Frequently asked questions for providers
On this page:
- Why is the screening start age changing?
- The change process
- Managing the transition period, prior to November 2019
- How do we manage women < 25 years who have not yet been invited to join the programme?
- Should women aged 20 to 24 years old continue to have cervical screening prior to raising the age for screening?
- What about women who have been invited but have not responded to the invitation?
- What should happen for women 20 to 24 years of age who have had an abnormal cervical screening test?
- After the screening start age is raised to 25 years
- When the start age is raised to 25 years, what should happen for women aged 20 to 24 years old who have already started screening?
- When the age is raised to 25 years, what should happen for women aged 20 to 24 years old who have an abnormal screening test?
- When the age is raised to 25 years, what should I tell women aged 20 to 24 years who request a screening test?
- Are there any exceptions to this guidance?
- Clinical guidance
- Will the change in start age for cervical screening mean that there will be an increase in women between 25 and 30 years being diagnosed with cervical cancer?
- If screening women under 25 years could pick up just one case early, wouldn’t this be worth it?
- What if a woman has symptoms?
- Does this decision save the Ministry of Health money?
- What impact does HPV immunisation have?
- Additional guidance
Screening women who are aged 20 to 24 years has been shown to be ineffective at preventing cervical cancer. Screening these younger women results in investigating and treating abnormalities that often resolve on their own. Further investigations and colposcopy can cause anxiety, and treatment can cause some harm. Additionally, increasing numbers of women in this age group are being vaccinated against HPV and this provides much greater protection for 20 to 24 year olds than screening tests can.
Most organised screening programmes in other countries and the World Health Organization’s International Agency for Research on Cancer, recommend starting screening at the age of 25 years or older. Australia, England, Wales, Scotland, Ireland, France, Belgium, Italy and Norway start screening at 25 years of age. Many other European countries, such as the Netherlands and Finland, start screening at age 30 years.
From November 2019, Primary Care Practice Management Systems (PMS) will be updated to reflect the change in the screening start age.
PMS vendors are working through a change request for their respective systems to support the cervical screening age change. These updates will be included in their November release cycles. The timing of releases may vary slightly by PMS provider and we will confirm the release dates for each vendor in the monthly sector updates.
Service providers and those involved in provision of the National Cervical Screening Programme (NCSP) will be kept informed of the planned changes and implementation date. Information will also be posted on the NCSP website.
The NCSP will be announcing the age change through a media statement in November, as well as providing information to women and users of the cervical screening service on the Time to Screen website. Updated printed resources will also be available in due course.
In February 2020 there will be a nationwide media campaign to raise awareness about the age change and the importance of cervical screening. This will be supported by a provider toolkit including key programme messages for those working in the sector.
We are now in the transition period to the change of screening start age in November 2019, so the NCSP recommends that from now on, women are not invited to join the cervical screening programme until they reach 24.5 years.
Should women aged 20 to 24 years old continue to have cervical screening prior to raising the age for screening?
Women aged between 20 and 24 years who are already engaged in the programme should continue to be screened according to the current pathway.
It is recommended that practices manage these women on a case-by-case basis. If appropriate, they can now be informed that they do not need to start screening until they are 25 years of age.
What should happen for women 20 to 24 years of age who have had an abnormal cervical screening test?
Women with abnormal cervical screening test results should continue on the current investigation and management pathway.
When the start age is raised to 25 years, what should happen for women aged 20 to 24 years old who have already started screening?
When the age to start screening is raised to 25 years, women aged 20 to 24 years who have already started screening should continue on the current screening pathway. Even if they have only had normal screening results, they will continue to be invited under the existing NCSP recommendations for screening.
When the age is raised to 25 years, what should happen for women aged 20 to 24 years old who have an abnormal screening test?
If an abnormality has already been identified in a woman aged 20 to 24 years, the current clinical guidelines for managing women with abnormal cervical cytology should be followed.
When the age is raised to 25 years, what should I tell women aged 20 to 24 years who request a screening test?
Changing the screening start age to 25 years will bring the NCSP in line with international best practice – Australia, England, Wales, Scotland, Ireland, France, Belgium, Italy and Norway start screening at 25 years of age and many other European countries, such as the Netherlands and Finland, start screening at age 30 years.
The World Health Organization’s International Agency on Research on Cancer (IARC) undertook a review in 2004 and concluded that there is minimal benefit in screening below age 25 years, recommending that organised screening programmes should not start cervical screening before the age of 25 years.
Evidence now shows there is little benefit to cervical screening for women aged 20 to 24 years and that there is a risk of harm associated with treatment complications. The evidence paper that was developed when the decision to raise the screening start age to 25 years, is available at Evidence supporting decision to stop cervical screening in women aged 20–24 years (Word, 2 MB).
Women who have symptoms, such as abnormal vaginal bleeding, persistent discharge or pelvic pain should see their health care provider, who will arrange appropriate investigation.
In some exceptional circumstances, screening may be appropriate for women younger than 25 years of age. Women who are immune deficient may be in this category.
Anyone with abnormal bleeding or other symptoms must continue to be managed appropriately (see Additional guidance) – this may include cervical cytology.
Will the change in start age for cervical screening mean that there will be an increase in women between 25 and 30 years being diagnosed with cervical cancer?
Research in the United Kingdom specifically looked at this issue. There is strong evidence that screening women aged 20 to 24 years has had little or no impact on rates of cervical cancer up to the age of 30 years.
England changed its screening age from 20 to 25 years in 2003, and since then, there has been no increase in cervical cancer mortality in women aged 20 to 24 years or for 25 to 30 year old women.
Cervical cancers in this age group are rare and not always detected by screening because of rapid progression of the disease. There would be rare cases of cervical cancer under 25 years of age even if we continued to screen women under 25.
The most important things that women under 25 years can do to protect themselves from cervical cancer is to be vaccinated against HPV, have symptoms investigated if they arise, and commence screening promptly when they reach 25 years of age.
If a woman is concerned about symptoms, such as abnormal bleeding or bleeding after sexual intercourse, persistent vaginal discharge or pelvic pain, she should consult a health professional as soon as possible.
The most important consideration in making the decision to cease cervical screening for women under 25 years is that screening is ineffective in this age group and has the potential to cause harm. Cancer in women under 25 years is rare. This change is driven by a strong body of evidence and aligns the programme with best international practice
HPV immunisation is the most effective way to reduce the incidence of cervical cancer. Those women who commenced immunisation with Gardasil-4 in 2008 at 12 to 14 years of age will be 23 to 25 years old when the transition is made in 2019. Immunisation with Gardasil-4 provides protection against HPV-16 and 18 as well as two low-risk types of HPV that cause genital warts. Gardasil-9, which protects against seven high-risk HPV types, is now fully funded for both males and females up to and including 26 years of age, providing even greater protection for a wider range of HPV types associated with cervical cancer. Those women who have not been immunised also receive some protection because there is less HPV transmission in the community as a result of the widespread immunisation of the population in this age group.
Intermenstrual bleeding and other irregular bleeding patterns are common. Although most women investigated for abnormal vaginal bleeding do not have serious disease, abnormal vaginal bleeding can be associated with genital tract malignancy and premalignant conditions, as well as other conditions such as polyps, adenomyosis, leiomyomas, coagulopathies, ovulatory disorders, endometrial disorders and iatrogenic causes. Postcoital bleeding (PCB) in particular, warrants investigation because it may be a symptom of cervical cancer.
Abnormal vaginal bleeding is relatively common in the 20 to 24 year age group.
Women under 25 years old should be properly evaluated for abnormal vaginal bleeding. This includes a thorough history (menstrual, contraceptive and sexual). If there is a suspected oral contraceptive problem, then it is appropriate to modify the oral contraceptive. If there is PCB, persistent bleeding or other signs and symptoms suggestive of malignancy, a speculum and pelvic examination must be performed.