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Home 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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screening-care-pathway/cervical-screening-care-pathway
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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
Send out
invitation

Person opts out CSAS notified and CSAS = Cervical Screening

Yes
from screening? person ceased Call and Recall

No - attends screening

Carry out cervical

screening test

Carry out
HPV test

hrHPV = high risk human papillomavirus

hrHPV * If test result is unavailable or cervical cytology
hrHPV Carry out
positive or is inadequate at any stage in the screening
positive cervical cytology test
negative? * 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
hrHPV Cytology
negative or
negative abnormal? * abnormal

Cytology negative
:
 Rescreen in
12 months' time

hrHPV
hrHPV
positive or
negative
negative? *

hrHPV positive

Carry out
cervical cytology test

Cytology
negative or Cytology
abnormal? * abnormal

Cytology negative

Rescreen in
12 months' time

hrHPV
hrHPV
positive or
negative
negative? *

hrHPV positive

Carry out
Routine Refer to colposcopy
cervical cytology
recall (see pathway part 2)
test **

** 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
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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.

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
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(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)
Colposcopy
examination

Colposcopy Yes
adequate?

No
Abnormal
What did the biopsy CIN1+
examination or colpscopic
show? impression of
CIN1 (no biopsy)

No CIN on biopsy,
no biopsy or no
Result of colposcopic impression
hrHPV / cytology of CIN
tests?

hrHPV positive
/cytology ≥high
grade or Result of
hrHPV positive / borderline hrHPV / cytology
cytology ≤low grade * (endocervical) tests?
Second consecutive hrHPV positive
hrHPV unavailable /cytology ≥high
or HPV positive/ grade or
cytology borderline
hrHPV positive /
inadequate (endocervical)
cytology ≤low grade*

Discuss at MDT Manage as

Repeat colposcopy
Undertake LLETZ Recall in 12 months Recall in 36 months meeting wtihin abnormal colposcopy
in 12 months**
2 months examination***

* excludes borderline change in endocervical cells LLETZ = large loop excision of the transformation zone
** if repeat colposcopy examination has inadequate
MDT = multidisciplinary team
outcome, consider LLETZ patient choice

*** see pathway part 3

1. Carry out the colposcopy examination. Is the

examination adequate?
Yes: go to question 3.
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No: go to question 2.

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 * This pathway only applies to
colposcopy individuals with CIN1 confirmed
result on biopsy or colposcopic impression
of CIN1 (no biopsy), who were
referred with low grade cytology or
hrHPV positive/cytology negative
results.
CIN1*? CIN2 / CIN3 Provide treatment
No or CGIN? CGIN** ** Individuals who have been
and recall in 6 months
adequately treated (complete
excision margins) for CGIN
or SMILE. For management of
Yes CIN2 or CIN3 those incompletely excised, or Ia1
cervical cancer, see section 4 of
hrHPV 'Cervical screening: programme
hrHPV
Provide treatment positive or and colposcopy management'
Recall in 12 months positive
and recall in 6 months negative? available at www.GOV.UK
*** If normal colposcopy and/or no
re-excision, complete 10-year
hrHPV negative follow-up. If hrHPV positive at any
point during 10 year follow up,
hrHPV refer to colposcopy (regardless of the
positive or presence or absence of endocervical
Recall in 12 months cells). If there is re-excision, begin
negative?
follow up of CGIN as per this pathway.
**** If colposcopy normal, recall in
hrHPV negative 12 months.
hrHPV ***** Further management based on
hrHPV
positive or findings from repeat colposcopy.
Recall in 36 months positive
negative?

hrHPV hrHPV positive

hrHPV hrHPV Carry out
positive or and cytology
positive negative cervical cytology test
negative? negative,
inadequate
or abnormal
Carry out
cervical cytology test
Cytology
Cytology
hrHPV negative, inadequate
abnormal
negative or abnormal?

Is cytology Cytology negative

Cytology or inadequate
negative or
abnormal
abnormal?
Refer to colposcopy.
If colposcopy normal,
Cytology negative recall in 12 months

Recall in 12 months
hrHPV
hrHPV
positive or
negative
negative?

hrHPV
hrHPV
positive or
negative hrHPV positive
negative?

Carry out
hrHPV positive cervical cytology test

Carry out
cervical cytology test
Cytology
Cytology
negative, inadequate
abnormal
or abnormal?

Cytology
Cytology Cytology
negative or Cytology negative
negative abnormal
abnormal? or inadequate

Refer to Refer to Refer to

Recall in 36 months colposcopy***** Recall in 36 months colposcopy**** 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.

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.
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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-and-
colposcopy-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?

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.
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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.

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
re-excision, 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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