Pap and HPV Cervical Screening#

• Pap test (cytology): a sample of cells is collected from your cervix (using a speculum and small brush) and examined under a microscope. The lab looks for abnormal cell changes that could indicate pre-cancer or cancer. This is the traditional screening test.
• HPV test (HPV DNA testing, usually PCR-based): the same kind of sample - or in some programs, a self-collected vaginal swab - is tested for the DNA of high-risk HPV strains. These include HPV 16 and HPV 18 (the two strains responsible for the most cervical cancer), plus a group of other cancer-causing types. Some programs or assays report HPV 18 and HPV 45 together as an 18/45 category. HPV testing detects the virus that causes cervical cancer, often years before any cell changes appear.

Multiple studies and Canadian guideline updates have shown that HPV primary screening is more sensitive than Pap cytology alone for identifying people at risk of cervical pre-cancer and cancer. The key advantages:

• More sensitive for detecting high-risk HPV infection - which is what causes cervical cancer in the first place.
• Earlier detection. A positive HPV test signals risk before cells have changed, allowing earlier follow-up.
• Self-collection is possible. Some HPV-primary programs, including BC, allow patients to collect their own vaginal swab at home or at a community location, instead of requiring a speculum exam.
• Longer screening intervals. A negative HPV test is more reassuring than a negative Pap, so screening can safely happen every 5 years with HPV (Ontario), or every 3 to 5 years depending on the test and pathway (BC), versus every 3 years with Pap.
• Lower discomfort and barrier for patients who find speculum exams uncomfortable or unavailable.

Ontario now uses HPV testing with reflex cytology as the primary cervical screening test under the Ontario Cervical Screening Program (OCSP), administered by Ontario Health (formerly Cancer Care Ontario). This change took effect March 3, 2025.

Key features of the Ontario program:

• HPV testing with reflex cytology is the primary screening test. A positive HPV result automatically triggers cytology (Pap) on the same sample to decide next steps.
• Samples are collected by a clinician (family doctor, nurse practitioner, or other authorized provider) using a brush. Patient self-collection has been considered in some settings but is not the routine pathway in Ontario at this time - patients should not assume at-home self-collection is currently available.
• The screening interval is every 5 years for patients with normal results.

Where to confirm current status:

• Ontario Cervical Screening Program (Ontario Health) - has up-to-date information on the program's current implementation.
• Your family doctor or local clinic - they can tell you which test is being ordered at their site right now.

The Ontario Cervical Screening Program covers people who:

• Have a cervix (this includes cisgender women, transgender men with a cervix, and non-binary people with a cervix).
• Are age 25 or older. Most people screen from age 25 until they meet stopping criteria between ages 65 and 69. Some people continue longer depending on screening history, HPV results, immunocompromise, or prior abnormalities (e.g., previously unscreened people aged 65-69 may continue until 74; immunocompromised people may also continue until 74).
• Have ever had any sexual contact. If you have never had any sexual contact, screening is typically deferred - discuss with your clinician.
• Are asymptomatic. If you have symptoms suggestive of cervical disease (bleeding between periods, bleeding after sex, persistent abnormal discharge, pelvic pain), you need an in-person diagnostic assessment, not routine screening - see "When is a speculum exam, Pap/cytology, or diagnostic assessment still needed?" below.

The cervical screening test is publicly funded for eligible Ontario residents under the OCSP.

• Through your family doctor or nurse practitioner. This is the most common route - they collect the sample during a routine visit.
• Through a walk-in clinic. Some walk-in clinics offer cervical screening; call ahead to confirm.
• Through a community health centre, sexual-health clinic, or public-health unit. Often free even without a family doctor.

If you don't have a family doctor and need help finding screening, Health Care Connect can help, or the Ontario Cervical Screening Program has a navigator to point you to the right resource.

BC was the first province in Canada to launch HPV primary screening with at-home self-collection, through the BC Cervix Screening Program (administered by BC Cancer). The program launched in January 2024.

Key features of the BC program:

• BC is transitioning from Pap (cytology) testing to HPV testing as the primary screening method. Cervix self-screening (a vaginal swab tested for HPV) is recommended every 5 years for eligible average-risk people. Provider-collected LBC/Pap testing remains available and is recommended every 3 years for people advised to follow a Pap pathway.
• Provider-collected samples are being phased into HPV-primary testing by age - the rollout is age-based and is expected to expand fully over time.
• Self-collection is available at home - patients can request a mailed kit, collect a vaginal swab themselves, and mail the sample back to the BC Cancer lab.
• In-clinic collection is still available for patients who prefer it or whose clinician collects the sample during a visit.

The BC program covers people who:

• Have a cervix.
• Are between ages 25 and 69.
• Are due for screening (every 3 to 5 years for patients with normal results, depending on the test type and pathway, or sooner if follow-up is needed).

For at-home self-screening specifically, BC generally recommends it for eligible people who are not pregnant, are not using a pessary, have had sexual contact, and have not been told they need co-testing, colposcopy follow-up, or a provider-collected sample because of their clinical history.

You can enrol in the BC Cervix Screening Program in several ways:

• Online: through screeningbc.ca/cervix - register for a mailed self-collection kit.
• Through your healthcare provider: your family doctor, nurse practitioner, or community clinic can order an HPV test on your behalf (either self-collected or clinician-collected).
• At a community pop-up or pharmacy site as the BC program expands community access points.

After self-collection, you mail the sample back to the BC Cancer lab in the prepaid packaging. Results are sent to you (and your provider, if you have one).

The at-home self-collection kit contains a long, slim swab (similar to a long Q-tip), instructions with diagrams, and a prepaid return mailer. The full process is:

1. Order the kit online through the BC Cervix Screening Program (or pick one up at a participating provider).
2. When the kit arrives, find a private spot (a bathroom is typical). Wash your hands.
3. Insert the swab gently into the vagina as directed in the kit, rotate it for about 20 seconds (BC Cancer's instructions say to slowly count to 20), and remove. The swab is much smaller than a speculum - there is no need to reach the cervix; the vaginal cells around the cervix carry the same HPV signal.
4. Place the swab into the sealed tube provided.
5. Mail it back in the prepaid envelope - no postage needed.

Most people complete the collection in under 5 minutes. Some mild discomfort or pressure is possible but it should not be painful. If you experience pain, stop and speak with a clinician.

How accurate is it compared with a clinician-collected sample? For validated PCR-based HPV tests, self-collected vaginal samples have comparable clinical accuracy to clinician-collected samples when collection instructions are followed. BC Cancer states that the self-collected sample is just as accurate as a provider-taken sample, and meta-analyses support this for PCR HPV assays - which is one of the main reasons HPV-primary screening with self-collection has been adopted.

A positive result means high-risk HPV DNA was detected. Next steps depend on which strain was positive and the reflex cytology result on the same sample.

Ontario's HPV-primary pathway:

• HPV type 16 or 18/45 detected → referral for colposcopy is recommended, regardless of reflex cytology result. These strains carry the highest cervical-cancer risk so direct colposcopy is the safer pathway.
• Other high-risk HPV types detected + reflex cytology normal or low-grade → repeat the cervical screening test in approximately 2 years to see whether the infection has cleared. Most do.
• Other high-risk HPV types detected + reflex cytology shows high-grade cell changes → referral for colposcopy.

Reflex means the lab automatically runs the follow-up cytology on the sample you already gave - no second collection visit is needed.

About colposcopy: an in-clinic procedure where a clinician uses a magnifying instrument to look at the cervix more closely; can be done with or without a small biopsy. The colposcopy exam itself usually feels similar to a speculum exam. If a biopsy is taken, brief cramping or pinching can occur.

BC's pathway has additional considerations for self-collected samples. If HPV is detected on a self-collected vaginal swab, cytology cannot be performed from that same swab (the self-swab is for HPV only). Depending on the HPV type and pathway, the next step may be a provider-collected cervical cytology/LBC sample or direct referral to colposcopy. Follow the BC Cancer result letter or your clinician's instructions.

In BC, HPV 16/18 generally leads to colposcopy. Other high-risk HPV types may require provider-collected cytology and/or repeat HPV testing, depending on the cytology result and clinical history.

Important context:

• About 80% of women have HPV at some point in their lives - the vast majority clear it within 1-2 years without intervention.
• A positive HPV test is the screening system working as intended - catching exposure early so any cell changes can be monitored before they become a problem.
• For most people, progression from a persistent high-risk HPV infection to cervical cancer takes many years - often a decade or longer - so there is time for follow-up.

No. HPV is not a notifiable infection, and partner testing is not routinely recommended. There is no routinely recommended HPV screening test for asymptomatic male partners comparable to cervical screening, and most adults have already been exposed to one or more HPV types over their lifetime. Specialty anal HPV/cytology pathways do exist for selected high-risk groups (e.g., men who have sex with men, especially with HIV) but are not part of routine partner screening.

The most useful step a partner can take is HPV vaccination if they have not already had it.

Yes, in a small percentage of cases. Common reasons:

• Sampling error - the cells the brush picks up may not include any abnormal cells, especially for cancers that are very early, very small, or located higher up in the cervical canal.
• Adenocarcinoma (a cancer of the glandular cells lining the upper cervical canal) is harder to detect on Pap because the glandular cells are not always sampled well by a standard brush.
• Interpretation error - cell abnormalities can be subtle and occasionally missed by the lab.
• Inflammation, blood, or atrophic changes can obscure cells - particularly in post-menopausal patients, patients on testosterone, or patients with active infection at the time of sampling.

A single Pap test can miss abnormalities because of sampling or interpretation limits - this is one of the reasons regular screening at recommended intervals matters. Anything missed on one screen is usually caught at the next.

Yes, but rarely. HPV testing is more sensitive than Pap, but limitations include:

• HPV-negative cervical cancers - a small percentage of cervical cancers (mostly certain adenocarcinomas and rare types like neuroendocrine cancer) are not caused by detectable high-risk HPV.
• Sampling error - the swab may not pick up enough material if the technique was poor.
• Strain coverage - high-risk HPV panels cover the most common cancer-causing types, but extremely rare cancer-causing strains may not be detected.
• Established cancer with low viral signal - in some advanced cancers, the active virus signal can fall below the detection threshold.

HPV testing is more sensitive than cytology, but it is not perfect. Using HPV testing first, with reflex cytology when HPV is positive, improves risk stratification and helps decide who needs colposcopy or repeat testing. It does not bring the false-negative rate to zero.

Schedule an in-person evaluation for any of:

• Bleeding between periods.
• Bleeding after sex.
• Bleeding after menopause (any vaginal bleeding once periods have stopped).
• Unusual, persistent vaginal discharge that does not improve with treatment of common infections (yeast, BV).
• Pelvic pain or pressure that is new or worsening.
• Pain during sex that is new or persistent.
• Lower-back or leg pain that is unexplained and persistent.

These symptoms are usually caused by something other than cancer - cervical polyps, infections, hormonal changes, fibroids. But because cervical cancer can develop or progress between routine screening intervals, none of these should be ignored just because your last Pap or HPV test was normal. An in-person speculum exam, possibly with a fresh Pap and additional tests, is the right next step.

Cervical screening is for asymptomatic people. If you have symptoms suggestive of cervical disease - bleeding between periods, bleeding after sex, bleeding after menopause, persistent abnormal discharge, or pelvic pain - you need an in-person diagnostic assessment, not routine screening.

Depending on findings, your clinician may perform a speculum exam, cervical screening (HPV or Pap), STI testing, an ultrasound, biopsy referral, or colposcopy. The right workup is decided in person based on what is seen.

The cervical screening test should not be used as a substitute for evaluation of symptoms.

People who are immunocompromised often need more frequent screening. In Ontario, immunocompromised patients with a negative HPV test generally screen every 3 years rather than every 5 years.

Ontario's definition of immunocompromised for screening purposes includes:

• HIV
• Solid organ or stem cell transplant
• Long-term immunosuppressive medication (e.g., for autoimmune disease)
• Systemic lupus erythematosus (SLE)
• End-stage renal disease / dialysis

Specific schedules and follow-up pathways should be individualized by your treating clinician - your HIV specialist, transplant clinician, family doctor, or rheumatologist will know the right cadence for your situation.

HPV primary screening is more sensitive at picking up risk than Pap, and is now the recommended standard. However, if your clinician's lab has not yet switched to HPV-primary testing, a Pap test on the recommended schedule is still excellent protection - it has prevented cervical cancer deaths for decades.

The most important thing is not to delay screening while you wait for HPV-primary to roll out at your specific clinic. Whichever test is currently available to you on schedule is the right test to do.

Yes. The HPV vaccine reduces but does not eliminate cervical cancer risk. Reasons screening is still recommended:

• The vaccine covers the most common high-risk types (16, 18, and seven others) but not every cancer-causing strain.
• You may have been exposed to HPV before vaccination - the vaccine does not clear existing infection.
• Long-term data on vaccine-only protection is still being gathered.

Vaccinated patients follow the same screening schedule as unvaccinated patients - the schedule depends on your province (every 5 years in Ontario, or every 3 to 5 years in BC depending on test and pathway).

HPV is almost always transmitted through sexual skin-to-skin contact. If you have never had any sexual contact (vaginal, anal, oral, or genital skin-to-skin), the risk of HPV is very low. Routine cervical screening is typically deferred in this situation. Discuss with your clinician - they may suggest starting screening if and when you become sexually active.

If you have had any sexual contact - including non-penetrative skin-to-skin contact - the standard screening schedule applies.

It depends on what kind of hysterectomy and why:

• Total hysterectomy (cervix removed) for non-cancer reasons (e.g., fibroids, heavy bleeding, prolapse) - screening can usually stop.
• Total hysterectomy for cervical pre-cancer or cancer - continue screening with vaginal vault cytology as your clinician recommends.
• Supracervical (partial) hysterectomy with cervix retained - continue routine cervical screening on the standard schedule.

If you are unsure which type of hysterectomy you had, ask your family doctor or the surgeon's office - the operative report will specify.

If you have a cervix, cervical screening is still recommended on the standard schedule from age 25 (every 5 years in Ontario, or every 3 to 5 years in BC depending on test and pathway). A few specific points:

• HPV self-collection is a major accessibility option - it avoids the speculum exam, which many trans masculine patients find dysphoria-inducing or physically uncomfortable, especially while on testosterone.
• Testosterone can cause atrophic changes in the cervix and vaginal tissues that may make Pap cytology harder to interpret. HPV testing is not affected by these changes, which is another reason HPV-primary testing is preferred for this group.
• In BC, you can order an HPV self-collection kit directly through the BC Cervix Screening Program regardless of how you are registered with the program.
• In Ontario, self-collection is not currently a routine pathway through the OCSP; look for trans-affirming clinics or community health centres experienced in cervical screening for transmasculine patients, where the clinician-collected swab can be performed sensitively.

• Pregnant patients who are due for cervical screening may still be eligible. In Ontario, the OCSP includes pregnant people in cervical screening eligibility, and the test is now HPV with reflex cytology.
• Timing should be coordinated with your prenatal-care provider - some clinicians screen at the first prenatal visit if you are due; others prefer to time screening with another routine prenatal exam.
• If HPV is positive or cytology is abnormal, colposcopy can often be performed during pregnancy when indicated. Biopsy and treatment decisions are individualized to the specific finding and stage of pregnancy.
• In BC, pregnant people who are due or overdue should use a provider-collected LBC sample - self-screening is not recommended during pregnancy. If you use a pessary, BC also recommends provider-collected LBC rather than self-screening.

Discuss with your prenatal-care provider, who will coordinate with the cervical screening program.

• Clinician-collected sample (speculum exam): the speculum can feel uncomfortable, with a sensation of pressure or stretching. The cervical brush may cause a brief pinching feeling. Most people describe it as "uncomfortable for a minute" rather than painful. Cramping can occur for a few hours after.
• Self-collected vaginal swab: generally not painful. Mild pressure or discomfort is possible but the swab is small and you control the depth and timing.

If you have a history of trauma, vaginismus, or pelvic pain, let your clinician know in advance - they can help make the exam more comfortable, or you may be a good candidate for self-collection.

For eligible residents with provincial health coverage, routine cervical screening through the provincial program is publicly funded - including the sample collection (clinician-collected or self-collected, where available) and the lab processing.

Self-collection kits in BC are also free for eligible residents. Patients without provincial coverage, non-residents, or those requesting screening outside the recommended pathway may incur out-of-pocket costs - your clinician or the provincial program can advise.

Earlier screening (under 25) is no longer recommended because:

• HPV infections in younger people usually clear on their own within 1-2 years - so testing earlier picks up many infections that would have resolved without intervention.
• Treating low-grade changes in young patients has been linked to a small increase in preterm birth risk in later pregnancies, so unnecessary intervention is now actively avoided.
• Cervical cancer is very rare under 25 in the absence of major risk factors.

The age threshold reflects evidence that routine screening before 25 leads to more harm than benefit for most people.

After age 69-70 with consistent normal results, the risk of new clinically meaningful HPV detection is low. Most cancers in older patients arise from long-standing infections that would have been detected at earlier screens. Continuing routine screening into very late adulthood adds discomfort and follow-up testing without meaningful mortality benefit.

If your screening history is incomplete or inconsistent, your clinician may recommend continuing screening past 69 until you have had a defined run of normal results.

No - they're different tests. Pap and HPV tests look for HPV / cervical-cell changes. They don't test for chlamydia, gonorrhea, trichomoniasis, HIV, syphilis, or other STIs.

• If you want STI screening, use the STI Testing and Treatment panel on TeleTest.
• If you want cervical-cancer screening, use your provincial program or family doctor (TeleTest doesn't currently offer this).

You can absolutely do both - many patients have an annual STI screen through TeleTest and a 5-year cervical screen through their provincial program.

See also STI Testing Overview.

Yes - Pap and HPV tests don't screen for the common STIs (chlamydia, gonorrhea, trichomoniasis, HIV, syphilis). Some clinicians do add an STI swab during the cervical-screening visit, but many don't.

If you're not sure whether STI screening was included with your Pap/HPV visit, ask the clinic that did the screening, or do separate STI testing through TeleTest or a walk-in clinic.