Summary of recommendations

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.

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  

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

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 

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

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

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.

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.

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

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

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.

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.

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)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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).

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.

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.

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.

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.

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.

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).

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.