Review ACOG guidance for adolescent screening
By Melanie Gold, DO
Clinical Associate Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
Kaiyti Duffy, MPH, Director of Education and Research
Anita Brakman, MS, Education & Research Manager
Physicians for Reproductive Choice and Health
New York City
In December 2009, the American College of Obstetricians and Gynecologists (ACOG ) released a clinical management guideline recommending changes to cervical cancer screening guidelines.1 This column will provide some background on human papillomavirus (HPV), the cause of cervical cancer, and ACOG's rationale for their shift in recommendations, with a focus on how this will impact adolescent and young women.
Human papillomavirus (HPV) is estimated to be the most common sexually transmitted disease in the United States2, infecting 50% of sexually active people at some point in their lives.3 Of the 30-40 sexually transmitted strains of HPV, 23 infect the cervix, and half of those are associated with invasive cervical cancer. Though in most cases HPV infection results in benign epithelial proliferations, oncogenic strains may cause malignancy in the presence of cofactors. Research indicates that HPV is the primary cause of cervical cancer and is present in more than 99% of cervical carcinomas.4
Like other sexually transmitted infections, HPV disproportionately affects adolescent and young adult women. Though prevalence rates are difficult to determine, 2007 research indicates that 24.5% of females ages 14-19 and 44.8% of women ages 20-24 had HPV.5 Among sexually active adolescents, the prevalence was 39.6% and 49.3%, respectively. A 2009 study reported lower prevalence rates of HPV among all young women ages 14-19 (18.3%) and among those who report being sexually active (29.5%).6
HPV commonly infects young women shortly after the initiation of sexual activity.6,7 Although 90% of HPV infections clear on their own within one to two years, some cases of HPV progress and eventually produce neoplastic changes.8 The American Cancer Society9, the American College of Obstetricians and Gynecologists(ACOG)10, and the U.S. Preventive Services Task Force11 issued recommendations to begin cervical cytology screening within three years of coitarche or by age 21.
However, the December 2009 ACOG practice bulletin and clinical management guideline recommends changes to the previous guidance. The new guidelines suggest initiating cervical cancer screening at age 21, regardless of the age of onset of sexual intercourse. To support this shift, ACOG refers to the low incidence of cervical cancer in younger women and possible adverse effects associated with the follow-up of abnormal cervical cytology results.
The bulletin contends that an average of 14 cases of invasive cancer are identified annually among females ages 15-19, making the incidence rate one to two cases per 1 million female adolescents. Because most HPV infections clear on their own, routine screening increases "anxiety, morbidity, and expense for the test itself and overuse of follow-up procedures."1
Though recommending a delay in cervical cancer screening, the ACOG practice bulletin underscores the need for counseling all sexually active adolescents about safe sex practices and for testing for sexually transmitted infections annually. In an asymptomatic female adolescent, this testing can be accomplished without the use of a speculum.
In addition to changing when to initiate screening, the new guidelines recommend those women ages 21-29 undergo a Pap smear every two years (revised from previous recommendations that it to be done annually).1
- Cervical Cytology Screening. ACOG Practice Bulletin No. 109. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:1,409-1,420.
- Weinstock H, Berman S, Cates W. Sexually transmitted infections in American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004; 36:6-10.
- Centers for Disease Control and Prevention. Genital HPV Infection Fact Sheet. Accessed at www.cdc.gov/STD/HPV/STDFact-HPV.htm.
- Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999; 189:12-19.
- Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection among females in the United States. JAMA 2007; 297:813-819.
- Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009; 124:1,505-1,512.
- Winer RL, Feng Q, Hughes JP, et al. Risk of female human papillomavirus acquisition associated with first male sex partner. J Infect Dis 2008; 197:279-282.
- Moscicki AB, Shiboski S, Broering J, et al. The natural history of human papillomavirus infection as measured by repeated DNA testing in adolescent and young women. J Pediatr 1998; 132:277-284.
- Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002; 52:342-362.
- Cervical cancer screening in adolescents. ACOG Committee Opinion No. 300. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004; 104:885-889.
- U.S. Preventive Task Force. Screening for Cervical Cancer. Systematic Evidence Review No. 25. Rockville, MD: Agency for Health Care Research and Quality; 2002.