🩺 Cervical Screening in the UK (HPV-First Pathway): What’s New for PLAB 2 Doctors

Ann Augustin
Oct 12
3 min read

Cervical screening is a common GP scenario in the PLAB 2 exam. You might meet a patient who receives an unexpected smear invitation, or one whose results show “mild dyskaryosis” or “HPV positive.”Let’s simplify what’s actually happening under the latest UK NHS Cervical Screening Programme (2025 update) — and what’s changed from before.

The Previous System (Before HPV-First)

Until a few years ago, the UK used cytology-based screening (the traditional Pap smear system).

How it worked:

Cytology (cell test) was done first.
If abnormal cells were seen → refer for colposcopy.
If normal, routine recall in:
- 3 years for ages 25–49
- 5 years for ages 50–64
HPV testing was done only if the cytology was abnormal (secondary/triage test).

🔹 Problem: Some women with HPV infection (but normal cytology) were missed until later.

🔹 Solution: Make HPV the first test — since HPV causes almost all cervical cancers.

🧬 The Current “Primary HPV” Pathway (HPV-First Screening)

Since 2019, all UK nations use HPV-primary screening — and in England, new updates from July 2025 extend the screening interval.

Step-by-Step (Simplified)

Result	Next Step	Rationale
hrHPV Negative	Return to routine recall	No infection → very low risk
hrHPV Positive → Reflex Cytology Done
⤷ Cytology Normal	Repeat test in 12 months	Give immune system time to clear virus
⤷ Cytology Borderline or Worse	Refer for Colposcopy	Early changes may need closer look
Two Inadequate Samples	Refer for Colposcopy	To ensure no abnormality missed

📘 Reference:NHS Cervical Screening Programme and Colposcopy Management, updated 9 July 2025👉 gov.uk/cervical-screening-programme-and-colposcopy-management

🧭 The 2025 Change — Longer Screening Interval for HPV-Negative Results

From 1 July 2025, anyone aged 25–49 who tests negative for high-risk HPV will now be recalled every 5 years instead of every 3.

Age Group	Recall (Old)	Recall (New 2025)
25–49 yrs	Every 3 years	Every 5 years if HPV-negative
50–64 yrs	Every 5 years	No change
>65 yrs	Only if recent abnormal results	—

🗣️ Why the change?If HPV isn’t present, the chance of developing cervical cancer within 5 years is extremely low. The NHS extended the interval to reduce unnecessary tests and anxiety.👉 Extended Screening Interval Clinical Pathway, NHS England 2025

🔍 When Is Colposcopy Needed?

📌 Referral Criteria (Current NHS Pathway)

Refer for colposcopy if:

HPV positive + abnormal cytology (borderline or worse)
Persistent HPV positivity (after 12 months × 2) even if cytology normal
Two inadequate samples (on separate occasions)
Clinical suspicion of malignancy (symptoms like post-coital bleeding, visible lesion)

🩹 What Happens at Colposcopy

A simple outpatient test using a microscope (colposcope) to view the cervix.Mild solutions are applied to highlight abnormal areas.If needed, small biopsies are taken.The procedure usually lasts 10–15 minutes and isn’t painful.

If histology shows:

CIN 1 (mild changes) → often observed (repeat test later).
CIN 2/3 (moderate/severe) → may need local treatment (LLETZ).

🔄 Summary of Key Differences

Aspect	Old System (Cytology First)	New System (HPV First)
Primary test	Cell changes first	HPV testing first
HPV role	Done only if cells abnormal	Done on everyone’s sample
Recall interval 25–49	3 years	5 years (from Jul 2025)
HPV negative result	Routine recall (3 y)	Routine recall (5 y)
HPV positive + normal cells	Repeat cytology 12 mo	Repeat HPV ± cytology 12 mo
Two inadequate samples	May repeat again	Direct colposcopy
Self-sampling	Not available	Pilot programs under evaluation

🧠 PLAB 2 Takeaway

During the exam:

Emphasize that HPV causes nearly all cervical cancers, so the test now looks for HPV first.
Reassure that HPV negative = very low risk = 5-year recall.
Explain that mild or borderline cell changes do not mean cancer.
Always describe colposcopy clearly and calmly.
Offer NHS leaflet or website link for reassurance.