HPV-driven squamous or glandular malignancy of the cervix; preventable with vaccination and screening.
Also known as: cervical cancer, HPV, cervical dysplasia, CIN, squamous cell carcinoma cervix
Overview
Malignancy of the cervix uteri, predominantly squamous cell carcinoma (~75%) or adenocarcinoma (~20-25%), driven by persistent infection with high-risk human papillomavirus (HPV) types — most commonly HPV 16 and 18, which together cause ~70% of cervical cancers.
Epidemiology
Globally, the fourth most common cancer in women; ~14,000 new US cases and ~4,000 deaths annually. Sharp incidence reduction since cytology screening introduced; HPV vaccination is reducing incidence further. Disparities affect under-screened populations.
Try two board-style Cervical Cancer and HPV questions
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Question 1ReproductiveMedium
A 52-year-old woman presents for a routine well-woman visit. Three years ago she underwent supracervical (partial) hysterectomy with retention of the cervix for symptomatic fibroids. She has no history of abnormal cervical cytology, is up to date on HPV vaccination, and is sexually active with one partner. BP 122/76 mm Hg, BMI 26 kg/m2. Pelvic exam reveals a normal-appearing cervix. She asks whether she still needs cervical cancer screening. Which of the following is the most appropriate recommendation regarding cervical cancer screening?
ADiscontinue all screening
BHPV testing every 3 years
CCytology testing every 5 years
DContinue age-based screening
EAnnual cytology screening
Reveal answer & full explanation
Correct answer: D — Continue age-based screening
ADiscontinue all screening
BHPV testing every 3 years
CCytology testing every 5 years
DContinue age-based screening✓
EAnnual cytology screening
Why Continue age-based screening is correct
This patient had a supracervical (partial) hysterectomy, meaning the cervix is intact and remains at risk for HPV-driven cervical neoplasia
She should continue routine cervical cancer screening according to standard age-based guidelines (e.g., USPSTF: cytology every 3 years, or HPV testing alone or co-testing every 5 years for ages 30-65; ACS: primary HPV testing every 5 years for ages 25-65)
Why the others are wrong
Discontinue all screening — applies only to women who have had a TOTAL hysterectomy (cervix removed) for benign indications AND no history of high-grade cervical dysplasia or cervical cancer; this patient retains her cervix
HPV testing every 3 years — a real modality at the wrong interval; clinician-collected primary HPV testing repeats every 5 years, and the 3-year interval applies only after a negative self-collected sample (ACS 2025), which this stem does not describe
Annual cytology screening — no longer recommended for any age group because of overdiagnosis of transient HPV-related changes
Cytology testing every 5 years — cytology is a valid screening test for her retained cervix, but the 5-year interval belongs to HPV-based screening (primary HPV testing or co-testing); cytology alone is repeated every 3 years because a single Pap test is less sensitive for high-grade lesions
Additional high-yield points
Key teaching point: always clarify supracervical vs total hysterectomy before counseling on screening cessation
Question 2ReproductiveEasy
A 26-year-old woman who is sexually active has never undergone cervical cancer screening. She is immunocompetent and has no history of an abnormal Pap test. According to current US Preventive Services Task Force (USPSTF) recommendations, which of the following is the most appropriate cervical cancer screening strategy for this patient?
AAge 30, cytology every 3 years
BAt sexual debut, annual HPV testing
CAge 21, annual cytology
DAge 21, cytology every 3 years
EAge 18, annual cytology
Reveal answer & full explanation
Correct answer: D — Age 21, cytology every 3 years
AAge 30, cytology every 3 years
BAt sexual debut, annual HPV testing
CAge 21, annual cytology
DAge 21, cytology every 3 years✓
EAge 18, annual cytology
Why age 21, cytology every 3 years is correct
Per USPSTF, cervical cancer screening begins at age 21 regardless of age at sexual debut, number of partners, or sexual activity
For ages 21-29, the recommended strategy is cervical cytology (Pap) alone every 3 years
HPV-based testing is not used before age 30 because transient HPV infection is common in this age group and would drive excess colposcopy without reducing cancer mortality
This 26-year-old falls squarely in the 21-29 band, so cytology every 3 years is the appropriate strategy
Why the others are wrong
Age 18, annual cytology — over-screening trap: no cervical screening is recommended before age 21 even if sexually active, and annual cytology was abandoned in favor of 3-year intervals; picked by learners anchoring on "sexually active, never screened."
Age 30, cytology every 3 years — confused-with-age-30 trap: 30 is the age at which HPV primary testing and co-testing become options, not the age screening starts; the interval is right but the start age is wrong.
At sexual debut, annual HPV testing — buzzword/anchoring trap: USPSTF screens by age, not by sexual debut, and HPV testing alone is not recommended under age 30; chosen by learners who tie screening to onset of sexual activity.
Age 21, annual cytology — outdated-interval trap: the start age is right, but annual cytology was abandoned because yearly Pap testing adds false positives and colposcopies for transient abnormalities with little added cancer protection; USPSTF recommends cytology every 3 years for ages 21-29; chosen by learners who equate more frequent screening with better care.
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Endometrial cancer with cervical extension — Postmenopausal bleeding, endometrial biopsy
Cervical polyp — Benign protrusion through os; postcoital spotting
Cervical ectropion — Reddened columnar epithelium on ectocervix; normal
Vaginal cancer (extending to cervix) — Rare; imaging and biopsy
Cervical fibroid — Firm mass; ultrasound
Diagnostic workup
Diagnostic criteria
USPSTF 2018 screening (still the final USPSTF statement): age 21-29 cytology every 3 years; age 30-65 cytology every 3 years, HPV testing alone every 5 years, OR co-testing every 5 years. Newer guidance favors primary HPV testing: ACOG Committee Statement 28 (2026) prefers clinician-collected primary HPV testing every 5 years for average-risk patients 30-65, with co-testing every 5 years still acceptable. Patient-collected HPV samples (accepted in the USPSTF 2024 draft and by ACS) are not interchangeable with clinician-collected testing; intervals and implementation requirements differ by source (ACS repeats a negative self-collected test in 3 years). ACS (2020, updated 2025) starts primary HPV testing at 25 and, to exit at 65, requires negative HPV-based tests at ages 60 and 65. Stop screening at 65 if adequate prior negative screening and no history of CIN 2+. After total hysterectomy (cervix removed) for benign disease with no CIN 2+ history, stop screening; after supracervical hysterectomy (cervix retained), continue age-based screening. FIGO 2018 staging from confined to cervix (IA microscopic, IB macroscopic) through extra-pelvic (IVB).
Labs
Cervical cytology (Pap) ± high-risk HPV co-test
Reflex HPV testing for ASC-US results
STI testing (often coexists)
CBC, BMP, LFTs
Imaging
Colposcopy with biopsy for abnormal cytology/HPV results; any grossly visible or suspicious cervical lesion is biopsied directly regardless of Pap result (Pap is a screening test, not diagnostic)
Endocervical curettage if transformation zone not fully visualized
MRI pelvis with contrast — primary tumor staging
PET-CT — nodal and distant metastatic staging
Examination under anesthesia in select cases for clinical staging
Diagnostic algorithm
flowchart TD
A["Abnormal cervical cytology<br/>or HPV"] --> B{Result}
B -->|ASC-US| C["Reflex HPV testing"]
C -->|HPV positive| D["Colposcopy + biopsy"]
C -->|HPV negative| E["Routine surveillance"]
B -->|LSIL| F["Age 25 or older: colposcopy<br/>± surveillance if low risk<br/>Age 21-24: repeat cytology<br/>at 1 and 2 years"]
B -->|HSIL / ASC-H / AGC| D
D --> G{Biopsy result}
G -->|CIN 1| H["Surveillance<br/>most regress"]
G -->|CIN 2-3 / HSIL| I["Excision preferred:<br/>LEEP or cold knife cone<br/>CIN 2 under 25: observation"]
G -->|Invasive cancer| J["FIGO staging:<br/>exam, MRI, PET-CT"]
J --> K{Stage}
K -->|IA1| L["Conization or<br/>simple hysterectomy"]
K -->|IA2-IB2| M["Radical hysterectomy<br/>+ lymphadenectomy"]
K -->|IB3-IVA| N["Concurrent<br/>chemoradiation + brachy"]
K -->|IVB / recurrent| O["Systemic therapy<br/>± immunotherapy"]
From abnormal cervical screening through staging and treatment.
Stage IA1 (microinvasion <3 mm depth, no LVSI): conization with negative margins for fertility-sparing; simple hysterectomy alternative
Stage IA2-IB2 (tumor <4 cm): radical hysterectomy with pelvic lymphadenectomy (definitive chemoradiation is an alternative); fertility-sparing radical trachelectomy in selected small tumors
<15 yo at first dose and immunocompetent: 2-dose schedule (0, 6-12 months); ≥15 yo or immunocompromised: 3-dose schedule (0, 1-2, 6 months)
No booster or post-vaccination titer is recommended after a completed series; vaccinated patients still follow routine screening
Screening abnormalities
ASC-US with positive HPV: colposcopy
LSIL: colposcopy if age ≥25 (surveillance acceptable if low risk); age 21-24 with ASC-US or LSIL: repeat cytology at 1 and 2 years instead of colposcopy, returning to routine screening after two negative results
ASC-H, AGC, HSIL: colposcopy; AGC also requires endocervical/endometrial sampling; HSIL in nonpregnant patients ≥25 may instead get expedited LEEP without prior biopsy
CIN 1: surveillance (most regress)
CIN 2-3: treatment, with excision (LEEP) preferred and ablation acceptable if the lesion and squamocolumnar junction are fully visible; CIN 2 in patients <25 or with future-pregnancy concerns may be observed
Complications
Hydronephrosis from parametrial invasion (uremia is a common cause of death in advanced disease)
Lymphedema after lymphadenectomy or radiation
Vaginal stenosis and sexual dysfunction post-radiation
Fistula formation (vesicovaginal, rectovaginal)
Pregnancy complications after conization (cervical insufficiency, preterm birth)
Recurrence (highest in first 2 years)
PANCE pearls
Persistent HPV infection (not transient) drives cervical cancer — most HPV infections clear spontaneously within 1-2 years.
HPV vaccination is most effective before sexual debut but is beneficial through age 26 and selectively to 45.
Co-testing (cytology + HPV) every 5 years has equivalent or better sensitivity than annual cytology with less screening burden.
Adenocarcinoma of cervix is more often missed on cytology than squamous cell carcinoma — HPV testing has higher sensitivity for adeno precursors.
Cisplatin-based chemoradiation is the standard for locally advanced disease; brachytherapy is essential for optimal cure rates.
Cervical cancer in pregnancy requires individualized multidisciplinary care; treatment delay until fetal maturity is often appropriate for early-stage disease.
ACS 2020 — Cervical Cancer Screening for Individuals at Average Risk: 2020 Guideline Update From the American Cancer Society (Fontham et al., CA Cancer J Clin 2020)
ASCCP 2019 — 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests (Perkins et al., J Low Genit Tract Dis 2020)
ACIP HPV 2019 — Human Papillomavirus Vaccination for Adults: ACIP Updated Recommendations (MMWR 2019)
FIGO 2018 — FIGO 2018 Staging System for Cervical Cancer (Bhatla et al., Int J Gynaecol Obstet 2019)
ACS 2025 update — Perkins RB et al., Self-Collected Vaginal Specimens for Human Papillomavirus Testing and Guidance on Screening Exit: An Update to the American Cancer Society Cervical Cancer Screening Guideline (CA Cancer J Clin 2026;76:e70041)
ACOG 2026 — ACOG Committee on Clinical Consensus–Gynecology, Screening for Cervical Cancer (committee statement; Obstet Gynecol 2026;148:e63-e67)
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