Pap and HPV Cotesting

Women’s health care professionals now know that almost all cases of cervical cancer are caused by long-lasting infection with certain types of human papillomavirus (HPV).1,2  What you need to know is few women who become infected with HPV will develop cervical cancer1-3, and regular screening can identify HPV infection and precancerous changes in cervical cells that can be treated.

If you are between the ages of 30 and 65, the recommended way to reduce your risk of developing cervical cancer is to have regular screening that includes a Pap test and a test to detect HPV infection in your cervical cells.1,4  When these two tests are performed during the same office visit, it is called cotesting. Cotesting is effective in preventing cervical cancer because it can detect both the virus that can cause cervical cells to become abnormal and the abnormal cervical cells themselves.

    • A Pap test is an exam in which a sample of cells is removed from your cervix, and the cells are viewed under a microscope to look for abnormal changes that could lead to cancer. 
    • The cervix is the lower portion of your uterus. It forms the opening of your uterus and extends into your vagina, which is the passageway that leads from your uterus to the outside of your body. 
    • The cells that form the lining of your cervix can undergo abnormal changes known as dysplasia. Most often, these changes are the result of infection with HPV, but they can also be caused by irritation, other infections, and hormonal changes.
    • HPV is a common virus that is spread by skin-to-skin contact, including sexual contact. Most sexually active people will become infected with HPV at some time in their lives.5 
    • There are more than 40 types of HPV that can infect the skin on and around the genitals.2  They are often referred to as either low-risk types or high-risk types. 
    • Some low-risk types of HPV cause warts to grow on or near the genitals. 
    • Certain high-risk types of HPV can cause cervical cells to undergo abnormal changes. Two types in particular, known as HPV 16 and HPV 18, are the cause of most cervical cancers.1,2 
    • There is no treatment for genital HPV infection.2,3,5 
    • It can take 10 to 15 years or longer for cells infected with a high-risk type of HPV to change from normal to abnormal and then become cancerous.2,5,6 
    • Most women who become infected with a high-risk type of HPV will not develop cervical cancer. 
      • Only 1 in 10 to 1 in 30 women who are infected with a high-risk type of HPV will develop abnormal changes in cervical cells.7 
      • Of those women who develop severely abnormal changes in their cervical cells, about 50% or fewer develop cervical cancer.2
    • Like a Pap test, an HPV test is performed on a sample of cells from your cervix. It looks for genetic material (either DNA or RNA) from high-risk types of human papillomavirus in your cervical cells. 
    • Since infection with high-risk types of HPV does not cause any symptoms, the only way to find out if you are infected is to have an HPV test.
    • If you are older than 30, it is recommended that your cervical cancer screening includes both a Pap test and an HPV test.1,4  The samples needed for both of these tests can be obtained at the same time.

  • The chart below explains HPV and Pap test results and how often follow-up testing for average-risk women age 30 and older* should occur. The information in the chart below is based on recommendations developed by the the American Society for Colposcopy and Cervical Pathology, the American Society for Clinical Pathology, and the American Cancer Society.4

    Normal Pap Test Result ASC-US Pap Test Result Abnormal Pap Test Result

    High-risk HPV not present

    There is no immediate risk for cervical cancer. Screening should be repeated in 5 years (Pap/HPV cotesting) or in 3 years (Pap test only) unless your risk factors change.

    Continue with routine screening or rescreen with Pap/HPV cotest in 5 years.

    Cervical disease is unlikely; however, understanding the reason for abnormal cells is important.

    Your doctor will likely perform colposcopy to examine your cervix more closely. In some cases, a tissue sample (biopsy) may be obtained for additional analysis.

    High-risk HPV present

    Option 1)  You will be rescreened with Pap/HPV cotesting in 12 months.  


    Option 2)  Your cervical cells will be tested for the presence of the types of high-risk HPV known to cause most cases of cervical cancer (types 16 and 18). If you test positive for HPV 16 and/or HPV 18, your doctor will likely perform colposcopy to examine your cervix more closely. If neither of these types of HPV is present, you should have another Pap/HPV cotest in 12 months.

    Your doctor will likely perform colposcopy to examine your cervix more closely.

    Women whose cervical cells are infected with high-risk types of HPV may be carefully monitored for cervical cell changes.

    Your doctor will likely perform colposcopy to examine your cervix more closely.

    * Current guidelines indicate women younger than 30 years of age do not need to be tested for HPV unless their Pap results are unclear or abnormal.

  • According to the American College of Obstetricians and Gynecologists (ACOG)1

    • Women between the ages of 30 and 65 should be screened for cervical cancer with a Pap test and HPV test every 5 years.
    • Screening with Pap testing alone every 3 years is also acceptable.
    • You should continue to be screened for cervical cancer, with either cotesting or Pap testing alone, through age 65. After age 65, you may be able to stop having cervical cancer screening tests if:
      • You do not have a history of moderate to severe cervical dysplasia or cancer, and 
      • You have had either 3 normal Pap tests in a row or 2 negative cotest results in a row within the past 10 years, with the most recent test performed in the past 5 years.
    • You do not need to be screened for cervical cancer if you have had a total hysterectomy (surgical removal of the uterus and cervix) and you do not have a history of moderate to severe cervical dysplasia.

    Your health care provider may recommend a different Pap testing routine than the ones outlined above if your risk of developing cervical cancer is increased because1: 

    • You are infected with HIV (the virus that causes AIDS).
    • Your body’s natural defense (immune) system has been weakened due to disease or an organ transplant.
    • Your mother took a drug called DES while she was pregnant with you.
    • You have been treated in the past for cervical cell changes called CIN-2 or CIN-3 or for cervical cancer.

Note: This material is provided for general information purposes only.  It is not intended as a substitute for medical advice and/or consultation with a physician or technical expert.

References

  1. American College of Obstetricians and Gynecologists. Screening for cervical cancer. ACOG Practice Bulletin No 131. November 2012. Obstetrics & Gynecology. 2012;120(5):1222-1238.
  2. National Cancer Institute. HPV and cancer fact sheet. National Cancer Institute website. http://www. cancer.gov/cancertopics/factsheet/Risk/HPV. Last reviewed March 15, 2012. Accessed August 19, 2014.
  3. What women should know about cervical cancer and the human papilloma virus. American Cancer Society website. http://www.cancer.org/cancer/cancercauses/othercarcinogens/infectiousagents/hpv/what-women-should-know-about-cervix-cancer-and-hpv. Last revised February 13, 2014. Accessed August 19, 2014.
  4. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. American Journal of Clinical Pathology. 2012;137:516-542.
  5. CDC fact sheet: Genital HPV infection. Centers for Disease Control and Prevention website. Available at http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Updated March 20, 2014. Accessed August 19, 2014.
  6. Making sense of your Pap and HPV test results. Centers for Disease Control and Prevention website. http://www.cdc.gov/std/HPV/pap/default.htm. Updated July 25, 2012. Accessed August 19, 2014.
  7. American College of Obstetricians and Gynecologists. Screening for cervical cancer. ACOG Practice Bulletin No 99. December 2008. Obstetrics & Gynecology. 2008;112:1419-1444.