- HIV infection
- immunosuppression for other reasons, e.g., organ transplant
- in utero exposure to diethylstilbestrol
- history of CIN 2, CIN 3, or cancer.
Two Pap tests are recommended in the first year after diagnosis of HIV infection, followed by annual screening. It can be presumed that women who have chronic immunosuppression should be managed similarly.
As for women known to have been exposed to diethylstilbestrol in utero, no specific recommendation is given other than “more frequent screening.”1
The relatively recent documentation that women with a history of CIN 2 or 3 (and probably adenocarcinoma in situ) remain at risk of developing cervical cancer for at least 20 years after treatment warrants annual screening for at least 20 years. The increased reassurance that no CIN 3 or greater is missed when cotesting is negative for both cytology and HPV testing might argue for extension of the screening interval for women who have negative cotest results and who have completed recommended posttreatment follow-up. However, at this time, we lack data on long-term follow-up of women who have been treated for cervical neoplasia and who have negative cotest results. Therefore, such a recommendation cannot be made at this time.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Do not increase the screening interval beyond annual testing for women who are HIV-positive, who are immunosuppressed, who were exposed in utero to diethylstilbestrol, or who have been treated for CIN 2 or 3 or adenocarcinoma in situ.
WHEN CAN SCREENING BE DISCONTINUED?
Routine cytology testing should be discontinued after total hysterectomy for benign indications, provided the woman has no history of high-grade cervical intraepithelial neoplasia or adenocarcinoma in situ.1 This recommendation has not changed since the 2003 ACOG guidelines on cervical cancer screening were published, and it is consistent with guidelines from the U.S. Preventive Services Task Force and the American Cancer Society.