ASC-H, LSIL-H, AGC, HSIL or AEC)	HPV-positive⁸	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy

Table 2: Post-discharge cervical screening recommendations for people treated in colposcopy (HSIL histology)
First post-discharge screening interval: HPV result at first post-treatment colposcopy visit	First post-discharge screening interval: HPV result at discharge	First post-discharge screening interval: Action	Second post-discharge screening interval: Screening result	Second post-discharge screening interval: Action	Third post-discharge screening interval: Screening result	Third post-discharge screening interval: Action
HPV-negative	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years	N/A	N/A	N/A	N/A
HPV-negative	HPV-positive⁸	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years
HPV-negative	HPV-positive⁸	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-positive⁸	Re-refer to colposcopy
HPV-negative	HPV-positive⁸	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy	N/A	N/A
HPV-positive	HPV-negative	Screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years	N/A	N/A
HPV-positive	HPV-negative	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy	N/A	N/A
HPV-positive	HPV-positive⁸	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years
HPV-positive	HPV-positive⁸	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-positive⁸	Re-refer to colposcopy
HPV-positive	HPV-positive⁸	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy	N/A	N/A

Table 3: Post-discharge cervical screening recommendations for people treated in colposcopy (AIS histology)
First post-discharge screening interval: HPV result at first post-treatment colposcopy visit	First post-discharge screening interval: HPV result at discharge	First post-discharge screening interval: Action	Second post-discharge screening interval: Screening result	Second post-discharge screening interval: Action	Third post-discharge screening interval: Screening result	Third post-discharge screening interval: Action	Fourth post-discharge screening interval: Screening result	Fourth post-discharge screening interval: Action
HPV-negative or HPV-positive⁸	HPV-negative	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-negative	Return to average risk screening in 5 years or immunocompromised screening in 3 years
HPV-negative or HPV-positive⁸	HPV-negative	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-positive⁸	Re-refer to colposcopy
HPV-negative or HPV-positive⁸	HPV-negative	Screen in 2 years	HPV-negative	Re-screen in 2 years	HPV-positive⁸	Re-refer to colposcopy	N/A	N/A
HPV-negative or HPV-positive⁸	HPV-negative	Screen in 2 years	HPV-positive⁸	Re-refer to colposcopy	N/A	N/A	N/A	N/A

Footnotes

Any visible cervical abnormalities or abnormal symptoms must be investigated, regardless of age. If a lesion is found during a routine cervical screening test, complete the test and refer the participant to colposcopy or a regional cancer centre. Do not wait for the cervical screening test results to refer someone for next steps.
The cervical screening test does not test for other sexually transmitted infections or non-oncogenic types of HPV, such as those that cause genital warts.
If the HPV test component of the cervical screening test is invalid, repeat sample collection at the participant’s earliest convenience, within 3 months. If the repeat HPV test is invalid, refer to colposcopy.
If the test is HPV-positive (other high-risk types) with unsatisfactory reflex cytology, repeat the cytology test only (i.e., do not repeat the HPV test) at the participant’s earliest convenience, within 3 months. If the repeat cytology test is unsatisfactory, refer to colposcopy. After an unsatisfactory cytology test result, a course of intravaginal estrogen therapy should be considered for people using transition-related hormone therapy (i.e., androgen therapy) and in post-menopausal people.
The following immunocompromised populations may be at a higher risk of cervical pre-cancer and cancer, and should screen every 3 years if their last HPV test was negative: people living with HIV/AIDS, regardless of CD4 cell count; people with congenital (primary) immunodeficiency; transplant recipients (solid organ or allogeneic stem cell transplants); people requiring treatment (either continuously or at frequent intervals) with medications that cause immune system suppression for 3 years or more; people who are living with systemic lupus erythematosus (SLE), regardless of whether they are receiving immunosuppressant treatment; and people who are living with renal failure and require dialysis.
Includes AGC-N/NOS, AEC-N/NOS (AGC-N = atypical glandular cells, favour neoplastic; AGC-NOS = AGC, not otherwise specified; AEC-N = atypical endocervical cells, favour neoplastic; AEC-NOS = AEC, not otherwise specified).
If someone has SCC, ACC, ACC-E and/or PDC results, refer them urgently to colposcopy or if they have an obvious lesion, consider referral to gynecologic oncology.
Regardless of HPV type or reflex cytology test result.