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Cervical cancer screening

Summary of recommendations

GUIDELINE UPDATES - This guideline was last updated 7/1/2022

This guideline contains evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in Table B.4 NHMRC approved recommendation types and definitions.

Table B.5. Key to types of recommendations in these guidelines outlines the types of recommendations appearing in these guidelines.

This is a summary of the recommendations in these guidelines, numbered according to chapter to which they relate. Please note that some chapters do not have associated recommendations.

Recommendations

4. Unsatisfactory cervical screening results

Practice point
REC4.1: Attempt adequate repeat preparations for an unsatisfactory LBC test 
In the case of unsatisfactory LBC, laboratories should ensure that adequate repeat preparations are attempted, after dealing with potentially remediable technical problems. 
Practice point
REC4.2: Report cellular abnormality for LBC specimens with abnormal cells 
Any LBC specimen with abnormal cells should not be reported as ‘Unsatisfactory’. The identified cellular abnormality should be reported. 
Practice point
REC4.3: Recall women in 6 weeks if they have an unsatisfactory screening report
A woman with an unsatisfactory screening report should have a repeat sample collected in 6 weeks. If the reason for the unsatisfactory sample has been identified then this problem should be corrected if possible before the repeat sample is collected. 

6. Management of HPV test results

MSAC evidence-based recommendation
REC6.1: Eligibility for screening on a self-collected sample to include all people eligible for cervical screening 
Anyone who is eligible for cervical screening (people with a cervix aged 25-74 years who have ever been sexually active) should be offered the choice of HPV testing on a self-collected vaginal sample or on a clinician-collected sample. 
Practice point
REC6.2: Clinican-collected cervical samples
A short course of topical oestrogen therapy could be considered in post-menopausal women, people experiencing vaginal dryness, or trans men, prior to collecting the sample, for example daily for a period of at least 2 weeks, ceasing 1-2 days prior to the appointment. The reason for this should be explained (to reduce discomfort from the speculum and to improve the diagnostic accuracy of any associated LBC).   

Oncogenic HPV types not detected

MSAC evidence-based recommendation
REC6.3: Oncogenic HPV types not detected at routine screening
Women who have a screening HPV test in which oncogenic HPV types are not detected should rescreen in 5 years.

Oncogenic HPV types 16 and/or 18

MSAC evidence-based recommendation
REC6.4: Women with a positive HPV (16/18) test result
Women with a positive oncogenic HPV (16/18) test result should be referred directly for colposcopic assessment, which will be informed by the result of LBC.  If the sample has been collected by a healthcare practitioner, then reflex LBC will be performed by the laboratory.  If the sample was self-collected, then a sample for LBC should be collected at the time of colposcopy.
Consensus-based recommendation*
REC6.5: Referral of women with a positive HPV (16/18) test result and LBC prediction of invasive cancer to a gynaecological oncologist
Women who have a positive oncogenic HPV (16/18) test result with a reflex LBC report of invasive cancer (squamous, glandular or other) should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks.
Practice point
REC6.6: Referral of women with a positive HPV (16/18) test result and reflex LBC pHSIL/HSIL
Women with a positive oncogenic HPV (16/18) test result and reflex LBC prediction of pHSIL/HSIL should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
Practice point
REC6.7: Referral of women with a positive HPV (16/18) test result and unsatisfactory LBC
When HPV 16/18 is detected, colposcopic referral is  required regardless of the LBC result and the screening episode should be classified as ‘Higher risk for cervical cancer or precursors’. If reflex LBC is unsatisfactory or the screening sample has been self-collected a cervical sample, then LBC should be collected at the time of colposcopy.  

Oncogenic HPV types not 16/18

Evidence-based recommendationGrade

REC6.8: Positive oncogenic HPV (not 16/18) test result at routine screening

  • Women with a positive oncogenic HPV (not 16/18) test result, with a LBC report of negative or prediction of pLSIL/LSIL, should have a repeat HPV test in 12 months. 
  • When the sample has been collected by a healthcare provider, then the laboratory will perform reflex LBC.  When the sample was self-collected,  the woman should be advised to return to her healthcare provider so that a cervical sample for LBC can be collected by the healthcare provider.

Note: Amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample at the follow-up test for people whose initial screening test was done on a clinician-collected sample will be effective from 1 November 2022.

C
Consensus-based recommendation*
REC6.9: Referral to gynaecological oncologist for LBC prediction of invasive disease
Women who have a positive oncogenic HPV (not 16/18) test result with a LBC report of invasive cancer (squamous, glandular or other) should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks.
Practice point
REC6.10: Referral of women with a positive oncogenic HPV (not 16/18) test result and LBC prediction of pHSIL, HSIL or any glandular abnormality
Women with a positive oncogenic HPV (not 16/18) test result, with a LBC prediction of pHSIL/HSIL or any glandular abnormality, should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
Evidence-based recommendationGrade

REC6.11: Management after follow-up HPV test at 12 months, following initial positive oncogenic HPV (not 16/18) screening test result

At follow-up HPV testing 12 months after a detection of HPV (not 16/18) and LBC results of negative or pLSIL/LSIL: 

  • if oncogenic HPV is not detected, the woman should be advised to return to routine 5-yearly screening. 
  • if HPV (16/18) is detected, then the woman should be referred for colposcopic assessment. If the follow-up sample was collected by a healthcare professional then the laboratory will undertake reflex LBC. If the follow-up sample was self-collected then a sample for LBC should be collected at the time of colposcopy

Management of those with HPV (not 16/18) detected at 12 months is described in REC6.12 - 6.14  

C
Practice point

REC6.12: Management after follow-up HPV test at 12 months, following initial positive detection of HPV (not 16/18), for women who: 

  • were overdue for screening by at least 2 years at the time of their initial positive oncogenic HPV (not 16/18) test result 
  • identify as Aboriginal and/or Torres Strait Islander 
  • are aged 50 years or older. 

If oncogenic HPV (any type) is detected at the follow-up HPV test, then the woman should be referred for colposcopic assessment. If the follow-up sample was collected by a healthcare professional then the laboratory will undertake reflex LBC. If the follow-up sample was self-collected then a sample for LBC should be collected at the time of colposcopy. 

Management of those with HPV (not 16/18) detected at 12 months who do not fall into any of the above categories is described in REC6.13-6.14  

Approval: 1-Feb-2021

Consensus-based recommendation

REC6.13: Management after follow-up HPV test at 12 months, following initial positive oncogenic HPV (not 16/18) screening test result: HPV (not 16/18) detected at 12 months 

If HPV (not 16/18) is detected again, and the woman does not fall into any of the categories in REC6.12, then LBC should be performed. If the follow-up sample was collected by a healthcare professional then the laboratory will undertake reflex LBC. If the follow-up sample was self-collected then the woman should be advised to return to her healthcare professional so that a sample can be collected for LBC. 

  • If the LBC is reported as invasive cancer (squamous, glandular or other) the woman should be referred to a gynaecological oncologist or gynaecological cancer centre for urgent evaluation, ideally within 2 weeks.
  • If the LBC is reported as pHSIL/HSIL or any glandular abnormality, she should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks 

Management of those with HPV (not 16/18) detected at 12 months with negative/ pLSIL/ LSIL LBC is described in REC6.14 

Approval: 1-Feb-2021 

Consensus-based recommendation

REC6.14: Management after follow-up HPV test at 12 months, following an initial positive oncogenic HPV (not 16/18) screening test result
At the follow-up HPV test 12 months after detection of HPV (not 16/18) with LBC results of negative, pLSIL or LSIL if the woman has a HPV (not 16/18) test result, with an LBC report of negative or prediction of pLSIL/LSIL, and she does not fall into any of the categories in REC6.12, she should have a second follow-up HPV test in a further 12 months. 

Approval: 1-Feb-2021

Note: Amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample at the follow-up test for people whose initial screening test was done on a clinician-collected sample will be effective from 1 November 2022.

Consensus-based recommendation

REC6.15: Management after second follow-up HPV test, following initial detection of HPV (not 16/18) at the baseline screening test
At the second follow-up HPV test, 12 months after a first follow-up HPV test with HPV (not 16/18) detected and LBC negative or pLSIL/LSIL:

  • If HPV (any type) is detected, the woman should be referred for colposcopic assessment. When the follow-up sample has been collected by a healthcare provider, then the laboratory will perform reflex LBC. When the follow-up sample was self-collected, then a sample should be collected for LBC at the time of colposcopy.
  • if HPV is not detected, the woman should be advised to return to routine 5- yearly screening.

Approval: 1-Feb-2021

Self-collected vaginal samples

Practice Point

REC6.16: Informed choice for patients about self-collection
When deciding whether to choose self-collection or clinician collection, people must be given clear information by the supervising healthcare professional about the likelihood that HPV may be detected and, if so, what follow-up will be required. If a person chooses self-collection then the healthcare professional should provide information about how to collect the sample and how they will receive the test results. 

Among those attending for a routine screening test, approximately 2% have HPV16/18 detected and approximately 6% have HPV (not 16/18) detected, although the latter varies by age.

Practice Point

REC6.17: Settings where self-collection can be performed
Cervical screening on a self-collected vaginal sample needs to be ordered and overseen by a healthcare professional. Patients attending an in-person consultation should be encouraged to collect a sample while they are still at the clinic, as sample collection is considered more likely in this context. The healthcare professional is not required to observe the patient collecting their sample unless this is the patient’s preference. 

However, with the aim to maximise participation in cervical screening, collection of the sample can occur in any setting that the healthcare professional* ordering the test believes is appropriate, including in the context of a telehealth consultation. The healthcare professional should facilitate access to screening, and the pathology laboratory should deliver the results to the requesting healthcare professional who will be responsible for informing patients of their results and any required follow-up. Within these constraints, healthcare professionals and laboratories have flexibility to develop models of screening that best meet the needs of their communities.

* Only doctors and nurse practitioners can sign the pathology request for tests under current MBS rules.

Practice Point
REC6.18 Assistance with sample self-collection
Women who have difficulty collecting a lower vaginal sample by themselves could be assisted to do so by the provider. Alternatively the provider could collect the sample using a self-collection swab without using a speculum. A sample collected in this way is still classified as self-collection on the pathology request form.
Practice Point
REC6.19 Support for underscreened women
Women in whom HPV (any type) is detected in a self-collected sample and who were overdue for screening may require additional and individualised support to progress along the clinical pathway, and access to follow-up services where they will receive sensitive treatment. This additional support may involve, for example, reassurance and explanation of the screening pathway and follow-up procedures, longer appointments, or additional follow-up contact.
Practice point
REC6.20 Indication for genital inspection
Routine genital inspection is not indicated in all people attending for cervical screening, but could still be offered to people who undergo screening on a self-collected sample with any clinical indication that genital inspection is appropriate or who are from populations who are at high risk for vulvar disease.
Practice point

REC6.21 Follow-up HPV test after initial self-collected screening sample
When follow-up HPV testing is required after an initial positive oncogenic HPV test result, the sample may be self-collected or collected by a clinician. The woman’s healthcare professional should advise the woman of the follow-up that will be recommended if HPV is detected, and explain that a clinician-collected sample allows for reflex LBC to be performed on the same sample, potentially avoiding the need for an additional visit to collect a cervical sample for LBC. HPV testing is not repeated on the clinician-collected sample in this circumstance.

Approval: 1-Feb-2021

Note: recommendation numbering changed Feb 2021, this was previously 6.14

Women undergoing exit testing

MSAC evidence-based recommendation
REC6:22 Women aged 70–74 years in whom oncogenic HPV is not detected (exit testing)
Women can be discharged from the NCSP if they are aged 70–74 years and have a screening test at which oncogenic HPV is not detected.
Note: recommendation numbering changed Feb 2021, this was previously REC 6.16
Consensus-based recommendation

REC6.23: Referral of women aged 70–74 years with a positive oncogenic HPV test result (exit testing)
Women aged 70–74 who have a positive oncogenic HPV (any type) screening test result should be referred directly for colposcopic assessment, which should be informed by the result of LBC. If the sample was collected by a healthcare provider, then the laboratory will perform reflex LBC. If the sample was self-collected , then a cervical sample for LBC should be collected at the time of colposcopy. 

Note: recommendation numbering changed Feb 2021, this was previously REC 6.17

Screening in women older than 75

NCSP recommendation
REC6.24 Women aged 75 years or older who request screening
Women who are 75 years or older who have never had a cervical screening test, or have not had one in the previous five years, may request a test and can be screened. The sample can be clinician-collected or self-collected, according to the woman’s choice.

7. Colposcopy

Colposcopy terminology

Practice point
REC7.1: New colposcopy terminology
The new terminology adopted by the IFCPC in 2011 should be incorporated into Australian practice.

History, examination and investigation

Practice point

REC7.2 Preparation for colposcopy: post menopausal women, people experiencing vaginal dryness, or trans men
Acetic acid should be applied for 2 minutes to allow sufficient time for aceto-white changes to become apparent. This is especially important when the lesion is low grade as it may take more time to become visible. 

Application of aqueous Iodine (Lugol’s or Schiller’s solutions) before or after biopsy may assist in defining the external limits of the TZ and any vaginal extension or separate lesions. Iodine can be applied to outline the TZ at the examination preceding therapy, and this is particularly useful when there is vaginal extension of the TZ.

Practice point
REC7.3: Colposcopy and acetic acid 
Acetic acid should be applied for 2 minutes to allow sufficient time for aceto-white changes to become apparent. This is especially important when the lesion is low grade as it may take more time to become visible.
Practice point
REC7.4: Colposcopy and VAIN
When the LBC report predicts a squamous abnormality and there is no colposcopically visible cervical lesion, careful colposcopic examination of the vagina should be performed to exclude VAIN, using acetic acid and Lugol’s Iodine.
Practice point

REC7.5: Repeat LBC usually not necessary at time of colposcopy
It is not necessary to take a cervical sample for LBC at the time of colposcopy except in the following circumstances:

  • delay in attending for colposcopy > 3 months after referral LBC
  • referral LBC is unsatisfactory
  • referral LBC is negative but lacks an endocervical component
  • prior LBC is not available because the HPV test was performed on a self-collected sample
  • the woman has developed symptoms suggestive of cervical cancer since undergoing her screening test.
Consensus-based recommendation*
REC7.6: Biopsy of high grade lesions
The cervix should be biopsied when the LBC prediction is pHSIL or HSIL and the colposcopic appearance shows major change (see IFCPC definition above) and the abnormal TZ is visible (Type 1 or Type 2 TZ).
Practice point
REC7.7: Biopsy visible lesion if suspicious for invasion when T3 TZ colposcopy
In some situations, when there is a visible high-grade lesion on the ectocervix but there is a T3 TZ (lesion extends into canal out of visual range), it may be reasonable to take a cervical biopsy of the visible lesion if there is any suspicion of superficially invasive or invasive carcinoma.
Practice point
REC7.8: Biopsy of low-grade lesions is encouraged but not always necessary
Women with a LBC prediction of pLSIL or LSIL and a colposcopic impression of low-grade disease or less may not always require a biopsy. However, biopsy is accepted practice for confirmation of the colposcopic impression and exclusion of high-grade disease, and should be encouraged, especially for less experienced colposcopists.
Practice point
REC7.9: Upper genital tract imaging
Upper genital tract imaging (usually transvaginal ultrasound) should be considered in cases where no lower genital tract abnormality is detected at colposcopy after referral with abnormal glandular cytology (including atypical glandular cells or endocervical cells of undetermined significance). In some women, further investigation, such as endometrial sampling to exclude an endometrial origin for atypical glandular cells, may be required.

Treatment

Consensus-based recommendation*

REC7.10: Colposcopy prior to treatment
All women should have an adequate† colposcopic assessment prior to treatment.

†adequate: the cervix is clearly seen (IFCPC 2011 terminology)

Consensus-based recommendation*
REC7.11: Histopathological confirmation prior to treatment
Treatment should be reserved for women with histologically confirmed HSIL (CIN2/3) or AIS, except for women requiring diagnostic excisional biopsy.
Consensus-based recommendation*
REC7.12: Biopsy prior to ablative treatment
Women should have a cervical biopsy prior to any ablative treatment.
Consensus-based recommendation
REC7.13: Pathology review of discordant test results
For women who have had a colposcopy with significant discordance between the histopathology and the referral cytology, both specimens should be reviewed by a pathologist from at least one of the reporting laboratories who should then convey the results of the review to the colposcopist in order to inform the management plan.
Practice point

REC7.14: Tertiary referral may be necessary
In some clinical situations, the woman should be referred to a more experienced colposcopist, a gynaecological oncologist, tertiary colposcopy clinic or gynaecological cancer centre:

  • adenocarcinoma in situ
  • abnormalities in pregnancy
  • immune-deficient women
  • women with multifocal lower genital tract disease.
Practice point
REC7.15: Second opinion
When there is any concern about diagnosis or patient management, a second opinion should be sought and documented.
Practice point

REC7.16: The role of multidisciplinary team review
It is not always practical for a colposcopist to access a multidisciplinary team review which is usually conducted in a tertiary referral centre. However, a multidisciplinary team review is particularly helpful when:

  • dealing with complex cases where there is discordance between histopathology and referral cytology (e.g. LBC prediction of HSIL, with negative or LSIL histology).
  • implementation of treatment is not urgent and therefore it is possible to take the required time to review the findings and optimise the management plan.
Practice point
REC7.17: Colposcopy at time of treatment
All treatments should be performed under colposcopic vision, with the exception of cold-knife cone biopsy.
Consensus-based recommendation*

REC7.18: Criteria for ablative treatment
Ablative therapy should be reserved for women intending to have children, and when the following conditions have all been met:

  • TZ is completely visible (Type 1 or Type 2).
  • There is no evidence of invasive or glandular disease.
  • A biopsy has been performed prior to treatment.
  • HSIL (CIN2/3) has been histologically confirmed.
  • There is no significant discordance between the histopathology and referral cytology results.
Practice point
REC7.19: Depth of ablation
A Type 1 TZ with a HSIL (CIN2/3) lesion requires 6–8 mm (and not more than 10 mm) of cervical ablation to be adequately treated.
Consensus-based recommendation*
REC7.20: Excision specimen quality and pathology
Excisional therapy should aim to remove the entire TZ with a pre-determined length of cervical tissue, ideally in one piece, with minimal distortion or artefact to the final histological specimen.†

†This is critical for management of suspected or histologically confirmed AIS.
Practice point
REC7.21: Excision specimen quality, pathology and very large ectocervical lesion
A very large ectocervical lesion may require removal in two pieces in order to remove the entire lesion. It is still important that the endocervical and stromal margins are suitable for pathological interpretation and that the specimens are accurately oriented and labelled.
Practice point
REC7.22: Excisional techniques and surgical competency
Therapeutic colposcopists should use the excisional techniques with which they are comfortable and competent and that produce the best histological specimen.
Practice point
REC7.23: Cold-knife cone biopsy: setting
Cold-knife cone biopsy should be performed in an operating theatre, under general anaesthesia, by a gynaecological oncologist or gynaecologist competent in the technique.
Practice point
REC7.24: Loop excisional biopsy technique (LEEP/LLETZ)
A single pass of the loop (side to side or posterior to anterior) to produce a specimen in one piece is optimal.
Practice point
REC7.25: Loop ‘top-hat’ excisions should be avoided (LEEP/LLETZ)
The ‘top-hat’ excision techniques using a wire loop, in which a second piece of endocervical tissue is removed after the first excision, is not an alternative to a properly performed single-piece Type 3 excision, and should be avoided.
Practice point
REC7.26: Cold-knife cone biopsy and AIS
Predicted or histologically confirmed AIS should be treated by a Type 3 excision (usually a cold-knife cone biopsy) performed in an operating theatre, under general anaesthesia, by a gynaecological oncologist or gynaecologist competent in the technique.
Practice point
REC7.27: Role of repeat excision in management of SISCCA
In the presence of a superficially invasive squamous carcinoma, if HSIL (CIN2/3) extends to any excision margin, a repeat excision (usually by cold-knife cone biopsy) is recommended.
Practice point
REC7.28: Do not treat at first visit with a LBC report of a low-grade lesion
Women who have a LBC prediction of pLSIL/LSIL should not be treated at the first visit.
Practice point
REC7.29: Excision required for recurrent disease after ablation
If there is recurrence of high-grade disease after previous ablation, treatment should be by excision.
Practice point

REC7.30: Repeat excision not necessarily required for incomplete excision of high-grade lesions
Women who have incomplete excision of HSIL (CIN2/3) with positive endocervical or stromal margins do not necessarily require immediate repeat excision and could be offered test of cure (HPV and LBC) surveillance, with the exception of:

  • women aged 50 years or over
  • women who may not be compliant with recommended follow-up
  • women in whom subsequent adequate colposcopy and follow-up cytology cannot be guaranteed.

8. Management of discordant colposcopic impression, histopathology and referral LBC prediction

Normal colposcopic findings following LBC prediction of negative, LSIL or HSIL

Consensus-based recommendation

REC8.1: Normal colposcopy following LBC prediction of negative or pLSIL/LSIL
For women with a positive oncogenic HPV (any type) test result, a LBC report of negative or pLSIL/LSIL, and normal colposcopy, the HPV test should be repeated in 12 months:

  • If HPV is not detected at 12 months, the woman should return to routine 5-yearly HPV screening.
  • If the woman has a positive oncogenic HPV (not 16/18) test result at 12 months and a LBC report of negative or pLSIL/LSIL, the HPV test should be repeated in another 12 months.
  • If the woman has a positive oncogenic HPV ( any type) test at the 24 month HPV test, she should be referred directly for colposcopic assessment, which will be informed by the result of the reflex LBC.
  • If the woman has a positive oncogenic HPV (not 16/18) test result at 12 months and a LBC prediction of pHSIL/HSIL or any glandular abnormality, she should be referred for colposcopic assessment at the earliest opportunity, ideally within 8 weeks.
  • If the woman has a positive oncogenic HPV (16/18) test result at 12 months, she should be referred directly for colposcopic assessment at the earliest opportunity, ideally within 8 weeks, and the reflex LBC result will inform the colposcopy.
Practice point
REC8.2: Normal colposcopy following LBC prediction of HSIL: cytopathology review
Cytopathology review is recommended to confirm HSIL before proceeding to excisional treatment for women with a normal colposcopy after a positive oncogenic HPV (any type) test result and an initial LBC prediction of pHSIL/HSIL.
Practice point
REC8.3: Normal colposcopy following LBC prediction of HSIL: exclude VAIN
When colposcopic impression is discordant with a referral LBC prediction of HSIL, colposcopic examination of the vagina is indicated to exclude a vaginal intraepithelial neoplasia before diagnostic excisional treatment.
Consensus-based recommendation
REC8.4: Normal colposcopy following LBC prediction of HSIL: diagnostic excision of TZ
For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a LBC prediction of HSIL on cytopathology review, diagnostic excision of the TZ should be performed.
Consensus-based recommendation
REC8.5: Normal colposcopy following LBC prediction of pHSIL: consider diagnostic excision of TZ
For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a LBC prediction of pHSIL on cytopathology review, diagnostic excision of the TZ should be considered, though observation is an option.
Practice point

REC8.6: Normal colposcopy following LBC prediction of pHSIL: diagnostic excision or observation
Some women with a positive oncogenic HPV test result for whom diagnostic excision of the TZ is recommended due to a confirmed LBC prediction of pHSIL on cytopathology review, despite normal colposcopic findings, may be concerned about the possibility of having unnecessary treatment. The colposcopist may have similar concerns.

Women who opt to defer treatment, particularly younger women with concerns about fertility, can be offered observation:

  • A HPV test and colposcopy should be repeated at 6 months, and a diagnostic excisional procedure should be reconsidered based on the test results (HPV and reflex LBC, if performed) obtained at that time.
  • If oncogenic HPV is not detected, and the colposcopic impression is unchanged, the HPV test should be repeated in 12 months and if oncogenic HPV is not detected, the woman can return to routine 5-yearly screening.
Consensus-based recommendation
REC8.7: Downgrading of discordant results
For women who have a positive oncogenic HPV (any type) test result, normal colposcopy, and a subsequent LBC report of pLSIL/LSIL or less on cytopathology review, management should be according to the reviewed cytological report (i.e. repeat HPV test in 12 months).
Practice point
REC8.8: Colposcopist should manage discordant results
Women with discordant colposcopy and LBC results should have their management supervised by the colposcopist until both the colposcopist and the woman are satisfied with the proposed management plan.

Type 3 TZ (previously termed ‘unsatisfactory’) colposcopy following LBC prediction of negative, LSIL or HSIL

Consensus-based recommendation

REC8.9: Repeat HPV test after Type 3 TZ colposcopy and referral LBC negative or pLSIL/LSIL
For women who have a positive oncogenic HPV (any type) test result with a LBC report of negative or pLSIL/LSIL, and colposcopy is reported as Type 3 TZ,† the HPV test should be repeated in 12 months:

  • If oncogenic HPV is not detected at 12 months, the HPV test should be repeated 12 months later.
  • If oncogenic HPV is not detected again at the second repeat HPV test, the woman should be advised to return to routine 5-yearly screening.
  • If the woman has a positive oncogenic HPV (any type) test result at 12 months, she should be referred directly for colposcopic assessment, with the LBC report available to inform the assessment.


†Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

Practice point

REC8.10: Cytopathology review prior to observation for pLSIL/LSIL and Type 3 TZ at colposcopy
When observation is advised, cytopathology review is recommended to confirm the low-grade cytological abnormality.

  • If pLSIL/LSIL is confirmed, observation is appropriate.
  • If pHSIL/HSIL is indicated, then diagnostic excision of the TZ should be considered.
Practice point
REC8.11: Role of ECC in Type 3 TZ colposcopy following LBC prediction of pLSIL/LSIL
Despite a lack of evidence, endocervical curettage can be considered for women who have a positive oncogenic HPV test result (any type) with a LBC report of persistent pLSIL/LSIL and colposcopy reported as Type 3 TZ.† A negative ECC may provide additional reassurance for a conservative (observational) approach.

†Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.
Consensus-based recommendation
REC8.12: Diagnostic excision of the TZ should not be performed if there is no cytological or histological evidence of a high-grade lesion after Type 3 TZ colposcopy
For asymptomatic women who have a positive oncogenic HPV (any type) test result, Type 3 TZ† colposcopy, and no cytological, colposcopic or histological evidence of a high-grade lesion, further diagnostic procedures (such as diagnostic excision of the transformation zone) should not routinely be performed.

†Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.
Practice point

REC8.13: Role of diagnostic excision: exceptions to recommendation against diagnostic excision of TZ in the absence of high-grade cytology or histology
Diagnostic excision of the TZ can be offered to certain groups of women who have a positive oncogenic HPV test result, a LBC report of negative or pLSIL/LSIL, and colposcopy reported as Type 3 TZ:†

  • women who have completed childbearing
  • women who are anxious about cancer risk
  • women aged over 50 years
  • concerns exist regarding a woman’s ability to comply with recommended surveillance.

†Type 3 TZ indicates failure to visualise the upper limit of the TZ, or the entire TZ is within the endocervical canal. It corresponds to ‘unsatisfactory’ in previous terminology.

Consensus-based recommendation
REC8.14: Diagnostic excision: Type 3 TZ colposcopy after LBC prediction of pHSIL/HSIL
Cytopathology review should be considered to confirm a high-grade cytological abnormality before excision, after a positive oncogenic HPV (any type) test result and an initial LBC prediction of pHSIL/HSIL, when there is a Type 3 TZ colposcopy.

This is particularly important when the LBC prediction is pHSIL because pHSIL has a lower PPV for high-grade disease and the subsequent excision specimens show no evidence of cervical pathology in 45–55% of cases.
Practice point
REC8.15: Cytopathology review: Type 3 TZ colposcopy following LBC prediction of pHSIL/HSIL
Cytopathology review should be considered to confirm a high-grade cytological abnormality before excision, after a positive oncogenic HPV (any type) test result and an initial LBC prediction of pHSIL/HSIL, when there is a Type 3 TZ colposcopy.

This is particularly important when the LBC prediction is pHSIL because pHSIL has a lower PPV for high-grade disease and the subsequent excision specimens show no evidence of cervical pathology in 45–55% of cases.
Practice point

REC8.16: Deferral of treatment following cytopathology review: Repeat HPV test and colposcopy in 6 months
Following cytopathology review, rarely the woman or the clinician wish to defer treatment. In this situation the woman should have a repeat HPV test and colposcopy in 6 months.

  • If HPV detected (any type) and LBC pLSIL/LSIL, repeat HPV test in 12 months.
  • If HPV detected (any type) and LBC pHSIL/HSIL, the woman should have diagnostic Type 3 excision of the TZ.

9. Management of histologically confirmed low-grade squamous abnormalities

Consensus-based recommendation

REC9.1: HPV test 12 months after histologically confirmed LSIL (≤ CIN1)
Women who have a positive oncogenic HPV (any type) test result with a LBC report of either negative or pLSIL/LSIL, and histologically confirmed ≤ CIN1 on biopsy, should have a repeat HPV test 12 months later:

  • If oncogenic HPV is not detected at the repeat HPV test, the woman should return to routine 5 yearly screening.
  • If the repeat test is positive for oncogenic HPV (not 16/18) and the LBC report is negative or pLSIL/LSIL, the woman should have a further repeat HPV test in 12 months.
    • If the second follow-up HPV test is negative the woman should return to routine 5-yearly screening.
    • If the second follow-up test is HPV positive, the woman should be referred for colposcopic assessment informed by reflex LBC.
  • If the repeat test is positive for oncogenic HPV (not 16/18) and the LBC report is pHSIL/HSIL, the woman should be referred for colposcopic assessment.
  • If the repeat test is positive for oncogenic HPV (16/18), the woman should be referred for colposcopic assessment informed by the reflex LBC.
Consensus-based recommendation
REC9.2: LSIL (≤ CIN1) should not be treated
Women who have a positive oncogenic HPV (any type) test result with a LBC report of negative or pLSIL/LSIL, who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), should not be treated, because these lesions are considered to be an expression of a productive HPV infection.
Consensus-based recommendation
REC9.3: Diagnostic excision when HSIL confirmed on cytopathology review
Women who have a positive oncogenic HPV test result (any type) with a LBC report of HSIL (confirmed after cytopathology review), and who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), should be offered diagnostic excision of the TZ.
Consensus-based recommendation

REC9.4: Option for observation following cytological prediction of pHSIL
Women who have a positive oncogenic HPV (any type) test result with a LBC prediction of pHSIL (confirmed after cytopathology review), and who have undergone colposcopy and have a histologically confirmed LSIL (≤ CIN1), could be offered diagnostic excision of the TZ. If the colposcopist considers a period of observation is preferable to treatment, or the woman with these findings wishes to defer diagnostic excision, she can be offered observation with a HPV test and colposcopy at 6–12 months:

  • If oncogenic HPV is not detected at the repeat test, the HPV test should be repeated again in 12 months.
  • If the second follow-up test is negative, the woman should return to routine 5-yearly screening.
  • If the woman has a positive oncogenic HPV (any type) test result at the repeat test, her reflex LBC report is negative or pLSIL/LSIL, and her colposcopic impression is normal or LSIL, the HPV test should be repeated annually.
  • When oncogenic HPV is not detected at two consecutive annual tests, the woman can return to 5-yearly screening.
  • If the woman has a positive oncogenic HPV (any type) test result at the repeat test, and her LBC prediction is pHSIL/HSIL or any glandular abnormality, she should have a diagnostic excision of the TZ.
Practice point

REC9.5: Criteria for observation following cytological prediction of pHSIL
Women should not be offered observation unless the colposcopic assessment meets all the following conditions:

  • Colposcopy is adequate.
  • TZ is completely visualised (Type 1 or 2 TZ^).
  • LSIL (≤ CIN1) has been confirmed on histopathological review.


^IFCPC: International Federation of Cervical Pathology and Colposcopy 2011

Practice point
REC9.6: Cytology review essential when test results are discordant
For women who have a positive oncogenic HPV (any type) test result with a histologically confirmed LSIL (≤ CIN1) after LBC prediction of pHSIL/HSIL, both the cytology and the histopathology should be reviewed by a pathologist from at least one of the reporting laboratories, who should then convey the results of the review to the colposcopist in order to inform the management plan.

10. Management of histologically confirmed high-grade squamous abnormalities

Diagnosis of HSIL

Consensus-based recommendation*
REC10.1: Histological diagnosis prior to treatment
For women who have a visible lesion at colposcopy, histological confirmation of HSIL is recommended before undertaking definitive treatment.

Treatment of HSIL

Consensus-based recommendation*
REC10.2: Treatment for HSIL (CIN2)
Women with a histological diagnosis of HSIL (CIN2) should be treated in order to reduce the risk of developing invasive cervical carcinoma.
Practice point
REC10.3: p16 should be used to clarify diagnosis of HSIL (CIN2)
The use of p16 immunohistochemistry is recommended to stratify the management of HSIL (CIN2) into immediate treatment or a period of observation.
Practice point

REC10.4: HSIL (CIN2) and observation
In some circumstances, it may be acceptable to offer a period of observation (generally 6–12 months) to women who have a histological diagnosis of HSIL (CIN2), and this would usually be supervised by an experienced colposcopist or at a tertiary centre. Observation may be considered for:

  • women who have not completed childbearing
  • women with discordant histology and LBC prediction of pLSIL/LSIL
  • women with focal minor changes on colposcopy and HSIL (CIN2) on histology
  • women recently treated for HSIL (CIN2).
Consensus-based recommendation*
REC10.5: Treatment of HSIL (CIN3)
Women with a histological diagnosis of HSIL (CIN3) should be treated in order to reduce the risk of developing invasive cervical carcinoma.
Consensus-based recommendation*
REC10.6: Referral of women with invasive disease
A woman with a histologically confirmed diagnosis of invasive or superficially invasive (squamous cell carcinoma) should be referred to a gynaecological oncologist or a gynaecological cancer centre for multidisciplinary team review.

Test of Cure after treatment for HSIL (CIN2/3)

Consensus-based recommendation
REC10.7: Test of Cure after treatment for HSIL (CIN2/3)
A woman who has been treated for HSIL (CIN2/3) should have a co-test† performed at 12 months after treatment, and annually thereafter, until she receives a negative co-test on two consecutive occasions, when she can return to routine 5 yearly screening.

†Co-testing can be performed by the woman’s usual healthcare professional.
Consensus-based recommendation
REC10.8: Abnormal Test of Cure results: positive oncogenic HPV (16/18) test result
If, at any time post treatment, the woman has a positive oncogenic HPV (16/18) test result, she should be referred for colposcopic assessment (regardless of the reflex LBC result).
Consensus-based recommendation*
REC10.9: Abnormal Test of Cure results: LBC pHSIL/HSIL or glandular abnormality
If, at any time during Test of Cure, the woman has a LBC prediction of pHSIL/HSIL or any glandular abnormality, irrespective of HPV status, she should be referred for colposcopic assessment.
Consensus-based recommendation
REC10.10: Abnormal Test of Cure results: positive oncogenic HPV (not 16/18) test result
If, at any time post-treatment, the woman has a positive oncogenic HPV (not 16/18) test result and a LBC report of negative or prediction of pLSIL/LSIL, she should continue to have annual co-testing until the she has a negative co-test on two consecutive occasions, when she can return to routine 5-yearly screening.
Practice point
REC10.11: Fluctuating Test of Cure results: positive oncogenic HPV (not 16/18) test result and/or pLSIL/LSIL
Some women may experience fluctuating results with a positive oncogenic HPV (not 16/18) test result and/or LBC prediction of pLSIL/LSIL. These women do not need colposcopic review but, if the woman is anxious, a colposcopic assessment may be appropriate to provide reassurance.
Practice point

REC10.12: Colposcopy is not necessary at the initial post-treatment visit
A post-treatment colposcopic assessment at 4–6 months has been the usual practice under pre-renewal NCSP guidelines. This practice is not evidence-based, but may provide reassurance to both the patient and clinician regarding the visual appearance of the cervix and allows for the discussion of any other relevant issues (bleeding, fertility, related symptoms etc.) following treatment.

The post-treatment review should:

  • include speculum examination of the vagina and cervix (but colposcopy is not considered necessary)
  • not involve HPV testing or LBC.

Subsequent post-treatment Test of Cure surveillance should be performed by the woman’s GP or health professional, who should follow the recommendations for the management of any abnormal test results.

11. Management of glandular abnormalities

Investigation of cytological glandular abnormalities

Consensus-based recommendation*
REC11.1: Colposcopy referral for atypical glandular/endocervical cells
Women who have a positive oncogenic HPV (any type) test result with a LBC report of atypical glandular/endocervical cells of undetermined significance should be referred to a gynaecologist with expertise in the colposcopic evaluation of suspected malignancies or a gynaecological oncologist.
Consensus-based recommendation*

REC11.2: Follow-up after normal colposcopy and LBC prediction of atypical glandular/endocervical cells
Women who have a positive oncogenic HPV test result (any type) with a LBC prediction of atypical glandular/endocervical cells of undetermined significance and normal colposcopy can be offered repeat co-testing (HPV and LBC) at 6–12 months:

  • If the follow-up co-test is negative, co-testing should be repeated annually until the woman has two consecutive negative co-tests, after which she can return to 5- yearly screening.
  • If there is either a positive oncogenic HPV (any type) test result or an abnormal LBC (any report other than negative), the woman should be referred for colposcopic assessment, and diagnostic excision of the TZ should be considered.
Practice point

REC11.3: Exclusion of upper genital tract disease before diagnostic excision
For women who have a positive oncogenic HPV test result (any type) and who have atypical glandular/endocervical cells of undetermined significance on cytology, investigation of the upper genital tract (endometrium, fallopian tube or ovary) using endometrial sampling and/or pelvic ultrasound should be considered, before diagnostic excision of the TZ is performed or the woman is advised to return for colposcopy and further tests in 6–12 months, in these groups of women:

  • women aged over 45 years
  • women aged over 35 years with a BMI greater than 30
  • women diagnosed with polycystic ovarian syndrome
  • women with abnormal vaginal bleeding.
Practice point

REC11.4: Role of immediate diagnostic excision of TZ versus observation
Immediate diagnostic excision of the TZ can be considered for women with atypical glandular/endocervical cells of undetermined significance if they prefer not to take a conservative observational approach. This might apply to:

  • women aged over 45 years
  • women who have completed childbearing
  • women who are particularly anxious about their cancer risk.
Consensus-based recommendation

REC11.5: Colposcopy for possible high-grade glandular lesions
Women who have a positive oncogenic HPV (any type) test result with a LBC prediction of possible high-grade glandular lesion should be referred to a gynaecologist with expertise in the colposcopic evaluation of suspected malignancies or a gynaecological oncologist. 

Diagnostic excision of the endocervical TZ should be performed in most cases.

Practice point

REC11.6: Women who decline treatment for possible high-grade glandular lesions
Women with a LBC prediction of possible high-grade glandular lesion who decline the recommended excision should be offered surveillance with co-testing (HPV and LBC) and colposcopy in 6 months.

  • If in 6 months the woman has a positive result, she should be encouraged to have a diagnostic excision of the TZ.
  • It is important that the woman understands the potential risk of underlying disease (21.5% risk of AIS and 5.5% risk of invasive cancer).
Consensus-based recommendation*

REC11.7: Colposcopy referral for AIS
Women with a LBC prediction of AIS should be referred to a gynaecologist with expertise in the colposcopic evaluation of suspected malignancies or to a gynaecological oncologist.

Diagnostic excision of the endocervical TZ should be performed.

Consensus-based recommendation*
REC11.8: Referral to gynaecological oncologist for LBC prediction of invasive disease
Women who have a positive oncogenic HPV (any type) test result with a LBC prediction of invasive adenocarcinoma should be referred to a gynaecological oncologist or a gynaecological oncology centre for urgent evaluation, ideally within 2 weeks.
Consensus-based recommendation*
REC11.9: Specimen for histological assessment of glandular abnormalities
When diagnostic excision of the TZ is performed in the investigation of glandular abnormalities, the method chosen should ensure that a single, intact specimen with interpretable margins is obtained for histological assessment.
Practice point
REC11.10: Cold-knife cone biopsy is the ‘gold standard’ for glandular abnormalities’
Cold-knife cone biopsy should be considered the ‘gold standard’ for the diagnostic assessment of glandular lesions. However, a diathermy excisional procedure may be appropriate in some circumstances and could provide an appropriate surgical specimen when performed by a gynaecologist with appropriate training, experience and expertise.
Practice point
REC11.11: Size of cone biopsy
The depth and extent of the cone biopsy should be tailored to the woman's age and fertility requirements. A Type 3 Excision of the TZ is usually required.
Practice point
REC11.12: Cone biopsy excision margins and multifocal AIS
Multifocal disease has been reported in 13–17% of cases of AIS, though the majority of lesions are unifocal. If the margin is close but apparently excised (less than 5 mm), close surveillance by Test of Cure, as recommended in these guidelines, is considered appropriate. In this situation further excision is not considered necessary.

Follow-up after excisional treatment for AIS

Consensus-based recommendation*

REC11.13: Follow-up of completely excised AIS
Women with histologically confirmed AIS who have undergone complete excision with clear margins should have annual co-testing indefinitely.†

If any abnormal result is obtained on follow-up co-testing, the woman should be referred for colposcopic assessment.

†Until sufficient data become available to support cessation of testing.

Consensus-based recommendation*
REC11.14: Repeat excision for incompletely excised AIS
If AIS is incompletely excised (positive endocervical margin and/or deep stromal margin, not ectocervical margin) or if the margins cannot be assessed, further excision to obtain clear margins should be performed.
Consensus-based recommendation
REC11.15: Role of hysterectomy in AIS
In women who have been treated for AIS by excision, with clear margins, there is no evidence to support completion hysterectomy. In this situation, hysterectomy is not recommended.

12. Screening in Aboriginal and Torres Strait Islander women

Consensus-based recommendation
REC12.1: Cervical Screening for Aboriginal and Torres Strait Islander women
Aboriginal and Torres Strait Islander women should be invited and encouraged to participate in the NCSP and have a 5-yearly HPV test, as recommended for all Australian women.
Practice point
REC12.2: Invitations to screen for Aboriginal and Torres Strait Islander women
Specific efforts should be made to maximise delivery of culturally appropriate invitations to Aboriginal and Torres Strait Islander women.
Practice point
REC12.3: Cervical screening services for Aboriginal and Torres Strait Islander women
Specific efforts should be made to provide accessible and culturally safe screening, diagnostic and treatment services to Aboriginal and Torres Strait Islander women.
Practice point
REC12.4: Eligibility for screening on self-collected sample: Aboriginal and Torres Strait Islander people
All eligible people, including Aboriginal and Torres Strait Islander people, should be offered the choice of HPV testing on a self-collected vaginal sample or on a clinician-collected sample.
Practice point
REC12.5: Data collection and recording Aboriginal and Torres Strait Islander status
Healthcare professionals should ask all women whether they identify as Aboriginal or Torres Strait Islander, and a woman’s Aboriginal and Torres Strait Islander status should be recorded on relevant clinical records, including pathology request forms, in accordance with the Australian Bureau of Statistics classification and standards. Aboriginal and Torres Strait Islander status influences clinical management of tests in some cases.

13. Screening after total hysterectomy

Consensus-based recommendation*
REC13.1: Total hysterectomy for benign disease
Women with a normal cervical screening history, who have undergone hysterectomy for benign disease (e.g. menorrhagia, uterine fibroids or utero-vaginal prolapse), and have no cervical pathology at the time of hysterectomy, do not require further screening or follow up.
Consensus-based recommendation*

REC13.2: Total hysterectomy after completed Test of Cure
Women who have had a total hysterectomy with no evidence of cervical pathology, have previously been successfully treated for histologically confirmed HSIL and have completed Test of Cure, do not require further follow-up. These women should be considered as having the same risk for vaginal neoplasia as the general population who have never had histologically confirmed HSIL and have a total hysterectomy. 

If unexpected LSIL or HSIL is identified in the cervix at the time of hysterectomy, then these women require follow-up with an annual co-test on a specimen from the vaginal vault until they have a negative co-test on two consecutive occasions.

Consensus-based recommendation

REC13.3: Total hysterectomy after adenocarcinoma in situ (AIS)
Women who have had a total hysterectomy, have been treated for AIS, and are under surveillance, should have a co-test on a specimen from the vaginal vault at 12 months and annually thereafter, indefinitely.† 

Women who have a total hysterectomy, as completion therapy or following incomplete excision of AIS at cold-knife cone biopsy or diathermy excision, should have a co-test on a specimen from the vaginal vault at 12 months and annually thereafter, indefinitely. 

† Until sufficient data become available to support cessation of testing

Consensus-based recommendation*

REC13.4: Total hysterectomy for treatment of high-grade CIN in the presence of benign gynaecological disease
Women who have had a total hysterectomy as definitive treatment for histologically confirmed HSIL in the presence of benign gynaecological disease, irrespective of cervical margins, should have a co-test on a specimen from the vaginal vault at 12 months after treatment and annually thereafter until the woman has tested negative by both tests on two consecutive occasions. 

After two annual consecutive negative co-tests, the woman can be advised that no further testing is required.

Consensus-based recommendation*

REC13.5: Total hysterectomy after histologically confirmed HSIL without Test of Cure
Women who have been treated for histologically confirmed HSIL, are under surveillance or have returned to routine screening without Test of Cure, and have had a total hysterectomy with no evidence of cervical pathology, should have a co-test on a specimen from the vaginal vault at 12 months and annually until the woman has tested negative on two consecutive occasions. 

After two annual consecutive negative co-tests, the woman can be advised that no further testing is required.

Consensus-based recommendation*

REC13.6: Total hysterectomy and no screening history
Women who have had a total hysterectomy with no evidence of cervical pathology, and whose cervical screening history is not available, should have a HPV test on a specimen from the vaginal vault at 12 months and annually thereafter until they have a negative HPV test on two consecutive occasions.

After two annual consecutive negative HPV tests, women can be advised that no further testing is required.

Note: Amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample for this specific use will be effective from 1 November 2022.

Practice point
REC13.7: Colposcopy referral for any positive co-test result following total hysterectomy
Women who have had a total hysterectomy and are under surveillance with co-testing, and have a positive oncogenic HPV (any type) test result and/or any cytological abnormality, should be referred for colposcopic assessment.
Practice point

REC13.8: Vaginal bleeding following total hysterectomy
Women who have vaginal bleeding† following total hysterectomy should be assessed by their GP or gynaecologist, regardless of the results of any surveillance tests. 

†Vaginal bleeding is quite common in the early weeks following hysterectomy and, where appropriate, should be investigated by the treating gynaecologist.

Practice point
REC13.9: Total hysterectomy after genital tract cancer
Women who have been treated for cervical or endometrial cancer are at risk of recurrent cancer in the vaginal vault. These women should be under ongoing surveillance from a gynaecological oncologist. Therefore, they will be guided by their specialist regarding appropriate surveillance and this is outside the scope of these guidelines.
Practice point
REC13.10: Subtotal hysterectomy
Women who have undergone subtotal hysterectomy (the cervix is not removed) should be invited to have 5-yearly HPV testing in accordance with the recommendation for the general population. Any detected abnormality should be managed according to these guidelines.

14. Screening in pregnancy

Consensus-based recommendation
REC14.1: Positive oncogenic HPV (not 16/18) test result with LBC negative or pLSIL/LSIL in pregnancy
Pregnant women who have a positive oncogenic HPV (not 16/18) test result with a LBC report of negative or prediction of pLSIL/LSIL should have a repeat HPV test in 12 months.
Consensus-based recommendation

REC14.2: Positive oncogenic HPV (not 16/18) test result with LBC pHSIL/HSIL or any glandular abnormality in pregnancy
Pregnant women who have a positive oncogenic HPV (not 16/18) test result with a LBC prediction of pHSIL/HSIL or any glandular abnormality should be referred for early† colposcopic assessment. 

† When practical and not deferred until the postpartum period.

Consensus-based recommendation

REC14.3: Positive HPV (16/18) test result in pregnancy
Pregnant women who have a positive oncogenic HPV (16/18) test result should be referred for early† colposcopic assessment regardless of their LBC test result. If the screening sample was collected by a healthcare professional then the laboratory will undertake, reflex LBC. If the screening sample was self-collected then a sample for LBC should be collected at the time of colposcopy. 

† When practical and not deferred until the postpartum period.

Consensus-based recommendation*

REC14.4: Referral of pregnant women with invasive disease
Pregnant women should be referred and seen within 2 weeks by a gynaecological oncologist/gynaecological cancer centre for multidisciplinary team review and management in the following situations:

  • LBC prediction of invasive disease
  • colposcopic impression of invasive or superficially invasive squamous cell carcinoma of the cervix
  • histologically confirmed diagnosis of invasive or superficially invasive squamous cell carcinoma of the cervix.
Consensus-based recommendation*
REC14.5: Colposcopy during pregnancy
The aim of colposcopy in pregnant women is to exclude the presence of invasive cancer and to reassure them that their pregnancy will not be affected by the presence of an abnormal cervical screening test result.
Practice point
REC14.6: Colposcopy during pregnancy
Colposcopy during pregnancy should be undertaken by a colposcopist experienced in assessing women during pregnancy.
Consensus-based recommendation*
REC14.7: Cervical biopsy in pregnancy is usually unnecessary
Biopsy of the cervix is usually unnecessary in pregnancy, unless invasive disease is suspected on colposcopy or reflex LBC predicts invasive disease.
Consensus-based recommendation*
REC14.8: Defer treatment until after pregnancy
Definitive treatment of a suspected high-grade lesion, except invasive cancer, may be safely deferred until after the pregnancy.
Practice point

REC14.9: Follow-up assessment after pregnancy
If postpartum follow-up assessment (colposcopy and/or HPV test and reflex LBC if necessary) is required, it should be done no less than 6 weeks after delivery and preferably at 3 months. This interval is optimal to reduce the risk of reflex LBC interpretation difficulties or unsatisfactory reflex LBC. 

The cervical sample (for HPV test and reflex LBC if necessary) could be collected at the time of postpartum check or at the time of the colposcopic assessment.

Practice point

REC14.10: Vaginal oestrogen prior to postpartum colposcopy
For women who are breastfeeding, the use of intra-vaginal oestrogen cream or pessary† prior to colposcopy may improve visualisation of the cervix and the quality of any cervical sample for LBC. 

†Daily for two weeks and cease approximately 3 days before colposcopy.

Practice point
REC14.11: Cervical screening in pregnancy
Routine antenatal and postpartum care should include a review of the woman’s cervical screening history. Women who are due or overdue for screening should be screened.
Practice point
REC14.12: Cervical screening in pregnancy
A woman can be safely screened at any time during pregnancy, provided that the correct sampling equipment is used. An endocervical brush should not be inserted into the cervical canal because of the risk of associated bleeding, which may distress women.
Practice point
REC14.13: Self-collection in pregnancy
All women who are due for cervical screening during pregnancy may be offered the option of self-collection of a vaginal swab for HPV testing, after counselling by a health care professional about the small risk of bleeding. Women testing positive for HPV (not 16/18) on a self-collected sample should be advised to return so that a cervical sample for LBC can be collected by the healthcare provider.

15. Screening in women who have experienced early sexual activity or have been victims of sexual abuse

MSAC evidence-based recommendation
REC15.1: Routine cervical screening is not recommended in young women
Routine cervical screening is not recommended in women under the age of 25 years.
Consensus-based recommendation

REC15.2: Early sexual activity and cervical screening in young women
Evidence does not support screening for women aged less than 25, even when they have experienced early sexual activity. However, for those who experience their first sexual activity at a young age (<14 years) and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis, but is not required. 

Note: Amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample for this specific use will be effective from 1 November 2022.

Consensus-based recommendation

REC15.3: Women with postcoital or intermenstrual bleeding
Women at any age who have signs or symptoms suggestive of cervical cancer or its precursors, where other common causes of abnormal vaginal bleeding such as a sexually transmitted infection have been excluded, should have a co-test† and be referred for appropriate investigation to exclude genital tract malignancy. 

† Co-testing (HPV and LBC) is recommended as the presence of blood has the potential to adversely affect the sensitivity of the HPV and/or LBC tests.

16. Screening in immune-deficient women

Consensus-based recommendation
REC16.1: Immune-deficient women in whom oncogenic HPV is not detected
Immune-deficient women who have a HPV test in which oncogenic HPV types are not detected should be screened every 3 years with a HPV test.
Consensus-based recommendation
REC16.2: Colposcopy referral: positive oncogenic HPV test result (any type) in immune-deficient women
Women who are immune-deficient and have HPV (any type) detected should be referred for colposcopic assessment. If the screening sample was collected by a healthcare provider, then reflex LBC will be performed by the laboratory. If the screening sample was self-collected, then LBC should be undertaken at colposcopy.
Consensus-based recommendation*
REC16.3: Colposcopy assessment and treatment in immune-deficient women
Assessment and treatment of immune-deficient women with screen-detected abnormalities should be by an experienced colposcopist or in a tertiary centre.
Consensus-based recommendation*
REC16.4: Colposcopy of whole lower genital tract in immune-deficient women
The entire lower anogenital tract should be assessed, as the same risk factors apply for cervical, vaginal, vulval, perianal and anal lesions.
Consensus-based recommendation*
REC16.5: Treatment in immune-deficient women
When treatment of the cervix is considered necessary in immune-deficient women, it should be by excisional methods
Practice point
REC16.6: Histological abnormalities of the cervix in immune-deficient women
Women with histologically confirmed abnormalities should be managed according to the same guidelines as women who are not immune-deficient.
Practice point
REC16.7: Test of Cure for treated immune-deficient women
Women who are immune-deficient and treated for HSIL (CIN2/3) should have follow-up with Test of Cure as recommended in these guidelines. Women who complete Test of Cure should return to routine 3-yearly screening with a HPV test.
Practice point
REC16.8: Screening before solid organ transplantation
Women aged between 25 and 74 years should have a review of cervical screening history when they are added to the organ transplant waiting list and while they remain on the waiting list, to confirm they are up to date with recommended screening for the general population. Women who are overdue for screening, or become due while on the waiting list ,should be screened with a HPV test so that any abnormalities can be investigated or treated as necessary prior to transplantation and commencement of immunosuppressive therapy.
Practice point
REC16.9: Screening women with a new diagnosis of HIV
Women aged between 25 and 74 years who have a new diagnosis of HIV should have a review of their cervical screening history to ensure they are up to date with screening in line with the recommended 3-yearly interval for this group.
Practice point

REC16.10: Other groups that may require special consideration
The groups listed below could be considered for screening every 3 years with a HPV test in accordance with the recommendation for HIV-positive women and solid organ transplant recipients:

  • women with congenital (primary) immune deficiency
  • women who are being treated with immunosuppressant therapy for autoimmune disease (e.g. inflammatory bowel disease, systemic lupus erythematosus, rheumatoid arthritis, neuromyelitis optica, sarcoidosis)
  • allogenic bone marrow transplant recipients treated for graft versus host disease.
Practice point
REC16.11: Regular screening for immune-deficient women
Women who are immune deficient should be educated regarding the increased risk from HPV infection and encouraged to attend for regular screening every 3 years.
Practice point

REC16.12: Young women with long term immune deficiency
For young women who are sexually active and who have been immune deficient for more than 5 years, a single HPV test between 20 and 24 years of age could be considered on an individual basis (regardless of HPV vaccination status). 

Note: Amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample for this specific use will be effective from 1 November 2022.

Practice point
REC16.13: Guidance for immune-deficient women and their healthcare professionals
It is important that immune-deficient women and their healthcare professionals are guided by a clinical immunology specialist when using these guidelines.

17. Screening in DES-exposed women

Consensus-based recommendation
REC17.1: Screening in DES-exposed women
Women exposed to DES in utero should be offered an annual co-test and colposcopic examination of both the cervix and vagina indefinitely.
Consensus-based recommendation*
REC17.2: Colposcopy referral for abnormalities in DES-exposed women
Women exposed to DES in utero who have a screen-detected abnormality should be managed by an experienced colposcopist.
Practice point

REC17.3: Daughters of women exposed to DES
These women should be screened in accordance with the NCSP policy (5-yearly HPV testing). Evidence of an adverse effect on the daughters of women exposed to DES in utero has not been found. 

However, if these women have concerns, testing similar to that recommended for their DESexposed mothers could be considered on an individual basis. Self-collection for HPV testing is not recommended.

18. Signs and symptoms of cervical cancer

Investigation of abnormal vaginal bleeding

Consensus-based recommendation

REC18.1: Postcoital and intermenstrual bleeding and testing for HPV and LBC
When women present with postcoital or persistent unexplained intermenstrual bleeding, appropriate investigations including a clinician-collected cervical sample for a co-test,† should be performed and not delayed due to the presence of blood.

†The woman’s recent cervical screening history should be considered.

Consensus-based recommendation
REC18.2: Postcoital bleeding in pre-menopausal women
Pre-menopausal women who have a single episode of postcoital bleeding and a clinically normal cervix do not need to be referred for colposcopy if oncogenic HPV is not detected and LBC is negative.
Consensus-based recommendation
REC18.3: Persistent or recurrent post coital bleeding in pre-menopausal women
Pre-menopausal women with recurrent or persistent postcoital bleeding, even in the presence of a negative co-test, should be referred to a gynaecologist for appropriate assessment, including colposcopy, to exclude genital tract malignancy.
Practice point
REC18.4: Postcoital bleeding and sexually transmitted infections
Sexually transmitted infections, including chlamydia infection, should be considered in all women presenting with postcoital bleeding. It is necessary to obtain a sexual health history and perform appropriate tests and investigations.
Consensus-based recommendation*
REC18.5: Symptomatic women with LBC prediction of cervical cancer
Women with symptoms and a LBC prediction of invasive cervical cancer should be referred to a gynaecological oncologist or gynaecological cancer centre for assessment, ideally within 2 weeks.
Consensus-based recommendation
REC18.6: Women with intermenstrual bleeding
Women with persistent unexplained intermenstrual bleeding require appropriate investigation and should be referred for gynaecological assessment which may or may not include colposcopy. Common benign causes including a sexually transmitted infection or hormonal contraception-related bleeding should be excluded.
Consensus-based recommendation
REC18.7: Postmenopausal women with vaginal bleeding require specialist referral
Postmenopausal women with any vaginal bleeding, including postcoital bleeding, should be referred for a specialist gynaecological assessment (which may or may not include colposcopy) regardless of test results, to exclude genital tract malignancy.
Consensus-based recommendation

REC18.8 Circumstances that do not require co-testing or referral for colposcopy
The following circumstances do not require co- testing or referral for colposcopy:

  • Breakthrough or irregular bleeding due to hormonal contraception
  • Contact bleeding at time of obtaining a routine cervical screening test sample
  • Heavy regular periods (heavy menstrual bleeding)
  • Irregular bleeding due to a sexually transmitted infection (STI), eg. chlamydia.

Investigations of other symptoms - vaginal discharge and deep dyspareunia

Consensus-based recommendation
REC18.9: Women with abnormal vaginal discharge and/or deep dyspareunia
Almost all women with vaginal discharge and/or deep dyspareunia have benign gynaecological disease. They should be investigated appropriately, and if due for cervical screening a routine CST should be performed (rather than a co-test).
Consensus-based recommendation
REC18.10: Women with unexplained persistent unusual vaginal discharge
In women of any age, unexplained persistent unusual vaginal discharge, especially if malodourous or blood stained, should be investigated with a co-test (HPV and LBC) and the woman should be referred for gynaecological assessment.
Consensus-based recommendation
REC18.11: Women with unexplained persistent deep dyspareunia
Women with unexplained persistent deep dyspareunia in the absence of bleeding or vaginal discharge should have a CST if due and referral for gynaecological assessment should be considered.

20. Transitioning to the renewed National Cervical Screening Program

Practice point
REC20.1: HPV test replaces the Pap test

All Pap tests are replaced by HPV testing.

Conventional Pap tests are no longer used.

Reflex LBC will be performed on any clinician-collected sample with a positive oncogenic HPV (any type) test result.

Co-testing (HPV and LBC) should be performed only as recommended in these guidelines, in the follow-up of screen-detected abnormalities or the investigation of abnormal vaginal bleeding.
Practice point

REC20.2: HPV testing for women in follow-up after pLSIL/LSIL
Women who are in follow-up for pLSIL/LSIL cytology in the previous program (pre-renewal NCSP) should have a HPV test at their next scheduled follow-up appointment.

  • Women with a positive oncogenic HPV (any type) test result should be referred for colposcopic assessment. If the test sample was collected by a healthcare professional then the laboratory will undertake, reflex LBC. If the test sample was self-collected then a sample for LBC should be collected at the time of colposcopy
  • If oncogenic HPV is not detected, the woman can return to 5-yearly screening
Practice point
REC20.3: Colposcopic management of a prior screen-detected abnormality should continue
Women who have been referred for colposcopic assessment following any cytological abnormality in the pre-renewal NCSP should continue their colposcopic management according to these guidelines.
Practice point

REC20.4: Prior treatment and Test of Cure
Women who have been treated for HSIL (CIN2/3) in the pre-renewal NCSP and are undergoing, or have not yet commenced Test of Cure, should start or continue Test of Cure in accordance with these guidelines. 

Women should have an annual co-test (HPV and LBC) performed at 12 months after treatment, and annually thereafter, until both tests are negative on two consecutive occasions, when they can return to routine 5-yearly screening. A co-test cannot be performed on a self-collected sample.

Practice point

REC20.5: Prior treatment for AIS
Women who have been treated for AIS in the pre-renewal NCSP, and are undergoing or have not yet commenced surveillance, should have annual co-testing (HPV and LBC) indefinitely.† A co-test cannot be performed on a self-collected sample. 

†Until sufficient data become available that may support a policy decision that cessation of testing is appropriate.

Author(s):

WEBSITE UPDATES - This website was last updated 7/1/2022

Cancer Council would like to acknowledge the traditional custodians of the land on which we live and work. We would also like to pay respect to the elders past and present and extend that respect to all other Aboriginal people.
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Cancer Council Australia