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Cervical screening care pathway - GOV.UK
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Population screening programmes
NHS cervical screening (CSP) programme
Cervical screening: care pathway
Public Health
England
Guidance
Cervical screening care
pathway
Published 18 August 2021
Applies to England
Contents
Flowchart part 1: sample taking and HPV testing and cytology triage
Flowchart part 2: colposcopy (Including histopathology)
Flowchart part 3: abnormal colposcopy result management (including sample
taking, colposcopy and histopathology)
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These flowcharts (illustrations and text descriptions below) describe the care
pathway for NHS cervical screening. The pathway is divided into 3 flowcharts:
invitation, sample taking and HPV testing and cytology triage
colposcopy (including histopathology)
abnormal colposcopy result management (including sample taking, colposcopy
and histopathology)
Flowchart part 1: sample taking and HPV
testing and cytology triage
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Send out
invitation
Person opts out
from screening?
Yes
CSAS notified and
person ceased
CSAS = Cervical Screening
Call and Recall
No - attends screening
Carry out cervical
screening test
Carry out
HPV test
hrHPV = high risk human papillomavirus
hrHPV
positive or
negative? *
hrHPV
positive
Carry out
cervical cytology test
Cytology
negative or
abnormal? *
hrHPV
negative
* If test result is unavailable or cervical cytology
is inadequate at any stage in the screening
pathway, the sample must be repeated in no
less than 3 months (allow up to 2 consecutive
unavailable or inadequate results - always refer
to colposcopy at the second).
Cytology
abnormal
Cytology negative
Rescreen in
12 months' time
hrHPV
negative
hrHPV
positive or
negative? *
hrHPV positive
Carry out
cervical cytology test
Cytology
negative or
Cytology
abnormal
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abnormal? *
abnormal
Cytology negative
Rescreen in
12 months' time
hrHPV
negative
hrHPV
positive or
negative? *
hrHPV positive
Routine
recall
Carry out
cervical cytology
test **
Refer to colposcopy
(see pathway part 2)
** Whatever the result of this test, always
refer to colposcopy as it is the third
consecutive hrHPV positive test result.
1. Send out the invitation. Does the woman opt out of
screening?
Yes: The Cervical Screening Call and Recall Service (CSAS) is notified and the
woman is ceased from screening. End of screening test pathway.
No: Woman attends screening. Go to question 2.
2. Carry out the test. Is the result high risk human
papillomavirus (hrHPV) negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test. Go to question 3.
Note: If a test result is unavailable or cervical cytology is inadequate at any stage
in the screening pathway, the sample must be repeated in no less than 3 months.
Allow up to 2 consecutive unavailable or inadequate repeats – always refer to
colposcopy at the second.
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3. Is cytology negative or abnormal?
Cytology negative: screen again in 12 months’ time. Go to question 4.
Cytology abnormal: refer to colposcopy. End of screening test pathway.
4. Is hrHPV test result negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test. Go to question 5.
5. Is cytology negative or abnormal?
Cytology negative: rescreen in 12 months’ time. Go to question 6.
Cytology abnormal: refer to colposcopy. End of screening test pathway.
6. Is hrHPV test result negative or positive?
hrHPV negative: return individual to routine recall. End of screening test pathway.
hrHPV positive: carry out cervical cytology test and refer to colposcopy
(regardless of the cytology test result as this is the third consecutive hrHPV
positive result). End of screening test pathway.
Flowchart part 2: colposcopy (Including
histopathology)
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Colposcopy
examination
Colposcopy
adequate?
Yes
No
What did the
examination
show?
No CIN on biopsy,
no biopsy or no
colposcopic impression
of CIN
Result of
hrHPV / cytology
tests?
hrHPV positive /
cytology ≤low grade *
hrHPV positive
/cytology ≥high
grade or
borderline
(endocervical)
Result of
hrHPV / cytology
tests?
Second consecutive
hrHPV unavailable
or HPV positive/
cytology
inadequate
Repeat colposcopy
in 12 months**
Abnormal
biopsy CIN1+
or colpscopic
impression of
CIN1 (no biopsy)
Undertake LLETZ
Recall in 12 months
hrHPV positive /
cytology ≤low grade*
Recall in 36 months
hrHPV positive
/cytology ≥high
grade or
borderline
(endocervical)
Discuss at MDT
meeting wtihin
2 months
* excludes borderline change in endocervical cells
LLETZ = large loop excision of the transformation zone
** if repeat colposcopy examination has inadequate
outcome, consider LLETZ patient choice
MDT = multidisciplinary team
Manage as
abnormal colposcopy
examination***
*** see pathway part 3
1. Carry out the colposcopy examination. Is the
examination adequate?
Yes: go to question 3.
No: go to question 2.
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2. What were the results of the hrHPV and cytology tests
(leading to colposcopy referral)?
hrHPV positive, cytology low grade or less (excluding borderline change in
endocervical cells): repeat colposcopy in 12 months. If repeat colposcopy
examination has inadequate outcome, consider large loop excision of the
transformation zone (LLETZ) patient choice. End of colposcopy management
pathway (for this colposcopy episode).
hrHPV positive, cytology high grade or worse, or borderline (endocervical):
undertake LLETZ. End of colposcopy management pathway (further management
based on findings from LLETZ).
3. What did the colposcopy examination show?
Abnormal biopsy showing cervical intra-epithelial neoplasia (CIN)1 or worse, or
colposcopic impression of CIN1 (no biopsy): manage as an abnormal colposcopy
examination. Go to Flowchart 3 (abnormal colposcopy result management
pathway) below.
No CIN on biopsy, no biopsy, or no colposcopic impression of CIN: go to question
4.
4. What were the results of the hrHPV and cytology tests
(leading to colposcopy referral)?
Second consecutive hrHPV unavailable or HPV positive with cytology inadequate:
recall in 12 months. End of colposcopy management pathway (for this colposcopy
episode)
hrHPV positive, cytology low grade or less: recall to screening in 36 months. End
of colposcopy management pathway (for this colposcopy episode). If HPV test is
negative at 36 months, return to routine screening interval. If HPV test is positive
at 36 months, follow the process outlined in pathway part 1 above.
hrHPV positive, cytology high grade or worse, or borderline (endocervical):
discuss at multidisciplinary team (MDT) meeting within 2 months. End of
colposcopy management pathway (for this colposcopy episode). Further
management based on results of MDT meeting.
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Flowchart part 3: abnormal colposcopy
result management (including sample
taking, colposcopy and histopathology)
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Abnormal
colposcopy
result
CIN1*?
CIN2 / CIN3
or CGIN?
No
CGIN**
Yes
CIN2 or CIN3
Recall in 12 months
Provide treatment
and recall in 6 months
* This pathway only applies to
individuals with CIN1 confirmed
on biopsy or colposcopic impression
of CIN1 (no biopsy), who were
referred with low grade cytology or
hrHPV positive/cytology negative
results.
Provide treatment
and recall in 6 months
hrHPV
positive or
negative?
** Individuals who have been
adequately treated (complete
excision margins) for CGIN
or SMILE. For management of
those incompletely excised, or Ia1
cervical cancer, see section 4 of
'Cervical screening: programme
and colposcopy management'
available at www.GOV.UK
hrHPV
positive
*** If normal colposcopy and/or no
re-excision, complete 10-year
follow-up. If hrHPV positive at any
point during 10 year follow up,
refer to colposcopy (regardless of the
presence or absence of endocervical
cells). If there is re-excision, begin
follow up of CGIN as per this pathway.
hrHPV negative
hrHPV
positive or
negative?
Recall in 12 months
**** If colposcopy normal, recall in
12 months.
hrHPV negative
hrHPV
positive or
negative?
Recall in 36 months
hrHPV
positive or
negative?
hrHPV
positive
hrHPV positive
and cytology
negative,
inadequate
or abnormal
Carry out
cervical cytology test
hrHPV
negative
Carry out
cervical cytology test
Cytology
negative, inadequate
or abnormal?
hrHPV
negative
Is cytology
negative or
abnormal?
***** Further management based on
findings from repeat colposcopy.
hrHPV
positive
Cytology
abnormal
Cytology negative
or inadequate
Cytology
abnormal
Refer to colposcopy.
If colposcopy normal,
recall in 12 months
Cytology negative
Recall in 12 months
hrHPV
negative
hrHPV
negative
hrHPV
positive or
negative?
hrHPV positive
hrHPV positive
Carry out
cervical cytology test
Carry out
cervical cytology test
Cytology
negative
Recall in 36 months
hrHPV
positive or
negative?
Cytology
negative or
abnormal?
Cytology
negative, inadequate
or abnormal?
Cytology
abnormal
Refer to
colposcopy*****
Cytology
abnormal
Cytology negative
or inadequate
Recall in 36 months
Refer to
colposcopy****
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Refer to
colposcopy***
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1. Abnormal biopsy result: was the result CIN1?
Yes: the CIN1 pathway only applies to individuals with CIN1 confirmed on biopsy
or colposcopic impression of CIN1 (no biopsy) who were referred with low grade
cytology, or hrHPV positive/cytology negative referrals. Recall in 12 months. Go to
question 2.
No: CIN2, CIN3 or cervical glandular intra-epithelial neoplasia (CGIN): Go to
question 6.
2. Is screening result hrHPV negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway
(for this colposcopy episode). If HPV test is negative at 36 months, return to
routine screening interval. If HPV test is positive at 36 months, follow the process
outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 3.
3. Is cytology negative or abnormal?
Cytology negative: recall in 12 months. Go to question 4.
Cytology abnormal: refer to colposcopy. End of abnormal colposcopy result
pathway (for this colposcopy episode). Further management based on findings
from repeat colposcopy.
4. Is hrHPV result negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway
(for this colposcopy episode). If HPV test is negative at 36 months, return to
routine screening interval. If HPV test is positive at 36 months, follow the process
outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 5.
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5. Is cytology negative or abnormal?
Cytology negative: recall in 36 months. End of abnormal colposcopy result
pathway (for this colposcopy episode). If HPV test is negative at 36 months, return
to routine screening interval. If HPV test is positive at 36 months, follow the
process outlined in pathway part 1 above.
Cytology abnormal: refer to colposcopy. End of abnormal colposcopy result
pathway (for this colposcopy episode). Further management based on findings of
repeat colposcopy.
6. Was result CIN2 or CIN3, or CGIN?
CIN2 or CIN3: provide treatment and recall in 6 months. Go to question 7.
CGIN: Provide treatment. Individuals who have been adequately treated
(complete excision margins) for CGIN or stratified mucin producing intraepithelial
lesions (SMILE), recall in 6 months. Go to question 8. For management of those
incompletely excised, or la1 cervical cancer, see section 4 of Cervical screening:
programme and colposcopy management
(https://www.gov.uk/government/publications/cervical-screening-programme-andcolposcopy-management).
7. Is screening result hrHPV negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway
(for this colposcopy episode). If HPV test is negative at 36 months, return to
routine screening interval. If HPV test is positive at 36 months, follow the process
outlined in pathway part 1 above.
hrHPV positive and cytology negative, inadequate or abnormal: refer to
colposcopy. End of abnormal colposcopy result pathway (for this colposcopy
episode). Further management based on findings of repeat colposcopy.
8. Is hrHPV result negative or positive?
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hrHPV negative: recall in 12 months. Go to question 9.
hrHPV positive: carry out cervical cytology test. Go to question 10.
9. Is hrHPV result after 12 months negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway
(for this colposcopy episode). If HPV test is negative at 36 months, return to
routine screening interval. If HPV test is positive at 36 months, follow the process
outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 10.
10. Is cytology result negative, inadequate or abnormal?
Cytology negative or inadequate: refer to colposcopy. If colposcopy normal, recall
in 12 months. Go to question 11.
Cytology abnormal: Refer for colposcopy. End of abnormal colposcopy result
pathway (for this colposcopy episode). If colposcopy is normal and/or there is no
re-excision, complete 10 year follow up. If hrHPV positive at any point during 10
year follow up, refer to colposcopy (regardless of the presence or absence of
endocervical cells). If there is re-excision, begin follow up of CGIN according to
this pathway (pathway part 3).
11. Is hrHPV result after 12 months negative or positive?
hrHPV negative: recall in 36 months. End of abnormal colposcopy result pathway
(for this colposcopy episode). If HPV test is negative at 36 months, return to
routine screening interval. If HPV test is positive at 36 months, follow the process
outlined in pathway part 1 above.
hrHPV positive: carry out cervical cytology test. Go to question 12.
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12. Is cytology result negative, inadequate or abnormal?
Cytology negative or inadequate: refer to colposcopy. If colposcopy normal, recall
in 12 months. End of abnormal colposcopy result pathway (for this colposcopy
episode). Note: after 12 month recall, go to question 11 above.
Cytology abnormal: refer to colposcopy. If normal colposcopy and/or no reexcision, complete 10 year follow up. If hrHPV positive at any point during 10 year
follow up, refer back to colposcopy (regardless of the presence or absence of
endocervical cells). End of abnormal colposcopy result pathway (for this
colposcopy episode). If there is further excision, begin follow up of CGIN
according to this pathway (pathway part 3).
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