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These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
No. The costs of GP consultations remain the same, and laboratory processing costs are identical whether samples are self-collected or clinician-collected. In fact, laboratories have had to invest in new instrumentation to accommodate the changes. Overall, the program is cost-neutral to government, and there’s an incredible amount of evidence behind these changes. The real benefit is that self-collection opens up screening to people who wouldn’t otherwise participate, and provides choice for those who are uncomfortable with pelvic examinations.
I think this is a natural question because we’ve spent decades educating GPs about the importance of visualising the cervix and taking the sample from the right area. And of course, in putting in a speculum and visualising the cervix, we don’t want people missing things that they happen to see along the way. However, in the absence of the screening need for that, any examination effectively becomes screening in its own right. And as GPs know, screening asymptomatic people requires careful consideration of benefits versus harms, which is why we have well-structured screening programmes in Australia.
No. In terms of the detection of pre-neoplastic lesions of the cervix, and indeed cancers, we’ve now got a very sensitive test. A comprehensive meta-analysis published in 2018 formed the basis for making self-collection universally available in 2022. This research demonstrated that PCR-based laboratory tests show no difference in performance between clinician-collected and self-collected samples. We can be very reassured about the detection of cervical abnormalities.
HPV-driven vaginal intraepithelial neoplasia should still be detected through self-collection. Vulval disease won’t be detected because we’re not examining the vulva, but this is the distinction between screening and clinical examination. Patients with symptoms relating to the vulva or vagina require clinical examination regardless of screening status.
While there hasn’t been an explicit literature review on that within the guidelines framework, we at ACPCC have looked at the literature and were unable to find any evidence of any disease averted or life years gained through examining the cervix of asymptomatic women.
Cervical polyps are commonly seen at colposcopy, and malignant disease within them is very rare. So the idea of examining everyone’s cervix in case there’s a polyp there would not stack up from a benefits and harms point of view.
Cervical screening is for everyone with a cervix aged 25 to 74 who has ever had sexual contact. It’s important to clarify what “sexual contact” means, as HPV can be transmitted through various mechanisms including genital contact, sex toys, and fingers—not just penetrative intercourse. So with that caveat, no, people who haven’t ever had sexual contact don’t need screening.
Yes. Participation is declining in the 25- to 29-year-old age group, and self-collection may help restore engagement in this demographic.
Nationally, between 40 and 50% of tests are now self-collected—an impressive uptake for a test that’s only been universally available for a few years.
Timing matters here. Self-collected HPV testing is appropriate after nine months, as this is considered close enough to the 12-month follow-up interval. However, if the patient presents earlier than nine months, cytology should be performed instead. In tricky scenarios like this, consult the guidelines or contact your laboratory—all laboratories that process cervical screening tests are happy to provide clinical advice for complex cases.
Even though this patient is not yet eligible for screening, symptoms that raise the possibility of cervical cancer must be investigated, regardless of age. Cervical cancer is very unlikely at this age, but must be considered, and the symptoms must be investigated appropriately. The guidelines recommend considering sexual health history and performing appropriate tests to determine the cause of the symptoms, such as a chlamydia test.
Any patient with persistent post-coital bleeding or unexplained intermenstrual bleeding needs a co-test and referral to colposcopy—even if the co-test is negative.
If this is a single episode of post-coital bleeding in a pre-menopausal woman and the cervix appears normal, they do not need to be referred. Advise them to return to you if it persists and refer them for gynae assessment at that point.
Laboratories have automatic access to National Cancer Screening Register history and use this, along with clinical history, to inform appropriate testing and recommendations. This acts as a safety net. However, the system is not entirely perfect, particularly for patients recently arrived from overseas or those who have opted off the register. In cases where you are aware that a co-test is required, you should ideally put it on the request form.
For patients with persistent post-coital bleeding, unexplained intermenstrual bleeding, or any post-menopausal bleeding (which always requires referral), refer them to gynaecology and let them decide on the workup. Self-collected HPV testing is unlikely to change management in these circumstances, as they’ll need cytology and direct visualisation regardless of the result.
For asymptomatic patients who can’t tolerate speculum examination—including those with sexual trauma or who have experienced genital cutting—self-collection is perfectly adequate. Don’t insist on a speculum unless it’s truly indicated.
Current guidelines recommend annual colposcopy while HPV 16/18 persists. However, there’s now a caveat: if colposcopy has been performed and repeat testing at 12 months shows HPV 16 with negative cytology (either through reflex cytology or repeat collection), women of any age can wait a further year before the next test. If HPV 16 still persists at 24 months, refer back to colposcopy.
It’s important to understand that these are emerging programmes with evolving evidence. GPs should watch this space as more longitudinal data from the Australian programme becomes available.
Yes. There’s concern about women over 50 with type 3 transformation zones, where colposcopists often cannot visualise the transformation zone well. In these cases, disease may be present higher up in the canal, and there’s a risk of delayed cancer diagnosis.
Guidelines recommend a short course of topical oestrogen prior to colposcopy for postmenopausal women, as well as people experiencing vaginal dryness including those who are post-partum or using testosterone for gender affirmation. Oestrogen improves diagnostic accuracy of both colposcopy and any liquid-based cytology or biopsy testing associated with it, and enhances patient comfort during the examination.
This is not recommended, largely because it often becomes almost impossible to visualise the transformation zone following LLETZ and it is not uncommon for HPV 16/18 to persist, making it very difficult to continue to monitor these patients.
Patients with persistent non-16/18 HPV can remain on a two-year colposcopy cycle. If high-grade disease or glandular abnormality is detected on reflex cytology, they should be referred immediately to colposcopy.
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