Reprinted from the spring 2025 issue of The Ohio Family Physician.
By: Colleen Reidy, DO; and Megan McBride, DO, The Ohio State University Wexner Medical Center
Introduction
Cervical cancer (CC) screening is a fundamental component of preventive care. Most patients can be routinely screened every three to five years if cytology and/or cotesting are normal. However, there are special populations that require a different approach to screening. It is crucial for family physicians to understand when and how to screen for CC in these unique populations.
Immunosuppression
Patients with human immunodeficiency virus (HIV), solid organ transplant, or allogeneic hematopoietic stem cell transplant, as well as those with systemic lupus erythematosus (SLE), inflammatory bowel disease, or rheumatologic disease requiring immunosuppressive therapy, have unique CC screening guidelines.1 CC screening for immunosuppressed individuals without HIV is based on data from patients with HIV.
For patients younger than 21 years old with immunosuppression, CC screening should begin within one year of onset sexual activity. For patients less than 30 years old with immunosuppression, cervical cytology should be done at the time immunosuppression is diagnosed, and then annually. If three consecutive annual cytology tests are normal, then cytology can be spaced out to every three years. Cotesting is not recommended in this age group, but if there is an abnormal cytology result, reflex HPV testing can be done.
For patients older than 30 years old with immunosuppression, screening can be done with cytology only or cotesting. Again, if three consecutive annual cytology tests or co-tests are normal, then cytology can be spaced out to every three years.
For all patients with immunosuppression, any cytology result worse than Atypical Squamous Cells of Undetermined Significance (ASCUS) requires colposcopy. For an ASCUS result without HPV testing, repeat cytology can be done in 6-12 months. For patients with normal cytology with high risk HPV (not 16/18), repeat testing can be done in one year. For any patient with HPV 16 or HPV 18, colposcopy is recommended.
Finally, it is recommended that immunosuppressed individuals should be screened for their entire lifetime, instead of stopping at age 65. The cessation of CC screening in immunocompromised individuals should involve shared decision making between the patient and physician.
Pregnancy
Pregnancy, itself, does not increase the risk of progression of cervical cancer. However, for many patients, pregnancy is a unique time that offers access to medical care. It is estimated that 11% of new mothers lose their health insurance in the postpartum period.1 Therefore, it is prudent that neither CC screening nor colposcopy, if indicated, should be delayed due to pregnancy. If colposcopy is indicated during pregnancy it should be done by an experienced colposcopist, as the physiologic changes of pregnancy can alter the appearance of the cervix and there is an increased risk of bleeding after biopsy. Endocervical curettage and endometrial biopsy are contraindicated during pregnancy. However, colposcopy and cervical biopsy are acceptable and safe during pregnancy when performed by a skilled physician; conversely endocervical curettage should never be performed during pregnancy. It is recommended to wait at least four weeks postpartum to perform a colposcopy.
Patients with Mental Disorders
Patients with mental health disorders or cognitive impairments may face challenges completing recommended CC screenings, often due to discomfort or difficulty with the process. This includes individuals with conditions such as mood disorders, substance use disorders, autism spectrum disorder, or intellectual disabilities. Research indicates that these patients have lower cancer survival rates compared to the general population,3 highlighting the importance of tailored care. To enhance patient comfort and improve screening accessibility, alternative approaches should be considered, such as screening using self-swabbing techniques.
Post-Hysterectomy
Patients may undergo hysterectomies for various reasons, which may or may not involve cervical pathology. For those who had a hysterectomy due to cervical pathology, it is recommended to perform HPV-based testing annually for three consecutive years.1 If these results are normal, surveillance should continue every three years for the next 25 years.1 In contrast, patients who underwent hysterectomies for reasons unrelated to cervical pathology generally do not require routine cervical screening.
Patients Greater than 65 Years Old
The United States Preventive Services Task Force recommends discontinuing CC screening at age 65 if the patient has been routinely screened in the last 10 years. However, continued surveillance is advised for patients with a recent history of abnormal CC screenings or prior treatment for cervical pathology.1 This is particularly relevant for patients with a history of cervical intraepithelial neoplasia grade 3, as they have an increased risk of developing cervical or vaginal cancer.1 The American Society for Colposcopy and Cervical Pathology guidelines for 30-64 year olds should be used in patients older than 65; however, for patients with a limited life expectancy, discontinuation of surveillance may be appropriate. Patient comfort may also pose a barrier to ongoing surveillance beyond the age of 65. In such cases, shared decision-making is essential to ensure personalized, patient-centered care.
Transgender Males
Transgender males who have a cervix should follow the same cervical cancer screening guidance as any other patient with a cervix. Transgender males without a cervix and no history of cervical dysplasia do not need further screening.
Conclusion
When caring for diverse patient populations, family physicians and primary care professionals must remain attentive to the unique preventive medicine recommendations that align with each individual’s needs. Patients may present with complex health histories, including chronic conditions, socioeconomic challenges, cultural differences, or language barriers, which can significantly impact their ability to access or adhere to recommended care. Addressing these barriers requires a holistic approach that considers social determinants of health, incorporates culturally sensitive communication, and tailors interventions to align with the patient’s circumstances and preferences.
References available on the Ohio Academy of Family Physicians website.