Guidelines for preventive activities in general practice

The Red Book
9.5 Cervical cancer
☰ Table of contents

Age range chart

0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80


Human papillomavirus vaccination (B)

For maximal effect, the vaccination should be given prior to the onset of sexual activity. It has no modifying effect on already acquired human papillomavirus (HPV) infections. It is available as part of the National Immunisation Program Schedule for girls and boys in year 7.81,82 HPV-vaccinated women still require cervical screening as the HPV vaccine does not protect against all the types of HPV that cause cervical cancer.


Australia has the lowest mortality rate and the second lowest incidence of cervical cancer in the world. The success of the cervical screening program is dependent upon the recruitment of women: 85% of women in Australia who develop cervical cancer have either not had a Papanicolaou (Pap) test or been inadequately screened in the past 10 years. Women aged >50 years are still under-screened.83

Australia’s National Cervical Cancer Screening Program will change from December 2017 (the change was originally planned for May 2017 but a delay was announced in February 2017). As of that date, women aged 25–74 years, both HPV vaccinated and unvaccinated, will be invited to undertake an HPV test every five years.84 Women of any age who have symptoms (including pain or bleeding) should have appropriate clinical assessment, which may include a cervical cytology test and an HPV test. Women between 70 and 74 years of age who have had a regular screening test will be recommended to have an exit HPV test before leaving the cervical screening program.

A comparison between the current program and the one starting in December 2017 is given in Box A. In the interim, the National Cervical Cancer Screening program continues to recommend Pap test screening every two years for women who have ever had sex and have an intact cervix, commencing from 18–20 years of age (or up to two years after first having sexual intercourse, whichever is later).85

GPs are advised to check with their pathology provider about their Pap testing arrangements during the transition period as testing times may be affected and a new Medicare rebate for the liquid based cytology has been introduced.

Box A. Comparison of the key aspects of the current national cervical screening program with that commencing from December 2017

Current recommendations

From December 2017


Human papillomavirus (HPV) vaccinated and unvaccinated women

HPV vaccinated and unvaccinated women


Pap test screening

HPV test

How often?

Every two years

Every five years


From 18–20 years of age (or two years after first having sexual intercourse, whichever is later)

From 25 years of age (or two years after first having sexual intercourse, whichever is later)


At 70 years of age for women who have had two normal Papanicolaou (Pap) tests within the last five years. Women >70 years of age who have never had a Pap test, or who request a Pap test, should be screened

Between 70 and 74 years of age

HPV, human papillomavirus; Pap, Papanicolaou;

Table 9.5.1. Cervical cancer: Identifying risk

Who is at risk?

What should be done?

How often?

Average risk

All women who have ever been sexually active

Papanicolaou (Pap) test (III–2, B)

All women who have ever been sexually active should start having Pap tests between 18 and 20 years of age (or two years after first having sexual intercourse, whichever is later)85 

Routine screening with Pap tests should be carried out every two years for women who have no symptoms or history suggestive of cervical pathology (Practice Point) 

Pap tests may cease at 70 years of age for women who had two normal Pap tests within the last five years. Women aged >70 years who have never had a Pap test, or who request a Pap test, should be screened 

Women with female sex partners are also at risk of developing cervical cancer and should be screened as above

Increased risk

Persistent infection with high-risk human papillomavirus (HPV) types is necessary for the development of cervical cancer. Other risk factors include:

  • immunosuppression
  • cigarette smoking
  • use of combined oral contraception >5 years

Pap test (Practice Point)

It is important to ensure the patient always receives the results of her test86, 87 

Low-grade squamous intraepithelial lesion (LSIL):

  • A woman with a Pap test report of possible/definite LSIL should have a repeat Pap test in 12 months (Practice Point). If the repeat test at 12 months shows LSIL (definite or possible) the woman should be referred for colposcopy
  • A woman aged ≥30 years with a Pap test report of LSIL, without a history of negative smears in the preceding two to three years, should be offered either colposcopy or a repeat Pap test at six months (Practice Point)

High-grade squamous intraepithelial lesion (HSIL):

  • Refer for colposcopy assessment and targeted biopsy where indicated

Glandular abnormality or adenocarcinoma:

  • Refer for colposcopy by an experienced gynaecologist or gynaecological oncologist
  • If the woman is symptomatic or if she has a clinically abnormal cervix, referral for colposcopy is recommended

HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion; Pap, Papanicolaou

Table 9.5.2. Tests to detect cervical cancer risk



Papanicolaou (Pap) test

A sample of the ectocervix (using an extended tip spatula) then the endocervix (using a cytobrush), provides the best method of sampling and can be used in all age groups of women (the cytobrush is not recommended for use during pregnancy)88 

The cervical broom can be used on its own in premenopausal women if it is possible to sample from both sides of the transformation zone. In postmenopausal women, the transformation zone tends to be higher in the endocervical canal 

The cervical cells should be placed onto a glass slide and fixed with spray within five seconds. If the smear is reported as technically unsatisfactory, it should not be repeated before six weeks 

In postmenopausal women with atrophic changes, it may be necessary to use vaginal oestrogen for 14–21 days prior to the test. Refer to Chapter 15. Screening tests of unproven benefit regarding evidence related to bimanual vaginal examination

Human papillomavirus (HPV) testing

As a primary screening tool85, 89, 90:

  • Current national guidelines do not support the use of HPV testing as a primary screening tool. This will change from May 2017

In triage of low-grade squamous intraepithelial lesion (LSIL):

  • The use of HPV testing in the triage of LSIL remains under investigation and is not currently recommended by the National Cervical Cancer Screening guidelines 85, 91–93

In follow-up of high-grade squamous intraepithelial lesion (HSIL):

  • In women treated for HSIL, cervical cytology plus HPV testing should be performed 12 months post-treatment and annually thereafter until both tests are negative on two consecutive occasions, at which point women can return to the routine cervical screening interval

Liquid-based cytology

Liquid-based cytology can be used as an additional test to the conventional smear, but not as a substitute. Its addition may be useful when repeating an unsatisfactory smear, or added if requested by the woman 94, 95


If patients do not agree to undergo Pap (or HPV) testing by a clinician, they can be assisted to collect the sample themselves 8496

The following resources provide helpful advice:

Pelvic examination

Screening pelvic examinations for the detection of pathology in asymptomatic, non-pregnant, adult women is not recommended because there is no evidence of benefit.98 Also refer to Chapter 15. Screening tests of unproven benefit.



Methods of encouraging women to undergo cervical screening include invitations, reminders, education, message framing, counselling, risk-factor assessment, procedures and economic interventions. Evidence supports the use of invitations and, to a lesser extent, educational materials. It is likely other methods are advantageous, but the evidence is not as strong. Further research is required.97


  1. Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook. 10th edn (2015 update). Canberra: Department of Health, 2015.
  2. Skinner SR, Garland SM, Stanley MA, Pitts M, Quinn MA. Human papillomavirus vaccination for the prevention of cervical neoplasia: Is it appropriate to vaccinate women older than 26? Med J Aust 2008;188(4):238–42.
  3. Cancer in Australia: an overview 2012 (online version) [Accessed 10 August 2015].
  4. Australian Government Department of Health. National Cervical Screening Program. Canberra: Department of Health, 2015. [Accessed 15 November 2015]
  5. National Health and Medical Research Council. Screening to prevent cervical cancer: Guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: NHMRC, 2005.
  6. EUROGIN. Conclusions: Cervical cancer control, priorities and new directions: International charter. France, 2003.
  7. Monsonego J, Bosch FX, Coursaget P, et al. Cervical cancer control, priorities and new directions. Int J Cancer 2004;108:329–33.
  8. Buntinx F, Brouwers M. Relation between sampling device and detection of abnormality in cervical smears: A meta-analysis of randomised and quasi-randomised studies. BMJ 1996;313(7068):1285–90.
  9. Mayrand MH, Duarte-Franco E, Rodrigues I, et al. Canadian Cervical Cancer Screening Trial Study Group. Human papillomavirus DNA versus papanicolaou screening tests for cervical cancer. N Engl J Med 2007;357(16):1579–88.
  10. Koliopoulos G, Arbyn M, Martin-Hirsch P, Kyrgiou M, Prendiville W, Paraskevaidis E. Diagnostic accuracy of human papillomavirus testing in primary cervical screening: A systematic review and meta-analysis of non-randomized studies. Gynecol Oncol 2007;104(1):232–46.
  11. Safaeian M, Solomon D, Wacholder S, Schiffman M, Castle P. Risk of precancer and follow-up management strategies for women with human papillomavirus-negative atypical squamous cells of undetermined significance. Obstet Gynecol 2007;109(6):1325–31.
  12. Arbyn M, Paraskevaidis E, Martin-Hirsch P, Prendiville W, Dillner J. Clinical utility of HPV-DNA detection: Triage of minor cervical lesions, follow-up of women treated for high-grade CIN: An update of pooled evidence. Gynecol Oncol 2005;99(3 Suppl 1):S7–11.
  13. Arbyn M, Buntinx F, Van Ranst M, Paraskevaidis E, Martin-Hirsch P, Dillner J. Virologic versus cytologic triage of women with equivocal Pap smears: A meta-analysis of the accuracy to detect high-grade intraepithelial neoplasia. J Natl Cancer Inst 2004;96(4):280–93.
  14. Ronco G, Cuzick J, Pierotti P, et al. Accuracy of liquid based versus conventional cytology: Overall results of new technologies for cervical cancer screening: Randomised controlled trial. BMJ 2007;335(7609):28.
  15. Davey E, Barratt A, Irwig L, et al. Effect of study design and quality on unsatisfactory rates, cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: A systematic review. Lancet 2006;367(9505):122–32.
  16. Arbyn M, Verdoodt F, Snijders PJ, et al. Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: A meta-analysis. Lancet Oncol 2014;15(2):172–83.
  17. Everett T, Bryant A, Griffin MF, Martin-Hirsch PPL, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database Syst Rev 2011;5:CD002834.